Intubation: Difference between revisions
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#Increased ICP (for hyperventilation) | #Increased ICP (for hyperventilation) | ||
#Combative, needing imaging | #Combative, needing imaging | ||
==Contraindications== | |||
==Equipment Needed== | |||
==Pneumonics for Predicting Difficulties== | ==Pneumonics for Predicting Difficulties== | ||
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{{Difficult cricothyrotomy SHORT}} | {{Difficult cricothyrotomy SHORT}} | ||
==Procedure== | |||
==Complications== | |||
==Special Situations== | ==Special Situations== | ||
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#Make sure end-tidal CO2 is at least as low as before | #Make sure end-tidal CO2 is at least as low as before | ||
===GI | ===Active GI Bleed=== | ||
#Empty the stomach | #Empty the stomach | ||
#*Place an NG and suction out blood | #*Place an NG and suction out blood | ||
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*[[Extubation]] | *[[Extubation]] | ||
== | ==References== | ||
< | <References/> | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category:Procedures]] | [[Category:Procedures]] | ||
Revision as of 22:50, 19 July 2015
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
Contraindications
Equipment Needed
Pneumonics for Predicting Difficulties
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 (LEMON)
- Look externally (gestalt)
- Evaluate 3-3-2 rule
- Mallampati
- Obstruction
- Neck mobility
Difficult Extraglottic Device (RODS)
- Restricted motnh opening
- Obstruction
- Distorted airway
- Stiff lungs or neck (c-spine)
Predictors of Difficult Cricothyrotomy (SHORT)
- Surgery
- Hematoma
- Obesity
- Radiation (Burn or other distortion)
- Tumor
Procedure
Complications
Special Situations
Severe Metabolic Acidosis
- Further drop in pH during intubation can be catastrophic
- NIV (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
Active GI Bleed
- 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!)
See Also
- Difficult Airway Algorithm
- Rapid Sequence Intubation (RSI)
- Ventilation (Main)
- LMA
- Needle cricothyrotomy
- Deterioration After Intubation (DOPE)
- DL vs VL
- Nasal intubation
- Extubation