joint special operations medical training center intubation review sfc hill

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int Special Operations Medical Training Center INTUBATION REVIEW SFC HILL

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Joint Special Operations Medical Training Center

INTUBATIONREVIEW

SFC HILL

Joint Special Operations Medical Training Center

Advantages/Complications of Tracheal Intubation

Joint Special Operations Medical Training Center

Advantages of tracheal intubations:

• Airway patency– Protects the airway – Maintains patency during positioning

• Control of ventilation – ventilation over a long period of time

without intubation can lead to gastric distention and regurgitation

Joint Special Operations Medical Training Center

Advantages of tracheal intubations:

• Route for inhalation anesthesia and emergency medications

• N - Narcan• A - Atropine• L - Lidocaine• E - Epinephrine

Joint Special Operations Medical Training Center

Complications of tracheal intubation:

• Trauma to the lips, teeth, and soft tissues of the airway. – Awareness – meticulous technique

• Bronchial intubation– frequent complication – auscultation of the chest bilaterally

Joint Special Operations Medical Training Center

Complications of tracheal intubations:

• Laryngospasm– common when extubation is done when

the patient is in a semiconscious state– extubation should be done in a

relatively deep anesthesia or when the protective laryngeal reflex has returned

• Postintubation hoarseness and sore throat– due to mechanical presence of the

tracheal tube

Joint Special Operations Medical Training Center

Preparation of Equipment • Assemble pharyngeal airways in

assorted sizes– Nasopharyngeal– Oropharyngeal

• Inspect laryngoscope for serviceability– Batteries– Light bulb– Blades; curved/straight (Macintosh or

Miller)

Joint Special Operations Medical Training Center

Selection of laryngoscope blade (preference)

• Macintosh is a curved blade whose tip is inserted into the vallecula (the space between the base of the tongue and the pharyngeal surface of the epiglottis). Most adults require a Macintosh number 3 or 4 blade.

Joint Special Operations Medical Training Center

Selection of laryngoscope blade (preference)

• Miller is a straight blade that is passed so that the tip of the blade lies beneath the laryngeal surface of the epiglottis. The epiglottis is then lifted to expose the vocal cords. Most adults require a Miller number 3 blade.

Joint Special Operations Medical Training Center

Preparation of Equipment -Inspect endotracheal tubes

• Tube size• adult male 8 mm to 9 mm tube • adult female 7 mm to 8 mm tube

• Tube length- extend from the lower incisor to a point midway between the cricoid cartilage and Louis's angle (the sternal angle) on the patient

• Endotracheal tube cuff

Joint Special Operations Medical Training Center

Preparation of Equipment

• Malleable stylet (should not extend past Murphy's eye)

• Lubrication

• Laryngeal sprays

Joint Special Operations Medical Training Center

Inspect resuscitator (AMBU bag) for serviceability

• Bag

• Mask

• Intake valve

• Valve body with relief valve

Joint Special Operations Medical Training Center

Inspect stethoscope

• Diaphragm

• Earpieces

• Tubing

Joint Special Operations Medical Training Center

Gather and prepare all equipment necessary for an

emergency Airway• Scalpel handle

• Surgical blades

• Curved hemostats

• Endotracheal tube

• Syringe

Joint Special Operations Medical Training Center

Intubation Technique

• ventilate with 100 percent oxygen for approximately 1 min

• Position bed height to bring the patient's head to a mid-abdominal height

• Flex the cervical spine and extend the head at the atlanto-occipital joint

• Long axis of the oral cavity, pharynx, and trachea lie almost in a straight line

Joint Special Operations Medical Training Center

Intubation Technique• introduce the blade into the right side of

the patient's mouth• move the blade posteriorly and toward the

midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the blade

• ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade

• advance the laryngoscope until the epiglottis is in view

Joint Special Operations Medical Training Center

Intubation Technique

• lift the laryngoscope upward and forward• insert the endotracheal tube from the right

with its concave curve facing downward and to the right side of the patient

• maneuver the endotracheal tube into the larynx, midway between the cricoid cartilage and the sternal angle

Joint Special Operations Medical Training Center

Intubation Technique

• inflate the cuff and apply positive pressure ventilation while the assistant auscultates

• secure the endotracheal tube in position

Joint Special Operations Medical Training Center

Curved Blade Technique

The curved blade technique is essentially similar. The only

difference being when the epiglottis is in view, advance the tip of the

laryngoscope blade into the vallecula, formed by the base of the

tongue and the epiglottis; lift upward and forward.

Joint Special Operations Medical Training Center

Nasotracheal intubation technique

• topical lidocaine or phenylephrine should be applied to the nasal passages

• 0.5-1.0% Neosynephrine and 4% Lidocaine, mixed 1:1 should also give satisfactory results

• generously lubricate the nares and endotracheal tube

• ET tube should be advanced through the nose directly backward toward the nasopharynx

Joint Special Operations Medical Training Center

Nasotracheal intubation technique

• loss of resistance marks the entrance into the oropharynx

• laryngoscope and Magill forceps can be used to guide the endotracheal tube into the trachea under direct vision

• for awake spontaneous breathing patients, the blind technique can be used

Joint Special Operations Medical Training Center

Confirmation of tracheal intubation:

• Direct visualization of the ET tube passing through the vocal cords

• CO2 in exhaled gases

• Bilateral breath sounds

• Absence of air movement during epigastric auscultation

Joint Special Operations Medical Training Center

Confirmation of tracheal intubation:

• Condensation (fogging) of water vapor in the tube on exhalation

• Refilling of reservoir bag during exhalation

• Maintenance of arterial oxygenation• Chest X-ray: the tip of the ET tube should

be between the carina and thoracic arc or approximately at the level of the aortic arch

Joint Special Operations Medical Training Center

Extubation

• ensure that the patient is recovering is breathing spontaneously with adequate volumes

• evaluate the patient's ability to protect his airway by observing whether the patient responds appropriately to verbal commands

Joint Special Operations Medical Training Center

Extubation steps:

• Oxygenate patient with 100 percent high flow O2 for 2 to 3 minutes

• if secretions are suspected in the tracheobronchial tree, remove them with a suction catheter through the lumen of the endotracheal tube

• ensure that the patient is not in a semiconscious state

Joint Special Operations Medical Training Center

Extubation steps:

• turn the patient onto his side if he is still unconscious

• unsecure the endotracheal tube from the patient's face

• deflate the cuff and remove the endotracheal tube quickly and smoothly during inspiration

• continue to give the patient O2 as required