RSI endotracheal insertion steps

Question 1

Endotracheal Tube Insertion - step 1

Answer 1

Hold laryngoscope in left hand.

Question 2

Endotracheal Tube Insertion - step 2

Answer 2

Use right hand to:

• Insert the ETT
• Operate suction catheter
• Manipulate larynx externally to enhance visualization.

Question 3

Endotracheal Tube Insertion - step 3

Answer 3

Insert blade into right corner of the patient’s mouth.

Question 4

Endotracheal Tube Insertion - step 4

Answer 4

Visualize arytenoids.

Question 5

Endotracheal Tube Insertion - step 5

Answer 5

Lift epiglottis.

Question 6

Endotracheal Tube Insertion - step 1 - comments

Answer 6

Holding laryngoscope at base, where the blade inserts to the handle

Question 7

Endotracheal Tube Insertion - step 2 - comments

Answer 7

Remove dentures and suction blood, secretions, or vomitus before insertion of ETT.

Use a semi-rigid, malleable, blunt-tipped, metal or plastic stylet to assist placement.

Tip of stylet must not extend beyond the end of the ETT or exit the Murphy eye.

Question 8

Endotracheal Tube Insertion - step 3 - comments

Answer 8

Curved Macintosh blade will push tongue toward left side of the oropharynx.

If blade is inserted midline, the tongue can impair the view posteriorly.

Question 9

Endotracheal Tube Insertion - step 4 - comments

Answer 9

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Question 10

Endotracheal Tube Insertion - step 5 - comments

Answer 10

Lift the epiglottis directly with the straight blade or indirectly with the curved blade

Question 11

Endotracheal Tube Insertion - step 6

Answer 11

Expose larynx

Question 12

Endotracheal Tube Insertion - step 7

Answer 12

Advance blade incrementally.

Question 13

Endotracheal Tube Insertion - step 8

Answer 13

Advance ETT.

Question 14

Endotracheal Tube Insertion - step 9

Answer 14

Check ETT placement.

Question 15

Endotracheal Tube Insertion - step 10

Answer 15

Inflate balloon.

Question 16

Endotracheal Tube Insertion - step 11

Answer 16

Secure ETT.

Question 17

Endotracheal Tube Insertion - step 6 - comments

Answer 17

Pull laryngoscope handle in the direction that it points (i.e., 90 degrees to the blade).

Cocking handle back risks fracturing central incisors and is ineffective at revealing the cords.

Question 18

Endotracheal Tube Insertion - step 7 - comments

Answer 18

Look for the arytenoid cartilages to avoid overly deep insertion of the blade, which is a common error.

BURP - Backward-upward-rightward pressure maneuver may improve visualization.

Question 19

Endotracheal Tube Insertion - step 8 - comments

Answer 19

Visualize tube and cuff passing through vocal cords.
Correct placement = minimum of 2 cm above carina
Base of the pilot tube (with adapter to inflate the cuff) is at teeth level

Question 20

Endotracheal Tube Insertion - step 9 - comments

Answer 20

Listen for bilateral breath sounds and the absence of epigastric sounds.
Confirm placement w/ colorimetric carbon dioxide detector OR capnography.

Question 21

Endotracheal Tube Insertion - step 10 - comments

Answer 21

5–7 cc of air. Ask technician to check cuff pressure to avoid tracheal injury (Goal = 25–40cm H2O).

Question 22

Endotracheal Tube Insertion - step 11 - comments

Answer 22

Dont impede cervical venous return with umbilical tape or a fixator; circumferential securing devices can cause skin breakdown if too tight or in place too long.

Use a modified clove-hitch knot or a commercial fixator to avoid kinking the pilot tube.