Intubation

Question 1

What is the cornerstone of emergency airway management?

Answer 1

Endotracheal intubation using rapid sequence intubation (RSI)

Question 2

Indications for intubation?

Answer 2

1. Inability to maintain airway
2. Inability to protect airway against aspiration
3. Ventilatory compromise
4. Failure to adequately oxygenate pulm capillary blood
5. Anticipation of deterioration that will eventually lead to inability to maintain airway

Question 3

What is the preferred method of intubation in the ED and why?

Answer 3

RSI because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis)

Question 4

RSI is most important for which patients?

Answer 4

Those who have not fasted (i.e. ED pts) and are at much greater risk for vomiting/aspiration

Question 5

Primary goal of RSI?

Answer 5

Intubate trachea w/o having to use bag-valve-mask (BVM) ventilation
*Often necessary when attempting to intubate w/sedative agents alone

Question 6

Standard of care for RSI?

Answer 6

Administration of an induction agent (e.g. etomidate) followed by a paralytic (e.g. succinylcholine) to render pt unconscious and paralyzed within 1 minute

Question 7

Related to emergent intubation, what is a/w significant decrease in complications?

Answer 7

Use of neuromuscular blocking agents (paralytics)

Question 8

What are the competitive inhibitor neuromuscular blocking drugs used in intubation?

Answer 8

• Pancuronium
• Vecuronium
• Rocuronium

Question 9

What are the non-competitive inhibitor neuromuscular blocking drugs used in intubation?

Answer 9

Succinylcholine

Question 10

Contraindications to RSI

Answer 10

Unconscious and apneic patient (instead, immediate BVM ventilation and intubation w/o pretreatment)

Question 11

For adequate visualization during intubation, how should a patient be positioned?

Answer 11

Sniffing position (flex neck, extend head)

Question 12

What does the Sniffing position accomplish for intubation?

Answer 12

Helps align axes and facilitates visualization of glottic opening

Question 13

What should be done before intubation?

Answer 13

Preoxygenate with 100% oxygen via a nonrebreather OR BVM

Question 14

How to confirm tube placement of intubation?

Answer 14

1. ET-CO2 monitor
2. 5 point auscultation method
3. CXR

Question 15

What is the 5 point auscultation method?

Answer 15

• Confirms ET placement
• Listen over each lateral lung field, L axilla, and L supraclavicular region
• NO air should occur over stomach

Question 16

What is an LMA?

Answer 16

• Laryngeal mask airway
• Supraglottic airway device
• Good alternative to BVM

Question 17

Absolute contraindications to LMA

Answer 17

• Cannot open mouth

- Complete upper airway obstruction

Question 18

Relative contraindications to LMA

Answer 18

• Increased risk of aspiration
• Prolonged BVM ventilation
• Morbid obesity
• 2nd or 3rd trimester preg
• Pts who have no fasted
• Upper GI bleed
• Suspected or known abnormalities in supraglottic anatomy
• Need for high airway pressures

Question 19

What is a combitube?

Answer 19

• Twin lumen device used in emergency situations and difficult airways
• Can be inserted w/o need for visualization in oropharynx

Question 20

Which airway is NOT available for use in children?

Answer 20

Combitube