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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 ass

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