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.
See Also
Air/Resus: Airway (RSI) Air/Resus: Rapid Sequence Intubation (RSI)
Source
2/06 DONALDSON (Adapted from Rosen, Lampe)