A PROTOCOL FOR THE MANAGEMENT OF INTUBATED PATIENTS IN 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 doctor 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 source 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 present 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 SUBSEQUENT ACTION 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 EXIT STRATEGY 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 NOTES (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 appropriate. (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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