Intubation: Difference between revisions
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==GI Bleeder== | ==GI Bleeder== | ||
#Empty the stomach | #Empty the stomach | ||
##Place | ##Place an NG and suction out blood | ||
##Metoclopramide 10mg | ###Varices are not a contraindication | ||
##Metoclopramide 10mg IV | |||
###Increases LES tone | |||
#Intubate with HOB at 45° | #Intubate with HOB at 45° | ||
##Consider Glidescope | |||
#Preoxygenate! | #Preoxygenate! | ||
##Want to avoid bagging if possible | ##Want to avoid bagging if possible | ||
#Intubation meds | #Intubation meds | ||
##Use sedative that is BP stable ( | ##Use sedative that is BP stable (etomidate, ketamine) | ||
##Use paralytics (actually increases | ##Use paralytics (actually increases LES tone) | ||
#If | #If need to bag: | ||
##Bag gently and slowly (10BPM) | ##Bag gently and slowly (10BPM) | ||
#If vomits place in Trendelenberg | ##Consider placing LMA | ||
#If aspirates anticipate a sepsis-like syndrome | #If pt vomits place in Trendelenberg | ||
##May need pressors, additional fluid | #If pt aspirates anticipate a sepsis-like syndrome | ||
##May need pressors, additional fluid (not abx!) | |||
==Nasal Intubation== | ==Nasal Intubation== | ||
Revision as of 09:59, 14 May 2011
Indications
- Failure to ventilate
- Failure to oxygenate
- Inability to protect airway (gag unhelpful)
- Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise)
- Increased ICP (for hyperventilation)
- Combative, needing imaging
Difficult BVM (MOANS)
- Mask seal
- Obesity
- Aged
- No teeth
- Stiffness (resistance to ventilation)
"Remove dentures to intubate; keep them in to bag/mask ventilate"
Difficult Intubation
- Look externally (gestalt)
- Evaluate 3-3-2 rule
- Mallampati
- Obstruction
- Neck mobility
Severe Metabolic Acidosis
- Further drop in pH during intubation can be catastrophic
- Ventilate (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
- Attach end-tidal CO2 and observe value
- Push RSI meds
- Turn the respiratory rate to 12
- Perform jaw thrust
- Wait 45sec
- Intubate
- Re-attach the ventilator
- Immediately increase rate to 30
- Change Vt to 8cc/kg
- Change flow rate to 60 LPM (normal setting)
- Make sure end-tidal CO2 is at least as low as before
GI Bleeder
- Empty the stomach
- Place an NG and suction out blood
- Varices are not a contraindication
- Metoclopramide 10mg IV
- Increases LES tone
- Place an NG and suction out blood
- Intubate with HOB at 45°
- Consider Glidescope
- Preoxygenate!
- Want to avoid bagging if possible
- Intubation meds
- Use sedative that is BP stable (etomidate, ketamine)
- Use paralytics (actually increases LES tone)
- If need to bag:
- Bag gently and slowly (10BPM)
- Consider placing LMA
- If pt vomits place in Trendelenberg
- If pt aspirates anticipate a sepsis-like syndrome
- May need pressors, additional fluid (not abx!)
Nasal Intubation
- sniffing position (like oral ET)
- pretreat with lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
- Tube size = 1.0 mm smaller
- listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
- when tube hits cords patient will cough, back up 1 or 2 cm. wait for beginning of inspiration, as patient begins inspiration advance 3-4 cm (tube should be 22-26cm in women, 23-28cm in men)
tips: occlude other nostril to hear better, cricoid pressure when advancing, use a small suciton catheter as a seldinger guide, precurve tube before insertion.
See Also
Rapid Sequence Intubation (RSI)
Source
Rosen
EMCrit Podcasts 3, 4, 5