Intubation

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

• 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
• Ventilator
• Suction
• Intubation adjuncts (bougie, lighted stylet, etc)
• BVM
• OPA/NPA
• Method of preoxygenation (NC, NRB, C-PAP, etc)
• Nasal cannula for apneic oxygenation

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

Special Situations

Severe Metabolic Acidosis

• Further drop in pH during intubation can be catastrophic

1. NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
2. Attach end-tidal CO2 and observe value
3. Push RSI meds
4. Turn the respiratory rate to 12
5. Perform jaw thrust
6. Wait 45sec
7. Intubate
8. Re-attach the ventilator
9. Immediately increase rate to 30
10. Change Vt to 8cc/kg
11. Change flow rate to 60 LPM (normal setting)
12. Make sure end-tidal CO2 is at least as low as before

Active GI Bleed

1. Empty the stomach
   • Place an NG and suction out blood
     • Varices are not a contraindication
   • Metoclopramide 10mg IV
     • Increases LES tone
2. Intubate with HOB at 45°
   • Consider Glidescope
3. Preoxygenate!
   • Want to avoid bagging if possible
4. Intubation meds
   • Use sedative that is BP stable (etomidate, ketamine)
   • Use paralytics (actually increases LES tone)
5. If need to bag:
   • Bag gently and slowly (10BPM)
   • Consider placing LMA
6. If pt vomits place in Trendelenberg
7. 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