approach to INTUBATION

intubation

Intubation can save a life or end it, and we need an approach that includes decision-making, preparation, technique and backup approaches

After attending the great AIME course, I developed the INTUBATION mnemonic that summarizes these steps:

 

First decide why they need to be intubated and what problems you may encounter

Indication: the system of greatest concern can influence the method of intubation

  • A: obstruction/arrest –> crash intubation; pending obstruction –> awake/double set-up/anesthesia; protection –> awake or RSI
  • B: hypoxic/hypercarbic –> awake or delayed (to maximize oxygenzation/ventilation pre-procedure)
  • C: VSA –> crash; shock –> awake or delayed (to maximize BP pre-procedure)
  • D: coma –> RSI

Not able: anticipate difficulties, which can change your approach from RSI to awake intubation or calling for anesthesia to assist

  • Difficult MASK: Mask seal –> lube; Adentulous –> leave in teeth; Sounds of obstruction; Kompliance of lungs
  • Difficult TUBE: Teeth –> remove false teeth, Under tongue; Block/narrowed airway; Extension of neck reduce (collar, adipose, fused)
  • Difficult CRIC: Cancer Radiation Impaired visualization (adipose) Cut previously (surgery)

 

Then prepare and position the patient

Treat prior, to attenuate the hypoxia and hypotension of intubation

  • A: open airway (jaw thrust +/- chin lift), suction secretions, consider nasal +/- oral airway
  • B: oxygen by nasal prongs + oxygen by BVM, +/- CPAP for hypoxic patients; avoid over-inflation
  • C: fluid bolus +/- pressors if need to avoid post-intubation hypotension (eg cardiac, brain injury)

Under head blanket (for sniffing), under back roll (for obese), under your umbilicus (for your optimal position); or position of comfort for awake

 

Then get your equipment and do the procedure

Blocking agent: if decision to RSI based on ability to BMV if fail

  • roc 1mg/kg
  • or sux 2mg/kg but beware SUCKS : Stiff masseter Uremic/Crush/K+ elevation Severe hyperthermia

Anesthetic

  • Ketamine 1-2mg/kg; good for respiratory/shock; consider lower dose for awake/delayed or if patient elderly/hypotensive/comatose
  • Etomidate 0.3 mg/kg; good for shock/head injury; consider lower dose if hypotensive/comatose
  • Propofol 2-3 mg/kg; good if don’t care about hypotension

Tube, blade –> intubate

 

And have your backup options available, in order of sequence

Introducer: bougie

Outside glottis, eg LMA

Neck: cric

INTUBATION

After INTUBATION you need to assess your ABCs for complications and further management

A: confirm placement in trachea: direct visualization + ETCO2 + air entry lungs and not abdomen

B: CHEST: assess oxygenation/ventilation

  • Collapse: r/o pneumothorax vs right-maisteam if decrease oxygen/air entry/lung slide
  • Hyperinflate: blood gas assess oxygenation/ventilation –> low rate/volume in asthma, low PEEP in hypovolemic

C: CARDIOVASCULAR: assess perfusion

  • Cardiogram: if brady r/o esophageal intubation/hypoxia/ACS/ICP/hyperkalemic; if tachy consider arrhtymia or inadequate analgesia
  • Dysfunctional LV: consider ACS if unstable, consider inotrope in heart failure
  • Volume depletion –> fluids
  • Lactate: sepsis –> pressors

D: appropriate analgesia (fentanyl or morphine) + sedation (propofol or midaz) +/- paralysis

E: ENDO

  • Electrolyte measure
  • Normothermia: if hyperthermic after sux consider malignant hyperthermia

G:

  • nasogastric or orogastric tube

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