1 / 43

Tracheal Intubation Tintinalli Chap. 19

Tracheal Intubation Tintinalli Chap. 19. Nicholas Cardinal, DO. Indications. Correction of hypoxia or hypercarbia Prevention of impending hypoventilation Ensuring maintenance of a patent airway Secondary Indications Provision of a route for resuscitative medication administration

ramya
Download Presentation

Tracheal Intubation Tintinalli Chap. 19

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Tracheal IntubationTintinalli Chap. 19 Nicholas Cardinal, DO

  2. Indications • Correction of hypoxia or hypercarbia • Prevention of impending hypoventilation • Ensuring maintenance of a patent airway • Secondary Indications • Provision of a route for resuscitative medication administration • To permit temporizing paralysis during diagnostic testing

  3. Endotracheal Tubes • Have appropriate size and another 0.5-1.0 mm smaller • Adult males • 8.0-8.5 mm • Adult females • 7.5-8.0 mm

  4. Laryngoscope Blades • Straight Miller blade • Number 3 or 4 • Physically lifts epiglottis • Mechanically easier to insert • Curved Macintosh blade • Number 2 or 3 • Placed in vallecula above the epiglottis • Indirectly lifts the epiglottis • Less trauma and less likely to stimulate airway reflex • Allows more room for adequate visualization

  5. Positioning • Sniffing Position • Flexion of lower neck with extension at the atlantooccipital joint • Alligns the oropharyngeal-laryngeal axis

  6. Assistance During Intubation • Cricoid Pressure (Sellick maneuver) • “Burp” Technique • Larynx is manually displaced posteriorly, superiorly, and laterally to the right • “Gum Elastic Bougie” • Eschmann Tracheal Tube Introducer/Stylet • Thin, flexible • Blindly inserted and ETT threaded over

  7. Tube Placement • Minimum of 2 cm above the carina • From corner of patient’s mouth • Men • Approximately 23 cm • Women • Approximately 21 cm

  8. Cuff Pressure • Minimum of 25 cm H2O to prevent aspiration • Less than 40 cm H2O to prevent mucosal ischemia

  9. Confirmation • “When in doubt, take it out.” • There is no clinically reliable substitute for direct visualization of the tube passing through the vocal cords. • Clinical Assessment • Auscultation • Tube Condensation • Symmetrical Chest Wall Expansion

  10. Confirmatory Adjuncts • End-tidal CO2 Detectors/Monitors • Detect/Measure CO2 in expired air • Capnometers • colormetric • Capnography • Real time CO2 waveforms • End-tidal CO2 Pressure Monitoring • May not occur even with proper ETT placement • States of low pulmonary perfusion • Massive obesity • Severe Pulmonary Edema • False Positive Detection • Gastric Distention from BVM • Ingestion of carbonated beverages • Few minutes following sodium bicarbonate bolus • Nebulizer • Epinephrine through ETT • Esophageal Detection Devices • Fit over 15-mm ETT connector • Do not depend on adequate cardiac output or pulmonary perfusion • Rely on anatomic differences between the trachea and esophagus

  11. Complications of Endotracheal Intubation • Obstruction • Secretions • Clot • Cuff Displacement • ETT cuff leaks • Arytenoid Cartilage Avulsion/Displacement • Intubation of Pyriform Sinus • Pharyngeal-esophageal Perforation • ChordalSynechiae • Commissural Stenosis • SubglotticStenosis • Most disastrous • Usually occurs in patients with poorly secured tubes or who are combative

  12. Alternative Airway Management • Nasotracheal Intubation • Helpful in situations where laryngoscopy or cricothyroidotomy may be difficult and neuromuscular blockade hazardous • Severely dyspneic patients who are awake and cannot tolerate supine position • CHF, COPD, Asthma • Difficulty aligning the oropharyngeal-laryngeal axis • Arthritis, masseter spasm, temperomandibular dislocation, recent oral surgical procedures • Others • Persistent trismus from seizures, facial trauma, infection, tetanus, decorticate-decerebrate rigidity, neuromuscular disorders/dystrophies

  13. NTI Tube Placement • Optimal Depth • Men • 28 cm at nares • Women • 26 cm at nares

  14. Complications of NTI • Epistaxis • Inadequate topical vasoconstriction • Excessive tube size • Poor technique • Anatomic defects • Obstruction • Retropharyngeal lacerations • Retropharyngeal abscesses • Nasal Necrosis • Paranasal Sinusitis • Risk correlates with duration

  15. Contraindications of NTI • Complex nasal fractures • Massive midfacial fractures

  16. Other Alternative Airway Techniques • Digital Intubation • Transillumination with lighted stylet • Laryngeal Mask Airway • Role is limited in ED d/t inability to protect against aspiration • Intubating LMA • Flexible Fiberoptic Laryngoscope • Indirect Fiberoptic Laryngoscopes • Retrograde Tracheal Intubation

  17. Rapid Sequence Intubation • Combined administration of a sedative and a neuromuscular blocking agent to facilitate intubation

  18. Pretreatment Agents • Attenuate pathophysiologic responses to largyngoscopy and intubation • Reflex Sympathetic Response • Causes increased heart rate and blood pressure • May be harmful in patients with intracranial hemorrhage, myocardial ischemia, or aortic dissection • Vagal Response • Predominates in children • Can result in significant bradycardia

  19. Pretreatment Agents

  20. Induction Agents

  21. Barbiturates • Avoid use in patients with hypotension, LV dysfunction, asthma, and porphyria • Thiopental • Short-acting sedative • Causes hypotension secondary to myocardial depression and venous dilatation • Methohexital • Twice as potent as thiopental • Ultra short-acting

  22. Ketamine • A phencyclidine derivative • Potent bronchodilator • Dissociative amnesia • Avoid in elderly patients and those with head injuries • “Emergence Phenomenon” • May occur as consciousness returns • Benzodiazepines may attenuate • Nightmares • Visual Hallucinations • Dissociative Sensations

  23. Etomidate • Non-barbiturate, non-receptor hypnotic • No analgesic activity • Does not blunt sympathetic response • Consider in patients with hypovolemia, closed head injury • Advantages • Protection from myocardial and cerebral ischemia • Minimal histamine release • Stable hemodynamic profile • Short duration of action

  24. Propofol • Highly lipophilic, rapid-acting sedative • No analgesic activity • Advantages • Antiemetic • Anticonvulsant • Lowers ICP

  25. Fentanyl • Not 1st line • Both sedative and analgesic activity • Neutral BP

  26. Paralytic Agents • Facilitate tracheal intubation • Improve mechanical ventilation • Help control intracranial hypertension • Decrease peak airway pressure

  27. Depolarizing Neuromuscular Blocking Agents • High affinity for cholinergic receptors of the motor endplate • Resistant to acetylcholinesterase • Produce transient muscle fasciculations followed by paralysis • Induction agent should be given prior unless significant head injury or overdose

  28. Succinylcholine • Most commonly used paralytic agent for tracheal intubation • More rapid onset and shorter duration than that of the nondepolarizing agents

  29. Relative Contraindications of Succinylcholine • Burns • Muscle Trauma • Crush Injuries • Myopathies • Rhabdomyolysis • Narrow-angle Glaucoma • Renal Failure • Neurologic Disorders • Guillain-Barre • Spinal Cord Injury

  30. Nondepolarizing Agents • Compete with acetylcholine for cholinergic receptors • Usually can be antagonized by anticholinesterase agents

  31. Reversal of Nondepolarizing Agents • Rarely necessary in the ED • Should not be attempted prior to some sign of motion or spontaneous recovery • Enzyme inhibitors will have no effect until at least 40% of spontaneous recovery has occured • Requires atropine 0.01 mg/kg IV to prevent muscarinic side effects

  32. Edrophonium • Acetylcholinesterase inhibitor • Faster onset and fewer side effects than neostigmine

  33. Difficult Airway • 2-3% of tracheal intubations prove impossible with standard techniques

  34. Identification of Difficult BVM • 2 out of 5 is predictive • Facial Hair • Obesity • Edentulous • Advanced Age • Snoring • Management • Better Positioning • Jaw Thrust • Two Person Bagging • Oral/Nasal Airways • Lubricant on Beard

  35. Factors Predictive of Intubation Difficulty • Facial Hair • Obesity • Short Neck • Small or Large Chin • Buckteeth • High arched Palate • Airway Deformity • Cervical Spine Immobility

  36. Mallampati’s Criteria • Class I • Faucial pillars, soft palate, and uvula can be visualized • Class II • Uvula is masked by base of tongue • Class III • Only base of uvula can be visualized • Up to 5% failure rate • Class IV • None of the structures can be visualized • Up to 20% failure rate

  37. Suspected Acute Intracranial Hypertension • Direct laryngoscopy can elevate ICP • Pretreatment with IV lidocaine or fentanyl may help blunt this response • Induction agents including Thiopental, Fentanyl, and Etomidate directly decrease ICP • Consider Nondepolarizing Agent as Succinylcholine may increase ICP • Keep MAP above 90 mmHg which will usually keep cerebral perfusion pressure above 70 mmHg • Maintain PaO2 of 100 mmHg • PEEP greater than 5 cm H2O will impair cerebral venous drainage • Avoid prophylactic hyperventilation therapy for 1st 24 hours after injury • Avoid extensively tight ETT straps, tight cervical collars, and Trendelenberg positioning which can potentiate elevated ICP

  38. Intubation of Patients with Cardiopulmonary Disease • Hypotension • Medications decrease sympathetic tone • Mechanical ventilation increases intrathoracic pressure which decreases venous return and preload

  39. Trauma Airway Management • Cervical Spine • Avoid barbiturates and benzodiazepines in hypotensive patients • Etomidate is induction agent of choice • Avoid ketamine if intracranial injury

  40. Aspiration • Occurs when tone of LES is insufficient to deal with increased intragastric pressure and protective laryngeal airway reflexes are depressed • Iatrogenic Causes • BVM Ventilation • Nasogastric Tubes • Paralytic Agents • Predisposing Conditions • Trauma • Bowel Obstruction • Obesity • Overdose • Pregnancy • Hiatal Hernia • Seizures

  41. Suctioning • Left Lateral Trendelenburg Position • Helps get tongue out of the way facilitating endotracheal suctioning • Use well-lubricated, soft, curved-tip catheter • Complications • Hypoxia • Cardiac Dysrhythmias • Hypotension • Pulmonic Collapse • Direct Mucosal Injury

  42. Mechanical Ventilatory Support • Modes • Controlled • Apneic patients • Assist-control (A/C) • Allows patient to trigger a cycle by inhaling • If not triggered, ventilator will deliver a controlled breath • Intermittent Mandatory Ventilation (IMV) • Unsynchronized delivery of ventilator-generated tidal volumes • SIMV is synchronized • Tidal Volume • Initially set at 10ml/kg • Peak Airway Pressure • Maintained below 35-45 cm H2O to prevent barotrauma • PEEP/CPAP • Consider if decreased pulmonary compliance prevents delivery of adequate tidal volume or if hypoxia persists despite 100% FiO2

  43. Extubation • Rarely indicated in ED • “Bucking” • Give 1-2 ml of 4% lidocaine down ETT • PostextubationLaryngospasm • Stridor following extubation • Treat with oxygen by positive pressure and nebulizedracemic epinephrine

More Related