The main purpose of patient assessment is to identify features of the patients anatomy, physiology or pathology that will require you to deviate from the standard RSI approach. This requires a step beyond a basic ‘airway assessment’ to make a plan to suit THIS patient and the resources available.
Airway management is dangerous. This is particularly true of emergency airway management in the ED or ICU. Our environment is often uncontrolled and our patients often have hemodynamic or respiratory compromise which significantly increases the risk of intubation. Moreover, although many tools exist to help predict a difficult airway, none are perfect and as such a difficult airway may present without warning. For these reasons we need to approach EVERY airway as a potentially difficult airway and articulate a clear plan for failed intubation and failed oxygenation.
What do I mean when I talk about preparing myself for a resuscitation. There are the obvious things, I put on my gloves and other protective equipment but more importantly I prepare myself mentally to respond to the challenge.
The key to safe and effective airway management is appropriate preparation.
I use the following format to remember the key aspects of preparation for intubation. This format works for any procedure from draining an abscess to putting a patient on ECMO.
- Self – protective equipment
- Staff – delegate roles
- Patient – consent, position etc
- Equipment – includes drugs
- Department – who will take care of other patients while you are doing procedure
- Prepare for failure – plans B & C
I thought we could start with an Airway case because there have been so many new developments in airway management over the last 2 years or so.
This 42 year old man is brought into your resuscitation room by ambulance with worsening shortness of breath and confusion.
Bariatric Times. 2012;9(6):18–19
His vital signs are as follows:
HR 128, BP 90/50, RR 36, Sats 89% on non-rebreather, Temp 38.9
He is agitated and keeps pulling off his non-rebreather mask leading to rapid desaturation.
Describe your approach to oxygenation and airway management for this patient.
Leave your thoughts in the comments section along with links to useful resources and references you may find. Over the course of the week we will collect, combine and curate resources that shed light on this difficult case.
I look forward to your thoughts