INTUBATION REVIEW SFC HILL Joint Special Operations Medical

INTUBATION REVIEW SFC HILL Joint Special Operations Medical Training Center

Advantages/Complications of Tracheal Intubation Joint Special Operations Medical Training Center

Advantages of tracheal intubations: • Airway patency – – Protects the airway Maintains patency during positioning • Control of ventilation – ventilation over a long period of time without intubation can lead to gastric distention and regurgitation Joint Special Operations Medical Training Center

Advantages of tracheal intubations: • Route for inhalation anesthesia and emergency medications • • N - Narcan A - Atropine L - Lidocaine E - Epinephrine Joint Special Operations Medical Training Center

Complications of tracheal intubation: • Trauma to the lips, teeth, and soft tissues of the airway. – – Awareness meticulous technique • Bronchial intubation – – frequent complication auscultation of the chest bilaterally Joint Special Operations Medical Training Center

Complications of tracheal intubations: • Laryngospasm – – common when extubation is done when the patient is in a semiconscious state extubation should be done in a relatively deep anesthesia or when the protective laryngeal reflex has returned • Postintubation hoarseness and sore throat – due to mechanical presence of the tracheal tube Joint Special Operations Medical Training Center

Preparation of Equipment • Assemble pharyngeal airways in assorted sizes – – Nasopharyngeal Oropharyngeal • Inspect laryngoscope for serviceability – – – Batteries Light bulb Blades; curved/straight (Macintosh or Miller) Joint Special Operations Medical Training Center

Selection of laryngoscope blade (preference) • Macintosh is a curved blade whose tip is inserted into the vallecula (the space between the base of the tongue and the pharyngeal surface of the epiglottis). Most adults require a Macintosh number 3 or 4 blade. Joint Special Operations Medical Training Center

Selection of laryngoscope blade (preference) • Miller is a straight blade that is passed so that the tip of the blade lies beneath the laryngeal surface of the epiglottis. The epiglottis is then lifted to expose the vocal cords. Most adults require a Miller number 3 blade. Joint Special Operations Medical Training Center

Preparation of Equipment Inspect endotracheal tubes • Tube size • • adult male 8 mm to 9 mm tube adult female 7 mm to 8 mm tube • Tube length- extend from the lower incisor to a point midway between the cricoid cartilage and Louis's angle (the sternal angle) on the patient • Endotracheal tube cuff Joint Special Operations Medical Training Center

Preparation of Equipment • Malleable stylet (should not extend past Murphy's eye) • Lubrication • Laryngeal sprays Joint Special Operations Medical Training Center

Inspect resuscitator (AMBU bag) for serviceability • • Bag Mask Intake valve Valve body with relief valve Joint Special Operations Medical Training Center

Inspect stethoscope • Diaphragm • Earpieces • Tubing Joint Special Operations Medical Training Center

Gather and prepare all equipment necessary for an emergency Airway • • • Scalpel handle Surgical blades Curved hemostats Endotracheal tube Syringe Joint Special Operations Medical Training Center

Intubation Technique • ventilate with 100 percent oxygen for approximately 1 min • Position bed height to bring the patient's head to a mid-abdominal height • Flex the cervical spine and extend the head at the atlanto-occipital joint • Long axis of the oral cavity, pharynx, and trachea lie almost in a straight line Joint Special Operations Medical Training Center

Intubation Technique • introduce the blade into the right side of the patient's mouth • move the blade posteriorly and toward the midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the blade • ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade • advance the laryngoscope until the epiglottis is in view Joint Special Operations Medical Training Center

Intubation Technique • lift the laryngoscope upward and forward • insert the endotracheal tube from the right with its concave curve facing downward and to the right side of the patient • maneuver the endotracheal tube into the larynx, midway between the cricoid cartilage and the sternal angle Joint Special Operations Medical Training Center

Intubation Technique • inflate the cuff and apply positive pressure ventilation while the assistant auscultates • secure the endotracheal tube in position Joint Special Operations Medical Training Center

Curved Blade Technique The curved blade technique is essentially similar. The only difference being when the epiglottis is in view, advance the tip of the laryngoscope blade into the vallecula, formed by the base of the tongue and the epiglottis; lift upward and forward. Joint Special Operations Medical Training Center

Nasotracheal intubation technique • topical lidocaine or phenylephrine should be applied to the nasal passages • 0. 5 -1. 0% Neosynephrine and 4% Lidocaine, mixed 1: 1 should also give satisfactory results • generously lubricate the nares and endotracheal tube • ET tube should be advanced through the nose directly backward toward the nasopharynx Joint Special Operations Medical Training Center

Nasotracheal intubation technique • loss of resistance marks the entrance into the oropharynx • laryngoscope and Magill forceps can be used to guide the endotracheal tube into the trachea under direct vision • for awake spontaneous breathing patients, the blind technique can be used Joint Special Operations Medical Training Center

Confirmation of tracheal intubation: • Direct visualization of the ET tube passing through the vocal cords • CO 2 in exhaled gases • Bilateral breath sounds • Absence of air movement during epigastric auscultation Joint Special Operations Medical Training Center

Confirmation of tracheal intubation: • Condensation (fogging) of water vapor in the tube on exhalation • Refilling of reservoir bag during exhalation • Maintenance of arterial oxygenation • Chest X-ray: the tip of the ET tube should be between the carina and thoracic arc or approximately at the level of the aortic arch Joint Special Operations Medical Training Center

Extubation • ensure that the patient is recovering is breathing spontaneously with adequate volumes • evaluate the patient's ability to protect his airway by observing whether the patient responds appropriately to verbal commands Joint Special Operations Medical Training Center

Extubation steps: • Oxygenate patient with 100 percent high flow O 2 for 2 to 3 minutes • if secretions are suspected in the tracheobronchial tree, remove them with a suction catheter through the lumen of the endotracheal tube • ensure that the patient is not in a semiconscious state Joint Special Operations Medical Training Center

Extubation steps: • turn the patient onto his side if he is still unconscious • unsecure the endotracheal tube from the patient's face • deflate the cuff and remove the endotracheal tube quickly and smoothly during inspiration • continue to give the patient O 2 as required Joint Special Operations Medical Training Center