Emergency Medicine

466 Practical Procedures

ENDOTRACHEAL INTUBATION

INDICATIONS

Endotracheal intubation creates, maintains and/or protects the airway, plus facil-

itates ventilation.

CONTRAINDICATIONS

1 Unskilled operator.

2 Awake patient, jaw clenching.

TECHNIQUE

1 Pre-oxygenate with 100% non-rebreather or bag-valve mask and position

patient in the ‘sniffing position’ with neck f lexed and head extended on a

pillow.

2 Remove poorly fitting dentures and suction oropharynx.

3 Standing at the patient’s head, hold the laryngoscope in the left hand and

gently insert the laryngoscope blade over the right side of the tongue.

4 Advance the curved blade of the laryngoscope until the tip of the blade sits

within the vallecula. Lift the blade forwards and upwards (taking care not to

use the upper teeth as a fulcrum) to visualize the vocal cords.

5 Use the BURP (backward, upward, rightward pressure) manoeuvre on the

thyroid cartilage as necessary to improve the view of the vocal cords.

6 Pass the endotracheal tube (size 8.5–9.5 mm internal diameter in adult

males, and a 7.5–8.5 mm diameter in adult females) through the cords under

direct vision, to a distance of 20–22 cm at the lips.

(i) Insert an introducer first to ‘stiffen’ the tube to facilitate placement.

7 Inf late the cuff, connect the oxygen supply, and check correct position of the

tube by exhaled carbon dioxide detection, and by observing tube fogging,

bilateral chest expansion and auscultation. Tie the tube in place.

8 Ventilate the lungs at 10 breaths/min.

COMPLICATIONS

1 Failure to intubate, with hypoxia.

2 Misplaced tube, e.g. oesophagus, or right main bronchus.

3 Airway trauma.

4 Aspiration.

5 Raised intracranial pressure.