Extubation isn’t traditionally considered a core emergency medicine skill. However, there is definitely a role for the procedure if resources permit — either because access block is so bad and the patient has been in the department for days and has recovered (yes it does happen some places!) or because there really is no need for the patient to remain intubated in the short term (e.g. intubated purely for a scan).
George Douros from EDTeaching.com has developed this algorithmic guide to the process of extubation in the ED:
It is based on the work of Scott Weingart and the Difficult Airway Society guidelines.
There are other great FOAM resources on this topic here:
- DAS — Extubation guidelines
- EMCrit Podcast 35 – Extubation in the ED (with a link to Scott Weingart’s paper and his protocol)
- LITFL CCC — Laryngospasm and Post-extubation stridor
- PulmCCM.org — Tobin: “Minimal” PEEP and pressure support during SBT kills some patients (AJRCCM)
- Resus.ME — Extubation Guidelines (from the Difficult Airway Society)
- Trauma Professional’s Blog — Extubation in the Emergency Departmen
About Chris Nickson
This is top notch work
Hi Chris
There was a great couple of lectures on the topic a few years back on EM RAP: critical care edition
Cannot recall the guests names sorry -- ask Mel Herbert
They were really good
C
Good stuff Chris, as usual. Any thoughts on the other indication for extubation in the ED, i.e. at the end of life?
For example, the case of a catastrophic medical or traumatic event resulting in brain death with family interested in withdrawal of care at the bedside. Do it in the ED? Don’t? Best practices?
I’ve been waffling on this for a while now. Initially I thought it always best to admit to ICU or inpatient unit on vent and do it there. But having dealt with this several times now and considering limited resources, family dynamics/emotions, etc. I’m starting to lean the other way.
Hi David
Palliative extubation in the ED depends on many factors:
- patient
- family
- staff
- the department
When sufficient time and resources are available to provide palliation in the ED appropriately, and the family are on board, I think it is good practice. Where I currently work there is often a need to wait for family to arrive, which means admission to ICU in most cases. It is always important to think about organ donation -- which may also need some time to work through.
Chris