Extubation Assessment in the ED

OVERVIEW

  • The general principles are the same as for extubation of ICU patients (see Extubation Assessment in the ICU)
  • However, the criteria for extubation in the ED are generally more stringent as most ED staff are less experienced and less familiar with the process

PATIENT SELECTION

The approach below is suitable for patients that have undergone short-term intubation. Such patients include:

  • alcohol-intoxicated head trauma patients following normal CT head
  • patients requiring short-term airway protection for procedural sedation (e.g. endoscopy in the ED)
  • overdose patients with short-term CNS obtundation (e.g. GHB intoxication)
  • patients who require palliation (…remember to consider organ donation)

MANAGEMENT CONSIDERATIONS

Consider the following early in the management of these patients to expedite the extubation process:

  • use a slightly smaller ETT than usual (e.g. size 7.5 instead of 8.0 on an adult male)
  • use fentanyl and propofol for sedation (wear off rapidly)
  • avoid ongoing neuromuscular blockade
  • consider continuing low dose fentanyl infusion at the time of extubation to control discomfort of intubation or pain from other sources

APPROACH

George Douros from EDTeaching.com has developed this algorithmic guide to the process of extubation in the ED based on the work of Scott Weingart and the Difficult Airway Society guidelines:

CCC Ventilation Series

Journal articles and textbooks

  • Weingart SD, Menaker J, Truong H, Bochicchio K, Scalea TM. Trauma patients can be safely extubated in the emergency department. J Emerg Med. 2011 Feb;40(2):235-9. PMID: 19703744. [Free fulltext via EMCrit]

Social media and web resources

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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