passive preoxygenation - a radical concept

Next time you intubate someone...

consider putting them on a nasal cannula at 15L per min under the NRB.  

this article advocates it as a form of "apneic oxygenation" which can prevent desaturation during intubation. 

Awake patients will not tolerate it at 15L/min, so you can start with 4-5 L and then increase to 15 after giving your induction and paralytic medications.

The point: Apneic oxygenation can extend the duration of safe apnea.

Note: High O2 could decrease the respiratory drive, but this is for people who you are committed to intubating already.  

I would love to hear your success stories with this new method!

Submitted by S. Morris.

Reference(s): Weingart, S., Levitan, R.  Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. Nov 2011. Vol 9. Iss 3. ; picture

Lidocaine pretreatment during intubation

CONCEPT:
--intubation is associated with transient increase in BP & heart rate, due to brief catecholamine surge after messing with the larynx (probably)
--this surge can result in increased ICP, which is not great for head injury/head bleed patients
--lidocaine pretreatment can help blunt the rise in ICP

EVIDENCE:
--lidocaine shown to blunt increased ICP during endotrach suctioning, but may not directly apply to ED setting (rapid sequence intubation)
--review (linked below) "could find no evidence that in acute traumatic head injury pretreatment with IV lignocaine/lidocaine before a RSI reduces ICP or improves neurological outcome"

10-SECOND TAKEAWAY:
--RSI may cause brief increase ICP
--lidocaine pretreat (1.5mg/kg) for RSI supposed to help blunt this response
--not exactly a mountain of proof this works

QUICK TANGENT:
--fentanyl might be an alternative (1-3mcg/kg), if the BP can handle it

Reference(s): our canadian bretheren, review article, uptodate: "Pretreatment agents for rapid sequence intubation in adults"