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Endotracheal Intubation

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					Endotracheal Intubation

Indications for intubation
Respiratory failure  Protection of the airway from aspiration  Decreased LOC (coma score <8/15)  Secretion clearance  Upper airway obstruction  Raised ICP treatment  surgery
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Objective measures indicating the need for intubation
RR >35  VC <15 ml/kg  PaO2 <60 on >40%  PaCO2 >50 (except in chronic retainers)  A-a gradient > 300 on 100% oxygen
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Differentiating difficult intubations
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Airway assessment only predicts ~50% of difficult intubations History: has the pt had a previous difficult intubation? PE: look for obesity, short neck, distorted neck anatomy, such as a goiter Airway exam: look for large faucial pillars/uvula, short thyromental distance (<6 cm from thyroid cartilage to the chin), restricted mouth opening, reduced neck extension, large tongue, buck teeth

Route of Intubation
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Oral
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Can use a larger tube, which reduces resistance from the ETT  Better secretion clearance with a larger tube  Easy/fast/can see where you are going  Preferred route in an emergency
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Nasal
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Preferred for conscious patients Easier to stabilize/more comfortable Have to use smaller tube, so more resistance Can do oral hygeine/mouth care Can cause sinusitis

Preparation for Intubation
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Gather equipment:
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Mask Resuscitation bag O2 tubing/O2 source Suction ETT’s of various sizes Syringe Laryngoscope and blades Stylet/Magill forceps Tape/ETT holder End-tidal CO2 detector

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Establish IV access

Preparation for Intubation, cont…
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Preoxygenate the patient by bagging with 100% for a few minutes Check the cuff of the ETT Attach monitors: EKG, sat Set up suction, turn it on, attach Yankauer Check light source/battery in laryngoscope Have crash cart on stand-by Assume patient has full stomach and take aspiration precautions Remove dentures

Rapid Sequence Induction
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Rapidly secures the airway, reducing the risk of aspiration during the procedure Process
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Preoxygenate the patient Administer anesthetic – Valium and Versed are commonly used…Versed is preferred b/c it causes amnesia Apply cricoid pressure (Sellick maneuver), then give paralytic – succinylcholine is commonly used for its quick onset and offset (~5 min) Intubate…don’t release cricoid until ETT position is confirmed with end-tidal/BS Tape tube Get CXR

Normal Intubation
Patient is usually stable  It’s been more than 6 hours since they ate  Cricoid pressure is not required  Patient is not necessarily paralyzed
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Difficult Intubations
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Topical anesthetics, such as cocaine, lidocaine, cetacaine used Patient is sedated but not usually paralyzed Can use a bronchoscope to place the tube Other intubation aids
– dilate the airway for better visuals  Stylets – hold the ETT shape  Magill forceps – grab the tube so you can guide it thru the cords
 Bougies

Failed Intubation
Intubation attempts should be stopped if it’s been more than ~30 sec and/or if the patient is decompensating  Bag the patient between attempts…if doing RSI, don’t let off cricoid pressure  Can re-attempt intubation or can try laryngeal mask airway
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Complications of Intubation
Hypoxemia  Aspiration  Bronchospasm  Trauma (teeth, vocal cords, airway)
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Care of ETT
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The distance from the tip of the ETT to the lips should be ~22-24 cm The tube can move by as much as 4 cm with changes in neck position (flexion vs extension) High cuff inflation pressure (>20 cm H2O), oversized ETT, head movement, and prolonged intubation cause pressure-induced ulcers, granulation tissue, and eventually tracheal stenosis


				
DOCUMENT INFO
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