Intubation
Revision as of 11:47, 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% |
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
- Empty the stomach
- Place an NG and suction out blood
- Varices are not a contraindication
- Metoclopramide 10mg IV
- Increases LES tone
- Place an NG and suction out blood
- Intubate with HOB at 45°
- Consider Glidescope
- Preoxygenate!
- Want to avoid bagging if possible
- Intubation meds
- Use sedative that is BP stable (etomidate, ketamine)
- Use paralytics (actually increases LES tone)
- If need to bag:
- Bag gently and slowly (10BPM)
- Consider placing LMA
- If pt vomits place in Trendelenberg
- If pt aspirates anticipate a sepsis-like syndrome
- May need pressors, additional fluid (not abx!)
See Also
- Difficult Airway Algorithm
- Rapid Sequence Intubation (RSI)
- Supraglottic airway
- Cricothyrotomy
- DL vs VL
- Nasal intubation
- Extubation
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Mechanical ventilation (main)
- Miscellaneous
References
- ↑ Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.