Intubation 101Intubation 101

From start to finishFrom start to finish

ObjectiveObjective

Recognizing landmarks and Recognizing landmarks and anatomyanatomy

Overview of equipmentOverview of equipment Overview of techniquesOverview of techniques Ventilation vs. oxygenationVentilation vs. oxygenation RSIRSI

AnatomyAnatomy

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View of larynxView of larynx

Mallampati class Mallampati class

This test is supposed to be done on a This test is supposed to be done on a conscious and cooperative pt, sitting conscious and cooperative pt, sitting upright, leaning forward….not upright, leaning forward….not unresponsive in a ditch. unresponsive in a ditch.

You still need an airway!!!You still need an airway!!!

Non-traumatic position Non-traumatic position of head pre-intubation of head pre-intubation

Adult: Proper head to chest relationship Adult: Proper head to chest relationship for ventilation defined by a horizontal for ventilation defined by a horizontal line connecting the ear to sternal notchline connecting the ear to sternal notch

Children: Have large heads vs. adults Children: Have large heads vs. adults tend to have large chests. Proper head tend to have large chests. Proper head to chest position is defined by a to chest position is defined by a horizontal line connecting ear to horizontal line connecting ear to anterior shoulderanterior shoulder

Pre-intubation positionPre-intubation position

4 steps to patent 4 steps to patent airwayairway

1)1) Proper patient position Proper patient position -ear horizontal to sternum -ear horizontal to sternum

2)2) Insertion of oral or nasal airwayInsertion of oral or nasal airway

3)3) Lifting of the mandibleLifting of the mandible

4)4) Suctioning the airwaySuctioning the airway

Oxygenation and Oxygenation and VentilationVentilation Maximizing oxygenation requires Maximizing oxygenation requires

maximizing the inspired concentration maximizing the inspired concentration of O2 as well as effective elimination of O2 as well as effective elimination of carbon dioxide from the alveolas. of carbon dioxide from the alveolas.

DON’T HYPERVENTILATE!!!!DON’T HYPERVENTILATE!!!! Hyper-oxygenate Hyper-oxygenate with BVM or NRB with BVM or NRB

mask with high-flow O2. mask with high-flow O2.

BVM using small volume 6-7 cc/kg, BVM using small volume 6-7 cc/kg, over 1-2 seconds, low pressure over 1-2 seconds, low pressure

Cricoid PressureCricoid Pressure

Application of downward pressure at Application of downward pressure at the cricoid ring causes compression of the cricoid ring causes compression of the underlying esophagus prevents the underlying esophagus prevents passive regurgitation of stomach passive regurgitation of stomach contents.contents.– Recommeded during BVM ventilations with Recommeded during BVM ventilations with

pediatrics pediatrics

- - Over aggressive pressure causes tracheal Over aggressive pressure causes tracheal compression making it hard to bag or compression making it hard to bag or intubate!!!intubate!!!

Criciod PressureCriciod Pressure

Once criciod pressure has been Once criciod pressure has been applied, this should be continued applied, this should be continued until intubations is complete and until intubations is complete and verified. verified.

EquipmentEquipment

Curved blades or Macintosh Curved blades or Macintosh bladesblades

Straight blades or MillerStraight blades or Miller Stylet shapingStylet shaping Handle and how to hold itHandle and how to hold it

Curved bladesCurved blades

Begin Begin SLOWSLOW insertion directly down insertion directly down the middle of the tongue not the right the middle of the tongue not the right side to find the epiglottis. side to find the epiglottis.

Blade tip is advanced into the vallecula Blade tip is advanced into the vallecula pressing on the hyoepiglottic ligament, pressing on the hyoepiglottic ligament, raising the epiglottis out of the way.raising the epiglottis out of the way.

If the epiglottis is missed upon blade If the epiglottis is missed upon blade insertion, the tip of he blade will enter insertion, the tip of he blade will enter the esophagus.the esophagus.

Straight bladeStraight blade

Directly lifts the epiglottis.Directly lifts the epiglottis. Proper epiglottis identification, Proper epiglottis identification,

tongue control, and tube passage tongue control, and tube passage are important in curved blades, are important in curved blades, are even more critical with straight are even more critical with straight blades.blades.

Flanges are much smaller with less Flanges are much smaller with less control of tonguecontrol of tongue

Recommended in infantsRecommended in infants

Enter on the right side of the Enter on the right side of the mouth, the epiglottis edge is lifted mouth, the epiglottis edge is lifted by the tip of the blade and the tip is by the tip of the blade and the tip is advanced into the laryngeal inlet. advanced into the laryngeal inlet.

The first structure seen is the The first structure seen is the interarytenoid notch, followed by interarytenoid notch, followed by the posterior cartilage, then the the posterior cartilage, then the vocal cords and glottic opening.vocal cords and glottic opening.

Dangers with straight Dangers with straight bladesblades Never blindly advance into the Never blindly advance into the

esophagus and then withdraw esophagus and then withdraw due to risk for puncture or due to risk for puncture or perforation to the hypo pharynx, perforation to the hypo pharynx, upper esophagus, and larynx. upper esophagus, and larynx.

Stylet shaping Stylet shaping

Straight-to-cuff tube/stylet aids in Straight-to-cuff tube/stylet aids in maneuverability and laryngeal maneuverability and laryngeal view. With the main body perfectly view. With the main body perfectly straight, with about a 35 degree straight, with about a 35 degree angle beginning just behind the angle beginning just behind the cuff. The stylet stopped 2-3 cm cuff. The stylet stopped 2-3 cm before the tip of the tube.before the tip of the tube.

Holding the handleHolding the handle

Correct grip of a laryngoscope is Correct grip of a laryngoscope is low down on handle, with your low down on handle, with your thumb pointing upwards.thumb pointing upwards.

With proper hand grip, keep your With proper hand grip, keep your elbow close to torso, it is easy to elbow close to torso, it is easy to transmit force along forearm and transmit force along forearm and to blade tip, making effective use to blade tip, making effective use of instrument without straining. of instrument without straining.

Proper gripProper grip

Know whether you are right or left eye Know whether you are right or left eye dominant. dominant.

Left eye dominance rotate there heads Left eye dominance rotate there heads slightly to the right bring the target slightly to the right bring the target closer and widens there view. closer and widens there view.

Right eye dominance do not need to Right eye dominance do not need to compensate keeping there heads compensate keeping there heads straight. straight.

Multiple intubations Multiple intubations attemptsattempts The decision about whether to temporarily The decision about whether to temporarily

suspend intubation attempts and bag the pt suspend intubation attempts and bag the pt (or not intubate a child at all) is dependent (or not intubate a child at all) is dependent upon pulse oximetry and pulse rate. upon pulse oximetry and pulse rate.

Without sufficient preoxygenation the onset Without sufficient preoxygenation the onset of critical hypoxia will be quickof critical hypoxia will be quick. .

PALS does state that it is acceptable to not PALS does state that it is acceptable to not intubate a pediatric patient as long as the intubate a pediatric patient as long as the patient is sufficiently oxygenated and patient is sufficiently oxygenated and ventilated during transfer to a higher level of ventilated during transfer to a higher level of care. Do not delay transport and other vital care. Do not delay transport and other vital care for difficult intubations if BVM is care for difficult intubations if BVM is effectiveeffective

PaO2PaO2

By maximizing oxygen By maximizing oxygen concentration in the alveoli, blood concentration in the alveoli, blood and tissues, the more time the and tissues, the more time the patient will tolerate apnea before patient will tolerate apnea before becoming dangerously hypoxic. becoming dangerously hypoxic.

Preoxygenation can take several Preoxygenation can take several minute. minute. TAKE YOUR TIME!!!!TAKE YOUR TIME!!!!

Combitube following Combitube following failed intubationsfailed intubations Leaving the Combitube in place Leaving the Combitube in place

following failed intubations is an following failed intubations is an appropriate stopping point, assuming appropriate stopping point, assuming oxygenation and ventilation have been oxygenation and ventilation have been achieved. achieved.

Placing the combitube with a Placing the combitube with a laryngoscope ensures proper laryngoscope ensures proper placement. Blind insertion may cause placement. Blind insertion may cause trauma and bleeding.trauma and bleeding.

Sedation may be required if pt biting Sedation may be required if pt biting on the tube. on the tube.

An OG can be placed down the An OG can be placed down the esophageal tube for decompression of esophageal tube for decompression of the stomach. the stomach.

DO NOTDO NOT remove the Combitube to remove the Combitube to intubate. If they haven’t thrown up intubate. If they haven’t thrown up yet, they will now!!! yet, they will now!!!

You can intubate around the You can intubate around the Combitube by deflating the pharyngeal Combitube by deflating the pharyngeal balloon, using a straight miller blade.balloon, using a straight miller blade.

Pediatric intubationsPediatric intubations

Differences from adult to pediatrics.Differences from adult to pediatrics.1)1) The larynx is positioned higher in neckThe larynx is positioned higher in neck2)2) The mandible in infants is under-developed, The mandible in infants is under-developed,

meaning shorter and narrower.meaning shorter and narrower.3)3) Increased size of the tongue relative to the Increased size of the tongue relative to the

size of the oral cavity in peds.size of the oral cavity in peds.4)4) Pediatrics have a increased length and Pediatrics have a increased length and

stiffness of the epiglottis.stiffness of the epiglottis.5)5) Lastly, the size of the head in peds. Lastly, the size of the head in peds. The narrowest point is the subglottic The narrowest point is the subglottic

region, not the vocal cords like adults. region, not the vocal cords like adults.

RSIRSI

The fastest most effective means of The fastest most effective means of controlling the emergency airway.controlling the emergency airway.

Patient safety in RSI is about Patient safety in RSI is about managing the inherent risk involved managing the inherent risk involved with the cessation of spontaneous with the cessation of spontaneous breathing. - breathing. - which you are about to take which you are about to take away!!!!away!!!!

Indications for RSIIndications for RSI

GCS less thanGCS less than 8 8 with the followingwith the following::

A.A. Pt is unable to maintain a patent Pt is unable to maintain a patent airway.airway.

B.B. Pt is unable to protect his/her airway.Pt is unable to protect his/her airway.

C.C. Pt is not being appropriately Pt is not being appropriately ventilated or oxygenated.ventilated or oxygenated.

D.D. Pt requires intubations for specific therapy Pt requires intubations for specific therapy or procedure. (flying in an aircraft)or procedure. (flying in an aircraft)

Contraindications for Contraindications for RSIRSI Known allergy for necessary Known allergy for necessary

medications.medications. Suspected epiglottitis, or edema.Suspected epiglottitis, or edema. Severe oral, mandibular, or neck Severe oral, mandibular, or neck

trauma.trauma. Age less than 3 months old.Age less than 3 months old. Significant hypotension.Significant hypotension.

Pre-RSI requirementsPre-RSI requirements

EKG 4-leadEKG 4-lead IV with normal saline, X 2 if possible.IV with normal saline, X 2 if possible. Pulse oximetryPulse oximetry Bag valve mask attached to high-flow Bag valve mask attached to high-flow

O2O2 SuctionSuction Combi-tube and/or cricothyrotomy Combi-tube and/or cricothyrotomy

kit.kit.

RSI chartRSI chart

RSI MedicationsRSI Medications

Lidocaine Lidocaine Dose: 1.5 mg/Kg IVPDose: 1.5 mg/Kg IVP Reduces cardiovascular and Reduces cardiovascular and

intracranial pressure responses intracranial pressure responses during intubations. during intubations.

Should be given at least 2 Should be given at least 2 minutes prior to starting minutes prior to starting intubations.intubations.

AtropineAtropine Dose: 0.02 mg/Kg IVP Dose: 0.02 mg/Kg IVP

(minimum dose of 0.1 mg)(minimum dose of 0.1 mg) Blunts the occurrence of bradycardia Blunts the occurrence of bradycardia

from vagel stimulation during from vagel stimulation during intubations and from the administration intubations and from the administration of Succinylcholine. Also dries up of Succinylcholine. Also dries up secretions.secretions.

Very important in Pediatrics.Very important in Pediatrics. Bradycardia during RSI intubations Bradycardia during RSI intubations

usually caused by hypoxia!!!usually caused by hypoxia!!!

Zemuron ( for defasiculating dose when Zemuron ( for defasiculating dose when succinylcholine is the paralytic agent.)succinylcholine is the paralytic agent.)

Dose: 0.1 mg/Kg IVPDose: 0.1 mg/Kg IVP This non-depolarizing neuromuscular This non-depolarizing neuromuscular

blocker prevents fasiculation's due to blocker prevents fasiculation's due to Succinycholine. This is small, involuntary Succinycholine. This is small, involuntary muscle contractions seen under the muscle contractions seen under the skin.skin.

Fasiculations can result in the release of Fasiculations can result in the release of potassium by the muscles. Consider potassium by the muscles. Consider using for patients with hyperkalemia.using for patients with hyperkalemia.

VersedVersed Dose: 0.1 mg/Kg under 50 lbs Dose: 0.1 mg/Kg under 50 lbs

2.0 mg IVP for adults 2.0 mg IVP for adults Duration is 5-10 minutes. Duration is 5-10 minutes.

This reversible, short-acting This reversible, short-acting benzodiazepine works as sedation and benzodiazepine works as sedation and analgesia. Administer to pt’s who might analgesia. Administer to pt’s who might be adversely affected by increased HR be adversely affected by increased HR and BP. (MI’s, CHF, HTN’s and head and BP. (MI’s, CHF, HTN’s and head injuries)injuries)

SuccinylcholineSuccinylcholine Dose: 1.5 mg/Kg IVPDose: 1.5 mg/Kg IVP This non-reversible depolarizing This non-reversible depolarizing

neuromuscular blocker provides neuromuscular blocker provides paralysis in 30-90 seconds. Duration is paralysis in 30-90 seconds. Duration is 3-6 minutes. 3-6 minutes. ALL ALL protective reflexes are gone!!!protective reflexes are gone!!!

Cricoid pressure is needed until Cricoid pressure is needed until intubation is completed to prevent intubation is completed to prevent aspiration.aspiration.

ZemuronZemuron Dose: 1.0 mg/KgDose: 1.0 mg/Kg This non-depolarizing This non-depolarizing

neuromuscular blocker has a neuromuscular blocker has a duration of 25-35 minutes when duration of 25-35 minutes when given in full dose. given in full dose.

Verification of Verification of placementplacement Watch it go through the “cords” Watch it go through the “cords”

and let everyone know.and let everyone know. AuscultationAuscultation Chest rise and fallChest rise and fall EtCO2EtCO2 Pulse OximetryPulse Oximetry