Don't just do something – stand there.
nice summary seth. I especially like the section on what to do if your awake intubation doesn't give you an adequate view; the most important point is to plan for this scenario. the view advantage paralysis offers is diminished with video. it's still there, but, especially with a hyperangulated blade, we see just about everyone's glottis these days, paralyzed or not. the RSI vs. awake decision in my opinion should be based on urgency (I agree you don't need a lot of time, but you need some time for awake) and likelihood of vomiting. patients at high risk to vomit (have been vomiting, UGIB, bowel obstruction) should probably be paralyzed in almost every case.lastly - if you have to apply brutane, you have to apply brutante, but you are better off in almost every case using more ketamine instead. dissociated patients require no restraint. agree re: small dose propofol for hypertonicity. nice jobreuben
Reuben: as always, thanks for your insightful comments. I agree that using a hyperangulated VL decreases the disadvantage of not paralyzing, but there is still a gap, and there is still the VL problem of seeing the cords you cannot deliver to -- as highlighted by my case discussed with Minh (http://prehospitalmed.com/2013/12/08/pharm-podcast-84-awake-intubation-with-seth-trueger/) -- of course the breathing patient with HFNC will often give you plenty of time to get the bougie in. I will of course repeat Minh's great point that UGIB, blood & other fluids coating the airway make topicalization more difficult as well. Re: brutane. The point is not to hold the patient down while you secure the airway, but rather to have a minion ready to grab the patient's hands if they start reaching for the tube -- to buy time to give more K (or other sedative).
nice work mate!a few suggestions!It seems a bit contradictory to say sedative only intubation is no good but essentially what you describe is sedative based intubation albeit using topicalisation! As we all know its not uncommon for topicalistion to be incomplete as even you admit! in that case then is it not a sedative dependent /assisted intubation?I think this is why you have the impression that it doesnt take a lot of extra time to do "awake" intubation. Cause in fact you are heavily relying upon the ketamine etc to assist the procedure!As for definition of RSI..you take that from Walls book and I accept the latest edition advises against using cricoid pressure. That is still though technically not the internationally accepted definition of RSI. The British still define it as involving cricoid pressure, and this is clear recommendation from the NAP4 project.I agree with Reuben about the urgency of the situation dictates your strategy and in my opinion it is not entirely accurate to say that "awake" intubation with topicalisation can be used in the urgent group cause it only adds a few minutes to the procedure.Nice summary of DSI at the end and I look forward to your next publication on it!
Minh-As always, your feedback is appreciated.Re: namingI’m not sure where the naming scheme I use came from (most likely Walls course) but sedative + topicalization = awake, whereas sedative without anything else = sedative only. Knowing that we may not get a perfect topicalization is more about managing the logistics than anything else.Walls & Strayer both talk a lot about the spectrum & balance of how much sedative (or ketamine) you need vs topicalization — if you were to intubate me awake right now, we could probably get by with no topicalization. A sick ED patient likely needs lots of sedative and just a touch of lido. Patients we intubate in the ED are rarely healthy enough to get by without any sedative.Re: RSI definition & CP:You’re losing the forest for the trees. The main tenets of RSI = simultaneous sedative + paralytic. Preoxygenation is necessary to do so safely. The rest is details. Compare: I might define an automobile is an engine driven vehicle that can transport adults on major roads. Whether the steering wheel is on the left or the right is a technical detail.re: “I agree with Reuben about the urgency of the situation dictates your strategy and in my opinion it is not entirely accurate to say that "awake" intubation with topicalisation can be used in the urgent group cause it only adds a few minutes to the procedure.”This entirely depends on your familiarity and comfort with the procedure and the available tools. I contend that the awake intubation technique described by Weingart (see his early podcasts) nearly any ED doc can do so in most — if not any — sick ED patient, while adding minimal time. And, in fact, I have done so on a number of occasions.“Nice summary of DSI at the end and I look forward to your next publication on it!” — thanks!