The LSUHSC New Orleans
Emergency Medicine Interest Group

Presents

The Student Procedure Manual


Endotracheal Intubation

by Richard Cashio with
Patrick Hymel

Indications
Contraindications
Equipment
-SSADMIT
-Endotracheal tube of appropriate size (calculated)
Procedure
Follow-up
Complications

Indications

Contraindications

Equipment

Procedure

  1. Preoxygenate the patient while preparing equipment, with or without the bag-valve-mask device, depending on clinical need. Monitor vital signs and use pulse oximetry throughout procedure.
  2. Elevate the bed to position the patient's head at the level of the physician's lower sternum.
  3. Open the airway by using the heat-tilt-chin-lift method (only if a C-spine injury is not a consideration, in which case in-line immobilization with jaw thrust would be applied).
  4. Connect the laryngoscope and blade and check light on the blade. The light should be on when the blade and laryngoscope are at 900 to each other.
  5. Select appropriate tube size and using the 10ml syringe, verify that the balloon on the tube inflates. Deflate after verification.
  6. Apply lubricant to distal end of tube and insert stylet, (the stylet should not extend past the end of the tube). Lubricant may be omitted if under time constraints.
  7. Place a slight curvature in the tube to facilitate entry.
  8. The physician positions behind the patient with the laryngoscope in the left hand.
  9. The patient's mouth is opened with the fight hand and the blade is inserted on the right side of the mouth displacing the tongue to the left. Constant visualization while advancing blade is a must.
  10. When the blade is fully inserted, the laryngoscope handle should be roughly at a 30' to 450 angle to the patient.
  11. Force is then applied vertically upward on the laryngoscope, taking care not to place pressure on the patient's teeth. Do not rock backwards onto the patient's teeth! This is a major mistake. The handle of the laryngoscope is used as a handle to lift straight upwards, NOT as a lever!
  12. If a straight blade is used, the epiglottis is raised using the tip of the blade. If the curved blade is used, the tip is placed anterior to the epiglottis into the vallecula and the epiglottis is elevated further. This will expose the vocal cords. If at first you are not able to see the cords, ask an assistant to apply slight downward pressure on the cricoid cartilage (Sellick maneuver). This should help put the cords into view.
  13. The tube is then slid along the right side of the mouth and visualized entering 1/2 to I inch into the vocal cords. DO NOT TAKE YOUR EYES OFF OF THE CORDS ONCE YOU SEE THEM! Ask an assistant to pass you the tube if necessary. Watch the tube pass through the cords and do not look away. It is appropriate to tell those around you what you see as you attempt this procedure (i.e. "I see the epiglottis... I see the cords... I am passing the tube through the cords") This lets everyone around you know that you are on the right track (or not).
  14. The laryngoscope is removed and the balloon at the end of the tube is inflated using the syringe.
  15. The tube is then secured to the patient's mouth using tape making sure not to tape the lips.

Follow-up

Complications

 


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