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:
References and Links
litfl.com
- CCC — Extubation Assessment in the ICU
- CCC — Laryngospasm
- CCC — Post-extubation stridor
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
- DAS — Extubation guidelines
- EMCrit Podcast 35 – Extubation in the ED (with a link to Scott Weingart’s paper and his protocol)
- PulmCCM.org — Tobin: “Minimal” PEEP and pressure support during SBT kills some patients (AJRCCM)
- Resus.ME — Extubation Guidelines (from the Difficult Airway Society)
- Trauma Professional’s Blog — Extubation in the Emergency Department
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC