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Prepare before you have a difficult intubation
When a man was transferred to the ED at St. John's Mercy Medical Center in St. Louis, MO, with burns and possible inhalation involvement, his room air saturation was in the lower 90% while remaining on a non-rebreather.
The ED physician who intubated the patient took extra time to gather the necessary equipment prior to the procedure, recalls Jessica VanLaere, RN, BSN, one of the ED nurses who cared for this patient.
"The physician eventually used the glydescope to appropriately intubate the patient and could see the burn marks in his throat, as the airway was visualized," says VanLaere. To anticipate the needs of the ED physician, VanLaere says to have the necessary supplies ready in the room before the patient's arrival.
"At the start of the shift, every nurse should be responsible for making sure that there are oxygen delivering devices, suction capabilities, bag valve mask, and monitoring equipment in each room," says Kelly Powers, RN, an ED nurse ED at Christiana Care Health System in Wilmington, DE. To prepare for a difficult intubation, do the following:
Have an airway emergency box ready.
Include different size endotracheal tubes, end tidal detectors, and laryngeal blades, says Powers. She also recommends using a rapid sequence intubation (RSI) kit.
"This ensures that you can save time looking for the necessary medications for intubation," says Powers. "Not having the essential equipment, suction, non-rebreather mask, or ambu-bag in every room could be detrimental to the patient's care."
At St. John's Mercy, ED nurses store a pre-assembled RSI kit in the automated medication dispenser. This includes the most commonly used sedation and paralytic medications. "That way, we only have to get one item for a patient that is having an airway emergency," says VanLaere.
VanLaere says that her "no. 1 tip" for ED nurses is to be familiar with the medications used for RSI and the typical doses used in the ED.
Assess the patient continuously.
Jayne K. McGrath, RN, MS, CCRN, CEN, CNS-BC, an ED clinical nurse specialist at University of Wisconsin Hospital & Clinics in Madison, says, "Facial or airway trauma, or even just a person's anatomy, can make an intubation difficult. Be the 'watchful eye' during these procedures."
Continually assess the pulse oximetry, says McGrath, and be sure your patient is adequately oxygenated prior to the intubation.
"Monitor the patient's oxygen saturation and heart rate to make sure they stay stable during the intubation process," says VanLaere. "Make sure the rest of the staff in the room are aware of the patient's vital signs and if there are any changes."
Be sure your equipment is ready and working.
McGrath says, "Have a tracheotomy tray available in the event that an emergency trach needs to be done."
For more information about preparation for difficult intubations, contact:
If intubation attempt is too long act
Attempting to intubate should not take the intubater more than 30 seconds, says Jayne K. McGrath, RN, MS, CCRN, CEN, CNS-BC, an ED clinical nurse specialist at University of Wisconsin Hospital & Clinics in Madison.
"If it is, then it's important to stop and re-bag the patient with 100% oxygen," McGrath says.