UMEM Educational Pearls

Category: Airway Management

Title: Intubation "P"earls

Keywords: Intubation, endotracheal intubation, position, laryngoscopy (PubMed Search)

Posted: 8/27/2008 by Ben Lawner, DO (Emailed: 9/4/2008) (Updated: 11/19/2019)
Click here to contact Ben Lawner, DO

To echo Dr. Rogers' fantastic airway tips:

When considering an intubation or managing an emergent respiratory concern, keep the "P"s of intubation in mind:

1. P osition:  No intubating on the floor!  Don't get sucked into the patient's oropharynx! Maintain an appropriate distance. Align the airway axes. Sniffing position is utilized for non traumatic adult airways; this involves flexion of the lower c-spine and a bit of extension at the upper cervical levels. Take off cervical collars. Use pillows / blankets to align the external auditory canal (EAC) with the sternal notch to help w/visualization. Cricoid pressure is NOT designed to facilitate passage of the ETT- it MAY help prevent excessive gastric insufflation.

2. P reparation: Two tubes. Two blades. Two intubators. Plan B(ougie) or Plan C(cric). Though your emergency airway plans may differ, think of ALL airways as potentially difficult ones. Respect the epiglottis. 

3. P reoxygenation: 100% via NRBM when possible to ensure oxygenation and nitrogen washout. In patinets with at least some reserve, this will help to avoid pulse ox pitfalls. True RSI does NOT involve positive pressure ventilation.

4. P remedication: Know your sedatives in advance. Etomidate ? Ketamine ? Diprivan ? Whatever your agent of choice, know indications and drug dosages. Emergent RSI is a less than ideal time to access Epocrates.

5. P aralysis:  This is pretty much the point of no return. Administration of paralytics commits you to securing a patient's airway. Both rocuronium and succynylcholine can be dosed at 1 mg/kg IV.

6. P ass the tube: What Dr. Rogers said.

7. P osition confirmation: Direct visualization of the tube through the glottic opening coupled with end tidal Co2 is ideal.

References

-Our very own Dr. Ken Butler: "Be prepared!"