Intubation: Difference between revisions
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*Failure to ventilate | *Failure to ventilate | ||
*Failure to oxygenate | *Failure to oxygenate | ||
*Inability to protect airway (gag | *Inability to protect airway | ||
*Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise) | **Gag reflex is absent at baseline in ~1/3 of people<ref>Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.</ref>, so lack of gag reflex is inadequate in determination of ability to protect airway. | ||
* | *Anticipated clinical course (anticipated deterioration, need for transport, or impending airway compromise) | ||
*Combative patient who needs imaging (suspicion of intracranial process, etc) | |||
==Contraindications== | ==Contraindications== | ||
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*Nasal cannula for apneic oxygenation | *Nasal cannula for apneic oxygenation | ||
== | ==Mnemonics for Predicting Difficulties== | ||
===Difficult BVM (MOANS)=== | ===Difficult BVM (MOANS)=== | ||
*'''M'''ask seal | *'''M'''ask seal | ||
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"Remove dentures to intubate; keep them in to bag/mask ventilate" | "Remove dentures to intubate; keep them in to bag/mask ventilate" | ||
===Difficult | ===Difficult Intubation (LEMON)=== | ||
*'''L'''ook externally (gestalt) | *'''L'''ook externally (gestalt) | ||
*'''E'''valuate 3-3-2 rule | *'''E'''valuate 3-3-2 rule | ||
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*'''N'''eck mobility | *'''N'''eck mobility | ||
===Difficult | ===Difficult Supraglottic Device (RODS)=== | ||
*'''R'''estricted motnh opening | *'''R'''estricted motnh opening | ||
*'''O'''bstruction | *'''O'''bstruction | ||
Revision as of 07:32, 10 August 2015
Indications
- Failure to ventilate
- Failure to oxygenate
- Inability to protect airway
- Gag reflex is absent at baseline in ~1/3 of people[1], so lack of gag reflex is inadequate in determination of ability to protect airway.
- Anticipated clinical course (anticipated deterioration, need for transport, or impending airway compromise)
- Combative patient who needs imaging (suspicion of intracranial process, etc)
Contraindications
- No absolute contraindications when performed as an emergent procedure.
Equipment Needed
- Medications
- Induction agent
- Paralytic agent
- Laryngoscope (type based on clinical indication and provider preference)
- Direct laryngoscope with blade of provider's choice or
- Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) or
- Fiberoptic device
- Endotracheal tube
- End-tidal CO2 device (colorimetric or quantitative)
- Ventilator
- Suction
- Intubation adjuncts (bougie, lighted stylet, etc)
- BVM
- OPA/NPA
- Method of preoxygenation (NC, NRB, C-PAP, etc)
- Nasal cannula for apneic oxygenation
Mnemonics 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 Supraglottic 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)
- Supraglottic airway
- Cricothyrotomy
- Deterioration After Intubation (DOPE)
- DL vs VL
- Nasal intubation
- Extubation
References
- ↑ Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.