Procedure - Intubation Flashcards
When you’re assessing how difficult someone may be to obtain an airway on, what two things should you assess?
- PMH (Past difficult intubations? Past problems with anesthesia? Snoring?)
- Head and neck anatomy
** Look in their chart for past intubation attempts, if you have time. They might be listed as procedure notes or under author-specialty anesthesia.
Review the four grades of laryngoscopy.
I: vocal cords fully visualizes
II: only posterior vocal cords visualized
III: only epiglottis seen (think 3piglottis)
IV: no recognizable airway structures
Review predictors of difficult intubation.
- Obesity
- Edema of the head and neck
- Jaw: micrognathia, retrognathia
- Neck: short thyromental distance (less than 6 cm or 3 finger lengths from tip of thyroid cartilage to chin with neck maximally extended), large neck, neck trauma, limited range of neck motion
- Mouth: large teeth, small mouth, inability to prognath (bring lower incisors in front of higher incisors), tonsillar hypertrophy
Why are rheumatoid arthritis and ankylosing spondylitis important diagnoses to document before airway attempts?
Limited neck ROM predicts difficult attempts
Review the Mallampati grading system.
I: Hard palate, soft palate, full uvula, tonsillar pillars
II: Hard palate, soft palate, partial
III: Hard palate, soft palate, base of uvula
IV: Hard palate
Edentulous patients often require a ____________ for bag-mask ventilation.
oropharyngeal airway
What is trismus?
The inability to open the mouth fully
Why are bearded men considered difficult airways?
It can be difficult to bag-mask them – because of lacking the seal – so intubation attempts are riskier.
How are nasal trumpets measured?
Nares to ear
What is Graham Snyder’s tip of intubation?
Move slowly and look for the epiglottis. More often than not, you fail by going too deep and ending up in the esophagus. You’ll think the esophagus is still the tongue and go deeper or lift harder, to no avail.
If you’re using a Miller blade and the tongue is in the way, try _____________.
sliding the blade just to the patient’s right so that the tongue flops to the left – out of your way
If you are in the vallecula and you lift upwards but still can’t see the vocal cords, try _____________.
extending the patient’s neck slightly
What is the 332 rule?
These make it easier to intubate:
- 3 fingers in the mouth
- 3 fingers beneath chin
- 2 fingers above cricothyroid and below jaw
What can you do to the bed to make intubation easier?
- Make sure the wheels are locked
- Make the height comfortable for you
- Tilt the bed slightly reverse trendelenburg
If you right mainstem, the pull back how many cm?
1
Bougies are used in what scenario?
When you can’t get an ET tube in the trachea but you can see it. You then put the bougie into the airway and slide the ETT over it.
What is the dose of succinylcholine for intubation?
2 mg/kg
What is the RSI dose of etomidate?
0.3 mg/kg
Why is rocuronium used in children?
The incidence of undiagnosed neuromuscular disorders that could cause hyperkalemia with succinylcholine is higher in kids.
True or false: you need to have absent gag reflexes to do RSI.
False
RSI involves the use of sedating drugs specifically to dampen reflexes with intubation. If someone already has absent reflexes (such as in a code when they are completely unresponsive), then they may not need RSI drugs.
What are the indications for a surgical airway?
Glottis edema
Significant oropharyngeal bleeding
Laryngeal fracture
Failure to intubate and failure to bag mask
If you advance your laryngoscope as far as it will go and you still don’t see epiglottis, then consider trying ____________ before withdrawing completely and trying the next size up of laryngoscope.
repositioning your scope by coming in from the right so that the tongue pushes to the left of the blade
This can help you “get farther” into the oropharynx because you aren’t fighting against the tongue.
What is a standard laryngoscope size for adults?
Macintosh 3 (for smaller adults) or 4 (for larger adults
What is a standard ETT size for adults?
7.5 mm
Once you see the vocal cords, do not ________________.
look away
If you are concerned that the ETT might be dislodged or main stemmed (such as from a desaturated patient who was just intubated), what can you do to know more?
Use the glide scope to see where your tube is and to withdraw it slightly
The dose of rocuronium for RSI is ____________.
0.6 to 1.2 mg/kg
When you anticipate a difficult airway, use ___________ for sedation.
ketamine
This allows the person to maintain whatever airway they have in the event that you aren’t successful.
What do the terms BIAD and ETI mean?
BIAD: blind-insertion airway devices (e.g., King, iGel, LMAs)
EIT: endotradcheal intubation
Review the steps you should follow with all intubations.
- Resuscitate the patient if stability permitting (IV fluids, phenyl sticks)
- Get patient in position (proper height of bed, patient to head of bed, roll under neck if possible)
- Ask the patient about dentures (or take a look if they are altered)
- Prepare your suction
- Prepare your tube and airway (anticipated tube plus one size smaller, Glidescope LoPro)
- Make sure your tube stylet is properly bent
- Make sure your tube is lubricated
- Check for ETCO2
- Ask about access
- Plan for post-RSI sedation
- Timeout: suction, airway, meds
- Meds
- Laryngoscopy
- Intubate
- Inflate cuff
- Check ETCO2
- Listen bilateral breath sounds
If you don’t get the tube on first try, what things should you optimize for the second try?
- Positioning: bed, patient’s neck/shoulders
- Tube: downsize, bend stylet, lubricate
- Pressure: cricoid pressure
- Backup: bougie -> King -> cricothyrotomy
Because plastic is not radio-opaque, ETTs have a _______________ to be seen on XR.
radio-opaque stripe
The size of an ETT (such as a 7.5) refers to _____________.
the diameter of the inner lumen in mm
Some tubes will have the outer diameter also documented on the tube.
Some ETTs have two black stripes just proximal to the cuff. What are these?
Indicators for where the vocal chords should be
What is a Murphy’s eye?
Some ETTs have a fenestration on the tube near the tip. This is there so there is a secondary air pathway if the tip of the ETT abuts the tracheal wall.
To make it easier for viewing and entering the vocal cords, the bevel of the ETT should point _________.
to the left
With the tube in your right hand and the bevel pointing to the right, the back of the tube will face your viewing angle (whether direct or video-assisted).
The hyperangulated stylet for glidescopes fits in tubes ____ and bigger.
6.5
To make a hyperangulated stylet for pediatric tubes, use ___________.
the medium gray stylet (not the tiny blue kne that is too flexible)
The McGrath is a hybrid between what tubes?
C-mac (more like DL) and the Glidescope
Bend the sylet to what angle?
Match the angle of your laryngoscope.
Why do you have to be careful that the stylet is not sticking out the ETT?
It can puncture the soft palate, particularly if you are using a Glidescope and you are not looking when you put the tube in.
Babies can be intubated with what size Glidescope?
Size 1
If a patient has a traumatic airway (e.g., facial or airway injury) then be sure to position them ____________.
in a way that the bleeding leaves the mouth (such as upright or on their side)
If there is blood coming from the airway, you can actually use ____________ to guide a bougie through.
large-bore suction catheters
For in-line stabilization of a patient in C-spine precautions, make sure the person stabilizing the neck is not limiting the __________..
mandible
When should you consider giving higher dose of paralytics?
In patients who are hypotensive
Lower blood pressure has been shown to decrease the amount of paralytic delivered
Starting I:E ratio for normal lung?
1:2
Starting TV for normal lung?
8 mL/kg (of ideal body weight)
Starting I:E ratio for obstructive illness?
1:4
(“You’re helping them to 4ce air out.”)
How do you alter TV for ARDS (or other stiff lung disorders)?
Decrease it, from a normal TV of 10 mL/kg to 6-8 mL/kg
This prevents volutrauma. Note, you need to increase RR from 10-12 to 16-20 BPM.
How long does etomidate work for?
8-10 minutes
What is the induction dose for propofol?
1 mg/kg
If you’re doing a ketamine (“awake”) intubation, when do you push paralytic?
When you can see the vocal chords
The idea is that you need to paralyze them when the tube is going into the airway but you don’t want to give the paralytic until you are sure that you can see the airway and it is not obstructed.
OPAs and NPAs are measured from their respective orifices to which landmark?
Earlobe
Other than critical airway patients, in which patients should you consider delayed sequence (aka “awake” intubations)?
Agitated/combative patients who are hypoxic
The reason is that you sedate them – calming the agitation – and then oxygenate them prior to paralyzing.
ertxy is vecuronium not often used for RSI?
It takes longer to take effect (up to 120 seconds).
Review the size of blade and tube for term, preterm, and extremely preterm infants.
- Term: blade 1, tube 4.0
- Preterm: blade 0, tube 3.5
- Extremely preterm (weeks 30 or earlier): blade 00, tube 3.0
What is the mnemonic for blade size in kids?
“2 if you’re two, size 3 for third graders (8-yos)”
Breaks down like this:
- neonate to 23 months: size 1
- 24 months to 7 years: size 2
- 8 years to puberty: size 3
What landmarks help you align the airway (in terms of patient presentation)?
Ear to sternal notch
For adults, you need to raise the head. For young kids you need to raise the body (because they have big occiputs).
Use atropine to intubate kids younger than ____.
6 months (to prevent brady arrests)
What is the dose of fentanyl for intubation?
2-3 mcg/kg
Why is atropine not good at secretions for RSI?
The effect takes 15 minutes
