Today, we talk about the theory and practice of the Dissociated Awake Intubation. This technique allows the rapid provision of an intubatable patient while preserving spontaneous respirations.
A few days ago I posted George Kovacs' thoughts on the matter.
This was in response to a blog post by frenemy of the show and brilliant airway tactician, Reub Strayer.
What is Dissociated Awake Intubation?
I coined this term to describe the administration of a dissociating dose of ketamine to allow a patient to be intubated for many of the same circumstances as the traditional topical awake approach.
This is theoretically distinct from the idea of using ketamine in a sedative-only intubation. The two ideas are separated by the intent, with the former subbing for a topical awake and the latter for a RSI, in systems where for whatever reason, paralytic can be used. In practice, they look the same–it is often the users that look different.
Kovacs has used the term ketamine facilitated intubation to encompass both uses. This post and podcast only deal with dissociated awake.
Awake Intubation Posts
- Emergency Awake Topicalized (EAT) Intubation – An Awake Intubation Update
- Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs
Why Awake Intubation?
If an airway is predicted to be difficult, consider an awake approach. This predicted difficulty could be an anatomic. It could also be physiological: namely Hemodynamics Kills, Oxygenation Kills, or pH Kills. When there is a combination of two or three of these elements, awake becomes almost a must.
Awake vs. RSI
RSI and awake are tradeoffs
- RSI gives you the easiest laryngoscopy/tube delivery at the expense of safe time for intubation
- Awake gives you a markedly harder laryngoscopy/tube delivery rewarded by a markedly extended safe intubation time
You must be a much better intubator to perform an awake laryngoscopy and tube delivery.
Topicalized vs. Dissociated Awake
In some cases you will try topical first, and then when the pt won't cooperate or you can't adequately topicalize, that will push you to dissociation. However, there are definitely a group of patients who I will choose primary dissociated awake. It comes down to cognitive bandwidth.
Nuts and Bolts of the Technique
- Give small aliquots of ketamine every 15 sec. or so until dissociation (25 mg at a time
- Have everything ready for RSI and failed airway, including paralytics prepared and ready before first dose of ketamine
- I still topicalize
Awake Intubation from George's Online Textbook
Kovacs AIME Airway Textbook (Infinity Edition) – Awake Intubation Chapter)
Additional New Information
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I think we will one day know how to get ketamine even closer to the hypothetically perfect drug, the drug that will keep the patient breathing, abolish consciousness and allow laryngoscopy, with no adverse effects. What is the role for pre-treatments? Some suggest pre-treating with conventional sedatives to decrease the likelihood of rigidity. How important is topicalization when the patient is dissociated? What is the right dosing strategy? For most adults getting PSA or DAI/KOBI, I put 200 mg ketamine in 100 cc saline and drip it in over a few minutes. I think this reduces likelihood of rigidity but… Read more »
Saw Farkas’ comment and I don’t buy that strategy at all. You get all of the problems of ketamine and none of the advantages and no reason to think this would abolish vomiting potential based on any extant lit. Reub and I discussed the laryngospasm thing by email. In my own practice, I very well may try a few maneuvers before proceeding to paralysis. What I want to get across to the less experienced folks is do not mess around. If the patient is spasming, do not burn through your preox, just proceed with RSI. Ketamine for PSA is a… Read more »
I think the point regarding the ready availability of paralytics (i.e. drawn up in a syringe and at the bedside before commencing KOBI) is critical. There’s been some discussion in various forums of extending this technique to the prehospital environment as a way to achieve safer airway management for providers who are not credentialed or trained to use paralytics. I think this has the potential to be very dangerous. I agree with Reuben that laryngospasm that cannot be corrected with BVM/laryngospasm notch/positioning is pretty rare, but it does occur. In my mind, KOBI is not a replacement for RSI per… Read more »
obviously we agree buddy. I want to emphasize that what you have very nicely outlined is the difference between DAI and Sedation-only Intubation using Ketamine. The latter is a horrible idea for people that are deemed to not have experience/practice pattern to allow RSI.
Great episode, Scott. Thanks for covering this topic so well.. One concern I have is the idea of doing ketamine-only for supraglottic airway placement in the prehospital setting. I don’t think doing any ketamine-only airway procedure without paralytics available is a good idea. While the risk of laryngospasm/jaw rigidity is probably quite low, especially if ketamine is given slowly, it would be a big problem if paralytics were not available. And while giving more ketamine may be a good option for increased tone, I don’t think we know yet if that is as reliable as paralyzing. Additionally, placing a supraglottic… Read more »
Excellent podcast. Pretty much sums up what I have been thought and have been doing for years. It has been around for decades (all the old skool attendings tend to use a lot of ketamine or Esketamine in all the variations mentioned here) but it was rarely published. Something to consider, is to pull the gastric tube out after emptying the stomach. Its in the way and in our experience it promotes regurgitation along the tube on the outside. I just stick a new one in after I secure the airway when they have abdominal problems and they need one… Read more »
this has actually been looked at–and the integrity of the LES is maintained despite the tube. No need to pull. I’ll dreg up the reference when I can.
remember this was posed as an alternative to Ketamine intubation, so the arguments re: laryngospasm and jaw rigidity are moot. Having placed a bunch of SGAs with just ketamine, I can tell you it is much easier than placing a tube–for whatever anecdotal experience is worth
Hey Scott, I’ve learn’t this from you…. way easier to articulate your views by audio as opposed to print. So here is my rebuttal while smoking a friday night brisket for 2 of my kids who are back in town:
http://aimeairway.ca/announcement/76/emcrit-post-on-ketamine-for-dissociated-awake-intubation-my-rebuttal-while-smoking-brisket
Take care
G
Dr Kovac thank you for your excellent work and clear and calm explanations in all your videos I feel I should do more really awake ( not ketamine, breathing ). But in all honesty I would do an RSI or breathing ketamine pretty much always. My main problem is how to get the practice in with the awake part. As well as shifting to doing awake intubations for emergencies and emergent cases. We’re I work you start with doing fibre optic intubation at every opportunity in year one (we do a few hundred spine cases a year in addition to… Read more »
think you just need to break the prejudice of doing awake topicalized. You can change the entire culture in a couple of years and it is a change worth making. At one of the busiest trauma centers in the US, we had a culture of always doing the spine cases awake topical–I think you would be well within Anesth. standards to start doing so,
nice stuff, George. Wish I can taste the brisket. One thing to respond to. I did not edit you for length, everything in that full video is gold and well worth the time. The edits took out the tangential teachings to restrict the edit to purely a response to DAI/KOBI–there was a bunch of wonderful teachings on history of RSI, techniques of topicalization, etc. These are wonderful but not essential for those that just wanted to follow the throughline conversation on DAI/KOBI that started with Reub’s blogpost and ended with your brisket comments.
Great podcast. I’m an EMS doc in Pennsylvania. We have the issue you touch on – they won’t give us paralytics. We have had Etomidate only sedation for awhile, works well as long as we do post Intubation sedation with fent and versed. Ketamine was added as an option and my service is piloting it. Initially we were pushing it over 2 minutes and medics reported they never got good sedation. I wonder if it is just something they were not used to – intubating a breathing patient. We have changed the push rate to 30-60 seconds and it has… Read more »
Hi, I’m interested if you use ketamine for larger chest tube placements. If you do what dosing and any addition pain medication or sedation. Traditionally at our hospital people use Fent + Versed, but recently an ER doc offered to do the sedation and used Ketamine and it was a much better experience for the patient and the clinician.
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