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Chapter 5 OROTRACHEAL INTUBATION

Mark Morocco Eric F. Reichman

INTRODUCTION
Airway control is the rst and most critical action of the Emergency Physician. The A in the ABCs demands that no other action may take place until the airway is secure. Endotracheal intubation inserts an articial airway connecting the respiratory system to the outside world and gives denitive control of the airway. Once the tube is in place, all methods of support can be applied. If the airway is not secure, nothing can help the patient. Endotracheal intubation can be accomplished by a variety of methods. The method of choice will be dictated by physician preference and experience, the patients condition, and the type of equipment available. The most common method of endotracheal intubation is orotracheal intubation. There are no good alternatives to intubation when oxygenation and ventilation are threatened. All actions should be focused on two objectives: to get the tube in quickly and in the right place. The proper preparation, practice, and personnel can assure that the nightmare airway is an extremely rare event.1

ANATOMY AND PATHOPHYSIOLOGY

For the purposes of intubation, our discussion of the anatomy starts at the lips and travels inward to end at the right mainstem bronchus. As you approach the patient, visualize the normal structures expected and match them with what is seen. Distortion occurs from edema or trauma. Structures may be hidden by vomit or blood. Since all structures are viewed upside-down, from the position over the head of the patient, the potential for disorientation multiplies. Begin at the face and move inward (Figures 5-1 and 5-2). The philtrum of the upper lip will be located at the

6 oclock (bottom) position. Symmetrical swelling, carbon deposits, blistering, or signs of trauma to the lips can indicate that the inner anatomy of the airway may be altered and the intubation more difcult. Moving inward, open the patients mouth and check the teeth for fractures, size, and the presence of removable dental devices. Large upper incisors and/or limited jaw opening will make endotracheal intubation more difcult. The tongue hangs down from the oor of the lower jaw (mandible) and ends with the tip against the upper (maxillary) incisors (Figure 5-2).Visualize the tongue as a hanging oval of tissue with two tips (Figure 5-2). The rst is the anterior tip of the tongue proper. The second is the epiglottis. The anatomic oor of this view is formed by the hard and soft palates, which end at the palatopharyngeal arch (Figure 5-2). The uvula is located inferiorly and in the midline. The palatoglossal arch and palatopharyngeal arch form twin vertical pillars that lie posterior to the molars of the upper teeth (Figure 5-2). All of these structures are potential sources of obstruction and must be evaluated for swelling, deformity, or trauma. The back wall is the posterior wall of the pharynx (Figure 5-2). At the posterior wall of the pharynx, the airway bends 90 degrees to run parallel to the bed. Visualized from the perspective of the top of the patients head, the root of the tongue and the lingual tonsils are located at the 12 oclock position (Figures 5-3 and 5-4). The tongue continues into a blind pocket known as the vallecula. Following the vallecula posteriorly, it is continuous with the epiglottis. The epiglottis hangs with its tip pointing downward. Directly behind and protected by the epiglottis is the entry to the remainder of the airway (Figure 5-4). The esophagus lies at the 6 oclock position. From the viewpoint of the intubator, the hypopharynx appears like the numeral 8. The top half is the airway and the bottom half the esophagus.
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Tip of tongue Uvula Lower lip Tongue Vallecula Trachea Esophagus Epiglottis Posterior pharyngeal wall Palatopharyngeal arch Palatoglossal arch Uvula Mandible Tongue

FIGURE 5-1 Schematic representation of the airway.

Under the epiglottis is the larynx (Figure 5-5). The vocal cords are located in the midline and form an A shape, with its apex toward the epiglottis. Identifying the vocal cords is important, since the visualization of the endotracheal tube passing between the cords is proof of a successful endotracheal intubation. The arytenoid cartilages are paired structures. One lies at the posterior aspect of each vocal cord. The aryepiglottic folds are paired structures that span from the lateral edge of the epiglottis to the arytenoid cartilages. They contain muscles that move the arytenoid cartilages and subsequently open and close the vocal cords. The trachea bifurcates at the carina into the right and left mainstem bronchi. In some patients the tracheal rings are easily visible through the vocal cords.

FIGURE 5-2 The oral structures as viewed from above the supine patients head.

head injury requiring hyperventilation, hypoxemia, hypoventilation, apnea, lack of a gag reex, and unconsciousness.

CONTRAINDICATIONS
Orotracheal intubation is relatively contraindicated in patients who do not need it, who are likely to be injured by the procedure, or whose injuries make success unlikely. Spontaneous breathing with adequate ventilation and normal mental status may allow less invasive techniques such as continuous positive airway pressure (CPAP) in patients whose medical conditions are likely to respond quickly to interventions, such as cardiogenic pulmonary edema or pneumonitis.2 Trauma patients, with likely cervical spine injury or anterior neck wounds, as well as severely immobile arthritis patients may be injured by the manipulation required during oral endotracheal intubation.3 Severe orofacial injuries, bleeding, deep airway obstruction, or gross deformity of the head and neck may make successful intubation impossible. A quickly changing obstruction, such as edema or an expanding hematoma, may require a surgical airway if oral endotracheal intubation is delayed. Choose a surgical airway if the manipulation or time required for oral endotracheal intubation puts the patient at risk for spinal injury or hypoxia.4 Orotracheal intubation

INDICATIONS
Any threat to oxygenation and/or ventilation is a relative indication for endotracheal intubation. If the threat is simple and easily removed, remove it. If there is uncertainty that the patients airway patency, respiratory drive, or oxygenation cannot be maintained without intervention, endotracheal intubation is required. Time is of the essence. The decision to intubate early can make the difference between a controlled, successful procedure and a chaotic, crashing nightmare. Endotracheal intubation can be performed to administer resuscitation medications, ensure a patent airway, deliver oxygen, isolate the airway, reduce the risk of aspiration of gastric or oral contents, suction the trachea, ventilate the patient, and apply positive-pressure ventilation. Other indications include altered mental status,

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Ventral

Body of tongue

Palatoglossal arch Lingual tonsil Palatine tonsil Vallecula Epiglottis Dorsal Root of tongue

FIGURE 5-3 The tongue and adjacent structures as viewed from above the supine patients head.

should not be performed by individuals unfamiliar with the equipment and technique.

EQUIPMENT
Endotracheal tubes, various sizes 10 mL syringe Water-soluble lubricant or anesthetic jelly Wire stylet, malleable type Laryngoscope handle Fresh batteries for the laryngoscope Laryngoscope blades, various sizes and shapes Supplemental oxygen with appropriate tubing and connectors Nonrebreather oxygen masks, various sizes Wall suction with appropriate tubing Yankauer suction catheter Bag-valve device, sizes: infant, child, adult small, adult medium, adult large Oral airways, sizes: infant, child, adult 3 to 5 Nasal airways, various sizes Benzoin adhesive Tape Pulse oximeter Cardiac monitor Automatic sphygmomanometer End-tidal carbon dioxide (CO2) monitor/device Cricothyrotomy backup tray Crash cart Resuscitation medicines

Personnel (respiratory technician, medication nurse, in-line stabilization assistant, recorder) Medications (premedications, induction, anesthetics, paralytics), see Table 5-1 Many institutions make an intubating/airway kit (Figure 5-6). It contains a combination of laryngoscope handles, laryngoscope blades, oropharyngeal airways, nasopharyngeal airways, tongue blades, a malleable stylet, various sizes of endotracheal tubes, syringes, tape, and commercially available devices to secure the endotracheal tube.

ENDOTRACHEAL TUBES
The choice of endotracheal tube size will vary based on the patients age, anatomic anomalies, body habitus, and airway anatomy (Table 5-1). The endotracheal tube is sized based on the internal diameter (ID) measured in millimeters. The size is printed onto the surface of the endotracheal tube for reference. The sizes begin with 2.5 mm and increase in 0.5 mm increments. Some generalities hold true in most patients. Adult males usually require a size 7.5 to 9.0 cuffed endotracheal tube. Adult females usually require a size 7.0 to 8.0 cuffed endotracheal tube. Endotracheal tube selection in children can be made by one of several methods. A Broselow tape will identify the proper size tube. Visually select a tube with an inside diameter that matches the size of the width of the nail of the patients little nger. If time allows, the following formula may be used to conrm the tube size:

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Ventral Root of tongue (lingual tonsil) Lingual tonsils on root of tongue Epiglottis

Vallecula Vallecula Epiglottis Airway trachea protected behind epiglottis Aryepiglottic fold

Vestibule

Vocal folds (true cords)

Trachea Esophagus Posterior pharynx Posterior pharyngeal wall Dorsal

Arytenoid cartilages

FIGURE 5-4 Structures of the hypopharynx as viewed from above the supine patients head.

FIGURE 5-5 The structures of the glottis as viewed from above the supine patients head.

tube size (4 childs age in years)/4. An uncuffed endotracheal tube should be used in children under 8 years of age to prevent the complications of subglottic and tracheal stenosis. After determining the proper size endotracheal tube, also select and prepare a tube that is one size smaller in case the airway is smaller than expected. The endotracheal tube is a clear polyvinyl chloride disposable tube that is open on both ends (Figure 5-7). The proximal end contains a standard size (15 mm) connector that will attach to the bag-valve device, a ventilator, and other sources of positive-pressure ventilation. The distal end is beveled. It has a perforation, located

approximately 0.5 to 0.75 cm from the tip and opposite the bevel, known as the Murphy eye. Printed on the tube are the size, a radiopaque line to aid in radiographic visualization, and 1 cm incremental marks beginning at the tip. An inatable cuff is positioned proximal to the Murphy eye. An ination port, to inate the cuff, hangs from the proximal third of the endotracheal tube. A syringe, lled with air, attaches to the ination port to inate and deate the cuff. The endotracheal tubes cuff is a high-volume, lowpressure balloon. It is designed to accommodate a high volume of air before the intracuff pressure rises. This is

TABLE 5-1. ORAL ENDOTRACHEAL TUBE SIZES AND POSITION BASED ON PATIENTS AGE
Patients age Premature Full-term/newborn 16 months 612 months 12 years 34 years 56 years 78 years 910 years 1113 years Female 14 years Male 14 years Size* (French) 10 12 14 16 18 20 22 24 26 2830 2830 3234 . Internal diameter (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.0 8.0 External diameter(mm) 3.3 4.04.2 4.74.8 5.35.6 6.0 6.3 6.77.0 7.37.6 8.0 8.2 8.79.3 9.310.0 9.310.0 10.7 11.3 Distance inserted from lips (cm) 10 11 11 12 13 14 1516 1617 1718 1820 2022 2224

*Calculated as follows: External diameter (mm)

Varies by manufacturer.
6

SOURCE: Modied from Stone and Gal.

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FIGURE 5-8 The laryngoscope handle. FIGURE 5-6 An airway/intubation kit. It contains the items most commonly needed for orotracheal intubation. From left to right: laryngoscope handle, laryngoscope blades, oropharyngeal airways, tongue blade, malleable stylet, endotracheal tubes, tape, and syringe.

an extremely important feature. If the intracuff pressure rises, it is transmitted to the delicate tracheal mucosa where it can cause pressure necrosis and ischemia. All endotracheal tubes should be examined for defects before use. Attach a 10 mL syringe lled with air to the ination port. Inject the air to inate the cuff. The cuff should inate symmetrically and have no air leak. Deate the cuff completely. Leave the syringe attached to the ination port in order to inate the cuff later on, after the endotracheal tube has been inserted into a patients airway. If a tube is defective, discard it and open a new endotracheal tube.

LARYNGOSCOPES
The laryngoscope is a handheld device that is used to elevate the tongue and epiglottis to expose the glottis (Figure 5-8). It is a device that is held in the left hand re-

gardless of which hand of the user is dominant. It consists of a handle and a blade. The handle contains the battery for the light source. The distal end of the handle has a tting where the handle connects to the blade. A transverse bar indicates where the indentation on the proximal blade attaches to the handle. The laryngoscope blade has a removable bulb attached to its distal third. A beroptic bundle within the blade transfers power from the handle to the bulb. The choice of the type and size of laryngoscope blade will vary with physician experience and preference. The best blade is one that the intubator feels comfortable and condent using. The curved Macintosh blade is most commonly used (Figure 5-9). It is the easier blade to use for those with little experience with orotracheal intubation. Many feel that it requires less forearm strength to use as compared to the straight blade. The straight Miller blade is often reserved for those experienced with the blade and with orotracheal intubation (Figure 5-10). The tip of the curved Macintosh blade ts into the vallecula and indirectly lifts the epiglottis to expose the

FIGURE 5-7 The endotracheal tube.

FIGURE 5-9 The Macintosh laryngoscope blade.

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FIGURE 5-10 The Miller laryngoscope blade.

vocal cords (Figure 5-11). A size 2 blade is used for 3- to 6-year-olds. A size 3 blade is used for children starting at about age 6, for women, and for small to average-size males. A size 4 blade is usually reserved for large males. The tip of the straight Miller blade goes directly under the epiglottis to expose the vocal cords (Figure 5-12). A size 0 to 1.0 blade is used for neonates, infants, and toddlers up to 2 years of age. A size 2 blade is used for children 3 to 6 years of age. A size 3 blade is used for women and average-size males. A size 4 blade is rarely used, and then mainly for large males.

FIGURE 5-12 Use of the Miller blade. It is inserted below the epiglottis to elevate the mandible, tongue, and epiglottis as a unit.

STYLETS
The stylet is a semirigid piece of metal that is bendable (Figure 5-13). It is often plastic-coated. It inserts into the lumen of the endotracheal tube. It should be lubricated with water-soluble lubricant or anesthetic jelly prior to insertion into the endotracheal tube. The tip of the stylet should be 1 cm proximal to the tip of the endotracheal tube to prevent injury to the patients airway. The endotracheal tube, with a stylet, can be bent to maintain a specic shape. This is used to facilitate passage of the endotracheal tube through the vocal cords. It is commonly bent into a hockey-stick or J shape for most intubations. A greater curvature is often used for intubations when the larynx is anterior, in difcult intubations, and in blind intubations.

PREPARATION
PHYSICIAN
Once the decision to intubate has been made, the physician must use training and experience to begin leading the team toward a successful intubation. Although the process must move quickly, the physician must, by example, ensure a calm and orderly environment. Making the decision to intubate earlier allows the team to follow a shorter and easier time line. The physician must visualize this time line and identify actions and potential problems before they occur. A backup

FIGURE 5-11 Use of the Macintosh blade. It is inserted into the vallecula to elevate the mandible, tongue, and epiglottis as a unit.

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EQUIPMENT
Check that the room is ready and all equipment is within arms reach. Turn on the suction and the oxygen. Conrm that both systems work. Attach the suction tip and check to see whether there is a small nger hole in the barrel that must be covered for the suction to work. If so, close it with a piece of tape so that the suction is always on. This is not a concern if a Yankauer suction catheter is being used. Ensure that the suction tubing is long enough to reach the center of the bed. Place the suction catheter under the mattress to the right of the patients head and within easy reach. Place the spare suction tip nearby. Set the oxygen ow regulator to 15 L/min. Apply a nonbreather mask to the oxygen and the patient. Place the bag-valve device near the head of the bed and within easy reach. Conrm that the noninvasive blood pressure cuff, cardiac monitor, and pulse oximeter are working and attached to the patient. Conrm that the end-tidal CO2 monitor is nearby and working. If such a monitor is unavailable, a disposable in-line monitoring device should be available. Ensure that the patient has at least one working intravenous line. Assemble the intubation equipment. Place the laryngoscope blade on the handle. Open the blade and conrm that the light works. Close the blade into the ready position, at against the handle, to keep the bulb cool and not drain the batteries. Take the endotracheal tube and the backup smaller one and prepare them. Insert the 10 mL syringe into the ination port for the endotracheal tube cuff. Inject enough air to inate the balloon. If there is no leak, deate the balloon until it is completely at against the endotracheal tube. Leave the syringe attached. Liberally lubricate the stylet. Insert the stylet into the endotracheal tube until its tip is 1 cm proximal to the distal tip of the endotracheal tube. Place a bend in the stylet as it enters the proximal end of the endotracheal tube to keep the stylet from advancing. Bend the stylet/endotracheal tube assembly into a curve roughly approximating a hockey stick or J (Figure 5-13). Lubricate the tip of the endotracheal tube and the collapsed cuff. Place the assembly back into the endotracheal tube package. Place the endotracheal tubes, laryngoscope, backup laryngoscope handle and blades, oral airways, and tape on a tray within easy reach of the bed. Check the room lighting. Raise the bed to minimize excessive bending and better visualize the patients airway.

FIGURE 5-13 The intubating stylet. It may be bent into any required shape. When inserted into an endotracheal tube, it will form the endotracheal tube into the desire shape. The most common shapes are the J and the hockey stick.

plan should also be available in case orotracheal intubation is impossible. Any Emergency Department patient about to be intubated is a high priority, so do not be afraid to use resources liberally. Obtain assistants to help as soon as the decision to intubate is made.

PERSONNEL
Shortly before the procedure begins, assemble the entire team near the bed and go over the game plan calmly and quickly. All personnel should be gloved, gowned, and masked. Eye protection should be worn by all personnel to protect against splash injury from blood and secretions. Explicitly identify assistants and assign their roles early. Give instructions clearly and calmly before the procedure begins. It is helpful to write down medications with doses in the order that they will be given and to review them quickly with the medication nurse. Emphasize that it will be the nurses job to draw up, label, and administer the medications, followed by a saline ush. Reinforce that during the procedure this will be a particular nurses only job. The respiratory assistant has three important tasks: helping to ventilate the patient, applying cricoid pressure, and handing the endotracheal tube to the intubator so that visual contact with the vocal cords is not lost. If cervical spine immobilization is needed, a third assistant should be explicitly instructed as to how and when the team leader would like the patients neck secured.

PATIENT PREPARATION
If the patient is competent and awake, explain the procedure, clarify advance directives, and obtain consent. If time permits, a history is especially helpful. The mnemonic AMPLE can help to provide quick informa-

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tion: allergies, medications, past medical history, last meal, and events leading to the current problem. Conrm again that the appropriate monitoring sources are working and attached to the patient. Conrm adequate intravenous access. Place the patient, with a normal neck, in the snifng position, with the head extended at the atlantooccipital joint while the neck is relatively exed. A folded towel under the occiput helps to gently raise and tilt the head back into the proper position (Figure 5-14). Correct positioning is probably the most important preparation of the patient. Dentures should be left in place temporarily, as they help to stabilize the mouth and prevent occlusion during preoxygenation and bag-valve-mask ventilation. If the patient is breathing spontaneously, begin preoxygenation for 5 minutes before the procedure (if time permits). Use a well-tting nonrebreather mask with the oxygen ow regulator set at 15 L/min. This displaces nitrogen from the lungs and gives the patient a physiologic reservoir of oxygen for approximately 5 minutes while apneic. Remember: 5 minutes of preoxygenation provides 5 minutes of protection.5 If bag-valve-mask ventilation is required, have an assistant apply posteriorly directed cricoid pressure to minimize gastric distention and decrease the chance of vomiting and aspiration. Have assistants ready to turn the patient onto his or her left side to minimize the risk of aspiration if vomiting occurs. Monitor the pulse oximeter to assure good oxygenation and ventilation. It should rise to the high 90s and remain there. If not, check the O2 circuit from the wall to the patient and conrm that spontaneous breathing is still occurring.

TECHNIQUE
The evaluation and preparation for orotracheal intubation are complex and essential. If done well, the intubation will hopefully be quick and anticlimactic. Position the respiratory assistant to the right side near the patients head. The intubator should stand at the head of the bed. Adjust the bed to place the mattress level with the intubators umbilicus. Pull the bed away from the wall at least 2 feet and clear a maneuvering space of tubes, lines, and equipment to prevent distractions. If in-line cervical immobilization is needed, the assistant should stand at the intubators left hip, ready to remove the collar and hold the neck in position. Grasp the laryngoscope with the left hand. It is a lefthanded instrument regardless of the handedness of the intubator. Pull it open and lock the blade onto the handle. Conrm that the light is functioning. The tip of the laryngoscope blade should be pointed toward the patients chin. Pass the prepared endotracheal tube and suction catheter to the respiratory assistant, who will

place them into the right hand when asked. This allows the intubator to keep visual contact with the patients airway during the procedure. Induction of anesthesia is the nal preparation for orotracheal intubation. The choice of drug sequence is based on the physicians experience and the patients condition (Table 5-2). A typical sequence begins with a defasciculating dose of a nondepolarizing neuromuscular blocking drug. After 2 to 3 minutes, induce anesthesia with a sedative followed immediately by a paralytic agent (i.e., succinylcholine). Apply cricoid pressure. Once the patients muscles are relaxed, perform the intubation as described below. Refer to Chapters 3 and 4 regarding the complete details of rapid sequence induction and the pharmacology of the induction agents. Some patients, especially the old and sick, may stop breathing earlier than anticipated. Be prepared to intubate before the expected time of drug onset. Observe the patients chest. Watch it rise. When it stops, note the time. Place your right thumb on the patients jaw. Gently pull down the lower lip and open the mouth. Reinspect the oral cavity. Remove any dentures or foreign bodies. Compare what you see with what you expect to see. Fix any problems as you go further into the airway. If blood or vomit is seen, ask for the suction catheter. Apply the suction catheter without removing your gaze from the patients airway.When done suctioning, hold the suction catheter up for the assistant to take. Firmly grasp the laryngoscope in the left hand (Figure 5-14A). Insert the tip of the laryngoscope blade into the right side of the patients mouth. Smoothly advance the blade inward while keeping pressure against the tongue. Use the blade to trap and push the tongue to the left as the blade is simultaneously moved to the midline, clearing a path for your gaze. Keep the left wrist rm. Use the forearm, wrist, and hand as a single unit and avoid bending or exing the wrist. It is essential to move the patients tongue up and to the left. The tongue will protect the mandibular teeth from being injured by the laryngoscope blade. It allows the laryngoscope blade to be moved away from the maxillary teeth. It also opens a path to visualize the patients airway. When the blade has been inserted all the way, lift the patients airway up and forward exactly along the long axis of the laryngoscope handle, which should be aimed toward a point directly above the patients chin (Figures 5-11, 5-12, and 5-14B). Do not cock or crank back on the laryngoscope handle with your wrist, or the back of the laryngoscope blade may break the incisors. The epiglottis should be seen at the base of the tongue.

INTUBATING WITH THE (CURVED) MACINTOSH BLADE

Advance the tip of the laryngoscope blade into the valleculathe space between the base of the tongue

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FIGURE 5-14 Orotracheal intubation. A. Proper positioning of the laryngoscope blade above the patients mouth. B. The blade is inserted into the vallecula. The handle is lifted anteriorly and inferiorly to elevate the mandible, tongue, and epiglottis (arrow). The glottis will be visible. C. The endotracheal tube is inserted into the trachea until the cuff is below the vocal cords. D. The laryngoscope has been removed and the cuff inated. E. The endotracheal tube is secured.

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TABLE 5-2. RAPID SEQUENCE INDUCTION MEDICATIONS FOR SPECIFIC PATIENT PROFILES
Patient type Normal adult Normal child Asthma, adult Asthma, child Head injury, adult Head injury, child Premedication* Vecuronium (0.01 mg/kg) Vecuronium (0.01 mg/kg) and atropine (0.02 mg/kg, min dose 0.1 mg) Lidocaine (1.5 mg/kg) and atropine (0.5 mg) Lidocaine (1.5 mg/kg) and atropine (0.02 mg, min 0.1 mg) Vecuronium (0.01 mg/kg) and lidocaine (1.5 mg/kg) and fentanyl (35 g/kg) Vecuronium (0.01 mg/kg) and atropine (0.02 mg/kg, min 0.1 mg) and lidocaine (1.5 mg/kg) and fentanyl (35 g/kg) Vecuronium (0.01 mg/kg) and fentanyl (3 g/kg) and lidocaine (1.5 mg/kg) Vecuronium (0.01 mg/kg) and atropine (0.02 mg/kg, min 0.1 mg) and lidocaine (1.5 mg/kg) and fentanyl (23 g/kg) None Induction and paralysis Etomidate (0.3 mg/kg) or propofol (1 2.5 mg/kg) or thiopental (3 mg/kg) and succinylcholine (2 mg/kg) Thiopental (5 mg/kg) and succinylcholine (2 mg/kg) Ketamine (12 mg/kg) and succinylcholine (2 mg/kg) Ketamine (12 mg/kg) and succinylcholine (2 mg/kg) Etomidate (0.3 mg/kg) and succinylcholine (2 mg/kg) Thiopental (5 mg/kg) and succinylcholine (2 mg/kg)

Head injury, adult, hypotensive Head injury, child, hypotensive Hyperkalemia or renal failure, adult Hyperkalemia or renal failure, child Status epilepticus, adult Status epilepticus, child Pregnancy

Etomidate (0.2 mg/kg) and succinylcholine (1.5 mg/kg) Midazolam (0.15 mg/kg) or etomidate (0.3 mg/kg) and succinylcholine (2 mg/kg) Etomidate (0.3 mg/kg) or propofol (1.02.5 mg/kg) or thiopental (3 mg/kg) and rocuronium (0.6 mg/kg) or vecuronium (0.01 mg/kg) Thiopental (5 mg/kg) and rocuronium (0.6 mg/kg) or vecuronium (0.01 mg/kg) Thiopental (3 mg/kg) and succinylcholine (2 mg/kg) Thiopental (5 mg/kg) and succinylcholine (2 mg/kg) Ketamine (12 mg/kg) and rocuronium (0.6 mg/kg) or vecuronium (0.01 mg/kg)

None None None Atropine (0.5 mg)

*Given 3 min before intubating (T 3).

Given simultaneously at the beginning of intubation (T 0) and wait for 45 to 60 seconds for onset of paralysis.

and the body of the epiglottis (Figures 5-11 and 5-14B). Lift the laryngoscope handle to raise the tongue, jaw, and epiglottis as a unit (Figure 5-11). Observe carefully as the epiglottis pivots upward and uncovers the glottis (Figure 5-5). The amount of upward/forward force needed to lift the airway structures can be surprisingly large. The vocal cords should be visualized. The application of cricoid pressure by pressing the cricoid cartilage back, upward, rightward, and posteriorly (in this sequence) can help bring the vocal cords into view when the intubator cannot apply more lifting force due to lack of strength or reluctance to lift the airway, as in suspected neck injury. This is known as the BURP maneuver.

INTUBATING WITH THE (STRAIGHT) MILLER BLADE

Insert the laryngoscope blade completely. If the epiglottis is seen, insert the tip directly under and slightly beyond it. Lift the epiglottis and airway as above by raising your hand along the long axis of the laryngoscope handle toward a point above the patients chin (Figure 5-12). If neither the epiglottis nor the vocal cords are seen, the tip of the laryngoscope blade is in the esophagus. Locate the airway by lifting as above while slowly withdrawing the laryngoscope blade. As the

tip slides back, it will catch the epiglottis and the airway should fall down into view. The BURP maneuver may now be applied if necessary. Some physicians use a variation of this to localize the epiglottis by inserting the blade deeply and lifting, then withdrawing while feeling for the give as the epiglottis tip falls off of the retreating blade, and then readvancing a small distance to scoop up the epiglottis, exposing the airway. When the vocal cords are visualized, ask the assistant to pass the endotracheal tube into your right hand. This allows you to keep a visual lock on the vocal cords. Insert the endotracheal tube into the right side of the patients mouth. Advance the endotracheal tube so that the tip reaches the vocal cords without letting the body of the tube block the view. Continue to advance the endotracheal tube through the vocal cords until the cuff passes through them and into the trachea (Figure 5-14C). Advance the tube an additional 2 to 3 cm. The tip and cuff of the endotracheal tube must be visualized passing through the vocal cords to assure placement in the trachea. The t of the endotracheal tube through the vocal cords always seems to be tight, even in larger patients. A well-lubricated tip with the cuff completely collapsed is essential. Rolling the tube gently between the thumb

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and index nger at the moment of insertion can also help pilot the tip between the vocal cords. If the endotracheal tube is too large or the vocal cord opening narrow, ask the assistant to pass the smaller tube, which has already been prepared. Once the endotracheal tube has been inserted, the intubators right hand must hold the tube in place continuously until it is properly taped and secured. The assistant should inate the endotracheal tube cuff with the attached 10 mL syringe of air (Figure 5-14D) and then remove the syringe and stylet. The intubator must hold the endotracheal tube rmly to make sure that it does not become dislodged. The assistant should attach the end-tidal CO2 monitor and the bag-valve device to the endotracheal tube. If symmetrical lung sounds are heard on auscultation and if pulse oximetry and CO2 monitoring appear appropriate, secure the endotracheal tube in position in the right corner of the patients mouth (Figure 5-14E).

ASSESSMENT
In the Emergency Department, simple commonsense methods will quickly and accurately assess endotracheal tube placement. The assessment must be made quickly! An endotracheal tube in the wrong place, the esophagus, is as quickly dangerous as a properly placed one is lifesaving. Was the endotracheal tube visualized passing through the A frame of the vocal cords? This is the most important assessment. If it was directly visualized being placed and continuously held in place, it is properly positioned. Is the pulse oximeter reading in the high 90s and steady or rising? Is the CO2 monitoring appropriate? Be familiar with the monitor in your institution. Electronic monitors will show a respiratory waveform and a numerical value. In-line monitors connected between the endotracheal tube and the respiratory circuit will change color with inspiration and expiration to indicate the ow of CO2 passed the device. Evaluate the patient. Symmetrical upper chest rise without increasing abdominal size suggests proper placement. Persistent fogging or condensation inside the endotracheal tube with each breath for at least six ventilations will also conrm proper placement. Auscultate lateral to the nipples for strong and symmetrical breath sounds during positive-pressure breaths. Avoid auscultating in the midline, where normal breath sounds can be heard from a misplaced endotracheal tube in the esophagus. Auscultate at the lateral apices and bases of the lungs. Auscultate over the epigastrium. Correct placement will give strong, symmetrical sounds except in the epigastrum. If epigastric sounds are strongest or gurgling or vocalization is heard, assume

incorrect endotracheal tube placement. Breath sounds that are asymmetrical and stronger on the right indicate a right mainstem intubation. Deate the cuff and gently withdraw the endotracheal tube in 1 cm increments while auscultating. Continue to withdraw the endotracheal tube until equal breath sounds are heard. Secure the tube and reinate the cuff. Obtain a chest radiograph after clinically conrming the placement of the endotracheal tube. The tip of the radioopaque stripe of the endotracheal tube should be over the third or fourth thoracic vertebra and 3 to 4 cm above the carina of the trachea. Always inspect the radiograph for any signs of a pneumomediastinum, pneumothorax, or hemothorax. Clinical assessment of the endotracheal tubes position should take less than 15 seconds. If you are unsure of the endotracheal tubes position, leave the rst tube in place while applying cricoid pressure. If the patients pulse oximetry is in the mid- to high 90s, the endotracheal tube can be removed and intubation reattempted. If the pulse oximetry is low, remove the endotracheal tube and ventilate the patient with a bag-valve-mask device for 30 to 60 seconds to allow the pulse oximetry to rise into the high 90s before making a second attempt at intubation. Do not ventilate the patient by bag-valvemask without the application of cricoid pressure. The stomach will inate with air and increase the risk of aspiration. Some physicians prefer to leave the misplaced endotracheal tube in place. Leaving the rst tube might seem to complicate subsequent attempts but can serve to vent gastric vomit out of the oropharynx as well as to locate the esophageal entrance during the next attempt at direct visualization of the airway. As long as ventilation is possible with the bag-valvemask device and pulse oximetry can be maintained above 92% (PO2 60 mmHg), two or three attempts can be made at orotracheal intubation. If 30 seconds elapse or pulse oximetry falls to 92%, stop the intubation attempt and ventilate the patient for 30 to 60 seconds, as above. In training programs, the third attempt should be made by the most skilled person available. Three failed attempts dene a failed airway and call for rescue intubation by an alternative method. Any patient in whom bag-valve-mask ventilation becomes impossible must be given a surgical airway.

COMPLICATIONS
Hypoxia is the most destructive complication. It often results from prolonged intubation attempts, with or without proper preoxygenation, and unrecognized misplaced endotracheal tubes. Without adequate oxygenation, irreversible brain injury begins to occur within 2 to 3 minutes. Hypoxia can also cause cardiac arrhythmias.

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SECTION ONE / RESPIRATORY PROCEDURES

An unrecognized esophageal intubation will result in signicant morbidity and mortality. After intubation, the proper endotracheal tube placement should be conrmed by auscultation, chest rise, fogging in the endotracheal tube, end-tidal CO2 monitoring, and chest radiography. Any manipulation or movement of the endotracheal tube or the patients upper body (head, neck, and torso) should be followed by an assessment of the endotracheal tubes position. It can easily become dislodged and migrate into the hypopharynx and esophagus. Other methods to conrm endotracheal tube placement include inserting a beroptic bronchoscope through the tube and visualizing the tracheal rings and carina (Chapter 10) or inserting a lighted stylet and following the illumination into the trachea (Chapter 8). Bradycardia can be produced by pharyngeal manipulation. It may be especially pronounced in children because of their higher vagal tone. Pretreatment with atropine (0.02 mg/kg with a minimum dose of 0.15 mg) in children under 6 years of age can avoid this. It will also serve to decrease airway secretions. Increased intracranial pressure can occur as a result of the direct laryngoscopy. The exact cause of this transient rise is unknown. Lidocaine has been postulated as being of benet in blunting this but is so far unproven. A dose of 1.5 to 2.0 mg/kg IV may be used as a premedication if time allows and the patients condition warrants its use. Direct mechanical complications from the laryngoscope include lacerations of the lips, trauma to the pharyngeal wall, broken teeth, or dentures that may be aspirated and require later removal. Vomiting can cause subsequent chemical and bacterial pneumonitis. Pneumothorax is a rarely seen complication of laryngoscopy. It is more often associated with positive-pressure ventilation. It may also cause apnea, bronchospasm, and/ or laryngospasm due to prolonged stimulation of the pharynx. Laryngospasm may result from insertion of the laryngoscope blade or attempts to advance the endotracheal tube through the vocal cords. This occurs more often in patients who are awake, semiconscious, not paralyzed, and not anesthetized. It may be prevented by the application of nebulized lidocaine, topical anesthetic spray, transtracheal injection of lidocaine, or laryngeal nerve blocks. If laryngospasm occurs during intubation, remove the laryngoscope and begin positive-pressure ventilation. Positive-pressure ventilation will often overcome the laryngospasm. If not, consider paralyzing the patient immediately with succinylcholine or performing a surgical airway. A leak of air out the patients mouth or nose during ventilation signies a mechanical problem with the endotracheal tube. If the cuff is damaged, the endotracheal

tube must be removed and replaced. Check the position of the endotracheal tube by direct laryngoscopy. If the cuff is located between or above the vocal cords, it will not secure the airway properly. Deate the cuff, advance it through the vocal cords, and reinate the cuff. If the cuff slowly deates, there may be a leak in the ination port. Reinate the cuff and apply a hemostat to the tubing attached to the ination port or attach a closed stopcock to the ination port. The risk of aspiration increases in patients with difcult airways or full stomachs. This includes obese and pregnant patients. The use of an awake endotracheal intubation or rapid sequence induction will minimize the risk of aspiration. A properly placed endotracheal tube with the cuff inated will decrease, but not totally eliminate, the risk of aspiration.

SUMMARY
Orotracheal intubation is both common and lifesaving. It is the primary and preferred method of airway management. Every Emergency Physician must master this skill. With proper preparation, denitive control of the airway can be obtained. This assures that patients can be oxygenated and ventilated when they cannot do this on their own. Good team leadership skills are nearly as important as physical dexterity and assure an orderly and quick procedure. Rapid patient assessment is important to prevent complications. If orotracheal intubation is unsuccessful, another form of intubation or a surgical airway should be performed.

REFERENCES 1. Sakles JC, Laurin EG: Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325 332. 2. Falk JL, OBrien JF, Shesser R: Heart failure, in Rosen P, Barkin R, Danzl DF, et al (eds): Emergency Medicine: Concepts and Clinical Practice, 4th ed. St. Louis: MosbyYear Book, 1998:16451646. 3. Thierbach AR: Airway management in trauma patients. Anesth Clin North Am 1999; 17(1):7071. 4. Walls RM: Management of the difcult airway in the trauma patient. Emerg Med Clin North Am 1998; 16(1):4755. 5. Gerardi MJ, Sacchetti AD, Cantor RM, et al: Rapid sequence intubation of the pediatric patient. Ann Emerg Med 1996; 28:5859. 6. Stone DJ, Gal TJ: Airway management, in Miller RD (ed): Anesthesia, vol 2. New York: Churchill Livingstone, 1990:12651292.