so let's crack on with this so you're called to intubate a 25 year old gcs3 patient in ed
with a presumed drug overdose the nurse asks you what you require for intubation
so i really want you guys to have this down pat every time i go into theater
i check my checklist because i know that in theater almost everything's always there but some
things are missed every now and again like the suction or maybe you know the sucks and methodium
or the muscle muscle relaxant storage box isn't taken out of the fridge whatever it is and when
you go into other foreign environments sometimes you will not know what their equipment is and you
won't have any familiarity i want you to make sure that in 10 seconds you know exactly that you've
got everything you need for a safe intubation and you never delay an intubation uh because you you
you know you think you don't have stuff likewise i don't want you to ever go ahead with an intubation
because you think you have everything ready but you actually don't i want you guys to
write down everything you want monitoring-wise medication-wise and airway equipment-wise under
those categories that i've provided there just write them down all the things the minimal stuff
you need this is definitely variable will change with your experience um for example when you're
a junior you might just really want to a video ring scope every single time that's really fair
just in terms of the crucial stuff that i thought might be necessary from monitoring
blood pressure fats and co2 i might be cheating but i'll put those two together
um ecg and abyss i like what you said because you said all the stuff that i would use i always have
a blood pressure stats that's monitoring end tidal co2 maybe even an ecg would you stop would you not
go ahead so would you not go ahead if you didn't have biz or would you not care about that too much
i guess that would depend on my level of comfort at the time with say something like tiva
um if we can use volatiles instead then i wouldn't necessarily need a bit because i could titrate
according to mac yep that's fair and my thought is that i always go ahead without beers i meant
to say um because i never i can never really get that on the wards and it doesn't really change
in the acute setting i always give a pretty good dose of profile or midazolam or whatever and it
never seems to make a difference so you and again you'll you'll see with your experience whether
that's the case or not so don't just believe me on that um but it would be one of those things
i'd really need but everything else with your monitoring perfectly right keep going okay um
medications wise i guess i just considered my basic anesthetic drugs as well as emergencies um
so i guess i'm a little less confident with these ones but i thought of propofol um fentanyl
such a methodium uh sibo fluorine for an inhaled anaesthetic and then i guess i was thinking like
rescue drugs wise if someone dropped their bundle maybe adrenaline as a first line yep but then i
sort of got into the weights i wasn't really sure now that's that's actually perfect you always need
sleepy stuff and propofol is always very easy to use and very comfortable from with most people in
its use so profile you definitely need a muscle relaxant to get the tube down and one of the
the quickest acting is such smotherium whether you said that or rocurine completely fine but
generally in ed you'll need a rapid sequence so you need a fast acting one and then i think so
this is what i call my spa drugs sp aaa and every anesthetic especially in difficult patients you'll
end up always giving aramine or adrenaline or atropine so i always have those ready as well
definitely depending on the situation you'd want to have dental or an opioid and fluids as well
but yeah the spa drugs are those and you you approach those absolutely correctly
uh habit airway equipment what would you do so yeah so thanks for the
hint um so obviously as you mentioned uh right fitting mark i wasn't completely sure about
i thought just general airway devices so either lma egt um b i thought that might be a bougie
in terms of trying to access the difficult airway yep um lns i thought laryngoscope and suction and
i actually wasn't sure what um e might be unless that was like ect yeah that's ett it just helped
the mnemonic that was passed down to me um there's all versions of this mnemonic but again it helps
me mask and airways uh you know in worst case scenario i need masks adele's referendums and lms
that's masking airways bees boujee and stilette again in ed every induction outside of operating
theaters are always more difficult and i'll almost always need a bougie especially if there's things
like you know trickier patients manual inline stabilization if they've got a c-spine fracture
and it's used very commonly ett and multiple sizes size in the worst airways you need a
size 6 tube because it's so much harder to get it through boujee sometimes but you need a few
ranges of range of egts as well depending on your experience two laryngoscopes always have a size
four business size three sometimes doesn't reach the molecular the point just above the epiglottis
and check that those are working and then suction suction is the one thing you can't fake if you
don't have that circuit with multiple connections working absolutely perfectly you can't exactly
get you know a straw and try to help you know help yourself out there it's just really ridiculous so
suction is one of those things you really want to have you can't just go grab and
grab suction from the next theater it's got to be working and the pipes have to be working whereas
if i don't have a syringe or don't have an ett i can always grab it from somewhere else that said
i do this checklist every morning without fail and that just makes sure that nothing's ever missing
and i just encourage you guys to do that as well the 4m the fourth m is the machine check or having
a lydell bag ready the machine is just a very complex little bag so i need to either have that
checked or outside of the operating theatre i need a ladel bag at the very very least this
can definitely change depending on where you are and how experienced you are as well okay would you
mind explaining what this is a bizarre spectral index monitoring it's just a proprietary algorithm
of a very limited eeg all that eeg data is then reproduced to present a number if the
numbers between 40 and 60 that's anesthesia surgical anesthesia 60 to 80 is thought to be
sedation and 80 and above is thought to be you know an awareness range um so having a biz has
some evidence and some contradictory evidence that doesn't work as well essentially where i'd use it
is two two reasons i'm running total intravenous anesthesia or teether because that's a higher
risk of awareness because you can't monitor how much propofol is in your bloodstream if i was
to run volatile you can always monitor the end tidal concentration very accurately and there's
no um and as i mentioned in the chat there's no evidence of awareness above 0.7 mac in any cases
but you're not really sure how much profile you're giving so biz is kind of a bit of a
standard to show that you're seen to be doing the right thing also the patient
is likely to need very low levels of anesthesia because they're very unstable so think about
the massive blood loss case where you need to just order really in a cardiac [ __ ] case we
have to run really low levels of volatile because they're so unstable due to the hemodynamic effects
of the anesthetic then i'd run biz to see how low i can go whilst keeping my patients stable
so really just two incidences that i would use it in um i don't there's there's really some
interesting evidence to show that it might not work at all but that's a whole other topic as
well uh you'd be very safe in using it for those two circumstances no worries at all