Procedure
Endotracheal Intubation Preparation
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Endotracheal Intubation Preparation
, SOAP-ME Mnemonic
See Also
Advanced Airway
Rapid Sequence Intubation
Endotracheal Tube
Endotracheal Intubation Preoxygenation
(and
Apneic Oxygenation
)
Direct Laryngoscope
Video Laryngoscope
Endotracheal Intubation
Extraglottic Device
(e.g.
Laryngeal Mask Airway
or LMA)
Tactile Orotracheal Intubation
(
Digital Intubation
)
Nasotracheal Intubation
Cricothyrotomy
Needle Cricothyrotomy
Emergency Decision Cycle
(
OODA Loop
,
AAADA Model
)
Approach
Emergency back-up plan
See
Emergency Decision Cycle
(
OODA Loop
,
AAADA Model
)
Clinician's responsibility to prepare with all necessary devices
Check that they are operational before pushing induction agents and paralytics
Levitan describes an emergency back-up parachute approach to intubation
Every step in intubation should have a back-up plan (Boy Scout "Be Prepared" motto)
Two ways to ventilate
Two ways to oxygenate
Two ways to intubate
UMMC
Shock
-Trauma
Advanced Airway
Plan
Intubation attempt with any technique
Intubation attempt using
Video Laryngoscope
and
Gum Elastic Bougie
Intubation attempt by back-up provider (or attending physician)
Attempt
Supraglottic Airway
(e.g.
Laryngeal Mask Airway
)
Surgical airway (
Cricothyrotomy
)
Be prepared for
Cricothyrotomy
Have plan A and plan B (see above)
Also have a "Go to Hell Plan" in case of "Can't Oxygenate, Can't Intubate"
Palpate the neck for the cricothyroid membrane prior to each intubation
Cricothyrotomy
kit should be immediately available in case of complete airway obstruction
Be prepared for failed definitive airway placement
Have
Extraglottic Device
(e.g.
Laryngeal Mask Airway
or LMA) available (with practiced use)
Have at least two methods of laryngeal exposure immediately available (with practiced use of each)
Direct Laryngoscope
Video Laryngoscope
Have at least 2
Endotracheal Tube
s available
Estimated size for the patient's body habitus
One
Endotracheal Tube
size smaller than expected
Have two oxygen sources (not on splitter)
Preoxygenation oxygen source (e.g.
Non-Rebreather Mask
with reservoir at 12 LPM)
Apneic Oxygenation
source (
High Flow Nasal Cannula
oxygen source at 15 LPM)
Have two suction devices
Open suction tubing without suction tip
Yankauer suction (or preferably a better tip such as “S3,” “Big Stick,” or “Big Yank” )
https://www.annemergmed.com/article/S0196-0644(16)30793-4/fulltext
Preparation
Mnemonic - SOAP-ME
Suction
Yankauer suction (or better alternative as above)
Second suction tubing with no tip attached
Oxygen
High Flow Oxygen
device (e.g.
Non-Rebreather Mask
with reservoir)
Consider
CPAP
or BIPAP for preoxygenation
Second oxygen source with
Nasal Cannula
(up to 15L/min) for
Apneic Oxygenation
Airway equipment
Direct Laryngoscope
Video Laryngoscope
Elastic Bougie
Endotracheal Tube
Laryngeal Mask Airway
(back-up plan)
Patient Positioning
Pull
Mandible
forward
Sit patient up (at least 20 degrees) into ramped position (especially if obese)
Reverse Trendelenburg if patient cannot be flexed at waist (e.g.
Hip Fracture
)
Inclined torso improves oxygenation and glottis view, and decreases aspiration risk
Khandelwal (2016) Anesth Analg 122(4): 1101-7 [PubMed]
Ear to sternal notch
http://www.emdocs.net/novel-tips-airway-management/
Head parallel with ceiling
Ear tragus at level of sternal notch
Adjust overall bed height to align patient to clinician
Patient's face should be at xiphoid of clinician for optimal intubation angle
Monitoring Equipment
Telemetry
Oxygen Saturation
Capnography
(
End-Tidal CO2
)
Preparation
Details
Prepare for
Rapid Sequence Intubation
Indicated if not crash airway or awake intubation needed for difficult airway
Monitoring Telemetry,
Capnography
and
Pulse Oximetry
(
Hypoxemia
,
Bradycardia
)
Pretreatment with
Atropine
0.02 mg/kg is no longer recommended
Some pediatric providers have it ready at itubation in case of
Symptomatic Bradycardia
(esp. age under 1 year)
Check
Laryngoscope
for light and blade size (See above)
Video Laryngoscopy
is superior to
Direct Laryngoscopy
for successful first-pass intubation (by
Odds Ratio
>2)
Video Laryngoscopy
is also associated with reduced risk of esophageal intubation
However, no difference in poor outcomes when compared with
Direct Laryngoscopy
De Jong (2014) Intensive Care Med 40(5): 629-39 [PubMed]
Direct Laryngoscope
(with working bulb and battery)
When
Video Laryngoscopy
fails,
Direct Laryngoscopy
is the most common rescue device
Suction (critical for all patients, especially for children)
Two suction tubes are ideal (one Yankauer and one with tubing only to suction large particulate matter)
Select ET size and length (See
Endotracheal Tube
)
Cuffed
ET Tube
s may be used in infants and children
Endotracheal Tube
(including a size smaller than anticipated)
Stylet should NOT extend beyond distal ET
Glidescope intubation requires glidescope stylet with deep hockey-stick bend
Elastic Bougie
Curl into a tight loop if using a hyperangulated
Laryngoscope Blade
(e.g. Glidescope)
Images
Prevention
Post-Intubation
Hypotension
Anticipate post-intubation
Hypotension
(related to sedation,
Positive Pressure Ventilation
,
PEEP
)
Monitor
Blood Pressure
frequently in the period around intubation
Post-intubation
Hypotension
is associated with worse outcomes
Hypotension
occurs in up to 25% of emergency intubations (
Cardiac Arrest
in 3% of intubations)
Hypotension
following RSI and intubation may be predictable and may be prevented with bolus
Children
Age over 65 years old
Septic Shock
Borderline MAP (65-70 mmHg) pre-intubation
Shock Index
(HR/SBP) > 0.8
Management
Consider
Normal Saline
10-20 ml/kg (to 500 to 1000 ml) bolus prior to RSI (especially in children)
Choose induction agents with less risk of
Hypotension
(
Etomidate
,
Ketamine
)
Jabre (2009) Lancet 374:293-300 +PMID:19573904 [PubMed]
Optimize mean arterial pressure >80-85 mmHg prior to intubation (fluids,
Vasopressor
s)
Consider
Delayed Sequence Intubation
Gradual titration of
Ketamine
while optimizing oxygenation and mean arterial pressure
References
Mallemat in Herbert (2017) EM:Rap 17(2): 4-5
Weingart and Swaminathan in Herbert (2021) EM:Rap 21(10): 3-5
Prevention
Aspiration
Decompress
Bowel Obstruction
with
Orogastric Tube
prior to intubation
Vomiting
otherwise may be profuse and result in significant aspiration and very difficult intubation
Resources
Airway Cam (Levitan)
http://www.airwaycam.com/
References
Levitan (2013) Practical Airway Management Course, Baltimore
Weingart et al in Herbert (2016) EM:Rap 16(11): 4-5
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