We've had a few gruesome airways in patients with GI bleeds and bellies full of coffee ground emesis.
This is a top 10 list encompassing my approach to this difficult situation:
1. Empty the Stomach
Place a salem sump and suck out all of the stomach contents.
Varices are not a contraindication (see: Digest Dis 1973;18(12):1032, Gastrointest Endosc. 2004 Feb;59(2):172-8, and Anesth Analg 1988;67:283)
Administer Metoclopramide 10 mg IVSS
2. Intubate the Patient with HOB at 45°
Semi-Fowler's position will keep the gastric contents from moving up the esophagus
3. Preoxygenate like mad
You do not want to bag these patients, give yourself a preox cushion
4. Intubation Meds
Use a sedative that is BP stable, use reduced doses.
These patients NEED paralytics. You need to optimize first pass success. Paralytic agents actually increase the lower esophageal sphincter tone (Br J Anaesth 1984;56:37).
5. Gather your equipment to optimize first pass
Use fiberoptic laryngoscopy if you have it (e.g. Glidescope)
At the bedside, have a bougie, an LMA, a meconium aspirator (more below), and 2 suction set-ups
Wear eye protection!
6. If you need to bag after a failed attempt…
Bag gently and slowly (10 times a minute)
Consider placing an LMA if you need to bag.
7. If the patient vomits: Trendelenberg
This potentially keeps the emesis out of the lungs
8. Meconium Aspirator
If the normal suction is too slow, attach the meconium aspirator to your ET tube. See this post on a novel ETT suction set-up for the full description.
9. No ABX for Aspiration
Aspiration in the initial phases is a chemical pneumonitis, not a bacterial pneumonia
See Marik's article (NEJM 2001;344(9):665)
Expect a sepsis-like syndrome from the aspiration. This folks may need pressors and tons of additional fluid
- COVID19 – Awake Pronation (aka the Pig Roast) A guest write-up by David Gordon, MD - April 6, 2020
- EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients - April 4, 2020
- EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer - March 31, 2020