Intubation

Revision as of 11:48, 26 August 2015 by Rossdonaldson1 (talk | contribs) (Severe Metabolic Acidosis)

Indications

  • Failure to ventilate
  • Failure to oxygenate
  • Inability to protect airway
    • Gag reflex is absent at baseline in ~1/3 of people[1], so lack of gag reflex is inadequate in determination of ability to protect airway.
  • Anticipated clinical course (anticipated deterioration, need for transport, or impending airway compromise)
  • Combative patient who needs imaging (suspicion of intracranial process, etc)

Absolute Contraindications

  • No absolute contraindications when performed as an emergent procedure.

Relative Contraindications (Mnemonics for Predicting Difficulties)

Difficult BVM (MOANS)

  • Mask seal
  • Obesity
  • Aged
  • No teeth
  • Stiffness (resistance to ventilation)

Difficult Intubation (LEMON)

  • Look externally (gestalt)
  • Evaluate 3-3-2 rule
  • Mallampati
  • Obstruction
  • Neck mobility

Equipment Needed

  • Medications
    • Induction agent
    • Paralytic agent
  • Laryngoscope (type based on clinical indication and provider preference)
    • Direct laryngoscope with blade of provider's choice or
    • Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) or
    • Fiberoptic device
  • Endotracheal tube
  • End-tidal CO2 device (colorimetric or quantitative)
  • Ventilator
  • Suction
  • Intubation adjuncts (bougie, lighted stylet, etc)
  • BVM
  • OPA/NPA
  • Method of preoxygenation (NC, NRB, C-PAP, etc)
  • Nasal cannula for apneic oxygenation

Procedure

Initial ventilation settings

Disease Tidal Volume (mL/kg^) Respiratory Rate I:E PEEP FiO2
Traditional 8 10-12 1:2 5 100%
Lung Protective (e.g. ARDS) 6 12-20 1:2 2-15 100%
Obstructive (e.g. bronchoconstriction) 6 5-8 1:4 0-5 100%
Hypovolemic 8 10-12 1:2 0-5 100%

^Ideal body weight

Complications

Special Situations

Severe Metabolic Acidosis

Further drop in pH during intubation can be catastrophic

  • NIV (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 medications
  • 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

Active GI Bleed

  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

Mechanical Ventilation Pages

References

  1. Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.