Airway - Intubation (RSI)
Indications
Airway
Loss of airway patency (burns, angioedema, facial trauma, upper airway obstruction)
Loss of airway protection (reduced level of consciousness, copious secretions)
Breathing
Type 1 or 2 respiratory failure
Respiratory distress with exhaustion
Apnoea or arrest
Circulation
Reduce oxygen consumption and lactate production (sepsis)
Disability
Status epilepticus
Facilitate neuroprotective ventilation after serious head injury
Anticipated deterioration
Severe agitation with risk to harm refractory to less restrictive alternatives
Environmental
Facilitate safe transfer or procedure
Cooling requiring paralysis
Refractory pain or distress
Contraindications (absolute in bold)
Advanced directive precludes intubation
Anatomy precludes attempt (laryngectomy, tracheal transection)
Sufficiently experienced operator unavailable
Alternatives
Laryngeal mask airway
Non-invasive ventilation
Antidotes to precipitant
Informed consent
Medical emergency
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
Potential complications
Airway
Failure to intubate
Failure to ventilate or oxygenate (after failed intubation)
Oesophageal intubation
Dental trauma
Damage to airway (cord injury, false passage creation)
Breathing
Endobronchial intubation
Aspiration
Barotrauma
Bronchospasm
Cardiovascular
Hypotension (drug-induced, loss of sympathetic tone, adverse drug reaction)
Hypertension and myocardial ischaemia
Disability
Increased intracranial pressure
Procedural hygiene
Standard precautions
PPE: non-sterile gloves, consider gown, mask and surgical or P2 respiratory mask (depending on infectious state)
Procedure
Intubation is a complex high-risk procedure best conducted in a resuscitation bay using a checklist and prepared airway plans in case of fail attempts
Preparation (area, staff, equipment)
Patient optimisation (positioning, oxygenation, haemodynamics)
Planning (verbalisation of airway plan to team)
Drug, doses and induction
Airway checklist
Airway plans
Post-procedure care
We recommend a post-intubation checklist incorporating:
Airway and endotracheal tube care
Breathing and ventilator setup
Circulation and fluids
Disability and sedation
Post-intubation checklist
Tips
Rapid-sequence induction checklists should not be bypassed outside of cardiac arrest
Expect to fail, mentally prepare yourself for the later steps in the airway plan prior to induction
Discussion
The ECI airway plan was designed by Chris Partyka and Daniel Gaetani (FACEMs Liverpool, Sydney, NSW). It contains the common elements of most airway checklists augmented by audit of over 500 consecutive intubations in the Liverpool Hospital emergency department and the data from the NSW airway registry. Every intubation requiring more than one attempt or resulting in hypoxia or hypotension was reviewed and repetitive oversights addressed.
Peer review
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Greater Sydney Area Helicopter Emergency Service
CareFlight
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
References
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Existing Australasian checklists: Emergency Care Institute checklist 2014, Royal North Shore Hospital, Westmead Hospital, Dubbo Base Hospital, Nepean Hospital, Wollongong Hospital, Queanbeyan Hospital, Royal Prince Alfred Hospital, Sunshine and Western Health, Royal Children's Hospital Melbourne, Sir Charles Gairdner Hospital (WA), Christchurch Hospital
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Walls RM, Murphy, MF. Manual of emergency airway management. (4th ed). Philadelphia PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.