Cervical spine injury with diaphragmatic paralysis.
Unprotected airway.
Decreased LOC with loss of airway reflexes (often GCS < 8).
Impending airway collapse: thermal burns, anaphylaxis, epiglottitis, severe drug overdoses, expanding neck hematoma or mass.
Airway trauma.
High risk of aspiration i.e. ongoing hematemesis in UGIB.
Performing surgery/procedures that require general anesthetic.
Impending respiratory failure.
Cyanosis, diaphoresis, tachypnea/tachycardia, heavy accessory muscle use.
Concern of muscle fatigue (i.e. persistently elevated respiratory rate).
Airway safety following high dose sedating medication use i.e. seizure termination in status.
To facilitate short term hyperventilation to manage increased ICP.
Transportation safety in patient at high risk of decompensation, i.e. high dose sedation for psychosis, trauma requiring imaging, etc.
Tools required for intubation: STOPMAID
Suction
Have two suction devices ready
‘Ducanto’ or other large bore suction device should be available if anticipate heavy bleeding or vomiting interfering with airway.
Tools for intubation
Hyperangulated blade (i.e. ‘Glidescope’)
Default Glidescope #3 blade for women and #4 blade for men.
Note: At KGH first pass is often done with glidescope 4 video laryngoscopy, but should have direct laryngoscope, bougie, BVM, and OPA/NPA/LMA available, and surgical access kit in emergent situation of can’t ventilate/can’t oxygenate.
ET tube x2 sizes.
Generally, size 7-7.5 for women, 7.5-8 for men.
Keep a size above and below in the room ready.
Stylet (bend to match curvature of hyper angulated blade).
10ml syringe to inflate cuff (+ manometer to ensure cuff pressure 20 – 30 cmH2O).
ETT securement device or tape.
Oxygen source.
Two sources!: nonrebreather mask + nasal prongs for preoxygenation.
BVM with reservoir + end tidal CO2 monitor.
Mechanical ventilator set up by RT.
Positioning tools
I.e. pillows, Troop pillow, elevating head of bed to facilitate “sniffing” position.
Note: sniffing = aligns airway axis. Ideally want to be able to see from the side of patient the earlobe lining up with the sternal notch.
Monitors
Continuous cardiac monitoring and pulse oximetry.
Non-invasive BP cycling q1-2 minutes.
Invasive BP monitoring (Arterial line) ideal in hemodynamic instability.
Assistants
RT available to assist with bag-mask ventilation and intubation.
Nursing for drug administration.
Second physician to monitor and manage hemodynamics if possible.
Intravenous access
Ideally want 2 or more peripheral IVs at a minimum.
Drugs
Induction agent(s).
Neuromuscular blocking agent.
Vasopressors.
Induction Agents:
Ketamine
Intubation dose:1-2 mg/kg (i.e. 100 mg IV is a good dose for most patients).
Time to effect: 45-60 seconds.
Duration of action: 10-20 minutes.
Benefits:
Hemodynamically stable (usually), can expect some tachycardia.
Bronchodilation, generally maintains respiratory drive (although apnea may still occur at doses >0.5mg/kg).