ROUTINE INTUBATION

OBJECTIVES

• To know the indications for tracheal incubation
• To be able prepare for and perform safe tracheal incubation
• To be able to identify the patient who is likely to be a "difficult incubation"
• To be able to prepare a Difficult Incubation Tray
• To have a methodical approach to the management of a "difficult incubation"
• To know and be able to perform the range of available options in the management of the "difficult incubation"
• The "BURP" technique (see later)
• The laryngeal mask
• Airway Boigie insertion
• Needle Hypothyroidism
• Hypothyroidism     - open technique       - Gelding technique
• To know the advantages, disadvantages, and complications of each of the above techniques.

INDICATIONS FOR INCUBATION

• To maintain airway potency
• To maintain airway protection (GCS 8 or less)
• Asphyxia / hypercritical (respiratory failure)
• Provision of therapy GE hyperventilation in head injury (controversial)
• Investigation GE CT scan without motion artifact

PREPARATION FOR TRACHEAL INCUBATION

1. The Staff

• Assemble the most experienced staff available
• The ideal number of staff required is 3
• the person incubating
• the person assigned to administer the medications and deliver the
• requested equipment
• the person assigned to provide Crisco pressure (or thyroid "BURP" pressure if difficult incubation is anticipated)
• A fourth staff member will be needed to perform in line stabilisation of the cervical spine if there is a possibility of injury.
• Allocate and demonstrate how to perform these specific tasks before  commencing the procedure so that all are clear as to their role.

2. The equipment

• Have a regular protocol established whereby all equipment required for the procedure is checked at the start of each shift as being present and functional. 
• Where time permits, recheck all equipment before commencing.
• Ensure :
• arthroscope is present and working. Have a size 3 and size 4 arthroscope blade available for adults.
• an appropriate sized pharyngeal airway is available
• the bag valve mask is functional and is attached to oxygen and has an appropriate sized face mask fitted
• the appropriate sized tracheal tube is present and, if it is cuffed, that the cuff does not leak. Tube sizes are usually :  adult male size 8-9 mm        adult female size 7-7.5 mm      child 4 mm + age/4 (cuffed up to age of 8 years)
• a lubricated introduce is placed inside the tracheal tube
• the Yankee suction is working
• all medications are ready and available in appropriate doses
• have the "crash trolley" and Difficult Incubation Tray ready

3. The Patient

• Secure IV access and flush annular to ensure potency
• Where feasible ensure the patient is fasted 4-6 hours (this is not usually possible in the emergency setting)
• If the need for incubation is not immediate, treat or exclude co morbid conditions which may be exacerbated by incubation GE pneumonia, hypoglycemia
• Position the patient supine with the head extended and the neck flexed. This may be facilitated by a thin pillow being placed under the head. This position will not only maintain an open airway to aid bag valve ventilation, but will also aid incubation.
• Cervical spine precautions should be observed where there is a likelihood of cervical spine injury. (use in line stabilisation IE a person is allocated to squat beside the incubator and hold the patent's head at the sides without applying traction and preventing movement as much as possible during incubation)
• Oxygenate with 100% oxygen for 5 minutes. This is usually achieved using a bag valve mask attached to oxygen. If the patient is breathing spontaneously manual ventilation is not necessary and may risk gastric distension and regurgitation/aspiration.
• Monitor : SaO2, ECG, PB

TRACHEAL INCUBATION

(Rapid Sequence Induction)

• Preparation as above
• Administer the sedation of choice GE
• enthronement 1 mg/kg and nitrate up to 4 mg/kg as necessary

OR

• Mazola 0.1-0.3 mg/kg
• Apply Crisco pressure
• Administer intramuscular blocker (only after patient sedated) GE Mentholatum 1-1.5 mg/kg
• Holding the arthroscope in the left hand insert the blade into the patent's mouth, down the right side of the tongue and pushing the tongue to the left. Insert down as far as the calculable. Then pull forward (don't lever on the top teeth)
• Identify the vocal cords and under direct vision , pass the tracheal tube between the cords and on into the trachea for 3-4 cm. The tube should measure 21 cm at the lips in females and 23 cm in males. Remove the introduce.
• Inflate the cuff until there is no air leak around it when ventilating.
•  Attach the tube to a bag valve mask attached to oxygen, manually ventilate and confirm tube placement in trachea by assessing :
• air entry in maxillae
• SA O2
• ETC O2 (if available), this should read about 40 mm Hg
• patient colour
• ECG
• PB
• If any problems, extenuate, re ventilate, and re oxygenate with bag valve mask attached to oxygen and re-incubate.
• Release the Crisco pressure only when the tube placement is confirmed.
• Anchor the tracheal tube firmly with linen tape
• Insert a gastric tube
• Arrange a chest Cray to check for tracheal and gastric tube position and for any complications of the procedure GE pneumonia.