STAT intubation advice PLEASE!!!!!!!!!!

On a general floor other than critical care areas, the crash cart has what the doc will need, page respiratory stat, page supervisor stat, nurse who has that patient stay there to answer questions for doc doing intubation. Offer to help if no one is there that is experienced besides the doc, tell the doc you have not assisted in this before. Offer to help bag the patient until respiratory arrives. #1, take a deep breath and dont panic. The second time will be sooooooooo much easier. Take another deep breath as they wheel the patient to the ICU and then chart what happened and what led up to the respiratory failure if you have not had time to do that yet. If the patient remains on your unit for a short period until a bed is made available, the doc will order a CXR and sometimes a blood gas. Respiratory will bring a ventilator to the room. IV access will need to be obtained. Some sedation drugs will be ordered. Wrist restraints will most likely be ordered to protect the artificial airway.

"...what the doc will need"....!!!!!

This is a CRNA forum -- i.e., for Certified Registered NURSE Anesthetists (and students and various wannabees), clinical specialists who intubate every day all by themselves and who don't need no stinkin' badges, as the saying goes. Perhaps Snowfreeze is not aware that CRNAs, not docs, do two-thirds of the hands-on anesthetics in America.

As to the OP's Q ... well, don't depend on that crash cart too much. It may very well NOT have what we need. Recently I found one in an ICU where EVERY laryngoscope blade failed to light. Some institutions provide a tray or tackle box for Anesthesia to carry to a Code. Varies.

Just go, keep a coool head, and slam dunk that ET.

One nice thing: those folks needing Stat intubations are very often *extremely* relaxed. Good luck.


deepz

Answering from the anesthesia provider viewpoint, the first thing that comes to my mind is to appreciate the action of muscle relaxants, and make the decision to use them very wisely.

If the intubation is truly stat, that in itself implies the patient is in profound distress, and quite possibly in respiratory arrest. There really is no need for muscle relaxation in this situation. But I am amazed at the number of people (usually non-anesthesia), who routinely reach for a muscle relaxant just because there is an intubation in progress. Once you push that syringe, you have taken full responsibility for that airway. You MUST get the tube in, whatever it takes. If you run into problems, you have obliterated whatever respiratory effort the patient had to begin with, if any. And if there wasn't any, you didn't need the relaxant.

Floor intubations are different from the controlled situation in the OR. If you are a student, there will be an additional learning curve to doing them, even if you are already pretty comfortable with "standard" intubations. It seems awkward at first to have to deal with cords that are still moving. You just have to get in synch with the patient's respiratory rate, and time your move.

There is also the issue of tube placement verification. You just have to be completely convinced you are in the right place before you can walk away. Be sure to follow your institutions policies exactly, if you don't and there is a mistake, you are out on a limb all alone to take the blame. Besides ascultation, most places use those disposable CO2 detectors and there is always the old fashioned CXR.

I guess that was more than one thing. There are probably some other "most important things" that I haven't covered, but others will.

loisane crna

Get to the head of the bed ASAP, bump said resident out of the way if necessary. Assume mask / ventilation. Try to go with pt if he/she is making ANY effort of spont ventilation. Assure working IV access and pulse ox. During this phase and you plan on using sux, ask morning K level, if bedridden then how long, and if pt has any renal failure, rhabdo, or known muscular dystrophy. Have suction on FULL BLAST and have Yankaur under patient's right shoulder. Look at abdomen and try and see how much air has been forced down there during aggressive mask ventilation. IV induction of choice given brief history.
Go in with blade of choice and suction. Someone needs to be able to hand you the tube when you want it. On patients with any form of non-humidified O2, expect to see a lattice work of dried snot covering the vocal cords. You can use the Yankaur to get rid of this. Intubate ASAP. Don't play around in there. Chances are the stomach is waiting to blow up on you. If this is your first intubation with about 35 people watching to see if you goose the esophagus, chances are you will mainstem on the intubation. Assure BBS and no epigastric sounds while RT or RN bags.
Just to be on the safe side, show the RT and RN closest to you the fact that the ETCO2 detector does color change with 3 successive ventilations.
Keep cool and everything will be good. Just remember the basics.
Like one poster said, usually these guys don't put up much of a fight. CO2 narcosis can be a lovely thing.

We have adult and pedi intubation boxes we arrive with. We know these boxes have working blades and tubes, propofol/thiopental/etomidate/sux/ and norcuron.

I appologize, I didnt look to see where this post originated.

As a PHRN who did intubate in a previous unit I worked in. Be nice to the staff assisting you might be a good #1.

In those instances, keep them breathing, do not paralyze, give titrated doses of Versed and numb the airway with Cetacaine (if available). Prior to the intubation introduce yourself to the patient and explain to them what you'll be doing for them. Explain that you are there to place a breathing tube in their airway so they can breath easier. Tell them that you will be as gentle as possible and that you'll give them medicine so that they won't remember the procedure. After making the bond with your patient, start with small doses of versed and start spraying the airway with the cetacaine. When patient relaxes, start your laryngoscopy and place the tube. Check the ETCO2, BBS and tape your tube, follow that with CXR.
Make sure the ICU nurses have adequate sedation orders for the patient while on the vent. I have been known to give more sedation before I leave if they need to call the MD for long term sedation orders. Before leaving, offer to place an A-line (good experience for you as an SRNA!) because our ICU nurses will 9 times out of 10 call you back a few hours later for it and you may be in bed!

Just be calm because your nervousness will be felt by both the patient and the staff.

repeat after me, "breathing is always good. breathing is always good."
i never paralyze outside the OR unless ABSOLUTELY necessary. if its a full blown resp arrest, you won't need paras, however if it's elective icu stuff, consider your options prior to paralysis. maybe heavy sedation will get you the cooperation you need, maybe a little propofol.
suction suction suction suction you get the pic. worst scenario, you go to tube pt pukes and suction tubing is not hooked up, on the floor, not in the room etc. big mistake, remember these patients have not been npo for surgery, bellies are almost always full with air, grits, egss etc . also consider arriving with blade you feel most comfortable with, i'm a miller man and sometimes you run into only mac blades in unit/floor etc (do try to be proficient with all blades just for this reason). and like loisanne said i think, never leave unless you can confirm right hole has the tube.
as a side note, remember you are the airway expert, people are looking to you for answers, exude confidence, be professional, be polite, and by all means take charge if necessary.
oh and good luck
d