Category: Resuscitation

Airway Part 4- What to Do If Intubation Fails

Verbalize the out loud prior to performing rapid sequence intubation.

The Bougie
  • Ideal for situations when you’re view is suboptimal
  • Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique).
Video Laryngoscopy (Glidescope)
  • Laryngoscope with a camera at the tip which displays on a screen at bedside
  • Ideal for situations when both view and direct access to the cords is suboptimal (c-collar, poor mallampati). Some physicians use this as their primary technique.
  • Use it like a camera that you advance into position so you can see the cords. Maneuver the endotracheal tube by watching indirectly on the screen.
Flexible Endoscopy
  • It is a flexible stylet that you can control and has a camera at the tip.
  • Advances through the cords like a bougie and the (preloaded) endotracheal tube advances over it.
  • Can intubate through both the nose or mouth with this
LMA (laryngeal mask airway)
  • Placed blindly and sits above the cords, forming a seal.
  • Not a “definitive” airway, but can oxygenate and ventilate the patient when in a difficult situation.
  • Immediately perform this step in “can’t intubate can’t oxygenate” situations
  • The 3-step EMCrit method is best in my opinion (see link below)
    • “Scalpel, Finger, Bougie”
Additional Reading
  • Overview of the bougie with videos (LITFL)
  • The 3-step cricothyrotomy (EMCrit)

Airway Part 3- Rapid Sequence Intubation

The most important thing to do when preparing for RSI is to PREOXYGENATE the patient.

Step 1: Choose Your Equipment
  • Miller or Mac blade?
    • Miller blade is straight (like the ‘L’ in miller)
      • Frequently used in kids
    • Mac blade is curved (like the ‘c’ in mac)
      • (Generally, this is the best choice to use on your clerkship and most common in the ED)
  • Tube Size?
    • 7.5 cuffed tube for a small adult
    • 8.0 cuffed tube for a big adult
Step 2: Choose your Meds
  • You need both a sedative and a paralytic to perform RSI
  • Paralytic options are succinylcholine or rocuronium
    • Succinylcholine is best if you need something short acting
      • For example, when frequent neurologic checks are required
    • Rocuronium is best because it’s easy to remember (1mg/kg)
      • “Rocuronium Rocks”
  • Sedative options include ketamine, propofol, and midazolam.
    • My favorite is ETOMIDATE.
      • It is hemodynamically neutral.
      • Dosing is 0.3mg/kg
Step 3: Prepare Your Equipment
  • Suction
  • Bag Valve Mask
  • Backup airway (ex. LMA)
  • Cardiac monitor
  • Capnography for tube placement
Step 4: DO IT
  • Push the sedative
  • Push the paralytic
  • Put the blade in your LEFT hand
  • Open mouth with right hand
  • Slowly advance (holding top of blade against tongue) until you see cords
    • The cords will be hiding under the white, cartilaginous, tongue-like epiglottis

NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great.

Step 5: Advance the Tube and then CLOSING STATEMENT
  • Generally, you want depth to equal 3x the size of the tube
  • Closing statement
    • “Please attach capnography to confirm tube placement”
    • “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)”


Airway Part 2- Bag Valve Mask Adjuncts

How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful?

Pharyngeal Airways
  • These tools bypass the posterior portion of the tongue to help with BVM ventilation
  • Nasopharyngeal Airway (NP)
    • Measure from earlobe to tip of nose
    • TEST QUESTION: Don’t use in a patient with possible skull fracture
  • Oropharyngeal Airway (OP)
    • Measure from earlobe to corner of mouth
Laryngeal Mask Airway (LMA)
  • Essentially a modified BVM to place inside the mouth
  • It fits OVER the larynx (cords, epiglottis, etc)
Retroglottic Airways
  • “King”
  • “Combitube”
Additional Reading

When to Stop CPR

Why is this Important?
  • It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal.
  • Hospitals need to steward their resources to distribute equitable care between its patients
When is it Appropriate to Stop CPR on a Pulseless Patient?
  • Patient shows signs of irreversible death
    • Rigor mortis
    • Decapitation
    • Rotting/decaying
  • Patient has dismal prognosis (3 studies discuss this)
    • Implementation of the universal BLS termination of resuscitation rule in a rural EMS system
      • Non-EMS witnessed arrest
      • No return of spontaneous circulation prior to transport
      • Only non-shockable rhythms present
    • Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation
      • Non-EM witnessed arrest
      • Non-shockable INITIAL rhythm
      • No ROSC despite 3 doses of epinepherine
  • Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study
    • Less than 1% chance of recovery after 46 minutes of resuscitation
Additional Reading
  • Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.
  • Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.
  • Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

Ventilator Basics

Step 1: Start Patient on Volume Assist-Control Ventilation
  • The most basic mode of ventilation
    • Provides a FIXED VOLUME at a FIXED RATE
  • If the patient over-breaths…
    • The ventilator will give another FULL breath
      • Can cause breath stacking and be uncomfortable in patients who are poorly sedated
      • This is not a problem in the ED because patients are typically deeply sedated
Step 2: Know your oxygenation and ventilation goals
  • Oxygenation (getting oxygen in)
    • Try to keep O2 saturation >92%
  • Ventilation (getting CO2 out)
    • Try to keep pCO2 <40
Step 3: Know the 4 Most Important Settings on a Ventilator
  • FiO2
    • The concentration of oxygen
      • Room air is 21% oxygen (or 0.21 on the vent)
      • Maximum is 100% oxygen (or 1.0 on the vent)
  • PEEP
    • The pressure applied during exhalation
      • Typical starting point is 5 (but can be increased significantly)
    • “Recruits” and opens alveoli
  • Tidal Volume
    • The volume of air moved during each cycle of the vent
  • Respiratory Rate
    • How fast the ventilator cycles/breaths for the patient
Step 4: Improving the patient’s OXYGENATION
  • FiO2
    • Increases the amount of oxygen present for exchange in non-damaged alveoli
  • PEEP
    • Increases the number of alveoli available to exchange oxygen
Step 5: Improving the patient’s VENTILATION
  • FORMULA: Minute Ventilation (MV) = Tidal Volume (Vt) x Respiratory Rate (RR)
  • Increasing either of these will improve ventilation
  • Patients with COPD/asthma
    • Have tendency to not get full breath out (“breath stacking”)
      • “Plateau pressures” will increase above 30
        • Can damage alveoli
        • Can cause pneumothorax
    • Treat by increasing the I:E ratio
      • Quick inhalation
      • Longggggggggggggg exhalation
Additional Reading

Cardiac Arrest (ACLS)

Hard, fast, unrelenting chest compressions are the core of ACLS!!!

Step 1: Check the Patient’s Pulse

  • If the patient does not have a pulse, start CPR
    • Hard, fast, unrelenting compressions
      • Intubated patients
        • Continuous Compressions
      • Non-intubated adults
        • 30 compressions then 2 breaths… Repeat
      • Non-intubated pediatrics
        • 15 compressions then 2 breaths… Repeat

Step 2: Determine if the Rhythm is Shockable or Non-shockable

  • Shockable rhythms
    • Ventricular Fibrillation (VF)
    • Ventricular Tachycardia (VT)
  • Non-shockable rhythms
    • Pulseless electrical activity (PEA)
    • Asystole

Step 3: Start a Timer For 2 Minutes

  • Do a rhythm/pulse check every 2 minutes

Step 4: Is the Patient in a Shockable Rhythm?

  • Repeat/coordinate shocks with every 2-minute pulse check
  • Give 1mg IV/IO epinephrine every 3-5 minutes
  • Give amiodarone
    • 300mg with first dose
    • 150mg with a repeat dose

Step 5: Is the Patient in a Non-Shockable Rhythm?

  • Give epinephrine every 4 minutes (every other cycle)

Quick Facts

  • Shockable rhythms (VT/VF) have best prognosis
    • Frequently related to myocardial infarction
  • Asystole has the worst prognosis
  • PEA has mixed prognosis (depends on diagnosis)
    • Two types (wide and narrow)
      • “Wide” PEA frequently caused by metabolic abnormalities
        • Consider bicarb and calcium chloride
      • “Narrow” PEA frequently caused by shock state
        • Perform bedside ultrasound in attempt to determine cause
    • “The H’s and T’s”
      • Hypoxemia
      • Hypovolemia
      • Hydrogen Ions
      • Hyper/hypokalemia
      • Tension pneumothorax
      • Tamponade
      • Toxins
      • Thrombosis (MI/PE)

Additional Reading

How to Transfuse Blood

Type and Screen? Type and Rh? Type and Cross? Emergency Release? I never received a talk in medical school about how to give blood to patients. So when I started residency, I was surprised and confused by how many options I could select when placing orders for blood! This episode covers the basic terminology you need to know so that you can sound smart on your clerkship.

The 4 orders you need to know:

  1. Type and Rh
    1. Blood type: A, B, AB, or O
    2. Rh factor: pos (+) or neg (-) 
    3. Order for: pregnant patients with vaginal bleeding
    4. Useful for: knowing whether to give RhoGam in Rh (-) women exposed to Rh (+) fetal blood
  2. Type and Screen
    1. Blood type: A, B, AB, or O
    2. Rh factor: pos (+) or neg (-) 
    3. Antibodies: pos (+) or neg (-) Looks for Ab’s to ALL possible RBC antigens
    4. Order for: pt who might need a blood transfusion (ex. GI bleed)
    5. Useful for: facilitating blood order from lab (order early, 30 min test)
  3. Type and Crossmatch
    1. Blood type: A, B, AB, or O
    2. Rh factor: positive (+) or negative (-) 
    3. Antibody screen: pos (+) or neg (-) Looks for Ab’s to ALL possible RBC antigens
    4. Crossmatch: pre-mixes specified units of requested blood with patient’s blood
      1. Final safety check before a blood transfusion
  4. Emergency release blood
    1. Universal donor blood: O (-)
    2. No time to wait for type and screen (when you have < 30 min to safe the pt’s life)
    3. Order for: pt who is dying in front of you

The basics:

  • RBC antigens determine blood type
  • We screen for RBC antigens by looking for their corresponding antibodies
  • A, B, and Rh are the most common RBC antigens (screened for by “Type and Rh”)
  • But HUNDREDS of other RBC antigens exist, as well (screened for by “Type and Screen”)
  • Rh (-) women are born without Ab’s to Rh antigen. Mother can have Rh (+) babies, but Hemolytic disease of the newborn may arise in future pregnancies if mother’s blood mixes with fetal blood (birth trauma, etc), leading to Rh antigen exposure and maternal IgG antibody formation


Today is episode C, the final episode in our 3 part podcast series on the approach to a crashing patient. In previous episodes we covered AIRWAY: how the first thing we need to do is suction and move the posterior portion of the patient’s tongue. We covered BREATHING: how we need to fix hypoxia by increasing FiO2 and adding PEEP. And today we are covering CIRCULATION.

With circulation, it all comes down to tank, clogged pipes, broken pipes, and pump. Which is a fancy way of saying… We fix all of the different types of SHOCK. So pay close attention, because the treatment of shock is a hugely important topic in Emergency Medicine. It is a topic that you need to master if you want to pass your shelf and do well on your SLOE.


Today is episode B in a series about our approach to the crashing patient. As we discussed in the previous episode, at some point during your clerkship, you will have a patient that starts dying right in front of your eyes. And it will be very scary! In Emergency Medicine, we fall back onto the “A-B-Cs” whenever this happens. We fall back onto an algorithm that lets us take control of virtually any situation in less than 60 seconds.

In this episode, we cover B-Breathing. In medical school, we learned that breathing equals both oxygenation and ventilation. However, between the two of these, oxygenation is BY FAR the most important in the acute setting. Hypoxia kills patients immediately, so you need to fix hypoxia immediately. As we will discuss in this episode, there are only two ways to do this. You either add FiO2, or you add PEEP.

Airway Part 1- Immediate Actions

During your clerkship, you will be encountering sick patients. This is obvious. However, I promise that at least one of these patients will catch you VERY off guard. It usually goes like this, you are walking into a room, ready to take a history from (what sounded like) a straight-forward patient. But as soon as you open that door… WHAM! You see an unconscious, hypoxic, hypotensive patient. Maybe they are simultaneously vomiting and pooping blood. Maybe they are limp, blue, and not breathing. Maybe they seize, fall on the floor, and smash their head. Your heart rate speeds up. A lump crawls into your throat. What do you do?

Easy. You start with the A-B-Cs.

In this episode, we cover A (Airway). And here is a hint, the algorithm does NOT start with intubation. Will you be able to intubate 5 minutes from now? Maybe. If the patient lives that long. But you need to act now. So what I plan on teaching you is an algorithm that allows you to take control of literally ANY situation in 60 seconds or less. I plan on giving you a FEAR algorithm. A plan for when soft, brown, mushy stool flies through the proverbial fan and sloshes all over your patient’s hemodynamic status.

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