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

Pneumonics for Predicting Difficulties

Difficult BVM (MOANS)

1. Mask seal
2. Obesity
3. Aged
4. No teeth
5. Stiffness (resistance to ventilation)

"Remove dentures to intubate; keep them in to bag/mask ventilate"

Difficult Intubation (LEMON)

1. Look externally (gestalt)
2. Evaluate 3-3-2 rule
3. Mallampati
4. Obstruction
5. Neck mobility

Difficult Extraglottic Device (RODS)

1. Restricted motnh opening
2. Obstruction
3. Distorted airway
4. Stiff lungs or neck (c-spine)

Difficult Critcothyrotomy (SHORT)

1. Surgery
2. Hematoma
3. Obesity
4. Radiation (Burn or other distortion)
5. Tumor

Nasal Intubation

1. sniffing position (like oral ET)
2. pretreat with lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
3. Tube size = 1.0 mm smaller
4. listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
5. 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.

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

GI Bleeder

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

See Also

• Difficult Airway Algorithm
• Rapid Sequence Intubation (RSI)
• Ventilation (Main)
• LMA
• Needle cricothyrotomy
• Deterioration After Intubation (DOPE)
• DL vs VL

Source

Rosen

EMCrit Podcasts 3, 4, 5