Let's review an intubation together - a ๐งต
A previously well patient in her 60's presents with a first seizure & post-ictal coma
A nasopharyngeal airway has been placed for airway patency
She weighs 100kg
She receives 70mg propofol /100mg rocuronium after checklist completion, pre-ox & application of nasal cannula O2
A nasopharyngeal airway has been placed for airway patency
She weighs 100kg
She receives 70mg propofol /100mg rocuronium after checklist completion, pre-ox & application of nasal cannula O2
This video shows what a nasopharygeal airway looks like, and how far it can go down
It was removed during laryngoscopy- not sure why. Consider leaving it in in case you need it to support facemask ventilation if laryngoscopy is unsuccessful
It was removed during laryngoscopy- not sure why. Consider leaving it in in case you need it to support facemask ventilation if laryngoscopy is unsuccessful
You can see a haematoma on the tongue, which might have been caused from biting during the seizure
There is a beautiful view of the larynx thanks to an inadvertent epiglottic lift. This is why this is sometimes done as a manouevre to improve your view.
However the laryngoscopist, presumably wanting to do it 'properly', moves the tip of the blade to the vallecula
However the laryngoscopist, presumably wanting to do it 'properly', moves the tip of the blade to the vallecula
The most concerning thing many of you will have noticed is that the patient is swallowing
1mg/kg of rocuronium is not a sufficient dose for timely paralysis in emergency airway management in some patients when you consider inaccuracy of weight estimation...
1mg/kg of rocuronium is not a sufficient dose for timely paralysis in emergency airway management in some patients when you consider inaccuracy of weight estimation...
...& use of a single induction agent
Intubation doses of rocuronium (1.2 mg/kg) have been validated in OR settings using multiple co-induction drugs that will contribute to airway relaxation
For rapid neuromuscular block in prehospital & ED patients our local services use 2mg/kg
Intubation doses of rocuronium (1.2 mg/kg) have been validated in OR settings using multiple co-induction drugs that will contribute to airway relaxation
For rapid neuromuscular block in prehospital & ED patients our local services use 2mg/kg
Despite this the patient is intubated uneventfully over a bougie. Note the 90 degree anticlockwise rotation of the tube to avoid hang-up of the beveled edge of the tube on the right arytenoid cartilage - a common issue with bougies and many types of ETT
The whole intubation feels very long to experienced operators. This was a trainee laryngoscopist who took about 55 seconds to intubate. I don't know who was coaching them.
However with apneic oxygenation via nasal cannuale there was no desaturation
However with apneic oxygenation via nasal cannuale there was no desaturation
It was from 3 years ago and captured by ED airway audit. By sharing the video and learning points, we could educate the whole team on preferred rocuronium dosing.
We haven't had a video of someone swallowing since
We haven't had a video of someone swallowing since
I hope this was useful to learners
This isn't a 'how to intubate' ๐งต
It's a 'what can we learn?' ๐งต
No doubt there will be a barrage of different opinions which is fine. Feel free to share your tips/experience
End of ๐งต
This isn't a 'how to intubate' ๐งต
It's a 'what can we learn?' ๐งต
No doubt there will be a barrage of different opinions which is fine. Feel free to share your tips/experience
End of ๐งต
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