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 Rh

  • What information it provides
    • Blood type (A, B, AB, O)
    • Rh status (Rh positive or negative)
  • When to order
    • Pregnant patients with vaginal bleeding
      • Need if Rh negative (prevents hemolytic disease of newborn)

Type and Screen

  • What information it provides
    • Blood type (A, B, AB, O)
    • Rh status (Rh positive or negative)
      • PLUS
    • Antibody status
      • Looks for all possible antibodies that may cause transfusion reaction
  • When to order
    • When the patient needs/might need a blood transfusion
      • Test typically takes 30 minutes to run… ORDER EARLY!

Type and Cross

  • What information it provides
    • Blood type (A, B, AB, O)
    • Rh status (Rh positive or negative)
    • Antibody status
      • PLUS
    • Specifically tests against patients blood
  • This blood is then set aside and officially “matched”
  • Acts as a final safety step before transfusion

Emergency Release Blood

  • Universal donor is O negative
  • Order if you can’t wait 30 minutes because the patient is dying

Additional Reading


Tank. Clogged Pipes. Broken Pipes. Pump.


  • “Tank”
    • Hypovolemic shock
    • Hemorrhagic shock
  • “Clogged Pipes”
    • Cardiac tamponade
    • Tension pneumothorax
    • Pulmonary embolism
  • “Broken Pipes”
    • Septic Shock
    • Neurogenic Shock
    • Anaphylactic Shock
  • “Pump”
    • Cardiogenic Shock

Step 1: Fill the Tank

  • Establish an IV
    • IO line alternative in emergent situations

Step 2: Consider Clogs

  • Cardiac tamponade
    • Diagnosis: Ultrasound
    • Treatment: Pericardiocentesis
  • Tension pneumothorax
    • Diagnosis: Clinical/Xray/Ultrasound
    • Treatment: Needle decompression and tube thoracostomy
  • Pulmonary embolism
    • Diagnosis: Clinical/CTA
    • Treatment: Thrombolytics

Step 3: Squeeze the Pipes

  • Administer vasopressors
    • Most common: Norepinephrine
    • Alternatives: Epinephrine, Phenylepherine

Step 4: Analyze the Pump

  • Get an EKG
    • Ischemia = Aspirin/Heparin/Cath lab
    • Dysrhythmia = Electricity

Additional Reading


Hypoxemia fixed by only TWO things: FiO2 and PEEP

Step 1: Add FiO2

  • If the patient is breathing…
    • Nasal cannula
    • Non-rebreather mask
  • If the patient is NOT breathing…
    • Bag-valve mask

Step 2: Add PEEP

  • *Cannot be completed in 60 seconds, but equipment can be requested
  • If patient is breathing…
    • BiPAP
  • If the patient is NOT breathing…
    • Intubation

Additional Reading


“Airway” does not necessarily mean “Intubation”


  • In emergency medicine we are taught “A-B-Cs”
    • These are actions that can be accomplished in first 60 seconds of patient encounter
      • Intubation takes several minutes to accomplish
      • Intubating a crashing patient might even KILL them!
    • Resuscitate THEN intubate

Step 1: Suction

  • Immediately suction if patient is…
    • Altered and vomiting
    • Gurgling

Step 2: Move the Tongue

  • Bedside maneuvers
    • Head tilt
    • Chin lift
    • Jaw thrust
  • Adjunct equipment
    • Oropharyngeal airway
    • Nasopharyngeal airway

Additional Reading

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