Indication for Intubation

in Emergency Room

Dr. Rumaisah Satyawati SpAn KIC

Intubation Indication

Is there a failure of
Airway maintenance or protection

Is there a failure of
Ventilation or oxygenation

What is the
anticipated clinical course ?
Cant Protect Airway

Can they talk ?

Can they swallow & manage
secretion ?
Cant Maintain Ventilation/Oxygention

SaO2 < 90% on High flow O2 or PaO2 < 60 on FiO2

> 40%
PaCo2 >55 if baseline is normal or 10 increase
from baseline
Respiratory rate
Expected Decline in Clinical Status

Deterioration/impending compromise
transport
Airway protection during procedures
(ie. Endoscopy
Intubate? 45 female
Alcoholic beverages
Empty pill bottles

HR 124 BP 98/40
RR 20 GCS 8
O2 sats 100% PRB
Indication ? No injuries
Cant Protect Airway

Deeply comatose from drug overdose.

Even if the patient is breathing on his own &
ventilation is adequate does not assure us that the
patient will be protect her airway if vomiting were to
occur
The morbidity and mortality from aspiration is quite
high.
Drug overdose pts may require 24-48 airway control
GCS 8 or less is an indication for intubation to Avoid
hypoxemia & hypercarbia

50 yo male
SOB over 2 days
Worsened overnight
HR 135 BP 150/90
RR 10
O2 sats 86% NRB
tight
Wheeze bilaterally
Cant Maintain Ventilation/Oxygention

Failure of oxygenation & ventilation

If the PaO2 can not be maintained with supplemental
oxygen or such techniques as BiPAP, the patient will
ultimately need ventilation through endotracheal
intubation
Intubate? 34 YO male
MVA ejected from
car
HR 100 BP 105/60
RR 20 GCS 10
O2 sats 100 (PRB)
Multiple injuries
Indication ? Trasfering to HSC
Expected Decline in Clinical Status

GCS 8 or less is an indication for intubation

-associated with increased intracranial pressure
Associated with need for operative pressure
Avoid hypocemi & hypercarbia which can increase
morbidity & mortality
If airway intervention will be necessary

How much time do I

have?

Is this a critical airway

and a crash situation?

Do I need to intubate
now or do I have a few
minutes to prepare?
If airway intervention will be necessary..
In a crash situation +
cardiopulmonary arrest l intubation
must proceed.
If there is time to prepare must
predict which airway intervention
most likely to succeed.
Must evaluate a difficult airway
first attempt at intubation fails, can the
patient be ventilated with a bag-
valve-mask. ?
unable to intubate and I can not
ventilate with a bag-valve-mask, am I
prepared to manage the situation ?
Rapid Sequence Intubation

The cornerstone of modern emergency airway management.

The virtually simultaneous

administration of a potent
sedative (induction) agent &
a rapidly acting
neuromuscular blocking
agent to induce
unconsciousness and motor
paralysis for tracheal
intubation.
 Important to recognize which airways
may give you problems before you begin

Ifmy intubation attempt does not succeed, will I be able

to ventilate the patient with a bag-valve-mask?

IfI can not ventilate the patient with a BVM, what should
be done next and what is my back up plan?
Am I prepared to provide a surgical airway?
Cant intubate & Cant Ventilate
 Conclution
3 Emergent Indicationfor Intubation in ED, Cant
protect airway & maintain ventilation/oxygention,
expected decline in Clinical Status
Rapid sequence intubation is the cornerstone of
modern emergency airway management, consists of a
series of discrete steps that are best followed to insure
the greatest success.
Anticipate the possibilitiy of difiicult airway
mangement by performance a thorough by airway
assement
Have the back up plans if the initial plan to secure
airway fails & Algorithms serve only as guideline