Airway - Emergency Department Advanced Airway Guideline

The indications for RSI are well described. In most instances aggressive and timely management of medical emergencies is appropriate, however maximal therapy may not always be in the best interests of the patient. Discussions on whether to limit care are complicated and should be based either on the wishes of the individual, or when the consultant responsible for a patient's care believes that specific interventions are not of clinical benefit. These discussions and the decision-making process around them are at their most difficult in the emergency setting. Early involvement of senior clinicians from emergency medicine, anaesthetics and critical care will increase the time and capacity available to formulate an appropriate escalation plan. Plans and limits should be carefully documented on Trak and conveyed where appropriate to the patient and family.

• It is the responsibility of the ED team leader to ensure that the right skill mix is present prior to embarking on RSI.
  
  
• If RSI is anticipated contact the senior emergency anaesthetist (Bleep 2200). This will usually be a consultant apart from Friday, Saturday and Sunday nights. If the 2200 bleep holder is unavailable to attend they may nominate another anaesthetist.
  
  
• An airway emergency can be declared by calling 2222 and asking for an "Adult Anaesthetist only for Royal Infirmary Emergency Department". This will activate: 2140 (CT1/2), 1669 (Cardiothoracic ST3+), 2200 (senior on site anaesthetist), 1719 (CEPOD ODP) and 2118 (CEPOD theatre co-ordinator).
  
  
• If clinical judgment demands RSI prior to anaesthetic review, the EP (ST3+) will proceed only if they have suitable assistance, skills and experience.
  
  
• When the anaesthetist arrives, they should discuss the management plan with the senior EP; this should include an agreed airway management plan (including role allocation and drug choice).
  
  
• After an airway plan is agreed the anaesthetist will generally remain in reserve (intubator 2) while the EP (ST3+) proceeds with RSI.
  
  
• If difficulty is anticipated by either of the intubators or team leader, a change of operator may be appropriate.
  
  
• An anaesthetist will manage the airway in cases of major trauma. If the anaesthetist determines they should manage the airway for any other reason this should be communicated to the ED team leader prior to starting the pre-induction checklist.
  
  
• The pre-induction checklist should be completed for every RSI. It is designed as a “challenge and response” checklist where one person reads the items aloud and a second person responds after a visual crosscheck, where applicable; for example, equipment, patient positioning, or monitoring. Part 1 is designed to be completed by the intubator and assistant, part 2 should be completed by the team leader and include all members of the team. If interrupted the checklist section that was interrupted should be re-started.
  
  
• The Resus room checklists are bound together with a metal ring and hang on a hook above the airway trolleys.

Responsibilities

• Emergency Medicine are in overall charge of patient care in the ED. Generally, responsibility will pass from them to Anaesthesia/Critical Care at the point of transfer.
  
  
• If a patient requires emergent surgery the ED team leader should discuss with the receiving specialty and relevant CEPOD anaesthetist (note this may not always be the attending anaesthetist).
  
  
• Multiple handovers can lead to loss of information. SBAR (Situation Background Assessment Recommendation) may be a useful format to guide hand over / updates between clinical teams.

Critical / onward care

• Airway support will usually be provided by the on-call anaesthetist. Onward care for patients post RSI is usually guided or provided by critical care. Early liaison will assist both with clinical management in the ED and expedite discharge from the ED.
  
  
• Not all intensivists are anaesthetists. Be aware that they may not have the airway skills to act in a supervisory role.

• Communication is key to successful management of stressful and difficult situations. 
  
  
• While urgent, few RSIs are required immediately.
  
  
• There will be a range of experience in the team. This should be utilised to deliver safe, patient focused care.
  
  
• Stay calm, optimise what you can and have a structured plan for management if unsuccessful. 

• Resuscitation room nurses are competent in providing cricoid pressure and many are experienced in assisting with intubation.
  
  
• Operating Department Practitioners should routinely attend ED RSI if available. They may either act to support competent nursing staff or take a more active role in cases of anticipated or encountered difficulty.

If difficulty is anticipated there are several potential courses of action:

• Maintain oxygenation and ventilation via other means (e.g. basic manoeuvres / adjuncts)
  
  
• Call for additional anaesthetist / ODP / EP / surgical help
  
  
• Summon the difficult airway trolley from theatres
  
  
• Move the patient to an operating theatre (consider the risks of transfer)
  
  

If an unanticipated difficult airway is encountered, the Difficult Airway Society (DAS) algorithm (on the front of the airway trolley) should be the default approach to management.

Optimising 1st Pass Success and Preparing for difficulty - “make the first attempt your best attempt”

• Positioning should be optimised for all patients. ‘Oxford HELP’ wedges (resus cupboard) and head rests (airway trolley) are available and should be used to achieve optimal head and neck positioning when the neck is not at risk. The ramped position has been shown not only to improve laryngeal exposure, but will increase FRC and extend safe apnoea time.
  
  
• McGrath video laryngoscopes(VL) are available in every airway trolley in the ED for use by individuals who are trained and comfortable to do so. Increasingly the use of VL is becoming the first line for laryngoscopy. If used the McGrath should accompany the patient to their final destination and then be immediately returned to the ED for cleaning. Return and cleaning of the McGrath after use is the responsibility of the operator.
  
  
• McGrath X blade (size 4) are available on the anaesthetic trolley for use if a hyper angulated blade is required. The use of a pre-formed silk stylet is recommended to manipulate the ETT anteriorly.
  
  
• Consider routine use of a gum elastic bougie.
  
  
• Gentle ventilation prior to intubation is safe. Patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation (2). Consider early use of OPA to limit gastric insufflation.
  
  
• NO DESAT (“nasal oxygen during efforts to secure a tube”): simple nasal cannula with 10l/min O2 can be administered beneath the facemask during preoxygenation and remain in place during BMV and laryngoscopy. Even low flow nasal O2 has been shown to extend safe apnoea time and does not require specialist equipment (3). This technique may however interfere with achieving a good mask seal.
  
  
• The Optiflow (and associated ancillaries) can be borrowed from theatres if High Flow Nasal Oxygen (HFNO) is required.
  
  
• In the event of difficult view at laryngoscopy consider early release, adjustment (BURP) and removal of cricoid pressure: this can often transform a difficult view into an easy one.
  
  
• Post-intubation checks should include careful cuff inflation and careful securing of the ETT.
  
  
• Front of neck access (FONA): In the event of a failed airway requiring FONA proceed as per DAS guidelines – scalpel/bougie/tube – using the VBM ScalpelCric kit in drawer D of the airway trolley.
  
  
• Awake Tracheal intubation is possible in the emergency department, however it should be recognised that this technique is uncommonly performed and requires an experienced skill mix (airway operator, airway assistant, sedation operator) and equipment that may be stored in the theatre complex and infrequently used in the ED. The patient with an emergency difficult airway poses additional challenges to that encountered electively, including:
  • lack of preparatory time;
  • unfamiliar location / equipment / drugs / fewer staff;
  • likely reduced physiological patient reserve;
  • concurrent emergency process that may or may not be related to airway;
  • and, likely increased patient anxiety.
  
  Careful consideration must be given to the appropriateness of this intervention, depending on the patient, presentation and time of day. A decision should be made as to whether performing this intervention in resus is safer or more appropriate than transferring the patient to theatre. Bail out plans must be discussed and help called early. An aide memoir can be accessed here or on the difficult airway trolley kept outside CEPOD.
  
  
• Delayed Sequence Induction: certain circumstances may require a more tailored or delayed approach to allow safe induction (e.g. to optimise oxygenation or cardiovascular status). This technique is usually achieved by administering aliquots of Ketamine to gain safe control of the clinical scenario. Regardless of technique oxygen delivery must be prioritised.

Capnography is mandatory for all intubations and should be used to confirm correct tube placement. All four of the Project for Universal Management of Airways (PUMA) criteria (Figure 1) must be met:

1. The level of CO₂ rises and falls appropriately with exhalation and inhalation.
   
   
2. There is consistent or increasing amplitude of the capnogram over 7 breaths.
   
   
3. The peak amplitude of CO₂ is >1 kPa above the baseline.
   
   
4. The capnography trace is clinically appropriate. Remember, even in low cardiac output states and cardiac arrest, there will still be an attenuated capnography trace (Figure 2).

Post-intubation checks should include careful cuff inflation and careful securing of the ETT.

The AAGBI Quick Reference Handbook (QRH) is available in resus.

Personal Protective Equipment (PPE)

• RSI and non-invasive ventilation are aerosol generating procedures (AGP). Where pathogens spread via the droplet/airborne route are suspected consider using aerosol PPE (FFP3 mask, full body fluid repellent gown and visor) as per ED PPE guidelines. In practice this includes respiratory symptoms, suspected CNS infection, and fever in returning traveller.
  
  
• For fever in the returning traveller please review specific guideline for HCID (High Consequence Infectious Disease) risk assessment. Additional precautions may be required.
• Recommendations for specific pathogens can be found in the National Infection Prevention and Control Manual Appendix 11.
• Consider using a visor if the airway is contaminated with blood.

Airway trolley/equipment

• In order to avoid contamination, airway equipment should not be opened prior to use.
  
  
• Avoid placing any loose parts such as IV giving set caps, transparent backing of ECG stickers etc on top of the airway trolley as this poses a risk of foreign body aspiration.
  
  
• Tubing from portable ventilators should be covered with the manufacturer's cap when not in use.

   

Suction Above Cuff Endotracheal Tube (SACETT)

• SACETT reduce the risk of ventilator-associated pneumonia and should be used for all patients being intubated in the ED.
  
  
• A size 8.0 tube is preferable but consider a size 7.0 for smaller adults.

   

Capnography

• Use of waveform capnography is mandatory for all endotracheal intubations (see previous section) and should be maintained during subsequent care and transfer.
  
  
• Transfer modules are stored on the shelving in Resus 2.
  
  
• The Mindray defibs in each resus bay have capnography that can be used as an emergency backup in the event of monitor/capnography failure.

Dentures

• Patient’s dentures are frequently misplaced in the ED. Please ensure dentures are removed, placed in a labelled denture pot and kept with the patient. Please record their location in the notes.

1. Airway management and transfers must be documented to theatre standard (anaesthetic forms are available in the ED). 
   
   
2. An electronic RSI audit form must be completed on Trak (EPR > Clinical Audit and QI > New > Emergency Department Intubation Registry). This remains the responsibility of the intubating doctor.
   
   
3. Unusual events or problems must be documented and where appropriate, a Datix form completed. The ED airway lead should be notified and these cases considered for discussion at the M&M meeting.

Bronchospasm including life-threatening asthma

• A salbutamol multi-dose inhaler (MDI) canister and in-line connector are available in the top of every airway trolley, and a nebuliser T-piece is available in the anaesthetic pendant. An aide memoire is in the resus room airway checklists.
  
  
• Volatile anaesthesia - A sevoflurane vaporizer is required if administration of volatile agents is desired. The vaporizer and scavenging system (with aide memoire) are stored in a box on the defibrillator trolley in Resus room 1B.

Trauma

• Oxygenation and airway maintenance remains the priority.  
  
  
• If the cervical spine is not ‘cleared’:
  • Remove the collar prior to RSI but aim to minimise movement.
  • Consider applying manual in-line stabilisation (MILS) but have a low threshold for removal in the event of difficult tracheal intubation as it is recognised to worsen glottic view.
  • Laryngeal view is likely to be at least one grade worse owing to suboptimal positioning: consider reverse Trendelenburg position and use of VL as first line.
  • When intubation is complete, cervical spine immobilisation should be carefully re-applied. Head blocks may be used as an alternative to a cervical collar in deeply sedated or paralysed patients with a significant brain injury.
  • See RIE Major Trauma Centre Clinical Guidelines for further information on immobilisation and cervical spine clearance.
    
    
• Some patients with facial injuries may be better managed sitting up to allow airway maintenance and postural drainage. Refer to ‘severe maxillofacial haemorrhage’ guideline on right decisions for guidance on management/packing of uncontrolled haemorrhage due to mobile midface fractures. Equipment (Epistat / bite block) can be found in the maxfax haemorrhage box on the Trauma Towers in Resus.
  
  
• RSI may precipitate cardiovascular compromise (induction agents and positive airway pressure); consider adequacy of volume resuscitation, timing / location of intervention and doses of induction agents.
• For further information see Damage Control Resuscitation in Anaesthesia

Neurocritical patients

• Neuro critical care aide memoire - This document acts as a convenient source of information for patients presenting with a neurological emergency, including traumatic brain injury. The Resus room checklists are bound together with a metal ring and hang on a hook above the airway trolleys. 

Pregnancy

• Please inform the obstetric anaesthetics trainee (bleep 2204) and consultant (via switch) in addition to the on-call anaesthetist (bleep 2200). 
  
  
• Refer to the ED Obstetric Emergencies Guide for management of common emergency scenarios.

Obesity  

• Anticipate difficulty and rapid desaturation.
  
  
• Ramp, consider using Oxford HELP pillows.
   
• Induction doses should be based on ideal body weight (height in centimetres, minus 100 [men] or 105 [women], with maintenance infusions based on adjusted body weight (ideal weight + 40% of excess).
  
  
• Use of BIS may aid assessment of anaesthetic depth.

This recommendation has been adapted from the guidance at sobauk.co.uk.

For more information, see DAS Obstetric Guidelines.

Laryngectomy / tracheostomy

• See National Tracheostomy Safety Project Guidelines (tracheostomy.org.uk) - printed copies are available in the bottom draw of the ED airway trolleys:
  • Emergency Laryngectomy Management
  • Emergency Tracheostomy Management
    
    
• Tracheostomy boxes with kit required to manage emergencies are stored in the Resus cupboard. These should stay with the patient and a new box supplied by critical care.

Double lumen tubes (DLTs)

• These specialist endotracheal tubes allow lung isolation; their use may be infrequently indicated following bronchial injury.
  
  
• DLTs are stocked in CEPOD and require additional equipment to insert.
  
  
• Depending on the situation a cardiothoracic anaesthetist may also be called to assist the attending anaesthetist.

Rapid Sequence Induction Agent Guidance