Extubation

Inherently more relaxing than intubation, extubation is nevertheless potentially hazardous. It should rarely occur in the ED. Patients who are recovering their protective airway reflexes may "fight" the tube yet still need to remain intubated. Instillation of 1 to 2 mL of 4% lidocaine (sterile for injection) down the Et tube will decrease bucking. The absorption of lidocaine via the airway yields a maximum serum level that is only slightly lower than that from an equivalent intravenous dose.

Prior to extubation, consider the impact of metabolic or circulatory abnormalities. The patient should be checked for respiratory insufficiency, and nasogastric decompression is advised. On command, the patient should have an inspiratory capacity of at least 15 mL/kg. Ideally there should be no intercostal or suprasternal reactions, and the patient's grip should be firm.

After suctioning secretions, assure adequate oxygenation and explain the procedure to the patient. Positive-pressure ventilation using a mask will help to exsufflate secretions while the cuff is deflated. At the end of a deep inspiration, to prevent secretory reaccumulation, remove the tube and oxygenate by mask.

Closely observe the patient for stridor. Postextubation laryngospasm is initially treated with oxygen by positive pressure. If necessary, nebulized racemic epinephrine (0.5 mL of 2.25% epinephrine in 4-mL saline) often helps.

CHAPTER REFERENCES

1. Takahata O, Kubota M, Mamiya K, et al: The efficacy of the "BURP" maneuver during a difficult laryngoscopy. Anesth Analg 84:419, 1997.

2. Barnhard WN, Cottrell JE, Sirakumarana C, et al: Adjustment of intracuff pressure to prevent aspiration. Anesthesiology 50:313, 1979.

3. Ward KR, Yealy DM: End-tidal carbon dioxide monitoring in emergency medicine, Part 2: clinical applications. Acad Emerg Med 5:637, 1998.

4. Bozeman WP, Hexter D, Liang HK, Kelen GD: Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation. Ann Emerg Med 27:595, 1996.

5. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice Guidelines for Management of the Difficult Airway. Anesthesiology 78:597, 1993.

6. Reed DB, Clinton JE: Proper depth of placement of nasotracheal tubes in adults prior to radiographic confirmation. Acad Emerg Med 4:1111, 1997.

7. Hooker EA, Hagan S, Coleman R, et al: Directional-tip endotracheal tubes for blind nasotracheal intubation. Acad Emerg Med 3:586, 1996.

8. Rosen CL, Wolfe RE, Chew SE, et al: Blind nasotracheal intubation in the presence of facial trauma. J Emerg Med 15:141, 1997.

9. Margolis GS, Menegazzi J, Abdlehak M, et al: The efficacy of a standard training program for transillumination-guided endotracheal intubation. Acad Emerg Med 3:371, 1996.

10. van Stralen DW, Rogers M, Perkin RM, et al: Retrograde intubation training using a mannequin. Am J Emerg Med 13:50, 1995.

11. Ma OJ, Bentley B II, Debehnke DJ: Airway management practices in emergency medicine residencies. Am J Emerg Med 13:501, 1995.

12. Sakles JC, Laurin EG, Rantapaa AA, et al: Airway management in the emergency department: A one-year study of 610 tracheal intubations. Ann Emerg Med 31:325, 1998.

13. Sivilotti MLA, Ducharme J: Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study. Ann Emerg Med 31:313, 1998.

14. Zink BJ, Snyder HS, Raccio-Robak N: Lack of a hyperkalemic response in emergency department patients receiving succinylcholine. Acad Emerg Med 2:974, 1995.

15. Mallampati SR, Gatt SP, Gugino LD, et al: A clinical sign to predict difficult tracheal intubation: A prospective study. Can Anaesth Soc J 32:429, 1985.

16. Brain Trauma Foundation: The use of hyperventilation in the acute management of severe traumatic brain injury. J Neurotrauma 13:699, 1996.

17. Schwartz DE, Matthay MA, Cohen NH: Death and other complications of emergency airway management in critically ill adults: A prospective investigation of 297 tracheal intubations. Anesthesiology 82:367, 1995.

18. Thibodeau LG, Verdile VP, Bartfield JM: Incidence of aspiration after urgent intubation. Am J Emerg Med 15:562, 1997.

19. Vandenberg JT, Rudman NT, Burke TF, et al: Large-diameter suction tubing significantly reduces evacuation time of simulated vomitus. Am J Emerg Med 16:242, 1998.

20. Orebaugh SL: Initiation of mechanical ventilation in the emergency department. Am J Emerg Med 14:59, 1996.

21. Antonelli M, Conti G, Rocco M, et al: A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429, 1998.

BIBLIOGRAPHY

USPDI, vol I. 19th ed, 1999, Micromedia and the US Pharmacopeia Connection.

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