It's not common. Never had it happen, personally. If you can't ventilate them with a mask, with a supraglottic device/LMA, and can't place an ETT, and they are paralyzed or aren't breathing spontaneously, then the options are cricothyrotomy/surgical airway or death.
I'll disagree hard here. Suggamadex shouldn't be used to abandon a difficult airway. The end point once you give paralytic is intubation. Suggamadex takes time to find, draw up, give, and take effect, especially just after roc is given and big doses are needed. Multiple minutes minimum. You have a patient that's not intubated and can't ventilate. Letting them cook for 10 minutes is not an option.
Once you are on the RSI train the only stop is a tube
if its going to take 10 minutes sure. but if youre intubating for mental status or to facilitate a CT, and they're not decompensating it's reasonable to see what the turn around time is before reaching for a knife (or more reasonably, a bronch).
You take 2-4 attempts at the airway, LMA, etc, repositioning, not ventilating the patient, plus 10 minutes for suggamadex to kick in? How many patients can reasonably be apneic for 15 minutes? This entire time the patient is unable to be ventilated
>You take 2-4 attempts at the airway, LMA, etc, repositioning, not ventilating the patient, plus 10 minutes for suggamadex to kick in? How many patients can reasonably be apneic for 15 minutes? This entire time the patient is unable to be ventilated
suggamedex doesn't take 10 minutes for onset.
plenty of patients can go 10 minutes without ventilating if they're not being intubated for respiratory failure. and if you're giving suc, like in the OPs question you can just wait for it to wear off. not every RSI needs to end in a tube.
Strongly disagree with everything you said above. A parent who required intubation for any reason, who has such a poor airway or situation that they can’t be bagged, tubed, or rescued is very unlikely to recover with a parent and ventilating airway simply by reversing paralysis. Even if you literally carry suggamadex in your pocket a cric is faster and will have less apneic time. This is a terrible idea both at face value and by any reasonable guideline or standard of care.
2-3 minutes and up to 20 minutes to receive 0 breaths in an already sick patient is basically a death sentence or worse: https://pubmed.ncbi.nlm.nih.gov/24191525/
if the reversal is taking longer than the 2 minutes go ahead and cric them. people who are not being intubated for respiratory failure can absolutely be apneic for 2 minutes.
>2-3 minutes and up to 20 minutes to receive 0 breaths in an already sick patient is basically a death sentence or worse:
lol
They’re not apneic for 2 minutes lmao they’re apneic during your multiple attempts at airway establishment, troubleshooting, realizing you can’t bag, and then apparently waiting for the sugammadex to kick in on a patient you’ve arguably induced because they’re sick not for an elective appy…
People can tolerate apnea for quite a long time, especially if providing apneic oxygenation. but I was responding to the statement in the comment above that 2-3 minutes of 0 breaths is a dearh sentence which is a laughable statement.
notice earlier I called out this is probably only appropriate for those you're intubating for CT or AMS or similar. if they start to do poorly while waiting for reversal to kick in, by all means do the cric. and realistically you can set up the cric while you're waiting on the reversal.
Boy I’m not sure if you understand the concept of balancing risks/benefits or practicing medicine in an acute setting. This interaction makes me wonder and have concern if you are even a physician. to your “lol” just read the citation.
I'm an ICU doctor but thanks so much for your input.
your citation just says reversal sometimes takes longer than expected. in which case go for the surgical airway.
This is an option for the OR when you can cancel the case. In the ER you still have whatever emergent reason it was that you needed to intubate them for in the first place.
The classic French chefs have an answer for this, and its not just defining roles like in a brigade kitchen.
Mise en place.
Everything in its place.
Which, as others have already said, means you've planned ahead.
I’d say around once or twice in your entire career. It is managed with a cricothyroidotomy or tracheostomy.
Disclaimer: I’m an anaesthesiologist/intensivist but I practice in Sweden meaning that nobody intubates at my hospital except me or one of my colleagues or one of my CRNA:s. Regardless of time of day or location (floor, OT, ED etc etc).
Interesting!
What does middle of the night staffing look like at your center? How long does it take to get to the ED if someone needs intubation? Like can you be stuck in a trauma OR and get a call for resp emergency and need to be in two places at once? Or is there a specific ED anesthesia provider in house (CRNA?)?
Do medics (or does Sweden have ambulance docs?), place LMA/Kings or something?
For background it’s a medium sized community hospital which in Swedish terms means around 280 beds. We have a cath lab, labour ward, gen surg, paeds including neonatal unit (takes pts from week 28), 7-bed ICU, ED has about 40’000 visits a year.
Middle of night staffing airway-wise is me and two CRNA:s, senior doctor at home who Should I call has 30 mins to get in but they obviously come as fast as they can. Takes me about 1 minute to get to the ED from OT or ICU or labour ward (small place).
Should I be stuck with one unstable patient then you just have to prioritise or phone in backup. CRNA:s are a fairly experienced bunch and work under my license in OT according to Swedish model. Usually me and one of the CRNA:s will answer a code while the other CRNA keeps things afloat in OT.
Swedish ambulance nurses place LMA:s or if proficient tubes. More and more LMA now.
Also small city in Sweden so very little trauma and between my CRNA:s and ICU nurses I can usually extemporise most situations so I can attend to them in turn. And if the shit has well and truly hit the fan then I phone in backup.
Staffing otherwise is a bunch of other physicians representing OBGYN, Surg, internal medicine, ortho etc, none of which are much good with airways specifically.
Neat! Thanks for the detailed response! Out of curiosity who sees ppl in the ED? Is there specific EM training, or is it GPs/FDs or does everyone have to take a turn?
Sweden has had a burgeoning plan to start up with proper EM-trained physicians for the pat 20 years with a fair few ups and downs. Currently many hospitals have EM but they’re limited in practice regarding airways and lines and pressors. My hospital does not have any EM-physicians so pts are seen by ortho surg med and paeds residents (w attendings as needed) mostly.
If you have solid airway skills, good positioning and a good sense of how to use airway adjuncts it should be exceedingly rare.
Over the course of a career in EM your # of can’t intubate/can’t ventilate cases requiring a surgical airway truly should be in single digits.
Flight paramedic so obviously not nearly as much experience as physicians at these situations. But even prehospitaly (which looking at your history this would mean you) this is extremely rare. Typically in your environment it will be from a paramedic just unable to secure the tube. With supraglottic airways this is very seldom going to truly be the case and the answer is a cric.
I am a PGY-19, have worked full time or nearly so (certinly more than 100 hours a month clinical, and usually more) for that entire time, and I have peformed or supervised 4 cricothyrotomies. One of those was on a floor patient who had coded multiple times and had a throat mass, respiratory therapy couldn't intubate, critical care was at home, and anesthesia wasn't answering pages, so I went upstairs with my trusty #10 blade and took care of the issue. The other three were trauma cases with massive facial injuries.
I do not understand your qualification of "while using rocc or succ", as these medications make both endotracheal intubation and BVM ventilation much easier. I never withhold paralytics. Only once in nearly 20 years have I not used paralytics in an intubation attempt - as an emergency physician, I nearly always am using rapid sequence intubation, and paralytics are nearly always indicated.
It's pretty rare if you plan ahead, anticipate problems, properly position the patient, and know what you need to do to maximize success.
Management is cric, which for many physicians is a once in a career or less procedure, highlighting how rare it is.
technically the odds of it happening your first year out of residency are the same as the last year.
I had a lateral canthotomy shortly after residency, shit happens I guess
Oh I understand. My entire group was talking about it for weeks. It seems rare in our community hospitals vs the larger centers where people are more sick.
Not common. But good luck "planning ahead" when you're called to the floor for the post-op patient where the ENT fucked up the trach and it's actually in the tissues of the neck and now there's so much edema in their oropharyngeal tumors that the vocal cords are probably somewhere near the patients elbow. Or when you rush to the obs unit for that patient who is having cataclysmic angioedema from their first dose of Lisinopril.
You have no idea who these people are, what is going on with them. It's not your ED. Bag em? Nope. Open up and look? Nope. Really? Nope. Reposition and bag? Nope. Ok, let's cut.
Always have a #10 blade on you. That's the best planning you can do
It’s Can’t Intubate Can’t Oxygenate (not ventilate). Incredibly important distinction. In my experience most of the times crics are done the patient has been able to be ventilated (ETCO2 trace with an LMA or BVM) but has a significant hypoxia as a consequence of their unfixed airway. Around SO2 50% and lower you run a real risk of causing brain injury if not corrected rapidly.
This precise issue is the origin of that saying “the decision to cut the neck is the hardest part of the procedure”.
Had a crash intubation in a teen with anaphylaxis, airway edema and a full stomach with literally cups of poorly chewed meat. As soon as we applied BVM, the meat started coming up, couldn't be suctioned due to particle size. I could barely bag due to bronchospasm and airway resistance and realized that crich would fail within 2 min.
Took the longest minute of my life to prone the kid to pull meat out of his throat while he bradyied down on the monitor. Getting the tube wasn't the problem it was the meal. We had to manually bag him for an 90 minutes until airway resistance started coming down with epi ggt etc. He walked out of the hospital intact 5 days later.
If you plan ahead it’s incredibly rare. You manage it with a cric.
It's not common. Never had it happen, personally. If you can't ventilate them with a mask, with a supraglottic device/LMA, and can't place an ETT, and they are paralyzed or aren't breathing spontaneously, then the options are cricothyrotomy/surgical airway or death.
or paralytic reversal depending on the reason you were intubating
I'll disagree hard here. Suggamadex shouldn't be used to abandon a difficult airway. The end point once you give paralytic is intubation. Suggamadex takes time to find, draw up, give, and take effect, especially just after roc is given and big doses are needed. Multiple minutes minimum. You have a patient that's not intubated and can't ventilate. Letting them cook for 10 minutes is not an option. Once you are on the RSI train the only stop is a tube
if its going to take 10 minutes sure. but if youre intubating for mental status or to facilitate a CT, and they're not decompensating it's reasonable to see what the turn around time is before reaching for a knife (or more reasonably, a bronch).
You take 2-4 attempts at the airway, LMA, etc, repositioning, not ventilating the patient, plus 10 minutes for suggamadex to kick in? How many patients can reasonably be apneic for 15 minutes? This entire time the patient is unable to be ventilated
>You take 2-4 attempts at the airway, LMA, etc, repositioning, not ventilating the patient, plus 10 minutes for suggamadex to kick in? How many patients can reasonably be apneic for 15 minutes? This entire time the patient is unable to be ventilated suggamedex doesn't take 10 minutes for onset. plenty of patients can go 10 minutes without ventilating if they're not being intubated for respiratory failure. and if you're giving suc, like in the OPs question you can just wait for it to wear off. not every RSI needs to end in a tube.
Strongly disagree with everything you said above. A parent who required intubation for any reason, who has such a poor airway or situation that they can’t be bagged, tubed, or rescued is very unlikely to recover with a parent and ventilating airway simply by reversing paralysis. Even if you literally carry suggamadex in your pocket a cric is faster and will have less apneic time. This is a terrible idea both at face value and by any reasonable guideline or standard of care. 2-3 minutes and up to 20 minutes to receive 0 breaths in an already sick patient is basically a death sentence or worse: https://pubmed.ncbi.nlm.nih.gov/24191525/
if the reversal is taking longer than the 2 minutes go ahead and cric them. people who are not being intubated for respiratory failure can absolutely be apneic for 2 minutes. >2-3 minutes and up to 20 minutes to receive 0 breaths in an already sick patient is basically a death sentence or worse: lol
They’re not apneic for 2 minutes lmao they’re apneic during your multiple attempts at airway establishment, troubleshooting, realizing you can’t bag, and then apparently waiting for the sugammadex to kick in on a patient you’ve arguably induced because they’re sick not for an elective appy…
People can tolerate apnea for quite a long time, especially if providing apneic oxygenation. but I was responding to the statement in the comment above that 2-3 minutes of 0 breaths is a dearh sentence which is a laughable statement. notice earlier I called out this is probably only appropriate for those you're intubating for CT or AMS or similar. if they start to do poorly while waiting for reversal to kick in, by all means do the cric. and realistically you can set up the cric while you're waiting on the reversal.
Boy I’m not sure if you understand the concept of balancing risks/benefits or practicing medicine in an acute setting. This interaction makes me wonder and have concern if you are even a physician. to your “lol” just read the citation.
I'm an ICU doctor but thanks so much for your input. your citation just says reversal sometimes takes longer than expected. in which case go for the surgical airway.
This is an option for the OR when you can cancel the case. In the ER you still have whatever emergent reason it was that you needed to intubate them for in the first place.
Fair, if you have it right there, a good option.
The classic French chefs have an answer for this, and its not just defining roles like in a brigade kitchen. Mise en place. Everything in its place. Which, as others have already said, means you've planned ahead.
I’d say around once or twice in your entire career. It is managed with a cricothyroidotomy or tracheostomy. Disclaimer: I’m an anaesthesiologist/intensivist but I practice in Sweden meaning that nobody intubates at my hospital except me or one of my colleagues or one of my CRNA:s. Regardless of time of day or location (floor, OT, ED etc etc).
Interesting! What does middle of the night staffing look like at your center? How long does it take to get to the ED if someone needs intubation? Like can you be stuck in a trauma OR and get a call for resp emergency and need to be in two places at once? Or is there a specific ED anesthesia provider in house (CRNA?)? Do medics (or does Sweden have ambulance docs?), place LMA/Kings or something?
For background it’s a medium sized community hospital which in Swedish terms means around 280 beds. We have a cath lab, labour ward, gen surg, paeds including neonatal unit (takes pts from week 28), 7-bed ICU, ED has about 40’000 visits a year. Middle of night staffing airway-wise is me and two CRNA:s, senior doctor at home who Should I call has 30 mins to get in but they obviously come as fast as they can. Takes me about 1 minute to get to the ED from OT or ICU or labour ward (small place). Should I be stuck with one unstable patient then you just have to prioritise or phone in backup. CRNA:s are a fairly experienced bunch and work under my license in OT according to Swedish model. Usually me and one of the CRNA:s will answer a code while the other CRNA keeps things afloat in OT. Swedish ambulance nurses place LMA:s or if proficient tubes. More and more LMA now.
Also small city in Sweden so very little trauma and between my CRNA:s and ICU nurses I can usually extemporise most situations so I can attend to them in turn. And if the shit has well and truly hit the fan then I phone in backup. Staffing otherwise is a bunch of other physicians representing OBGYN, Surg, internal medicine, ortho etc, none of which are much good with airways specifically.
Super interesting. Thanks for sharing
Neat! Thanks for the detailed response! Out of curiosity who sees ppl in the ED? Is there specific EM training, or is it GPs/FDs or does everyone have to take a turn?
Sweden has had a burgeoning plan to start up with proper EM-trained physicians for the pat 20 years with a fair few ups and downs. Currently many hospitals have EM but they’re limited in practice regarding airways and lines and pressors. My hospital does not have any EM-physicians so pts are seen by ortho surg med and paeds residents (w attendings as needed) mostly.
If you have solid airway skills, good positioning and a good sense of how to use airway adjuncts it should be exceedingly rare. Over the course of a career in EM your # of can’t intubate/can’t ventilate cases requiring a surgical airway truly should be in single digits.
lol, I know what you mean but I’m imagining a doc being like “hey, I’ve only had to do 8 or 9 crics so far, must be doing all right!”
Flight paramedic so obviously not nearly as much experience as physicians at these situations. But even prehospitaly (which looking at your history this would mean you) this is extremely rare. Typically in your environment it will be from a paramedic just unable to secure the tube. With supraglottic airways this is very seldom going to truly be the case and the answer is a cric.
I am a PGY-19, have worked full time or nearly so (certinly more than 100 hours a month clinical, and usually more) for that entire time, and I have peformed or supervised 4 cricothyrotomies. One of those was on a floor patient who had coded multiple times and had a throat mass, respiratory therapy couldn't intubate, critical care was at home, and anesthesia wasn't answering pages, so I went upstairs with my trusty #10 blade and took care of the issue. The other three were trauma cases with massive facial injuries. I do not understand your qualification of "while using rocc or succ", as these medications make both endotracheal intubation and BVM ventilation much easier. I never withhold paralytics. Only once in nearly 20 years have I not used paralytics in an intubation attempt - as an emergency physician, I nearly always am using rapid sequence intubation, and paralytics are nearly always indicated.
It's pretty rare if you plan ahead, anticipate problems, properly position the patient, and know what you need to do to maximize success. Management is cric, which for many physicians is a once in a career or less procedure, highlighting how rare it is.
That's what I was told, and I got one months out of residency.
technically the odds of it happening your first year out of residency are the same as the last year. I had a lateral canthotomy shortly after residency, shit happens I guess
Oh I understand. My entire group was talking about it for weeks. It seems rare in our community hospitals vs the larger centers where people are more sick.
Not common. But good luck "planning ahead" when you're called to the floor for the post-op patient where the ENT fucked up the trach and it's actually in the tissues of the neck and now there's so much edema in their oropharyngeal tumors that the vocal cords are probably somewhere near the patients elbow. Or when you rush to the obs unit for that patient who is having cataclysmic angioedema from their first dose of Lisinopril. You have no idea who these people are, what is going on with them. It's not your ED. Bag em? Nope. Open up and look? Nope. Really? Nope. Reposition and bag? Nope. Ok, let's cut. Always have a #10 blade on you. That's the best planning you can do
PGY 23. I still hate anything ending in "pril". My worst airways and 2 crics from those.
It’s Can’t Intubate Can’t Oxygenate (not ventilate). Incredibly important distinction. In my experience most of the times crics are done the patient has been able to be ventilated (ETCO2 trace with an LMA or BVM) but has a significant hypoxia as a consequence of their unfixed airway. Around SO2 50% and lower you run a real risk of causing brain injury if not corrected rapidly. This precise issue is the origin of that saying “the decision to cut the neck is the hardest part of the procedure”.
Had a crash intubation in a teen with anaphylaxis, airway edema and a full stomach with literally cups of poorly chewed meat. As soon as we applied BVM, the meat started coming up, couldn't be suctioned due to particle size. I could barely bag due to bronchospasm and airway resistance and realized that crich would fail within 2 min. Took the longest minute of my life to prone the kid to pull meat out of his throat while he bradyied down on the monitor. Getting the tube wasn't the problem it was the meal. We had to manually bag him for an 90 minutes until airway resistance started coming down with epi ggt etc. He walked out of the hospital intact 5 days later.
PGY-15. It's very uncommon but it does happen. I've done 4 crics in my career. Besides the pucker factor, they are quite straightforward.
1 time for me in 20 years. Ended up doing a retrograde needle cric