We’ve all been there. The patient in respiratory distress (or any other reason) that you’ve now decided needs an intubation. You’re all set up, you’ve done your checklist, you’ve done your time out, and the meds have gone in. You wait till you think the meds have probably worked and slide the blade into the mouth only to find the patient fighting the jaw opening or the vocal cords (if you got that far) still moving. There are no good options at that point and now you’re mentally kicking yourself for not adequately paralyzing the patient prior to your attempt. Oops…

It’s common teaching (and well studied) that first pass success is key to better outcomes post intubation and that adequate paralysis is a key to first pass success. So what can you do to make sure you get perfect paralysis every time? One method published in the Journal of EM is using waveform capnography during induction to determine paralysis. How does this work in a practical sense? Many places (including Sinai) have NC with waveform attachments. Just use that instead of the standard NC and have it plugged in and monitoring. Look for a flatline waveform after paralysis for about 10 seconds (if you can wait that long) and go for your intubation knowing you have adequate paralysis on board.

Bottom Line: Use the waveform capnography NC for preoxygenation and induction to guarantee success.



Waveform capnography: an alternative to physician gestalt in determining optimal intubating conditions after administration of paralytic agents.  Emerg Med J. 2017 Oct 10. pii: emermed-2017-206922. doi: 10.1136/emermed-2017-206922.

Special thanks to Journal Feed for bringing this article to my attention. 

May 2024