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

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
    • 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

Source

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