Emergency Intubation: Non-COVID Patient

OK, so Mr. Jones, as we’ve explained, we’re going to need to get you off to sleep now, OK? I was just wondering if you could answer a couple of questions that I’ve got. Have you had an anaesthetic before? No. You’ve not had an anaesthetic before. As far as you’re aware, no problems that run in the family with anaesthetics? No. Good, OK. Can you open your mouth as wide as you can for me? Great. That looks great. OK, so nice and normal. Have you got any caps, crowns, loose or wobbly teeth?

No. OK, you don’t. OK, that’s great. Have you– you don’t have any problems with reflux? No, OK. That’s great. Fantastic. OK, so there’s going to be a few people come in. OK? And that’s just so we can keep you nice and safe once we get you off to sleep, OK? All right. OK. We’ll just– at the moment, we’ll just be setting up. And in a few minutes, we’ll just drift you gently off to sleep, OK?

Grand. OK, so the team we’ve got– I feel breathless. You feel breathless. So what we’re going to did is get you off to sleep, and then we’re getting support to the ventilator, OK?

So this is Rachel. She’s another one of the doctors in the intensive care unit. Hello. I’m one of your doctors. This is also Rachel. She’s one of our advanced nursing practitioners here. And then Jane’s also here to help as well, OK? So there’ll be a lot of equipment and things. We’ll just be talking a lot, but it’s just getting everything ready to make sure that you’re nice and safe once we do this, OK? All right. OK, grand. OK. So can we bring the airway trolley in, is that OK? Fantastic. And do we have a checklist there? Yeah, we have a checklist. Great. Would you mind– I wouldn’t say that.

OK, so if you could do the checklist away, that would be great. OK, fine. So preparing the patient. Have we IV access? So we’ve got two intravenous accesses, and we’ve got fluids running through one. Optimised positions are sit up on a hard mattress. So we’ve got our Oxford help pillow in to help optimise the position and– are you comfortable enough there? Are you fine? It looks like he’s in a nice position there for him to go off to sleep. Airway assessments identified. So we’ll just have a a little feel of your neck here. Yes, so his cricothyroid membrane is easily felt. Perfect. And awake intubation option? No. And so optimal pre-oxygenation?

So at the moment, what we’re doing is we’re pre-oxygenating with our high flow nasal oxygen, 70 litre flow on 100%. And as he goes off to sleep, we’ll just check. We’ll take over oxygenation with the c - circuit.

Optimised patient states with fluids, pressors, inotropes. So we’ve got drugs there. Yes, I have some adrenaline, and I’ve got some ephedrine, metaraminol as uppers. Great. And we’ve got fluid bolus should we require it as well. Does he have an NG tube in? He doesn’t have one in. And delayed sequence induction? No. Any allergies? You don’t have any allergies, do you? No, great. And then monitoring. So sats, end-tidal waveform, ECG, and blood pressure. So we have sats. Yep. We have an end-tidal that we’ve checked– I have checked prior to this, and it’s working. It’s just not attached to implement. Can we check that blood pressure is cycling every minute?

Perfect, that’s great. OK. And we’ve got two tracheal tube cuffs checked? What size would you like? So he is quite a big guy, if we get a size 9 tube out, and we’ll have a size 8 available. OK. And then two laryngoscopes and a video laryngoscope. Would you like me to check this one? Yeah, that’d be great actually. So you’ve got in a video laryngoscope. And we’ve got plenty of battery. And we’ve also got normal laryngoscope Which size would you like? A mac 4 would be good.

And there’s a bougie and a stylet on the side. Yeah. We have a bougie. And working suction? Yes, the suction is here. Somebody is tell me when it is set to max. And we’ve got supraglottic airways? A guedel and nasal airways. Yep, indeed. And what size supraglotic airway are you going to need? If we have a size 4 i-gel that would be great. OK.

There should be a flexible scope and aintree catheter. Yes, we do. Yes. And front of neck. Yes. Yes. So if you’re going to do front of neck access, it would be scalpel, bougie and a size six tube. So drugs? Yeah. So Rachel are you happy for the drugs for this? Yes. So we’ll just confirm doses. And I have fentanyl, 100 mics. 100 mics,. Yep. And I’ve got thiopentone. Yep. We need to go 50 mils. Yeah, so 375 that will do. And suxamethonium 100mg. Yes. If we need it we can give some metaraminol or ephedrine to support the blood pressure as well.

So allocating roles . So you need a team leader. So at the moment, I’ll be the team leader. And I’ll also be the first intubator. Perfect. Rachel, you’re happy to do the drugs? Drugs, yeah. Jane, you’re happy to be the airway assistant? Yeah, that’s right. And Rachel, are you happy to do cricoid pressure? Absolutely. And then we need monitoring patient. Yeah. And would you mind, Rachel, monitoring the patient, and if we need to give him something to support the blood pressure. And from a runner point of view, if we’ve taken cricoid pressure off, I’d like you to go and ask for help.

Otherwise, Jane if we are at a point in which we need help with cricoid pressure still on, could you go and get help for us? That’s fine. And front of neck access So in the situation that we’re unable to oxygenate the patient, I will come around the front of the bed and will do front of neck access. If we can’t oxygenate the patient, we’ll move fast and call for help. And who do we call for help? The next one.

So when we go through our airway plan, if we’re at a point in which we are unable to oxygenate, and the stats at any point get bellow 90% and are not rising, even if I don’t ask for help, I would like someone to go get me some. So go and pick up the phone, dial 2222, and say that there’s an airway emergency in Ward 116D. And I’m noting the time .

So preparing for difficulty. Can we wake the patient if intubation fails? No So verbalise early Yeah, so our airway plan, our Plan A is going to be a Mac 4 blade with or without a bougie and a size 9 tube. Our plan B would be secondary oxygenation. So that would be initially through a superglottic airway . “patient speaks” We’re just going through the plan. So our plan– again, Plan A, Mac 4 blade with or without a bougie. Plan B would be a size 4 i-gel Plan C would be reverting to face mask ventilation with or without an oropharyngeal airway And then, at that point, we would ask for help. Is everybody happy with that plan?

Does anyone think there’s anything else that we haven’t got or haven’t covered? Would you prefer a tie or tape to secure the ET tube?

A tie is absolutely fine. The thing I forgot to say Rachel was if I ask you to take the cricoid off, just take it off straight away. All right. So we’re just going to start getting everything ready, start gently drifting you off to sleep. OK? Yeah. So let me know when you’re happy. I’m just going to pop this little oxygen mask on your face. Take couple of nice, deep breaths for me. And breathe. That’s great. Is everybody happy? Great. We can start now.

Let me feel your neck.

How are we doing there? How are you doing? Are you warm enough there? Are you warm enough?

Are you warm enough?

All right.

How are you doing?

So he’s off to sleep. Great. We can get the Sux .

Perfect. Lovely. And if you could just circle that blood pressure now, that would be great. All right.

I’m just going to check to see if he is face mask ventilating. And I can, which is good.

Does that need to be set ? Yeah.

Lovely. Let’s have a look. Thank you.

Got a grade one view. Thank you.

Great. Pop the cuff up for me?

Let’s just confirm those things. Are you happy with the blood pressure. Good. Would you mind having a listen for me? We’ve got end tidal CO2. A quick listen. Can you hear that Jane?

Yeah. Good air entry?

Yeah, good breath sounds. Great. Lovely. Cricoid can come off. Let’s secure the tube. Can you cycle the that blood pressure again? Sorry. [ Great. So we can– do you mind giving him a little bit of..

Mm-hmm. How do you want the ventilator set? 100%? 100% oxygen.

So if we do , unfixed ventilation for him would probably be about 420, 8 breaths a minute. And if we set up a PEEP of 8 that would be lovely.

Great. And you’re giving a bit more Lovely And that fluids running in through the– Yeah. Great.

Lovely. OK. So we can connect up to the ventilator. And we’ll– we’ve got some ongoing sedation ready as well.

There we go. Shall I connect up the propofol as well? Yeah, that would be great. And let’s just double check. Chest moving.

And we are ventilating. We are indeed. Perfect