Difference between revisions of "Intubation"

(Created page with "==Indications== 1) Failure to ventilate 2) Failure to oxygenate 3) Inability to protect airway (gag unhelpful) 4) Anticipated clinical course (anticipated deterioration, tra...")
 
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==Indications==
 
==Indications==
 
  
 
1) Failure to ventilate
 
1) Failure to ventilate
 
 
2) Failure to oxygenate
 
2) Failure to oxygenate
 
 
3) Inability to protect airway (gag unhelpful)
 
3) Inability to protect airway (gag unhelpful)
 
 
4) Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise)
 
4) Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise)
 
 
*5) Increased ICP (for hyperventilation)
 
*5) Increased ICP (for hyperventilation)
 
 
*6) Combative, needing imaging
 
*6) Combative, needing imaging
 
 
  
 
==Premedication==
 
==Premedication==
 
  
 
1) Lidocaine (1.5mg/kg): inc ICP, severe asthma
 
1) Lidocaine (1.5mg/kg): inc ICP, severe asthma
 
 
2) Fentanyl (3mcg/kg): ischemic CAD, inc ICP, aortic dissect
 
2) Fentanyl (3mcg/kg): ischemic CAD, inc ICP, aortic dissect
 
 
3) Atropine (0.02mg/kg): children <10 yrs
 
3) Atropine (0.02mg/kg): children <10 yrs
 
 
 
 
*consider ketamine (1.5mg/kg) in place of etomidate for induction in asthma
 
*consider ketamine (1.5mg/kg) in place of etomidate for induction in asthma
 
== ==
 
 
  
 
==Difficult BVM (MOANS)==
 
==Difficult BVM (MOANS)==
 
  
 
Mask seal
 
Mask seal
 
 
Obesity
 
Obesity
 
 
Aged
 
Aged
 
 
No teeth
 
No teeth
 
 
Stiffness (resistance to ventilation)
 
Stiffness (resistance to ventilation)
 
 
"Remove dentures to intubate; keep them in to bag/mask ventilate"
 
"Remove dentures to intubate; keep them in to bag/mask ventilate"
 
 
  
 
==Difficult Intubation==
 
==Difficult Intubation==
 
  
 
Look externally (gestalt)
 
Look externally (gestalt)
 
 
Evaluate 3-3-2 rule
 
Evaluate 3-3-2 rule
 
 
Mallampati
 
Mallampati
 
 
Obstruction
 
Obstruction
 
 
Neck mobility
 
Neck mobility
 
 
  
 
==Laryngoscopy Grades  (Cormack & Lehane)==
 
==Laryngoscopy Grades  (Cormack & Lehane)==
 
  
 
I    whole aperture    (0%)
 
I    whole aperture    (0%)
 
 
II.a    ayretenoids +partial cords (4%)
 
II.a    ayretenoids +partial cords (4%)
 
 
II.b    ayretenoids only (67%)
 
II.b    ayretenoids only (67%)
 
 
III    epiglottis only (>67%)
 
III    epiglottis only (>67%)
 
 
IV    no epiglottis (?%)
 
IV    no epiglottis (?%)
 
 
 
 
*(failure rate)  
 
*(failure rate)  
 
 
  
 
==Nasal Intubation==
 
==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)
  
sniffing position (like oral ET)
+
tips: occlude other nostril to hear better, cricoid pressure when advancing, use a small suciton catheter as a seldinger guide, precurve tube before insertion.  
 
 
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==
 
==See Also==
 
  
 
Air/Resus: Airway (RSI)
 
Air/Resus: Airway (RSI)
 
 
Air/Resus: Rapid Sequence Intubation (RSI)
 
Air/Resus: Rapid Sequence Intubation (RSI)
 
 
  
 
==Source ==
 
==Source ==
 
  
 
2/06  DONALDSON (Adapted from Rosen, Lampe)
 
2/06  DONALDSON (Adapted from Rosen, Lampe)
 
 
 
  
 
[[Category:Airway/Resus]]
 
[[Category:Airway/Resus]]

Revision as of 08:25, 2 March 2011

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)