The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Endotracheal Intubation

by Richard Cashio with
Patrick Hymel

Indications
Contraindications
Equipment
-SSADMIT
-Endotracheal tube of appropriate size (calculated)
Procedure
Follow-up
Complications

Indications

• Cardiac arrest with ongoing chest compressions
  
• Inability of a conscious patient to adequately ventilate/oxygenate
  
• Inability of the patient to protect their airway (coma (GCS <9), areflexia, loss of gag reflex or cardiac arrest)
  
• Inability to ventilate the unconscious patient with conventional methods
  
• The number one indication is thinking of it. If the patient's condition is serious enough to consider intubation and mechanical ventilation, more often than not, the proper course is to proceed. Elective intubation carries far fewer dangers than emergent incubation, and delays create unnecessary dangers for the patient.

Contraindications

• Any situation where the pharynx is obstructed (pharyngeal foreign body, massive swelling of the pharynx), or if there is serious maxillofacial trauma (see Cricothyrotomy)
  
• Special care must be taken in any patient where a C-spine injury is possible. DO NOT LIFT THE CHIN! The jaw thrust maneuver, with in-line immobilization should be used.

Equipment

• SSADMIT
  • System of 02 Delivery
    
  • SUCTION - this is very important
  • Airway Equipment
    • Laryngoscope and an appropriate sized blade(adult or pediatric)
      
    • A curved Macintosh blade (size #3 or #4) or a straight Miller / Wisconsin blade (size #2 or #3) should be available for physician preference
      
    • Oral and nasal airway
      
    • Ambu bag and bag valve mask
      
    • #10 scalpel blade Oust in case)
  • Drugs for Rapid Sequence Intubation
    
  • Monitor
    
  • IV and fVF
    
  • Tape, Tube and Table
• Endotracheal tube of appropriate size (calculated as follows):
  • Children:
    • Airway length (cm)
      = age/2+ 12
      = height (cm) / 10 + 5
      = weight (kg) / 15 + 12
      
    • A fast way to determine tube size for a child is that the diameter of the tube should be approximately the size of the child's little finger or nostril, or (16 + age)/4.
  • Adults:
    • Estimation of ideal ETT placement length is roughly 21 cm in wornen and 23 cm in men, "tube taped at the teeth".
      
    • For wornen use a 7.0 to 7.5 mm tube and men 7.5 to 8.0 mm tube (this indicates tube's internal diameter)
      
    • Malleable stylet
      
    • 10 ml syringe
      
    • Magil forceps for removing foreign material
      
    • Water-soluble lubricant
      
    • Tape

Procedure

1. Preoxygenate the patient while preparing equipment, with or without the bag-valve-mask device, depending on clinical need. Monitor vital signs and use pulse oximetry throughout procedure.
   
2. Elevate the bed to position the patient's head at the level of the physician's lower sternum.
   
3. Open the airway by using the heat-tilt-chin-lift method (only if a C-spine injury is not a consideration, in which case in-line immobilization with jaw thrust would be applied).
   
4. Connect the laryngoscope and blade and check light on the blade. The light should be on when the blade and laryngoscope are at 900 to each other.
   
5. Select appropriate tube size and using the 10ml syringe, verify that the balloon on the tube inflates. Deflate after verification.
   
6. Apply lubricant to distal end of tube and insert stylet, (the stylet should not extend past the end of the tube). Lubricant may be omitted if under time constraints.
   
7. Place a slight curvature in the tube to facilitate entry.
   
8. The physician positions behind the patient with the laryngoscope in the left hand.
   
9. The patient's mouth is opened with the fight hand and the blade is inserted on the right side of the mouth displacing the tongue to the left. Constant visualization while advancing blade is a must.
   
10. When the blade is fully inserted, the laryngoscope handle should be roughly at a 30' to 450 angle to the patient.
    
11. Force is then applied vertically upward on the laryngoscope, taking care not to place pressure on the patient's teeth. Do not rock backwards onto the patient's teeth! This is a major mistake. The handle of the laryngoscope is used as a handle to lift straight upwards, NOT as a lever!
    
12. If a straight blade is used, the epiglottis is raised using the tip of the blade. If the curved blade is used, the tip is placed anterior to the epiglottis into the vallecula and the epiglottis is elevated further. This will expose the vocal cords. If at first you are not able to see the cords, ask an assistant to apply slight downward pressure on the cricoid cartilage (Sellick maneuver). This should help put the cords into view.
    
13. The tube is then slid along the right side of the mouth and visualized entering 1/2 to I inch into the vocal cords. DO NOT TAKE YOUR EYES OFF OF THE CORDS ONCE YOU SEE THEM! Ask an assistant to pass you the tube if necessary. Watch the tube pass through the cords and do not look away. It is appropriate to tell those around you what you see as you attempt this procedure (i.e. "I see the epiglottis... I see the cords... I am passing the tube through the cords") This lets everyone around you know that you are on the right track (or not).
    
14. The laryngoscope is removed and the balloon at the end of the tube is inflated using the syringe.
    
15. The tube is then secured to the patient's mouth using tape making sure not to tape the lips.

Follow-up

• The most accurate method of confirming tube placement (short of an x-ray) is end tidal CO2. This should be measured after giving the patient three ventilations, and may not be accurate in cases of cardiac arrest. The most common device is a detector that attaches directly to the tube and changes color to indicate the CO2 level. However, end tidal CO2 is NOT accurate for patient's in cardiac arrest.
  
• Observe the right and left hemithorax rise and fall with ventilations.
  
• Auscultation of bilateral breath sounds. Listen over the gastric region of the abdomen FIRST to make sure you are not in the esophagus.
  
• Palpation of the endotracheal cuff in the sternal notch.
  
• Portable chest x-ray

Complications

• The laryngoscope blade can lacerate lips and tongue.
  
• Teeth may be chipped or avulsed.
  
• Corneal abrasion - Watch out for the eyes! This is one of the most common injuries to result from intubation.
  
• The tip of the stylet or tube may lacerate the pharyngeal or tracheal mucosa resulting in bleeding.
  
• Injury to the vocal cords. (Famous opera tenor Jose' Carreras underwent cancer surgery under local anesthesia to avoid any such damage)
  
• Insertion of the tube into the esophagus.
  
• Insertion of the tube into a main bronchus resulting in hypoxia due to inadequate ventilation of the other lung. Listen for equal breath sounds. If they are unequal (R>L) back the tube out l cm and listen again.
  
• Jaw clenching by the patient inhibiting entry can be overcome by using neuromuscular blocking agents (see Rapid Sequence Induction) or placing a bite block.