Intubation

Indications

1) Failure to ventilate

2) Failure to oxygenate

3) Inability to protect airway (gag unhelpful)

4) Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise)

• 5) Increased ICP (for hyperventilation)

• 6) Combative, needing imaging

Premedication

1) Lidocaine (1.5mg/kg): inc ICP, severe asthma

2) Fentanyl (3mcg/kg): ischemic CAD, inc ICP, aortic dissect

3) Atropine (0.02mg/kg): children <10 yrs

• consider ketamine (1.5mg/kg) in place of etomidate for induction in asthma

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

Laryngoscopy Grades (Cormack & Lehane)

I whole aperture (0%)

II.a ayretenoids +partial cords (4%)

II.b ayretenoids only (67%)

III epiglottis only (>67%)

IV no epiglottis (?%)

• (failure rate)

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

Air/Resus: Airway (RSI)

Air/Resus: Rapid Sequence Intubation (RSI)

Source

2/06 DONALDSON (Adapted from Rosen, Lampe)