Attending here. Here's some thoughts from my practice...
I personally like pre-treating with reglan/erythromycin. Usually I'm volume resuscitating these patients and providing O2 via high flow NC+Non-rebreather and if you give it right away, then it has time to work while you are resuscitating/oxygenating/setting up to intubate these patients.
I intubate with the head of bed at at least 30-45 degrees always
Avoid bagging these patients if at all possible. The most experienced operator tubes these patients. Period. Aggressive pre-oxygenation is the order of the day. I don't know why some people push paralytics and then proceed to ambubag the patient who's sats are 100%. I've seen attendings and experienced RT's do this, and the only thing you're doing is potentially insufflating the stomach more. It adds zero benefit.
Everyone of these intubations gets a dual suction setup. Two yankauers, two canisters, two wall suction ports...If you can't do that, then piggyback the canisters inline so you don't run out of space. Also, you can have one yankauer and a "suction as you go" ETT (search EM crit for this, it's pretty spiffy). The time to construct this setup/figure it out is on a slow day when you have time and not right before you intubate them.
Awake fiberoptic is great, I use 2mg/kg of ketamine IV, then I can suction, place NG, etc if I need to before I push paralytics.
Agree with comments above about Roc, but I also think there is some value to using succinylcholine in these patients because its onset of action is faster than rocuronium, especially if you are going to just do RSI with etomidate as opposed to a facilitated/awake look or delayed sequence intubation. What you don't want is the etomidate-induced myoclonus in these patients, which occurs in around 10% of patients.
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Variceal bleed/hematemesis intubations
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