*Intubation: ETTube choice depends on the size of the individual. A general rule is to look at the patient's "pinky" finger for the diameter of tube to use. Generally, 7.0-8.0 for a woman and 8.0-9.0 for a man. Check the balloon with a 10cc syringe by inflating the balloon, while still maintaining sterile in package. Put pressure on the inflated balloon, then deflate by withdrawing the 10mL of air. Make sure suction is available to suction out the mouth. Then, choose the type of blade to use.
Straight blade (Miller Blade) - goes over the
epiglottis and exposes the glotic
opening visualizing the chords directly.
Also called a direct intubation.
Curved blade (Macintosh Blade) - goes into the
vallecula (the space between the epiglotis
and the tongue) and displaces the epiglottis
anteriorlly as you lift up to visuallize the vocal
chords (white upside down V like shape).
This is also referred to as an indirect
intubation.
Make sure your bulb is "white, tight, and bright." Many laryngoscopes are now fiberoptic and have no bulb. Older models would still have a bulb that could burn out or become loose and fall into the lungs if not tightened. Change batteries in the handle if needed. Provide cricoid pressure (Sellick's maneuver) with the thumb and fore finger to the cricoid cartilage (just below the "Adam's apple").
The goal is to place the endotracheal tube (ETT) or another advanced airway in the glotic opening of the Larynx; the balloon is to be just past the vocal chords (1-2cm past). Take no longer than 30 seconds to attempt to intubate. Note: NEVER, EVER, LET GO OF THE TUBE UNTIL IT IS SECURED.
Primary confirmation is now with a device such as an end-tidal CO2 monitor (bag the patient 6 times at least then place the device on the ETT and it will turn yellow to indicate CO2 if it is in the right spot, the trachea) or an esophageal detector as well as auscultation of breath sounds.
Listen for breath sounds with a stethoscope over the epigastric area and both lung fields at the midaxillary line for breath sounds as someone bags the patient. The recommendation is 500-600mL of tidal volume will cause chest rise instead of the previous thought of 700-1000mL, but most importantly visable chest rise, since we wouldn't be measuring the tidal volume.
Other airway devices are the Laryngeal Mask Airway (LMA), the Esophageal-Tracheal Combitube, and the Esophageal Orbturator Airway (EOA). These are devices that can be used by personnel that cannot intubate by placing them into the esphagus to provide indirect oxygenation to the lungs.
*Person Collapses (Adult, assume cardiac arrest)
*Assess Responsiveness (Shake and Shout or if trauma, Touch and Talk
to pt) "Are you awake?"
*Activate emergency response system (call 911 or if in a medical setting
call a code blue or call for a defibrillator) - the main rhythm
associated with cardiac arrest in an adult is V.fib/Pulseless V. Tach
and NEEDS to be shocked as soon as possible to survive.
Begin the Primary Survey
A=Airway, Open and assess airway. Use head tilt-chin lift or if trauma suspected jaw thrust method to open the airway. Look (for chest rise), listen (over the mouth for air movement), and feel (for breathing against our face). Treat occasional gasps as if not breathing. The new guidelines recommend that if in the field and ALONE (one person), open all airways by head tilt-chin lift. The rationale is that one person doing a jaw thrust will need to stay and maintain that head positioning. It is more of a priority to open the airway and breath for the patient than it is to maintain the head in proper alignment.
B=Breathing, take 5-10 seconds to check for breathing. If none, give 2 slow breaths over 1 second and enough to cause visible chest rise. If the first does not go in, reposition the head (reopen the airway) and try again.
C=Circulation, Assess pulse and skin color and movement from pt for signs of circulation. If no carotid pulse within 10 seconds, start Chest Compressions hard (1 1/2 to 2 inches) and fast (100 compressions per minute). (Give 30 chest compressions for every 2 breaths for two minutes, then switch). If there is a pulse, provide rescue breathe for the pt 10-12 times per minute, give a breath enough to cause chest rise and complete
recoil.
Helps Arrives
D=Defibrillation, Attach to a defibrillator-monitor or with paddles do a quick look for a shockable rhythm. We are looking for V.fib or V.Tach to defibrilate.
Begin Secondary Survey
A=Airway, Insert oral airway, use a bag-valve-mask with 100% oxygen to ventilate (10-12 times per minute with a perfusing rhythm) the patient while equipment is being prepared for intubation. *Note: Hyperventilate 2-3 breaths just before attempting to intubate.
B=Breathing, Confirm and secure the tube with an approved airway device and ventilate the patient with 100% oxygen (8-10 times per minute, greater rate than this can reduce venous return and reduce cardiac output). For obstructive pulmonary disease reduce further to 6-8 breaths per minute to allow for maximum exhalation. Once advanced airway is in place, do not have to syncronize breaths with compressions any longer. If a patient is on a ventilator, the patient needs to be removed and ventilated with a bag-valve mask. This is usually due to the pressure the compressions cause that may limit the ventilator from giving a breath.
C=Circulation, Reassess circulation resume CPR, Note: Asynchronous chest compression may now be done with ETTube placement. Place IV, antecubital vein is the first choice and run IVFs if appropriate - Normal Saline or Lactated Ringers are the preferred choices or Intraosseous access.
D=Differential Diagnosis, Search for and treat reversible causes including but not limited to 5 Hs and 5 Ts: Hypovolemia, Hypoxia, Hypo/hyperkalemia(low or high K level), Hydrogen Ion (acidosis), Hypothermia/Hyperthermia, Hypoglycemia, Thrombosis Pulmonary (PE), Thrombosis Cardiac (MI), Tension Pneumothorax, Cardiac Tamponade, Tablets (OD) see PEA for tx of each, Trauma.
