The Post-Intubation Package
There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient's course in the hospital. Preventing badness starts with us.
Achieve Adequate Analgesia and Sedation
I won't belabor this, because I've discussed it in so many other podcasts, such as the one about not leaving your patient in a nightmare
Secure the Tube Well
We use the Hollister Anchor Fast (as always, no conflicts of interest).
Raise the Head of the Bed to at Least 30°
May or may not help prevent VAP, but it definitely helps lung mechanics
Confirm Lung Protective Vent Settings
See the Dominating the Vent Lecture for more on all that
Humidify the Air
Either with a humidification circuit on the vent or a Heat-Moisture-Exchanger (HME)
Place In-Line Suction and then Actually Use It
In-line is probably no better than intermittent with sterile technique, but who is actually going to use sterile technique
Suction the mouth each time you suction the tube as well
Hook Up the ETCO2
You read NAP4 right? Continuous waveform ETCO2 until the ET tube gets pulled
Empty the stomach to reduce the chances of aspiration
If they were intubated for reactive airway disease, then they need frequent nebs. In some hospitals, all patients get intermittent MDIs. Make sure to remove the HME for nebulizer or MDI treatments.
Prevent Aspiration past the Cuff of the ETT
Lube on the tube cuff may help avoid micro-aspiration (Anesthesiology 2001; 95:377–81 & Anaesthesia. 2006 Feb;61(2):133-7.)
Continuous Subglottic Suction ETTs
May prevent 4 cases annually if used for all patients in an average US hospital (Critical Care 2012, 16:446)
A listener, Dan Hierholzer, DO (last name: Here-Hole-Zer) reports on 1 issue with these tubes: they have a wider external diameter so if you are trying to pass them through an intubating supra-glottic airway, you need to go 1 size lower. Dan demanded a shout-out to the residents at Geisinger Medical Center in exchange for this excellent tip.
Get a Blood Gas
I like arterial, but if you want to go venous and you have a sat between 90-95% then knock yourself out.
Check Tube Depth
I start with 21 cm for women and 23 cm for men. Adjust based on size obviously. Then get an ultrasound and/or X-ray. When getting an x-ray make sure the head is in a neutral vertical position (remember the tube follows the nose, nose down-tube deep).
Bonus Meds-SUP and DVT Proph
Have an institutional plan for which meds and when
Put a BVM at the Bedside ± PEEP Valve
When something goes wrong you should not need to search for this. Put the mask on the O2 tubing.
Have a Plan for Vent Alarms
Treat them like a cardiac arrest announced overhead.
This amazing post from my bud Kane Guthrie from LITFL is worth a read stat: Key things to know about ventilator-associated pneumonia (VAP)
This article is geared to the ED prevention of VAP later in the patient's course: Ventilator-associated pneumonia: the potential
Jeffrey Siegler, an EM PGY1, made the first foray into turning this into a checklist
I received a second one, this one index-card-sized, from Chris Huntley, PA from the University of Washington ED.
Now on to the Podcast…
- EMCrit 277 – COVID Pulmonary Physiology with Martin Tobin - July 9, 2020
- EMCrit 276 – The Rapid Code Status Conversation with Kei Ouchi - June 25, 2020
- EMCrit 275 – NeuroCritical Care with Neha Dangayach - June 10, 2020