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For all procedures, ask yourself, 'does this need to be done 'now vs later'? And should this be done by 'me vs someone else?' Very often the answers will be 'now' and 'me' - so read on!

Delayed/Rapid Sequence Intubation

Description

Urgent/emergent intubation in the non-cardiac arrest patient.

Indications

There are many indications to intubate. The following are some examples:
-Respiratory failure eg severe COPD, CCF in patients for whom non-invasive ventilation (BiPAP, CPAP) is not appropriate or not effective.
-Airway protection eg. obtunded patient unable to protect their own airway.
-Neuroprotection - head injury, reduce cerebral metabolism
-Transport - protecting an airway for transport.

Contraindications

There are potentially many contraindications. The following are the common examples. Pros and cons / risks and benefits should be weighed.
-Patient who is haemodynamically unstable in whom we need to do more work to optimize their physiology beforehand. If still unstable - consider 'awake intubation'.
-Allergy to planned medications.
-Predicted difficult airway (=relative contradindication). Consider doing 'awake intubation'
-Inadequate number of personnel present (=relative contraindication)

Equipment / Preparation

The CARE Course cards and checklists - linked in this section.

• predicting difficult laryngoscopy, BVM ventilation, rescue device, surgical airway
• 'set up' checklist - 3 trays, final check through to sterile cockpit - and all the equipment listed on that checklist
• medication card
• procedure card
• push dose pressor - drawn up
• maintenance of anaesthesia - infusion

Procedure

Review cards for predicting difficult airway (laryngoscopy, BVM ventilation, rescue device, surgical airway)

Review the steps of the procedure - on this card

Consider whether an awake 'look' / awake intubation might be preferable (difficult airway anatomically or physiologically 'very shocked' patent who might be better continuing to breathe on their own, thus preserving their preload)

Optimize patient's physiology: BP/ volume , oxygenation

Use the cards linked above to take you through the procedure

Potential pitfalls

Rushing
Not optimizing patients physiology prior to intubation - BP/volume, oxygenation
Intubating the acidotic, tachypnoeic patient and then not being able to ventilate them as well as they were ventilating on their own - resulting in increased acidosis
Not considering awake intubation
Not using the checklists and getting the room quiet and into "sterile cockpit' prior to pushing the drugs

"Plan B"

Rescue airway device / BVM or emergency cricothyroidotomy.

Re-attempt endotracheal intubation - improve patient position, bigger blade, video laryngoscopy

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