GuidelinesOther guideline
FASTHUG
The following evidence based interventions have been shown to decrease the time of intubation and impact on morbidity and mortality.
Other additional measures for all intubated patients in Emergency Centre
Emergency Centres intubate and ventilate patients as part of daily practise and these patient’s length of EC stay are increasing due to the limited availability of Intensive Care Unit (ICU) beds.
The Emergency Centre have the first opportunity to provide appropriate critical care and in doing so impact on morbidity and mortality.
| Feeding | Assess safety /appropriateness of oral feeding? If not, consider enteral feed via NGT or parenteral where available. Early feeding prevents mucosal translocation of bacteria with subsequent systemic infection. |
| Analgesia | Provide aggressive appropriate analgesia to relieve pain, beware of excessive dosing. Opioids are the drug of choice (fentanyl, remi-fentanyl, morphine) |
| Sedation | Optimise comfort level of the patient without over sedation. Aim for a comfortable, cooperating,calm patient. Using sedation scales to quantify the sedation is appropriate.* |
| Thromboembolism | Prophylaxis with Unfractionated Heparin 5000 U 8 hrly sc. or LMWH (low-molecular-weight heparin) or mechanical adjuncts (compression stockings / pneumatic inflatable stockings) |
| Head elevation | Elevate head of bed to30° - 45° except if contraindications present e.g. compromising CPP (cerebral perfusion pressure) |
| Ulcer prophylaxis | Consider Sucralfate, H2antagonists or PPI’s (proton pump inhibitors) |
| Glucose control | Manage hyperglycaemia (target 8 - 10 mmol/l) aggressively with vigilance to prevent hypoglycaemia. |
*Ramsay sedation scale
| Awake | 1 | Patient anxious,agitated, restless or both |
| 2 | Patient cooperative,oriented & tranquil | |
| 3 | Patient responds to commands only | |
| Awake | 4 | A brisk response to alight glabellar tap or loud auditory stimulus |
| 5 | A sluggish response to a light glabellar tap or loud auditory stimulus | |
| 6 | No response to alight glabellar tap or loud auditory stimulus |
Other additional measures for all intubated patients in Emergency Centre
| Secure Endotracheal Tube | Adhesive plaster e.g.“Elastoplast” or commercial ETT securing device. |
| Heat Moisture Exchanger HME | Heat & moisture addition to breaths (simulates the physiological function of the nasal passages) |
| In-line Suction | Decrease suction difficulty, improves infection control, minimises loss of PEEP & decrease atelectasis (suction-related alveolar de-recruitment) |
| Continuous Capnography | Is the standard of care for confirmation of ETT placement. Assists in detecting of airway catastrophes (ETT displacement / kinked / obstructed ETT), cardiac arrest and appropriate ventilation settings (hyper / hypo-capnoea) |
| ETT Cuff Pressure monitoring | 20-30 cm H20 (Estimation by feel is inaccurate) measure cuff pressure Appropriate cuff pressure prevents micro-aspiration & VAP (low pressures) and prevents subglottic stenosis (increased cuff pressure) |
| In-Line Nebulizers | Intubated Asthma/COPD and inhalational burns patients |
| Naso / Orogastric Tube | Intubated patients require gastric decompression to ↓ aspiration risk, Oro-gastric tubes → advantage to cause less nosocomial sinusitis. |