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General Intubation Concepts

Setup for intubation different than setting up for supraglottics

Pre-assessment first 

General assessment most helpful

Set your self up for success

Sometimes the situation dictates where you may be delivering the tube. Modify to make easy for you if the situation permits

LEMON 

L - Look

E-Evaluate 3-3-2 - The 3-3-2 rule involves measuring 3 different distances in the patient's neck using the clinician's fingers. These measurements aid in predicting the ease or difficulty of intubation. 

M-Mallampati - The Mallampati score is one assessment to describe the relative size of the base of the tongue compared to the oropharyngeal opening in hopes of predicting the difficult airway. Essentially the amount of  space between the tongue and hard palate.

O-Obstruction or Obesity

N-Neck Mobility

S-Saturations

The tongue depressor is underutilized for airway visualization

Who intubates? The person needing the experience or the most experienced? Select the cases for the new providers carefully. Physiologically difficult cases NEED to be done by the most experienced provider.

Age/4+4 for peds tube sizes

If patient has airway burns, expanding hematoma, angioedema, failure to intubate usually means direct to surgical option. A supraglottic is unlikely to work with upper airway insults such as these. 

Remove false teeth if noted

Consider putting patient on cot and work more like an anesthesiologist, put the head up on the cot. 

Work at eye level rather than crouching to visualize the airway.

Physiological benefits include, less likely to vomit, patient will breathe easier prior to intubation. and chest and belly fat will be drawn down and away from chest. 

Align ear to sternal notch. Do not confuse head tilt chin lift with "sniffing position". Sniffing position is face out and forward.

Direct (Standard) Laryngoscopes are not dead. Practice with both. Camera head may not be charged, malfunction, or be obscured by blood, secretions, or vomitus.

Practice with all blades - you may not be given a choice same day and need proficiency with all

You should not be struggling with the laryngoscope, its a finesse procedure

Don't stick things down the view channel of the laryngoscope

Ones wrist is a gimbal, once you have a view you can rotate blade up and to the left to open up the view

There are several nuanced moves once the blade is introduced. Introduced midline, slightly to right, sweep left, advance blade incrementally identifying structures as you go, visualize glottic opening, then make space if needed by rotating wrist left and up. Introduce tube. 

Anatomy knowledge of the upper airway is necessary for success. 

Train like you practice. 

Have equipment loaded up and ready before you take a look. Have a backup plan, and the backup to that. 

You must know your equipment, and must know what fits together. 

Teeth are not a fulcrum.

Know your limitations. Back out if you are not being successful.

Non-intubating staff need to call vitals and SpO2.

If the thing didn't work, change SOMETHING on the next attempt.

Depth perception requires both eyes to triangulate depth perception.

Tube size is important and does matter. The smaller the more resistance to airflow.

Inflate the cuff to proper volume. Volume is not all of a 10ml syringe. High cuff pressures can cause tracheal necrosis. 

"Cuff to Seal" approach is putting just enough air enough to seal up airway. 

If you have a cuff pressure meter, set to 20-30. 

Watch the tube cuff and the black line go past cords, that's the correct depth. 

Check lungs sounds to assure that we are not mainstemed

Consider use of bougie - there are studies that show routine use on every tube after training improves success rates

If the tube delivery gets hung up on the cords over the bougie, twist the tube on its long axis.

If you pass a bougie into the trachea, "clicks" should be appreciated as it runs over the tracheal rings

If your bougie does not stop, you are in the belly. The concept of "hold up" means that your in the airway and have passed the bougie until resistance is felt. 

A tube missed tube left in place (assuming patient can still be bagged) marks where not to go next attempt. 

VL devices mat need to have light to turn on

Channeled blades do not use a stylette or bougie

Most EMS VL devices are placed into the oropharynx flat with the chest and the rotated back until view obtained.

If recordings are captured by the VL device, attached them onto the ePCR.

Fingertip hold on most video laryngoscopes.

Monitor all the things once tube delivered - Spo2, Capno, BP, EKG, etc.

A c-collar regardless of trauma, is helpful at maintaining tube placement of any advanced airway.

The Protocols

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