8-4
NOTES: Providing oxygen allows time to treat the underlying respiratory problem.
- The nasal cannula is the simplest method suitable for a spontaneously breathing patient. Each additional
liter/min of flow adds approximately 4% to the 21% O 2 available normally at sea level. - Facemasks provide higher and more precise levels of inspired oxygen—up to .35-.60
a. Venturi mask delivers 24%-50% Fi O 2
b. Non-rebreather delivers 60%-90% Fi O 2
c. A continuous positive pressure device (CPAP) can deliver up to 100% - Use a BVM device to assist or control ventilation until a more secure airway can be obtained. If used
correctly, 100% oxygen can be delivered this way.
What Not To Do:
If it takes 2 additional people to hold down a casualty to intubate them, re-evaluate the need for intubation
since they have to be exchanging oxygen to maintain muscle strength and resist.
Do not proceed to directly to intubation in a patient with respiratory disease. Evaluate ways to improve their
airway, then assist with respiratory effort. Ambu or bag-valve mask ventilation, timed with a patient’s efforts
can help relax and improve their respiratory status, and potentially avoid the risk of intubation.
Procedure: Intubation
MAJ John Hlavnicka, AN, USAWhat: Establish a temporary emergency airway through the mouth or nose, and pharynx.
When: To control the airway during cardiopulmonary resuscitation or respiratory failure, prior to the onset
of expected complications (e.g., laryngeal edema from inhalation burns), during complications from surgical
anesthesia or other complications.
What You Need: Oxygen source and tubing, tonsil-tip suction and source, bag-valve-mask (BVM) device
with self-inflating reservoir and oxygen coupling, face masks of different sizes, oral and nasopharyngeal
airways (different sizes), water-soluble lubricant, straight and curved blade laryngoscopes, endotracheal tubes
of different sizes, a syringe to inflate the cuff, stylets, tongue blades, nasogastric tube, and emergency drugs.
What To Do:
First: Patient Evaluation
Evaluate the airway during the initial injury assessment, and administer supplemental oxygen during this
time if possible. Continual airway assessment is crucial since subtle changes in mental or respiratory status
can occur at any time. Airway characteristics that can make fitting the mask and tracheal intubation difficult
include:
- Short, thick, muscular or fat neck with full set of teeth;
- Full beard, facial burns, or facial injuries;
- Receding or malformed jaw;
- Protruding maxillary incisors; and
- Poor mandibular (lower jaw) mobility.
Co-existing injuries such as known or suspected cervical spine injury, thoracic trauma, skull fractures, scalp
lacerations, ocular injuries and airway trauma must be included when planning airway management.
Second: Technique
Endotracheal intubation indications include anatomic traits making mask management difficult or impossible,
need for frequent suctioning, prevention of aspiration of gastric contents, respiratory failure or insufficiency,
disease or trauma to airway, type of surgery or position of patient during surgery, need for postoperative
ventilatory support, and traumatic injuries or musculoskeletal malformations making ventilation difficult.
- Gather and check all previously listed equipment for proper function. Check light on laryngoscope, inflate
ET cuff with 5-10cc air and check for leaks, then deflate and leave syringe attached, insert lubricated
stylet so it does not protrude beyond distal end of ET and bend into hockey stick form, and have
suction on.