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): useful for incr ICP, severe asthma
2. Fentanyl (3mcg/kg): useful for ischemic CAD, incr ICP, aortic dissection
3. Atropine (0.02mg/kg): useful for children <10 yrs

^consider ketamine (1.5mg/kg) in place of etomidate for induction in asthma

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

1. Look externally (gestalt)
2. Evaluate 3-3-2 rule
3. Mallampati
4. Obstruction
5. Neck mobility

Laryngoscopy Grades (Cormack & Lehane)

Grade	View	Failure Rate
I	whole aperture	0%
IIa	ayretenoids +partial cords	4%
IIb	ayretenoids only	67%
III	epiglottis only	>67%
IV	no epiglottis	?%

Nasal Intubation

1. sniffing position (like oral ET)
2. pretreat with lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
3. Tube size = 1.0 mm smaller
4. listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
5. 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

Difficult Airway Algorithm

Rapid Sequence Intubation (RSI)

Source

2/06 DONALDSON (Adapted from Rosen, Lampe)