We've had a few gruesome airways in patients with GI bleeds and bellies full of coffee ground emesis. Once they vomit, things go bad pretty quickly–it is best to manage these patients with a regimented approach and be prepared for the predictable disasters.
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 or erthromycin 250
Ketamine for DSI will allow for placement if the patient's condition precludes cooperation
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)
10. SIRS
Expect a sepsis-like syndrome from the aspiration. This folks may need pressors and tons of additional fluid
Additional New Information
The biggest game changer is the SALAD Technique. If you don't already know about it–jump over to the link ASAP
More on EMCrit
IBCC Chapter & Cast: GI Hemorrhage
Blakemore Tube Placement for Massive Upper GI Hemorrhage
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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great summary scott. additional thought: although you want to not bag, if you must bag, you want to minimize the amount of air transmitted to the stomach. So abort your laryngoscopy attempts earlier so you’re more likely to bag slowly, gently, and, even better – through an LMA.
Great checklist for the next UGIB intubation, Scott.
As I watched an oropharynx fill with coffee grounds a couple months ago, I was reminded of that really large bore perforated suction catheter on display at an ACEP SA past. Couldn’t find it just now, after doing a quick search online, but a larger bore catheter and tubing would go along well with the meconium aspirator.
I would add that this is a time that you want to have a blind technique ready like the Intubating LMA… although a bougie is technically a blind technique ILMA, would be better… (saved me the last time i saw a mouth full of blood despite 2 yankauers)
Taku,
Absolutely! I had LMA in number 6, but an ILMA would be even better if you have them.
Scott
Scott, I just had a woman with right sided lung CA who developed MASSIVE hemoptysis…actually was just pouring out blood from lungs. She quickly went into respiratory arrest then cardiac arrest. We suctioned 500 mL of blood from her mouth and airway in the first 3 minutes. I called anesthesia (first time I ever thought I wouldn’t be able to intubate someone), couldn’t find a meconium aspirator, but anesthesia intubated anyway, though we couldn’t confirm due to amount of blood. Then of course we couldn’t ventilate her. She died, and I think it was 1. from respiratory then cardiac arrest… Read more »
I have said before… Love your podcast. So yesterday I just had a GI bleeder that started crashing, but was able to stabilize and thankfully didn’t have to intubate. Now in hindsight I am here reviewing the “what if’s” and googling “Intubate the GI Bleeder”, and the first thing that pops up on google is this podcast, which it turns out I have alreaded downloaded onto my iPhone (along with all your podcasts), but hadn’t yet listened to this one. So, thanks again for this (and every) posting, please keep them coming. This brings me to my question: Any chance… Read more »
Do you know this device?
http://www.synmedic.ch/uploads/tx_products/492_3015_40_Suction_Booster__CH_.pdf
we sometimes use this in EMS in Germany.
wow, never saw it. That is great! I bet it is much more expensive than a meconium aspirator and suction port for in-hospital use.
Is there any reason you couldn’t place an OG instead of NG prior to RSI/DSI? I’m a paramedic and all we have are OGs. If you can, would you be better off doing this after a low dose of ketamine or prior to any sedation?
OG is fine; sometimes gets in the way during intubation
Whilst doing a summary of this podcast for our doctors at work, I thought out this mnemonic which I thought would help perhaps: Intubating these patients is NO CHRISTMAS!
N=NGT+metoclopramide
O=pre-Oxygenate
CH=chest and head elevation (45 degrees)
R=RSI meds
I=intubation success (first pass)
S=slow, gentle BVM if failed
T=Trendelenberg, if vomits
M=meconium aspirator
A=antibiotics not indicated early
S=SIRS response expected
What do you think??
Love your podcasts, by the way…it’s like a bible for our unit in South Africa!!
super creative!
Hi Scott
What would you think of using erythromycin IV as part of DSI instead of or with Reglan. Seems like it would need 25-30 minute lead time, but emptying is enhanced.
http://onlinelibrary.wiley.com/store/10.1111/j.1365-2036.2011.04708.x/asset/j.1365-2036.2011.04708.x.pdf;jsessionid=996AAFFFD11AC01AE200E777DDD4B55D.f01t02?v=1&t=i5ndonwc&s=f0606661f8a520375638177560f4c389460d9580
http://www.medscape.com/viewarticle/746146_1
Not sure why it needs to be part of DSI. By all means give the med, but don’t need to link it to the stressful moment of peri-intubation. It is the NGT that is doing the work, not the reglan.
Hi Scott
I just re-listened to this podcast.
What size Salem Sump are you placing?
Is it a case of bigger=better?
How are you selecting your induction meds?
Are you going with etomidate or ketofol type induction, in reduced doses?
Thanks for this podcast
Dean
yes, bigger is better
reduced dose ketamine is my drug of choice
see the intubating hemodynamic unstable podcast for full scoop
Hi Scott
Have you experimented with a DSI reduced dose of ketamine to place the large Salem Sump?
I can only imagine the patient coughing & protesting as one of these large tubes is placed to empty the stomach.
Would you have any concerns relating to this approach?
Dean
some of the pts in the DSI study received it solely to get salem sump
Hi Scott, what´s the pro´s n´con´s for using ApOx with nasal canula in this particular situation? Is there increased possibility, to inflate the stomach with air and therefore increase possibility for regurgitation or insuflate the airway with gastric content if regurgitation took place, doing the ApOx on a nasal canola @15 l/min?!
Thanks for a really good podcast.
/Ulf
Your rational for each intervention is so beautiful – it makes an enjoyable read – Thank you