Intubation Flashcards
What are the steps to endotracheal intubation?
Step 1 - Prepare
Step 2 - Preoxygenate
Step 3 - Drugs
Step 4 - Laryngoscopy & Intubation
What is involved in the preparation step for intubation? (6)
Anaesthetic pre-assessment - Identify potential problems
Team x2 - Intubator and assistant (for standard intubation)
IV access, (Unless gas induction -paeds or needle phobia, IV obtained after)
Monitoring (3 then 9)
Plan A, B, C, D agreed upon - if things don’t go to plan
All equipment ready, available for monitoring and plan ABCD
What monitoring is done prior to intubation?
Sats
NIBP (Non-Invasive BP)
ECG
What monitoring is done during intubation?
Sats
NIBP (Non-invasive BP)
ECG
EtCO2 - End tidal COP, Capnograph FiO2 - inspired oxygen fraction FeO2 - expired oxygen fraction Volatile/MAC - gas analysis Airway pressure Nerve stimulator - paralysed patients
What is Plan A-D?
A - Normal intubation - Three looks with scope without tubing
B - Maintain with supraglottic airway
C - Ventilate with bag and mask
D - Front of neck access
What is the aim of preoxygenation (step 2)?
To replace the entire FRC (functional residual capacity = expiratory reserve volume + residual volume) from air (20% O2) to 100% oxygen.
Slows the rate of desaturation while apnoeic during intubation by creating an oxygen reserve from the FRC of the lung
How is preoxygenation (step 2) performed?
3 minutes of normal (tidal volume) breaths on 100% O2, or 8 vital capacity breaths.
What drugs are used in a standard intubation?
What sequence are they used in?
1st: Analgesic agent - Fentanyl (reduced airway reflexes - laryngospasm, tachycardias or hypotension)
2nd: Anaesthesic induction agent, usually Propofol - Given slowly over 30 seconds or longer until loss of response to direct command
3rd: Muscle relaxant to paralyse vocal cords - Suxamethonium (Dep) (RSI - quickest), Rocuronium (RSI or norm), Atracurium (Norm - slow)
- Whilst waiting bag and mask to reduce desaturation.
What tool is used for intubation?
Laryngoscope, typically McCoy Blade
Where does the tip of the McCoy blade sit?
Between the base of tongue and epiglottis - vallecula
How do you describe the view of the larynx?
Cormack-Lehane grading - Grade 1 (best) - 4 (worst)
What can be done to improve the Grade of the view of the larynx?
Repositioning
Gentle larynx pressure by assistant
What signs indicate the tube is in the correct place?
ET tube misting and clearing - in warm body cavity
Equal chest rise and bilateral breath sounds - tube not in too far (endobronchial intubation)
Capnograph trace shows good EtCO2 trace - tube is in lungs
When is RSI induction used?
In non-fasted (inc. emergency) patients or those will delayed gastric emptying (e.g. all acute abdo surgeries, appendicitis, bowel obstruction)
What is the aim of RSI induction?
Reduce the chance of passive regurgitation of stomach contents into the airway
