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)