Post Intubation Care.

I had a reasonably busy few days at work last week, intubating 3 patients in 4 shifts.  All of them went nice and smoothly due to careful planning, setup and communication, followed by techniques such as apnoeic oxygenation with nasal cannula.

But don’t worry, this isn’t another post on intubation.  This is a very brief post on how I look after patients after I intubate them.

Ok, so we have the tube in, air is going in and out and we are happy.  Now, on with looking after out patient.

  • First of all we obviously have to secure the tube.  I really only have one option for this, trache tape.  You may have many and varied devices or means.  Regardless, it is important, especially in the patient with head injury, brain bleed, that sort of thing, to make sure that you don’t cinch things up so tight that you impair drainage by compressing the jugular veins.
  • Once the tube is secure I make sure that the analgesia and sedation that I am providing is adequate.  This is absolutely vital in any patient that has been RSI’d especially if a long acting neuromuscular blockade is used.  In fact, it is absolutely non-negotiable, there is no way that NMBAs can be given without analgesia and sedation.
    The method I am currently restricted to is a morphine/midazolam or fentanyl/midazolam infusion.  That’s fine for most cases, but I would dearly love to have ketamine as an alternative (for many things).  Note that I say infusion.  It is my opinion (yes, opinion) that this is the best method to provide adequate steady state analgesia and sedation that can be easily titrated to effect and side-effects.  I am aware of many services that use bolus doses only, but this is not something that I am personally very comfortable with as there are inevitable peaks and troughs of sedation and analgesia and it is very easy to under-sedate a patient.
    Note that analgesia is the most important aspect with the sedation being the added extra, the cherry on the top.
    The degree of sedation can be variable as well.  There is not always a need to completely “snow” a patient.  Light sedation and analgesia may be adequate in some cases, others may require deeper sedation: again this is on a case by case basis.  Heavy sedation can have longer term undesirable effects, so I generally try to aim for the lowest level of sedation required to have a happy, non-tearing/fighting/biting/writhing patient whilst maintaining good perfusion.
  • I don’t routinely give long term muscle relaxants.  There are a certain subset of patient (traumatic brain injury) in whom my protocol mandates paralytics, but the rest of the time I weigh up whether I really need to give them.  There is evidence that NMBAs, especially if their use is prolonged  can lead to ongoing muscle weakness.  However some patients (such as those who are difficult to ventilate as in ARDS) may have improved outcomes if NMBAs are used, so this has to be weighed up on a case by case basis.  NMBAs in the setting of impaired cerebral auto-regulation can avoid spikes in ICP as the patient coughs/gags.
  • Positioning.  Unless there is some compelling reason why I cannot do so, I position the patient with the head of the stretcher elevated approximately 30-40°.  Even if there is suspicion of c-spine injury there is no reason why this cannot be done.  Elevating the head of the stretcher achieves a few things.  First it allows for a better V/Q matching that you can’t get when the patient is supine which will improve oxygenation and ventilation and reduce complications like absorption atelectasis.  Secondly, very importantly, it can significantly reduce the danger of Ventilator Associated Pneumonia (VAP).  Finally it also may help with ICP management by allowing efficient venous drainage.
  • Whilst we are on VAP, suctioning is very important.  It is necessary to not only suction the tube itself, but also the oropharynx.  VAP can occur from micro-aspiration around the ETT cuff, so it is important to make sure that there is as little gunk as possible floating around the cords.  Use a fresh suction catheter every time you suction the tube (unless you have those flash fully encapsulated numbers.  I don’t)
  • Oro/nasogastric tubes.  I place these on most of my patients, especially if they have been ventilated by face mask prior to intubation.  It is very difficult to avoid getting some air in the belly when ventilation occurs with face mask.  This is especially true when the person ventilating is inexperienced, and doubly so if ventilation has occurred prior to ambulance arrival.  Of course none of my patients are fasted (although only having 6 beers in the half hour prior to crashing the car my constitute fasting for some) so it’s nice to get all that out of the belly as well so it can’t go anywhere else and can’t impinge upon the diaphragm.  Personally I find placing gastric tubes far harder than placing any other kind of tubes.  Maybe that is just me.
  • Tape the eyes.  It’s not nice to let the patient’s eyeballs dry out, so I always tape the eyelids down.  It also makes sure, in the semi-chaos of the back of an ambulance with swinging giving sets and so on, that the eyes do not get damaged by something falling in them or brushing across them.  The method I use is simply a bit of 1″ tape stuck first to the patient’s forehead to render it slightly less sticky, and then I pull gently on the corner of the eye to pull the eyelids shut and tape them down.
  • Blankets.  A simple thing, but one that is easy to forget.  The patient who is sedated (and maybe paralysed) cannot regulate their own temperature effectively.  This may be fine in the post arrest patient who we are actively cooling, but it’s not so good in the trauma patient.
  • Comfort.  I try do some basic nursing care and make the patient comfortable.  Try to minimise any noxious stimuli that the patient may receive.  Make sure they aren’t lying on broken glass from the car for example.  Make sure the sheets aren’t rucked up under them and make sure they are off the spineboard you used to get them out of the car onto the stretcher (which is the only role a spineboard has anyway)  The less noxious stimuli the better as it will mean you need less sedation and will end up with a happier patient.  By the same token, try to make sure that any fractures are aligned and splinted (including the pelvis)

Ok, so that wasn’t such a brief post.  It’s not all that much really: keep your patient pain free, warm, comfortable and ventilating well.
The attentive reader will note that I have not mentioned ventilation at all.  This is because that is a topic that deserves a post of it’s own, which I will come to in due course.

That’s about it.  I would love to hear from others.  Is there anything you do that could help me look after patients?  Anything that I do that you think is a bit rubbish?  Any tips or tricks for looking after these patients in the back of an ambulance (or helicopter for that matter)?  Drop me a line and let me know.

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4 Responses to Post Intubation Care.

  1. johnwood237 says:

    Great post – agree with all you write and your practice really shows paramedics working safely at a very high level. This level of care is something that I (along with many others no doubt) aspire to be able to deliver, one day, in the UK. Now having said that I hope you won’t mind if I raise the issue of the twitter title of your excellent piece. I know I don’t have to explain to someone of your experience and authority that a great battle is being constantly fought to portray the paramedic profession as just that – a profession. Individuals and organisations such as ‘The College of Paramedics’ UK and ‘Paramedic Australasia’ constantly campaign to be recognised as a discreet profession and get away from – yes you guessed it – the image of ………… ambulance driver! Now you may have used this term ironically and to show you are very far from an ambulance driver but I still think its unhelpful (as well as driving me nuts). One tweeter did say that the title would put them off reading your piece which is a real pity. I think your blogs are very very good especially as they are clinically focused and indicate the level of practice that we, as paramedics, are able to achieve. So – nuff said. I look forward to your next post and think you for this one (despite the title) g’day

    • ambofoam says:

      Hi John. Thanks for the feedback, you have a very valid point. I have a bad habit of referring to myself as an Ambulance Driver. This is just a bit of self-deprecation on my behalf (to pull my own head out of my own posterior) but it does of course appear derogatory to all those who are working tirelessly to improve the standing of pre-hospital professionals the world over.
      I will do my utmost to avoid this in the future as I have no desire to denigrate any EMTs or paramedics anywhere. It is something I need to adjust now that I have a wider audience for my rants instead of just the hapless staff who happen to be nearby when I go off on a tangent!
      This is one of the great things about #FOAMed: it allows us all to examine how we carry out our daily business, from high end clinical stuff to how we present ourselves to the world.
      I am glad that others get some benefit out of my rambling and I would not like to put anyone off thinking my attitude or approach was off-colour or unhelpful.

      Thanks again for you feedback, knowing that people are taking an interest and getting involved is one of the great excitements in the FOAMed world.

      Cheers

      Robbie

  2. Tingles says:

    Hi Robbie,

    I just stumbled upon your site and found your great blog on post-intubation care – well done!! I fully support all your points and would like to suggest a few additions / extensions to your thoughts:

    1. End tidal CO2 monitoring. I’m sure you use this routinely. It should be considered MANDATORY if you are going to be intubating anyone. It not only confirms tube placement, but waveform capnography (is there any other?) provides ongoing information on the effectiveness of ventilation, in addition to information on tube migration, airway changes (eg obstruction, bronchospasm) and impending cardiovascular collapse. I find it useful to fit it to the BVM prior to intubation as it confirms that it’s working and also indicates apnoea / onset of muscle paralysis following NMBA administration (especially if using roc instead of sux)

    2. PEEP. There are very few Pts who will not benefit from at least a little bit of PEEP. It improves oxygenation by recruiting alveoli and reduces atelectotrauma. If a bag/valve is used for ventilation a disposable PEEP valve can be fitted.

    3. “Safe” ventilator settings (i.e. tidal volumes of 8ml/kg or less). Excess CO2 can be blown off by increasing RR, For mechanical ventilation ensure the plateau pressure does not exceed 30cmH2O. For high airway pressures, go as low as 4ml/kg and increase PEEP to ensure adequate oxygenation (but watch for dynamic hyperinflation).

    4. Blood gas (where available) – then adjust your vent settings accordingly. If not, aim for the lowest FiO2 that will give you sats of 95-100%, and rate to give ETCO2 35-40mmHg (remember PaCO2 will always be higher than ETCO2

    5. Temperature. As you stated, thermal protection is mandatory, but just as important (where available) is temperature measurement. Ideally an oesophageal probe for continuous monitoring should be placed. Remember some pathologies (as well as use of neuromuscular blockade) will expose you patient to a higher risk of hypothermia.

    Thanks again for a great site, I look forward to exploring it further.

    Cheers,

    Tingles.

  3. ambofoam says:

    Hi Tingles. EtCO2 is indeed mandatory. No EtCO2 means no intubation, in this day and age it is not acceptable to be intubating patients without it. I also always have EtCO2 attached prior to intubation to ensure that it is working and that adequate ventilation is occurring with pre-oxygenation if a BVM is being used.
    Ventilation (including blood gas) is a topic for another post I have in the works, but you raise excellent points that I will hopefully address then.
    Sadly I am restricted to using tympanic temperature for monitoring my patients. I would love to have oesophageal monitoring, but until I am the boss I have to work with what I have! You are right though, oesophageal probes are the ideal temperature monitoring device.
    Thanks for the comments, I am pleased that my blog is reaching people, and the feedback is great to further my own practice.
    Cheers

    Robbie

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