We are thrilled to announce the next installment of ALiEM CAPSULES: Pharmacology of Emergency Airway Management (part 1), which was just published to the ALiEMU site. This is the first part of a 2-part course focusing on the pharmacology of the emergency airway. For this CAPSULES module we are introducing a multimedia-enhanced learning experience. You will find HD videos throughout the module providing further educational content. Some of the quizzes are also accompanied by video cases followed by a question based on the case you just watched. If you cannot use audio on your device, no problem, all videos are closed captioned (just hit the CC button in the YouTube window). We hope these videos further enrich your ALiEMU CAPSULES educational experience and we welcome any suggestions or comments!

Go to the ALiEMU module on the Pharmacology of Emergency Airway Management (Part 1).

Role Team Member Background Authors Chris Edwards, PharmD, BCPS

@emergencypharm Emergency Medicine Pharmacist, University of Arizona Medical Center Rob Pugliese, PharmD, BCPS

@theEDpharmacist Emergency Medicine Pharmacist, Thomas Jefferson University PharmD Reviewer Meghan Groth, PharmD, BCPS

@EMpharmgirl Emergency Medicine Pharmacist, University of Vermont Medical Center Physician Reviewer Lewis Nelson, MD, FAACT, FACMT, FACEP

@LNelsonMD Professor of Emergency Medicine, New York University Creator and Lead Editor Bryan Hayes, PharmD, DABAT, FAACT

@PharmERToxGuy Emergency Medicine Pharmacist, Clinical Associate Professor; University of Maryland Chief of Design and Development Chris Gaafary, MD

@cgaafary EM Chief Resident, University of Tennessee Chattanooga

Course 3 Outline

Review of the medications that should be planned for and prepared alongside critical supplies required for intubation

The role of preoxygenation and apneic oxygenation

Choosing medications to facilitate awake intubation

Sedation methods for delayed sequence intubation

The pediatric airway

Summary

1. The 7’Ps of RSI

Medications should be planned for and prepared alongside the other critical supplies required for intubation including: Pretreatment, oxygenation, induction and paralytic selection, post-intubation analgesia/sedation Communicate all plans clearly with the team



2. Preoxygenation and apneic oxygenation

Standard pre-oxygenation: Non-rebreather mask with oxygen turned up past 15L max indicator

Apneic oxygenation: Oxygen via nasal cannula set at 15L or higher during apneic period and throughout intubation attempt.

Both strategies should be utilized for a majority of intubation situations

3. Awake Intubation

Topical anesthetics to facilitate intubation of awake patient 4% lidocaine solution atomized into airway using nasal or naso-tracheal delivery system 2% viscous lidocaine gargled by patient 2% lidocaine jelly used as lubricant on endotracheal tube Max total lidocaine dose is 300mg (based on data for intradermal use)

There are numerous modalities for providing conscious sedation for awake intubation with consideration for prevention of oversedation and the unique pharmacology of the sedative agent selected

4. Delayed sequence intubation (procedural sedation for preoxygenation)

Ketamine studied at dose of 1mg/kg slow IV push followed by 0.5mg/kg additional doses until adequate dissociation was achieved (average dose used 1.4mg/kg)

Once sedated, oxygenation can occur via non rebreather or positive pressure ventilation for three minutes

After preoxygenation, assess level of sedation from initial sedative dose prior to administering paralytic for intubation

5. The Pediatric Airway

Know where your pediatric equipment and resources are located and practice using them before you encounter a child requiring emergent airway management

Preparation and practice with actual pediatric equipment and supplies, especially in primarily adult institutions, is the key to optimizing care in this population

The Broselow® Pediatric Emergency Tape has pre-calculated doses for most meds used in RSI/PALS and also equipment sizes (endotracheal tube size).

Read more about The CAPSULES series.