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Todd Lang, MD
VVMC ED
8/31/2005
Basic Airway Management:
Bag-Mask Ventilation
Paralyze •Succinylcholine
•Rocuronium
•Vecuronium
Pressure is applied to the Should be applied to prevent
cricoid regurgitation
Pass the tube Should be accomplished
within 30 seconds. If not,
may be attempted again after
oxygenation
Placement is confirmed •Rise and fall of the patient’s
chest, CXR
•Listen over stomach
•Bilateral breath sounds
•Is patient improving?
Post-intubation plan is made •Securing the tube
•Continually assess patient’s
condition/need for sedation
Pre-oxygenate
( Time - 5 Minutes)
• 100 % oxygen for 5 minutes
• 4 conscious deep breaths of 100 % O2
• Fill FRC with reservoir of 100 % O2
• Allows 3 to 5 minutes of apnea
• Essential to allow avoidance of bagging
• If necessary bag with cricoid pressure
Preparation
( Time - 5 Minutes )
• ETT, stylet, blades, suction, BVM
• Cardiac monitor, pulse oximeter,
ETCO2
• One ( preferably two ) iv lines
• Drugs
• Difficult airway kit including cric kit
• Patient positioning
Equipment for Intubation
• Laryngoscope
– Handle
• contains the batteries for
the light source
– Blades
• Straight blade: Miller
• Curved: MacIntosh
Intubation
Equipment
• ET tube • Laryngoscope
– Adult female: 7-8 mm – batteries
– Adult male: 8-8.5 mm – light source
• Stylet • Blades
• 10 cc Syringe – straight (used more for
infants)
• Water soluble gel
– Curved (some believe it
reduces dental trauma)
Oddly, the peds code cart blades
that are included in the Broslow
packs do not fit our
laryngoscopes. You need to use
the metal ones in the top of the
cart. The doctor will probably
not know this at VVMC.
Intubation Equipment
• Stylet
– Helps conform the
endotracheal tube to any
desired configuration,
facilitating insertion of the
tube into the larynx and
trachea.
– The end of the stylet must
always be recessed at least ½
inch from the distal end of the
tube.
Additional Intubation Equipment
• Magill Forceps
– Helps direct the tip of the
ET tube into the larynx
during intubation and to
remove some foreign
bodies
Prepare 8.0 tube for men, and 7.5
for women WITH A STYLET.
Pre-treatment/ Prime
( Time - 2 Minutes )
• Lidocaine 1.5 mg/kg iv
• Defasciculating dose of non-depolarizing
NMB
• Beta-blocker or fentanyl
• Induction agent
– Etomidate 0.3 mg/kg
– Midazolam 0.1 - 0.4mg/kg
– Ketamine 1.5 - 2.0 mg/kg
Paralyze ( Time Zero )
• Succinylcholine 1.5 mg/kg iv
• Allow 45 - 60 seconds for complete
muscle relaxation
• Alternatives
– Vecuromium 0.1 - 0.2 mg/kg
– Rocuronium 0.6 - 1.2 mg/kg
Pressure
• Sellick maneuver
• initiate upon loss of consciousness
• continue until ETT balloon inflation
• release if active vomiting
• Cricoid pressure should be
applied by a second Intubation
rescuer during Procedure
endotracheal intubation in
adults to protect against
regurgitation of gastric
contents and to ensure
placement in the tracheal
orifice
• Cricoid pressure should be
maintained until until the
cuff of the endotracheal
tube is inflated
• Inability to oxygenate
The Failed Intubation
• If can’t intubate but can ventilate with
BVM have time to consider options
– Light guided technique (Lighted stylet)
– Combitube
– LMA
– Fiberoptic techniques
– Retrograde intubation
– Cricothyrotomy
The Failed Intubation
• If can’t intubate, can’t ventilate , must
act immediately
– Cricothyrotomy
– Percutaneous Transtracheal Jet Ventilation
– Combitube
– LMA
– The last three are temporizing measures and
not definitive airway management
It is part of your job as a nurse to
move the team to Plan B when
needed: Especially after three
failed laryngoscopy attempts.
Difficult Airway Kit
• Is being made now and will be brought
to intubations in the future.
VVMC Difficult Airway Options
• Combitube
• Cricothyrotomy
• Fiber Optic
• LMA
Multilumen airways
should be considered
when conventional
tracheal intubation
measures are unsuccessful
or unavailable