This is the second guideline from a new project called Foundational Stabilization (FoundStab). I need your help to create a bedrock level of care across all venues in which a sick patient may show up. This should become the new foundation, the absolute lowest level of care that we deem acceptable. Even more advanced resuscitative and critical care can be built on top of this foundation. This is a crowd-sourced project–it only works if you comment, so please do!!!
Please see prior SOPs on the FoundStab Page
Provisional SOP for Standard Intubation
First Publication: 2024-04-05, Last Updated: 2024-06-13
This SOP pertains to the following patients:
- Adults
- Acceptable for RSI/DSI after a difficult airway assessment
- Without special circumstances that will dictate different strategies (anatomically difficult airway, physiologically unstable patients, neurocritical intubations, etc.)
Equipment
1. All equipment for intubation and failed airway management should be stored in an immediately accessible and ready to use system
- EMCrit Resus SCRAM Dump Kit
- Suctions already set up
- BVM already set up
See EMCrit Resus Room Readiness Episode
2. Waveform capnography should be immediately available in the standard locations for intubation
3. Attach ETCO2 and PEEP Valve to BVM prior to intubation
See EMCrit 217 – The Ultimate “Ultimate” BVM
4. Have all failed airway equipment present at the bedside
Oral airway, properly sized EGA, Bougie, Scalpel, 6.5 ETT or 6-0 Trach (preferably one with small OD), back-up direct laryngoscope
5. Place equipment on a table rather than the patient's bed or body
6. Have properly labelled medications at the bedside for intubation, hemodynamic rescue, and post-intubation sedation
Preparation for Intubation
7. Place patient in optimal positioning
Ears to Sternal Line, Face Plane parallel to ceiling, +/- slight HOB up
See EMCrit 226 – Airway Update – Bougie and Positioning
8.Use an effective Preintubation Oxygenation Optimization Strategy
Based on the Recent PREOXI Trial, Choose One of the Following Options:
- NIPPV or Ventilator attached to NIPPV Mask with settings IPAP >=10, EPAP >+5. RR >=10, FiO2 100%
- BVM at flush rate + NC >=15 + PEEP Valve, bagging during the apneic period
- Oxylator with a PEEP Valve
See EMCrit – When it comes to Preintubation Terminology we stink like POO
9. Patients should have a Nasal Cannula at ≥ 15 lpm in place throughout Intubation Procedure
10. Perform physiological and hemodynamic stabilization prior to intubation whenever possible
Resuscitate before you intubate
11. Perform a checklist timeout prior to intubation
See EMCrit 176 – Updated EMCrit Rapid Sequence Intubation Checklist
12. Verbalize an airway algorithm
- When to terminate an attempt
See EMCrit 233 – EMCrit Failed Airway Algorithm 2018 from ResusTO
Intubation Procedure
13. Perform RSI/DSI using Ketamine and Rocuronium (preferred) or Succinylcholine
14. Unless contra-indicated, Provide Gentle Ventilation during Apneic Period
EMCrit 237 – Vent & PreVENT – An Update
15. Use video laryngoscopy for all intubations
16. Consider Bougie with First Pass if using a Standard Geometry Video Blade
17. Perform optimization maneuvers prior to abandoning attempt if patient remains well saturated
See EMCrit 253 – Kovacs Kata to Optimize a Failing Laryngoscopy Attempt
18. Use large-bore suction catheters
2 suction set-ups preferred
Reoxygenation and Failed Intubations
19. Perform BVM breaths with a two-hand mask grip, oral airway, and ETCO2 confirmation
20. Do not perform more than three attempts at laryngoscopy without a cognitive and physiological reset from Extra-Glottic Airway Placement
- Definition of an Attempt
21. Perform a surgical airway if laryngoscopy and extra-glottic airway placement do not provide ETCO2 waveform and acceptable saturations
See EMCrit Cric Page
Post-Intubation Care
22. Confirm placement with Waveform ETCO2
23. Perform a Debrief after airway management
- Can be a just in your own mind debrief
- If others were present, can be helpful to be more formal
- Reviewing video recordings of the intubation can be a force multiplier for upping and retaining laryngoscopy skills
Additional Information
European Society for Emergency Medicine Guidelines
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Now on to the Podcast
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Hey guys! Amazing podcast. Kaitlin Roth is an Emergency Medicine physician at DH and listens to your podcasts religiously. It’s her birthday coming up 4/21/24 and I think it would be kinda cute if y’all gave her a shoutout at some point on the podcast. Cool if its no! Keep doing what you do. – Joel Z
you lost me
Scratch that – didn’t see in first read that you already mentioned post-intubation sedation meds.
Great episode, I really appreciated the idea that min standard should be a standard that we would all be ok with and that’s higher than a lot of places are doing. Just a couple thoughts I think the extraglotic airway should an initial reox option vs facemask. We have some evidence that LMA is easier to learn/retain and the logistical/cognitive benefits of just putting in the igel for a couple mins seem significant. Do you think there should be a recommendation for paralytic dosing? It seems like the airway thinkers are more and more recommending 1.5-2mg/kg TBW for both sux/roc… Read more »
hi scott, Thanks for this excellent podcast, as always. It is very interesting that you quote the EuSEM guideline and appreciate it. The lead author comes from Germany. Although emergency medicine is not a separate specialty in Germany, the German Society for Intensive Care and Emergency Medicine (DIVI) has designed an officially specialist society-sponsored airway course for pre-hospital and in-hospital emergency medicine. It is called – ANNA – airway management and anesthesia in emergency and acute medicine – and defines the standard for airway management in Germany. The content of the course is well adapted to the current state of… Read more »
Another excellent podcast! I’m actually in the middle of creating my own Standard operating procedure for intubation so the timing couldn’t be more perfect. I especially liked the “Debrief” suggestion. I think this is essential after these critical events to highlight the things we did well and the things we can improve upon for next time.
I’ve also always been in favor of verbalizing your plan aloud and assigning roles.
The “intubation scenario” should be treated similar to a code.
I definitely will be adding some of these to help my own team.
Thanks!
Hi Scott, This is a great topic, thank you. One comment on the preoxygenation strategy. Personally, I think BVM should be the default or top strategy with NRB listed as another alternative. Some colleagues and I have demonstrated there is no difference in ETO2 levels between flush rate NRB and BVM. But I think there are other benefits that can be gained: With nasal cannula O2 the BVM can act like CPAP therefore buying some recruitment of lung (you have taught me this!) PEEP can be applied (this is routinely on all of our BVMs and set to 5cmH2O) Is… Read more »
yes, the study has been done by the Sydney HEMS folks, NC + NRB is almost as good as BVM, hence why it is on the list.
There definitely are emcrit listeners in the German emergency medicine society, so I guess some of them will be in the European one as well. For example, DSI by Weingart has been mentioned in our trauma guidelines for years, even as those are dominated by surgeons 😉 I have one question regarding standard geometry VL: Don’t you think trying to get a direct view of the chords (without the video) is better, as 1. you will have an easier time passing the bougie (a good view on the video does not necessarily mean an easy passing) and 2. you will… Read more »
Hey buddy,
Went over a lot of these issues with the teaching laryngocopy episode. There is a transition period for developing the video game reflexive ability to have your hands doing one thing while your eyes are looking at the screen. Once that barrier is surpassed, I would argue that one is markedly better always looking at the screen. I noticed this transition in my own practice and now would never go back to DL.
Hey Scott, thanks for the great podcast, I really appreciate it, as a surgeon. You mentioned intubation through a supraglottig airway, is there an article I´ve missed, or can I read up on that anywhere?
in this case the SGA being referred to is an LMA. All of them can be intubated through them through a variety of methods.
With the advent of disposable fiberoptic bronchoscopes I think it might now be cost effective for paramedics to temporize the airway with an IGEL and if ETA is short and oxygenation/ventilation is effective simply transport. However, if ETA is longer or ventilation/oxygenation is problematic. I think many EMS systems could convert IGEL to ETT with continuous ventilation via a bronchport. Seems like a fairly easy skill to learn and a much safer approach than standard DL or VL. It is my understanding that the screen is around $2000 and disposables are another $200. Interested in the views of others more… Read more »
I am not seeing the advantage of the conversion in the field. If the SGA is maintaining good ETCO2, let it ride IMO
Great SOP for intubation! The focus on teamwork and patient safety is crucial. This resource will greatly enhance clinical practices. Thank you!