Unless ventilatory or oxygenation failure is resulting from a rapidly reversible cause, such as opioid overdose, or a condition known to be successfully managed with noninvasive ventilation e.
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Most patients who require emergency intubation have one or more of the previously discussed indications: failure of airway maintenance, airway protection, oxygenation, or ventilation. However, there is a large and important group for whom intubation is indicated, even if none of these fundamental failures are present at the time of evaluation.
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These are the patients for whom intubation is likely or inevitable because their conditions, and airways, are predicted to deteriorate from dynamic and progressive changes related to the presenting pathophysiology or because the work of breathing will become overwhelming in the face of catastrophic illness or injury. For example, consider the patient who presents with a stab wound to the midzone of the anterior neck and a visible hematoma.
At presentation, the patient may have perfectly adequate airway maintenance and protection and be ventilating and oxygenating well. The hematoma, however, provides clear evidence of significant vascular injury. Ongoing bleeding may be clinically occult because the blood often tracks down the tissue planes of the neck e.
Furthermore, the anatomical distortion caused by the enlarging internal hematoma may well thwart a variety of airway management techniques that would have been successful if undertaken earlier. The patient inexorably progresses from awake and alert with a patent airway to a state in which the airway becomes obstructed, often quite suddenly, and the anatomy is so distorted that airway management is difficult or impossible.
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Analogous considerations apply to the polytrauma patient who presents with hypotension and multiple severe injuries, including chest trauma. Although this patient initially maintains and protects his airway, and ventilation and oxygenation are adequate, intubation is indicated as part of the management of the constellation of injuries i. The reason for intubation becomes clear when one examines the anticipated clinical course of this patient. The hypotension mandates fluid resuscitation and evaluation for the source. Pelvic fractures, if unstable, require immobilization and likely embolization of bleeding vessels.
Long bone fractures often require operative intervention. Chest tubes may be required to treat hemopneumothorax or in preparation for positive-pressure ventilation during surgery. Combative behavior confounds efforts to maintain spine precautions and requires pharmacologic restraint and evaluation by head CT scan. This debt significantly affects the muscles of respiration, and progressive respiratory fatigue and failure often supervene.
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In addition, intubation improves tissue oxygenation during shock and helps reduce the increasing metabolic debt burden. Sometimes, the anticipated clinical course may necessitate intubation because the patient will be exposed to a period of increased risk on account of patient transport, a medical procedure, or diagnostic imaging.
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For example, the patient with multiple injuries who appears relatively stable might be appropriately managed without intubation while geographically located in the emergency department ED. However, if that same patient requires CT scans, angiography, o r any other prolonged diagnostic procedure, it may be more appropriate to intubate the patient before allowing him or her to leave the ED so that an airway crisis will not ensue in the radiology suite, where recognition may be delayed and response may not be optimal.
Similarly, if such a patient is to be transferred from one hospital to another, airway management may be indicated on the basis of the increased risk to the patient during that transfer. Not every trauma patient or every patient with a serious medical disorder requires intubation. However, in general, it is better to err on the side of performing an intubation that might not, in retrospect, have been required, than to delay intubation, thus exposing the patient to the risk of serious deterioration.
When evaluating a patient for emergency airway management, the first assessment should be of the patency and adequacy of the airway. In many cases, the adequacy of the airway is confirmed by having the patient speak.
A normal voice as opposed to a muffled or distorted voice , the ability to inhale and exhale in the modulated manner required for speech, and the ability to comprehend the question and follow instructions are strong evidence of adequate upper airway function. Although such an evaluation should not be taken as proof that the upper airway is definitively secure, it is strongly suggestive that the airway is adequate at that moment.
More important, the inability of the patient to phonate properly; inability to sense and swallow secretions; or the presence of stridor, dyspnea, or altered mental status precluding responses to questioning should prompt a detailed assessment of the adequacy of the airway and ventilation see Box After assessing verbal response to questions, conduct a more detailed examination of the mouth and oropharynx. Examine the mouth for bleeding, swelling of the tongue or uvula, abnormalities of the oropharynx e.
Examine the mandible and central face for integrity. Examination of the anterior neck requires both visual inspection for deformity, asymmetry, or abnormality and palpation of the anterior neck, including the larynx and trachea. During palpation, assess carefully for the presence of subcutaneous air. This is identified by a crackling feeling on compression of the cutaneous tissues of the neck, much as if a sheet of wrinkled tissue paper were lying immediately beneath the skin.
The presence of subcutaneous air indicates disruption of an air-filled passage, often the airway itself, especially in the setting of blunt or penetrating chest or neck trauma. Subcutaneous air in the neck also can be caused by pulmonary injury, esophageal rupture, or, rarely, gas-forming infection. Although these latter two conditions are not immediately threatening to the airway, patients may nevertheless rapidly deteriorate, requiring subsequent airway management. In the setting of blunt anterior neck trauma, assess the larynx for pain on motion.
Absence of crepitus may be caused by edema between the larynx and the upper esophagus. BOX Four key signs of upper airway obstruction. The first two signs do not necessarily herald imminent total upper airway obstruction; stridor, if new or progressive, usually does, and dyspnea also is a compelling symptom. The presence of inspiratory stridor, however slight, indicates some degree of upper airway obstruction.
Lower airway obstruction, occurring beyond the level of the glottis, more often produces expiratory stridor. The volume and pitch of stridor are related to the velocity and turbulence of ventilatory airflow.
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Most often, stridor is audible without a stethoscope. Auscultation of the neck with a stethoscope can reveal subauditory stridor that may also indicate potential airway compromise. Stridor is a late sign, especially in adult patients, who have large-diameter airways, and significant airway compromise may develop before any sign of stridor is evident.
When evaluating the respiratory pattern, observe the chest through several respiratory cycles, looking for normal symmetrical, concordant chest movement.
In cases where there is significant injury, paradoxical movement of a flail segment of the chest may be observed. If spinal cord injury has impaired intercostal muscle functioning, diaphragmatic breathing may be present. In this form of breathing, there is little movement of the chest wall, and inspiration is evidenced by an increase in abdominal volume caused by descent of the diaphragm.
Auscultate the chest to assess the adequacy of air exchange. Decreased breath sounds indicate pneumothorax, hemothorax, pleural effusion, emphysema, or other pulmonary pathology. The assessment of ventilation and oxygenation is a clinical one. Arterial blood gas determination provides little additional information as to whether intubation is necessary, and may be misleading. Oxygen saturation is monitored continuously by pulse oximetry, so arterial blood gases rarely are indicated for the purpose of determining arterial oxygen tension. In certain circumstances, oxygen saturation monitoring is unreliable because of poor peripheral perfusion, and arterial blood gases may then be required to assess oxygenation or to provide a correlation with pulse oximetry measurements.
In patients with obstructive lung disease, such as asthma or chronic obstructive pulmonary disease COPD , intubation may be required in the face of relatively low CO2 tensions if the patient is becoming fatigued. Other times, high CO2 tensions may be managed successfully with noninvasive positive-pressure ventilation instead of intubation if the patient is showing clinical signs of improvement e.
Similarly, if the patient has a condition that is at risk of worsening over time, especially if it is likely to compromise the airway itself, early airway management is indicated. The same consideration applies to patients who require interfacility transfer by air or ground or a prolonged procedure in an area with diminished resuscitation capability.
Intubation before transfer is preferable to a difficult, uncontrolled intubation in an austere environment after the condition has worsened. In all circumstances, the decision to intubate should be given precedence. If doubt exists as to whether the patient requires intubation, err on the side of intubating the patient.
It is preferable to intubate the patient and ensure the integrity of the airway than to leave the patient without a secure airway and have a preventable crisis occur. Are there reliable indicators of the need to intubate? Some measurable data and patient characteristics can be helpful, whereas others are largely folklore.
First, the gag reflex continues to be taught in some settings as a key determinant in assessing the adequacy of airway protection or the need for intubation, yet the literature does not support this claim. Moreover, many conditions can often be managed without definitive airway management even when the patient seems, initially, to be in severe respiratory distress.
COPD and acute pulmonary edema are uncommon causes of ED intubation and can typically be managed with medical therapy and noninvasive positive airway pressure. Comparative evaluation of Glasgow Coma Score and gag reflex in predicting aspiration pneumonitis in acute poisoning. J Crit Care. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. Although both difficult and failed airways are discussed in this chapter, the two concepts are distinct.
A difficult airway is one in which identifiable anatomical attributes predict technical difficulty with securing the airway. A failed airway is one for which the chosen technique has failed, and rescue must be undertaken. Obviously, there is much overlap, but it is important to keep the two notions distinct. In addition, one can think about airway difficulty in two categories: an anatomically difficult airway and a physiologically difficult airway.
The former presents anatomical or logistical barriers to successful airway management, whereas the latter requires the operator to optimize overall patient management in the context of critically low oxygen saturation, blood pressure, or metabolic derangement, such as severe metabolic acidosis.