Perron's Airway Pearls from AAEM 2017

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The following airway pearls were gleaned from Dr. Mike Winters' lecture "Critical Care Quickies - Pearls for the Moribund Patient." This was presented at the pre-conference workshop "Resuscitation for Emergency Physicians" (23rd Annual Scientific Assembly of the American Academy of Emergency Medicine in Orlando, Fl).

 

 

1.  Driver BE et al: Flush rate O2 for emergency airway preoxygenation.  Ann Emerg Med 2017; 69: 1-6.

  • Study question:  What is the best way to preoxygenate your patient? 
  • Study groups: 
    • #1.  Non-rebreather mask @ 15 L/min.  
    • #2.  Non-rebreather mask turned “all the way up” aka “flush rate.”
    • #3.  Bag valve mask at 15 L/Min
    • #4.  Simple face mask @ “flush rate”.
  • Outcome Measure:  Expired O2 at 10 seconds after 3 minutes of preoxygenation with each method
  • Results: 
    • #1 = 54% 
    • #2 = 86% 
    • #3 = 77% 
    • #4 = 72%

Takeaway Pearl:  Non-rebreather mask at "flush rate" provides the highest preoxygenation as measured by exhaled O2.

2.  Khandelwal N, et al: Head-elevated patient positioning decreases complications of emergent tracheal intubation in the ward and ICU.  Anesth Analg 2016;122:1101-1107.     

https://commons.wikimedia.org/wiki/File:Not-Intubation.jpg

https://commons.wikimedia.org/wiki/File:Not-Intubation.jpg

  • Study Question:  Does patient positioning for intubation (supine vs BUHU -“bed-up, head-up”) affect odds of hypoxemia, aspiration, and esophageal intubation?
  • Study groups:  528 non operating room intubations randomized to BUHU or supine
  • Outcome measure:  Composite of difficult intubation / hypoxemia / esophageal intubation / aspiration
  • Results:  Composite endpoint met in 22.6% of supine patients and 9.3% of BUHU patients (OR 0.42)

Takeaway Pearl:  Placing patients in BUHU position reduced the odds of hypoxemia, aspiration, and esophageal intubation.

3.  Bhat et al: Analysis of RSI medication dosing in obese patients intubated in the ED.  Am J Emerg Med 2016.      

  •  Study Question: How do the rates of appropriate succinylcholine and etomidate doses in obese and nonobese patients compare?
  • Study groups:  Obese vs non obese patients getting rapid sequence intubation 
  • "Appropriate doses”  
    • Succinylcholine (dosage 1-1.5 mg/kg total body weight) and Etomidate (0.2-0.4 mg/kg total body weight)
  • 440 patients (71% non-obese, 29% obese)
  • Results: 
    • 56% of patients got inappropriate dose of succinylcholine (almost all in the obese group). 
      • Odds Ratio for underdosing succinylcholine was 63.7
      • Most got either 100 mg or 120 mg of succinylcholine
    • 24% got an inappropriate dose of etomidate (almost all in the obese group). 
      • OR for under dosing etomidate = 178.3
      • Most got 20 mg or 30 mg dose

Takeaway Pearl:  Dose your etomidate and succinylcholine according to total body weight (otherwise you are likely going to undershoot in the obese patient).

http://careritecenters.com/signature-programs/ventilator-care/

http://careritecenters.com/signature-programs/ventilator-care/

  • Study Question:  Does an "analgesia first" vs  a “sedative first” protocol in intubated patients differ in levels of sedation, duration of mechanical ventilation, length of stay in the ICU, and pain management (measured with RASS /CPOT)?
  • Retrospective before/after study in Dallas TX.
  • 65 pre-implementation (propofol first then narcotics / second sedative - versed or ativan) / 79 post-implementation patients (IV narcotics first / propofol second).
  • Outcomes:  Post implementation group had lighter levels of sedation, decreased duration of mechanical ventilation, decreased LOS in ICU, better pain management(measured with RASS /CPOT)

Takeaway Pearl:  Consider aggressive up-front analgesia in intubated patients to improve multiple patient oriented outcomes.

 

Written by Andrew Perron, MD, FACEP

Edited and Posted by Jeffrey A. Holmes, MD