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
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)
Grade |
View |
Failure Rate |
I |
whole aperture | 0% |
IIa |
ayretenoids +partial cords | 4% |
IIb |
ayretenoids only | 67% |
III |
epiglottis only | >67% |
IV |
no epiglottis | ?% |
Severe Metabolic Acidosis
- Further drop in pH during intubation can be catastrophic
- Ventilate (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
- Attach end-tidal CO2 and observe value
- Push RSI meds
- Turn the respiratory rate to 12
- Perform jaw thrust
- Wait 45sec
- Intubate
- Re-attach the ventilator
- Immediately increase rate to 30
- Change Vt to 8cc/kg
- Change flow rate to 60 LPM (normal setting)
- Make sure end-tidal CO2 is at least as low as before
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
Rapid Sequence Intubation (RSI)
Source
Rosen EMCrit #3