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Prepared by: JO-ANNE KAREN SERDENA

BSN-34TH

Endotracheal Intubation & ER

Board Exam Questions

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Endotracheal intubation is the

placement of a tube into the trachea

(windpipe) in order to maintain an open

airway in patients who are unconscious or

unable to breathe on their own. Oxygen,

anesthetics, or other gaseous medications

can be delivered through the tube.

Definition

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Purpose

Specifically, endotracheal intubation is used forthe following conditions: respiratory arrest

respiratory failure

airway obstruction

need for prolonged ventilatory support

Class III or IV hemorrhage with poor perfusion

severe flail chest or pulmonary contusion

multiple trauma, head injury and abnormal mental

status inhalation injury with erythema/edema of the vocal

cords

protection from aspiration

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CONTRAINDICATIONS:

1.AWAKE PATIENT.

2. AIRWAY CAN BE MANAGED LESS INVASIVELY.

EQUIPMENTS:

1. IV ACCESS, EKG, PULSE OX MONITORS.

2. SUCTION APPARATUS.

3. OROPHARYNGEAL, NASOPHARYNGEAL

AIRWAYS.

4. NON- REBREATHER MASK.5. OXYGEN.

6. BAG VALVE MASK.

7. APPROPRIATE SIZE ENDOTRACHEAL TUBE (7.5

MM ADULT, CHILD = DIAMETER OF LITTLE

FINGER); WITH STYLET AND 10CC SYRINGE.8. LARYNGOSCOPE BLADE AND HANDLE

(APPROPRIATE SIZE).

9. TAPE.

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Endotracheal tube and laryngoscope sizes:

Age: Preemie Neonate 6 mo. 1-2 yr. 4-6 yr. 8-12 yr. Adult

Tubesize:

2.5 3-3.5 3.5-4 4-5 5-5.5 6-7 7.5-8.5

Blade

size:

0 0-1 1 1-2 2 2-3 4-5

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Preparation

For endotracheal intubation, the patient is placed on theoperating table lying on the back with a pillow under thehead. The anesthesiologist wears gloves, a gown andgoggles. General anesthesia is administered to thepatient before starting intubation.

Confirm that intubation equipment is functional.

Assess the patient for difficult airway (see DifficultAirway Assessment section below for recommendedmethod). If the patient meets criteria for difficult airway,

rapid sequence intubation (RSI) may be inappropriate.Nonparalysis procedures may be an alternative.

Establish intravenous access.

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Draw up essential drugs and determinesequence of administration (induction agentimmediately followed by paralytic agent).

Review possible contraindications to

medications. Attach necessary monitoring equipment.

Check endotracheal (ET) tube cuff for leak.

Ensure functioning light bulb on laryngoscopeblade.

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Preoxygenation Administer 100% oxygen via a nonrebreather mask for 3

minutes for nitrogen washout. This is done without

positive pressure ventilation using a tight seal. Though rarely possible in the emergent situation, the

patient can take 8 vital capacity (as deep as possible)breaths of 100% oxygen. Studies have shown this canprevent apnea-induced desaturation for 3-5 minutes.[36]

Assist ventilation with bag-valve-mask (BVM) systemonly if needed to obtain oxygen saturation 90%.

Pretreatment Consider administration of drugs to mitigate the adverse

effects associated with intubation.

See Anesthesia for more information.

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Paralysis with induction

Administer a rapidly-acting induction agentto produce loss of consciousness.

Administer a neuromuscular blocking

agent immediately after the inductionagent.

These medications should be

administered as an intravenous push.

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Positioning

In cases of trauma in which cervical spine injury issuspected and not yet ruled out, intubation must beperformed without movement of the head. Immobilizationis best provided by an experienced assistant. In cases inwhich cervical injury is not a concern, proper headpositioning greatly improves visualization.

In the neutral position, the oral, pharyngeal, andlaryngeal axes are not aligned to permit adequatevisualization of the glottic opening (see image below).Proper alignment of the axes for tracheal intubation.

http://refimgshow%281%29/

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Proper alignment of the axes for tracheal

intubation. Place the patient in the sniffing position for

adequate visualization; flex the neck and extendthe head. This position helps to align the axes and

facilitates visualization of the glottic opening. Recent studies have shown that simple head

extension alone (without neck flexion) was aseffective as the sniffing position in facilitating

endotracheal intubation.[35]

Aspiration

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Procedure: Assess airway note landmarks,

swelling, deformities. Remove

dentures. Assess tongue size,

dental obstruction, visibility of

oropharynx, degree of neck

mobility. - Maintain cervical spine

stability as necessary. Open airway: suction or manually

extract foreign material. Chin

lift, jaw thrust.

Heimlich maneuver as needed.

Use artificial airways if needed:

oropharyngeal,

nasopharyngeal. (See Figure 1)

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Preoxygenate with 100% non-rebreather or bag-valve-

mask. Keep pulse ox greater than 95% at all times.

Position patient into sniffing position if possible;

restrain as necessary.

Standing at the supine patients head, gentle insert

laryngoscope blade with left hand. Use suction as

necessary with right hand. (See Figure 2)

Visualize glottic opening/vocal cords.

Advance ETT with right hand through cords. (See

Figure 3)

Remove stylet.

Inflate ETT cuff with 5 10 cc air via syringe.

Ventilate with bag and oxygen.

Confirm tube placement with chest auscultation, CO2

monitor and chest x-ray.

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Secure tube with

tape.

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To begin the procedure, an anesthesiologist opens the patient'smouth by separating the lips and pulling on the upper jaw withthe index finger. Holding a laryngoscope in the left hand, he orshe inserts it into the mouth of the patient with the blade directed

to the right tonsil. Once the right tonsil is reached, thelaryngoscope is swept to the midline, keeping the tongue on theleft to bring the epiglottis into view. The laryngoscope blade isthen advanced until it reaches the angle between the base ofthe tongue and the epiglottis. Next, the laryngoscope is liftedupwards towards the chest and away from the nose to bring the

vocal cords into view. Often an assistant has to press on thetrachea to provide a direct view of the larynx. Theanesthesiologist then takes the endotracheal tube, made offlexible plastic, in the right hand and starts inserting it throughthe mouth opening. The tube is inserted through the cords to thepoint that the cuff rests just below the cords. Finally, the cuff is

inflated to provide a minimal leak when the bag is squeezed.Using a stethoscope , the anesthesiologist listens for breathingsounds to ensure correct placement of the tube.

http://www.surgeryencyclopedia.com/St-Wr/Stethoscope.htmlhttp://www.surgeryencyclopedia.com/St-Wr/Stethoscope.html

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Placement with proof

Visualize the ET tube passing through thevocal cords.

Confirm tube placement.

Observe color change on a qualitative end-tidal carbon dioxide device.

Use the 5-point auscultation method: Listen

over each lateral lung field, the left axilla, andthe left supraclavicular region for good breath

sounds. No air movement should occur over

the stomach.

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Two pilot studies have

shown that

ultrasonography canreliably detect passage

of a tracheal tube into

either the trachea or

esophagus without

inadvertent ventilation

of the stomach.

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Postintubation management

Secure the ET tube into place.

Initiate mechanical ventilation.

Obtain a chest radiograph.Assess pulmonary status.

Note this modality does not confirm placement;rather, it assesses the height above the carina.

Ensure that mainstem intubation has notoccurred.

Administer appropriate analgesic andsedative agents for patient comfort, todecrease O2 demand, and to decrease ICP.

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Complications

Esophageal intubation Iatrogenic induction of an obstructive airway

Right mainstem intubation

Pneumothorax

Dental trauma Postintubation pneumonia

Vocal cord avulsion

Failure to intubate

Hypotension

http://emedicine.medscape.com/article/424547-overviewhttp://emedicine.medscape.com/article/424547-overview

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ER Board Exam Questions

1.The nurse employed in the emergency roomis responsible for triage of four clients injuredin a motor vehicle accident. Which of the

following clients should receive priority incare?

A. A 10-year-old with lacerations of the face

B. A 15-year-old with sternal bruises

C. A 34-year-old with a fractured femur

D. A 50-year-old with dislocation of the elbow

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Answer B is correct. The teenager withsternal bruising might be experiencing airwayand oxygenation problems and, thus, should

be seen first. In answer A, the 10-year-oldwith lacerations might look bad but is not indistress. The client in answer C with afractured femur should be immobilized but

can be seen after the client with sternalbruising. The client in answer D with thedislocated elbow can be seen later as well.

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2. The client is scheduled for a pericentesis.Which instruction should be given to the

client before the exam? A.You will need to lay flat during the

exam.

B. You need to empty your bladder beforethe procedure.

C.You will be asleep during theprocedure.

D.The doctor will inject a medication totreat your illness during the procedure.

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Answer B is correct. The client scheduled fora pericentesis should be told to empty the

bladder, to prevent the risk of puncturing thebladder when the needle is inserted. Apericentesis is done to remove fluid from theperitoneal cavity. The client will be positioned

sitting up or leaning over a table, makinganswer A incorrect. The client is usuallyawake during the procedure, and medicationsare not commonly inserted into the peritonealcavity during this procedure; thus, answers C

and D are incorrect (although this coulddepend on the circumstances).

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3.A 25-year-old male is brought to the

emergency room with a piece of metal inhis eye. Which action by the nurse is

correct?

A.Use a magnet to remove the object.

B.Rinse the eye thoroughly with saline.

C.Cover both eyes with paper cups.

D.Patch the affected eye only.

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Answer C is correct. Covering both eyes

prevents consensual movement of theaffected eye. The nurse should notattempt to remove the object from the eyebecause this might cause trauma, asstated in answer A. Rinsing the eye, asstated in answer B, might be ordered bythe doctor, but this is not the first step for

the nurse. Answer D is not correctbecause often when one eye moves, theother also does.

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4.The client is admitted to the emergency roomwith shortness of breath, anxiety, andtachycardia. His ECG reveals atrial fibrillationwith a ventricular response rate of 130 beatsper minute. The doctor orders quinidine

sulfate. While he is receiving quinidine, thenurse should monitor his ECG for:

A.Peaked P wave

B.Elevated ST segment

C.Inverted T wave

D.Prolonged QT interval

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Answer D is correct. Quinidine can cause

widened Q-T intervals and heart block.Other signs of myocardial toxicity are

notched P waves and widened QRS

complexes. The most common side effects

are diarrhea, nausea, and vomiting. The

client might experience tinnitus, vertigo,

headache, visual disturbances, and

confusion. Answers A, B, and C are notrelated to the use of quinidine.

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5. Which clients can be assigned to share a roomin the emergency department during the disaster?

A.The schizophrenic client having visual andauditory hallucinations and the client withulcerative colitis

B.The client who is 6 months pregnant withabdominal pain and the client with faciallacerations and a broken arm

C. A child whose pupils are fixed and dilated andhis parents, and the client with a frontal head

injury D. The client who arrives with a large puncture

wound to the abdomen and the client with chestpain

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Answer B is correct. Out of all of these

clients, it is best to hold the pregnant client

and the client with a broken arm and facial

lacerations in the same room. The clients

in answer A need to be placed in separaterooms because these clients are disruptive

or have infections. In the case of answer

C, the child is terminal and should be in aprivate room with his parents.

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Thank You!