A protocol for the management of intubated patients in by axe11963


                  THE A&E DEPARTMENT
                       Patrick Nee

See also ‘CT head scanning for out- of- hours neurological emergencies’

INDICATIONS        Actual or impending airway obstruction
                   Eg. Burns, facial fractures, altered consciousness
                   Hypoxia unresponsive to supplemental oxygen/ bag-
                   valve-mask support
                   Coma, exhaustion, hypoventilation
                   Cardiac arrest
                   Preparatory to CT scanning in obtunded patient

PERSONNEL          Anaesthetist, ODP, A&E Nurse (most senior nurse
                   allocated to Resuscitation), A&E senior doctor, A&E junior

EQUIPMENT          Bag, valve mask device, high flow oxygen
                   Yankauer suction, laryngoscopes, Gum elastic bougie,
                   stylet and selection of ET tubes, tube ties
                   NG tube, urinary catheter
                   Difficult airway cart, fibre-optic laryngoscope and light
                   Portable ventilator

DRUGS              Anaesthetist will select from:
                   Etomidate, Sodium Thiopentone (+water), Propofol,
                   Midazolam, Fentanyl
                   Suxamethonium, Atracurium, Pancuronium

MONITORING         ECG, NIBP, SpO2, ETCo2 (calibration takes up to 15
                   minutes). Arterial line as indicated by senior doctor

OTHER              In certain circumstances the anaesthetist may call for an
                   anaesthetic machine plus volatile anaesthetic agents;
                   (Isoflurane, Sevoflurane). Liase with theatre and ODP.

PROCEDURE          Performed by the anaesthetist, supported by other
                   clinicians as above. Pre-oxygenation, rapid sequence
                   induction of anaesthesia with muscle relaxation followed
                   by orotracheal intubation. Cricoid pressure applied by
                   experienced assistant

                       Will be determined by the condition and directed by the
                       senior doctor present. All patients who have been
                       intubated for > 30 minutes and for whom active treatment
                       is ongoing should be made known to the ICU team. The
                       responsibility for this lies with the senior attending
                       Medical AED staff. Intubated patients should not
                       normally wait in the resuscitation room for more than
                       ONE HOUR before transfer to definitive care


       Refers to patients intubated for CT
       Senior doctor makes a decision on likely disposal while the patient is
       still in the CT suite:

Likely Outcome                            Action

Extubate for likely recovery              Return to resuscitation room
Extubate for TLC (1) (2) (3)              Return to resuscitation room
Transfer to other hospital (4)            Return to resuscitation room
Early transfer to Theatre (5) (6)         Transfer direct from CT suite
Early transfer to ICU (5) (6)             Transfer direct from CT suite

(1) Senior doctor determines that the injury is not survivable. Options for
    disposal include: Cubicle 10 or Observation Ward (only where death
    expected within 1 hour), or other ward appropriate to condition.
(2) Transfer to ICU solely for the purposes of organ harvesting is not
(3) Intravenous Morphine should be administered in doses adequate to
    relieve the patient’s distress. Intra-cranial haemorrhage should be
    expected to cause significant pain.
(4) Eg Walton, CTC, RLUH, AHCH, Aintree
(5) If any delay is anticipated before internal transfer (ICU, Theatre) then
    return the patient to Resuscitation Room.
(6) The patient should not generally wait more than ONE HOUR in the
    resuscitation room before transfer to definitive care.

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