Intubation during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. If you don’t intubate often, you’re likely to be nervous. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us, rather than against us.
Step one, therefore, is to remain in control of your own sense of alarm. The leaders, which includes the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.
Step two is to quickly assess the situation. Is the patient being ventilated? Ventilation takes priority over intubation. Is there suction available? Without suction you many not be able to see the glottis, and you won’t be able to manage emesis. What help do you have? The intubator almost always needs some assistance in having someone hand equipment, or assist with cricoid pressure, among other tasks. As I tell my students, intubation is a team sport.
Finally you need to assess what position the patient is in, and how can you optimize that position. The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Illustrations are copyright from Anyone Can Intubate, 5th Edition.
Intubation On The Ground
When the patient lies on the ground, you must get down on the patient’s level. One technique is to kneel. Mechanical advantage is more difficult from this position. You must rely more heavily on your arm strength to lift the head rather than your upper back and shoulder muscles. The natural tendency to lean forward and bend your arm will make it hard for you to balance. The weight of the patient pulls you forward when you try to lift (Fig 10-1: note figure numbers refer to the book Anyone Can Intubate)
Kneeling behind the cardiac arrest victim during intubation allows the intubator to ergonomically lift the patient’s head with the strength of the back and shoulders, not just the arm. It provides the distance needed to use binocular vision to see the larynx.
Instead, keep your left arm and your back as straight as you can, leaning backward. Tense your lower back and thigh muscles to form a firm base of support. Lift upward (Fig. 10-2). Position your head and shoulders over the patient’s head to improve your center of gravity. Straddling the head with your knees allows you to steady the head, steady yourself, and improve your angle or approach. A folded sheet under the head can lift it into the sniffing position.
You can also sit to the patient’s right side, facing the feet. Your hips should be level with the back of your patient’s head. Bend your knees slightly to allow you to maintain balance while shifting your weight to optimize the position of your outstretched left arm doing the laryngoscopy. This position gives you good leverage without pressing on the upper teeth. You will need to twist your back to pass the endotracheal tube with your right hand.
Sitting to the right of a cardiac arrest victim during intubation allows the intubator to ergonomically lift the patient’s head and see the glottis. You can lean backward to counterbalance the weight of the head.
Intubation in The Bed
Unfortunately, having the patient lie in the typical hospital bed is also awkward. Look at the contrasting approaches in the suboptimal figure 10-4 and the more optimal 10-5.
Most hospital beds have a fairly high headboard that prevents easy access to the patient’s head (10-4). Have someone remove the headboard while you prepare your equipment (10-5).
If you can’t easily reach the patient, pull him toward you. Small individuals like myself will have more effective control because you don’t have to lean forward.
You’ll often find the patient on a soft hospital mattress with the hard cardiac arrest board under his back. Because the backboard allows effective CPR, we take this position for granted. We often fail to notice that the patient’s head now hangs fully extended off the back of the board, forcing you to lift the patient’s head much higher to straighten the airway.
Optimal vs suboptimal positioning of a patient in a bed for intubation during cardiac arrest.
Head Position
CPR often places the patient’s head in hyperextension as the head falls backward behind the CPR backboard under the patient. If you don’t correct for this, your view will be extremely anterior, making it difficult to see the glottis and to pass the tube.
Head hyperextension impedes intubation because it makes the larynx appear very anterior. You can compensate by lifting the head into a sniffing position.
You must get the head into a sniffing position. Lifting a heavy head high during CPR is difficult. Use pillows to put the head in the sniffing position and decrease the lift needed.
Use your helpers. Don’t hesitate to ask for help in lifting while you place the tube. your helper must not move the head during laryngoscopy, or else tooth damage could occur. Cricoid pressure to push the larynx down can also help, as can pulling back the cheek.
Optimizing head position during resuscitation may entail having a helper assist you in holding the head up. Your help must not move the head in order to avoid tooth damage.
Chest Compressions Hinder Intubation
CPR means that someone is rhythmically and forcefully pushing on the patient’s chest. The patient and bed are both moving up and down. Moving targets are hard to hit at the best of times.
In emergency situations, I often choose a Macintosh curved blade. In my opinion, its broader flange is more forgiving of less than perfect placement, awkward positioning, and moving target: conditions common in the emergency intubation. It also makes balancing the patient’s head easier in those circumstances.
I usually get in position, visualize the larynx, and try to pass the tube. If movement prevents intubation, I say the command “stop CPR.” Pass the tube. I then say the command “begin CPR.” This attempt should take no longer than 15 to 20 seconds, usually less. If you have any difficulty passing the tube have your associates begin CPR again. Remove your blade, and ventilate the patient. Ventilation is the priority. Try again.
Video Laryngoscopy
Video laryngoscopy is another technique that can help in awkward positions. since my hospital has acquired Glidescopes I routinely bring one of ours to emergency intubations and I use it primarily rather than try direct laryngoscopy first. Video laryngoscopy makes difficult intubations faster, and reliably easier during cardiac arrest situations. It also makes intubation easier and less stimulating during emergency intubations for respiratory distress in the fragile patient.
It’s important your your helpers to clear a space for the video laryngoscopy monitor. Remind them that you must be able to see it during the key moments of the intubation — helpers have a tendency to step to the side of the bed to help, pushing it out of the way at inopportune moments.
Ideally the video laryngoscope you bring with you to an emergency is fully mobile. However I have intubated on the floor using a pole mounted glidescope on wheels by having another provider tilt the screen lower to the ground so that I could see it. The monitor ended up being on its side, but the view was clear and allowed me to see what I needed to see.
Don’t Delay Compressions But Do Provide Ventilation
Never delay CPR for an extended period because of an intubation attempt. If you have any difficulty passing the tube have your associates begin CPR again. Remove your blade, and ventilate the patient. Ventilation is the priority. If you have to place a device such as a laryngeal mask airway to ensure ventilation until you are in a better position to intubate, don’t hesitate to do so. This is far from ideal as cardiac arrest victims are at high risk of potentially massive emesis, but ventilation is key.
Following intubation, suction the tube and trachea carefully to remove any possible secretions and blood aspirated during the resuscitation.
May The Force Be With You!
Christine Whitten MD,
Author, Anyone Can Intubate: A Step by Step Guide, 5th Edition
and
Pediatric Airway Management: A Step by Step Guide
Hi Christine,
I am pleasure to read your post while I am preparing a clinical session to my co workers about CPR and airway management.
We are anesthesiologist and Intubation in this context is a challenge aniway.
ERC guideliness says that you should not stop chest compressions fore more than 5 seconds to get the intubation! Sometimes it is really a challenge.
Regards
Julia
There is no question that avoiding interruption in chest compressions is a major challenge. However, is it easier if the team communicates well and anticipates next steps. I am finding that review and critiquing of teamwork and communication with your students is equally important to making sure your providers know how many chest compressions to give with how many breaths. I highly recommend TeamSTEPPS.
Interesting article, but with all the delays and the focus on compressions, would it not be better to focus on getting airway management done with supraglottic devices and once ROSC occurs if needed to secure a airway the with an ET ?
Thank you for your observation. Intubation in the average patient can be performed fairly quickly during cardiac resuscitation with chest compressions. The reason to try to secure the airway with intubation is that patients who are in shock or cardiac arrest are at very high risk of vomiting and aspiration. During my career, I have seen several instances of massive emesis during CPR. You can also supply much more reliable ventilation through an endotracheal tube during the compression cycle, rather than wait for the 30:2 pause for ventilation. However, having said that if there is any difficulty with intubation, use of an supraglottic airway can be a good temporizing measure. To protect against aspiration, using an SGA that allows suction of the stomach, such as an LMA Supreme, would be preferred to protect from the high aspiration risk.
I thought cricoid pressure was controversed and not really EBM…