Section 2: Resuscitation & Stabilization

Endotracheal Intubation

INDICATIONS

• Respiratory

  • Apnea

  • Hypoventilation

  • Severe respiratory distress/respiratory muscle weakness

  • Acute respiratory failure (PaO₂ <50 mmHg in patient with FiO₂ >0.5 and PaCO₂ >55 mmHg acutely)

  • Need to control oxygen delivery (e.g., institution of positive end-expiratory pressure [PEEP], accurate delivery of FiO₂ >0.5)

  • Need to control ventilation (e.g., to decrease work of breathing, to control PaCO₂, to provide muscle relaxation)

• Neurologic

  • Inadequate chest wall function (e.g., in patient with Guillain-Barre syndrome, poliomyelitis)

  • Absence of protective airway reflexes (loss of cough, gag)

  • Glasgow Coma Score <8

• Airway

  • Upper airway obstruction

  • Infectious processes (epiglottis, croup)

  • Trauma to the airway

  • Burns (concern for airway edema)

• Cardiac

  • Cardiopulmonary failure/arrest

  • Low cardiac output states (reduced oxygen demand/consumption)

• Other

  • Transport of a patient with potential for respiratory failure

CONTRAINDICATIONS

• Absolute

  • Nasotracheal intubation is contraindicated in patients with nasal fractures or basilar skull fractures

• Relative

  • None

RISKS

• Bradycardia

• Hypoxemia/desaturation

• Hypotension

• Inability to intubate

EQUIPMENT-SEE FIGURES 6-1 AND 6-2

• Suction – source, catheters; should have a tonsil-tipped suction device or a large-bore suction catheter, as well as a suction catheter of appropriate size that fits into the endotracheal tube (ETT)

• Oxygen – source

• Ventilation bags – flow inflating bags and self-inflating bags

• Masks – appropriate sizes for ventilation

• Laryngoscope – blade (straight or curved), handle, bulb, battery

  • Handle with battery and blade with light source

  • Adult and pediatric handles fit all blades and differ only in handle diameter

• Video laryngoscope if available

• Endotracheal tubes – appropriate sizes, cuffed, uncuffed

• Forceps

• Oropharyngeal airway

• Tongue blade

• Bite block

• Tape – to secure tube or tube securement device

• Stylet – appropriate sizes

• CO₂ detector device – colorimetric detection device or capnography

• Syringe to inflate the endotracheal tube balloon on cuffed tubes

• Laryngeal mask airways (LMA) – appropriate sizes

• Medications (see medication section later)

• Normal saline or Lactated Ringer’s for fluid resuscitation

GUIDELINES FOR LARYNGOSCOPE, ETT, SUCTION CATHETERS BASED ON AGE AND WEIGHT – SEE TABLE 6-1

• Historically, uncuffed tubes were recommended for children <8 years of age; however, current research shows that cuffed tubes are safe in all patients except in the newborn period.

• If a difficult intubation is anticipated due to altered supraglottic anatomy, absolutely no irreversible anesthetics or muscle relaxants should be administered.

• Such patients should generally be intubated awake or in the operating room with inhaled anesthetic.

• For difficult intubations, other techniques, such as ...