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.

Source

2/06 DONALDSON (Adapted from Rosen, Lampe)

Authors: