Unassisted Intubation (Adult)
 
Unassisted Intubation Indications
Indications:
• Respiratory arrest
• Cardiac arrest
• Absent airway reflexes
   
General Precautions
• Time to intubation at hospital versus time to intubate at scene
• Poor baseline neurological function and major co-morbidities
• Advanced Care Plan / Refusal of Medical Treatment document specifies “Not for Intubation”
   
General Preparations
Position Pt. If a cervical collar is fitted it should be opened while maintaining manual cervical support
Pre-oxygenate with 100% O2 and electronic capnograph attached
Ensure pulse oximeter and cardiac monitor are functional
Prepare equipment and assistance
- Suction
- ETT (plus one size smaller than predicted immediately available) with introducer - Oesophageal Detector Device (ODD).
- Ensure equipment for a difficult / failed intubation is immediately available, including bougie, LMA, cricothyroidotomy kit
- Mark cricothyroid membrane as necessary
- Brief assistant to provide cricoid pressure, where appropriate
- If suspected spinal injury, where possible a second assistant should be available to stabilise the head and neck
Ensure functional and secure IV access
   
Insertion of ETT
Observe passage of ETT through cords noting AS standard markings and grade of view
Check ETT position using Oesophageal Detector Device (ODD).
Inflate cuff.
Confirm tracheal placement via capnography (note: Pt in cardiac arrest may not have EtCO2 initially detectable).
Exclude right main bronchus intubation by performing the cuff palpation (“tracheal squash”) test and by comparing air entry at the axillae.
Note length of ETT at lips/teeth.
Cuff Palpation
Auscultate chest/epigastrium
- Chest rise and fall, bag movement, SpO2, colour, tube misting
Note supplemental cues of correct placement (e.g. tube “misting”, bag movement in the spontaneously ventilating Pt, improved oxygen saturation and colour).
Secure the ETT and insert a bite block if required.
If there is ANY doubt about tracheal placement, the ETT must be removed
If unable to intubate after ensuring correct technique and problem solving, then proceed to Failed Intubation Drill
 
   
Successful Intubation?
                        Yes   No  
                       
     
             
             
   
Does Pt's require sedation or paralysis to maintain intubation and ventilation?
    Yes     No
Yes
    
Post Intubation Sedation
     
Post Intubation Paralysis
Restlessness/signs of under sedation in the absence of other noxious stimuli
- e.g. ETT too deep/irritating, occult pain
      
Prevention of shivering for Pts receiving therapeutic cooling
Primary Neurological Pts
Where sedation alone is ineffective at maintaining intubation or allowing adequate ventilation / oxygenation
As prescribed for interhospital transfer
 
All Pts receiving paralysis MUST receive ongoing sedation
The ETT must be secured and tracheal placement reconfirmed with electronic capnography
C/I for Pt in Status epilepticus
Sedate as per Post Intubation Sedation
Pancuronium 8mg IV
- Repeat if evidence of returning muscular activity
(movement, chewing, cough, gag, curare cleft)
Signs of inadequate sedation
Non Paralysed:
- As per Paralysed
- Cough/gag/movement up together
Pt Paralysed Pt:
- HR and BP trending
- Tearing
- Diaphoresis		      
Morphine/Midazolam infusion 1 - 10mg/hr IV
- 0.5mg - 5mg IV boluses as required
      
Until Morphine/Midazolam infusion established:
- Midazolam 0.5mg - 5mg IV as required or
- Midazolam/Morphine 0.5mg - 5mg IV each drug		      
   
   
         
 
Care / Ventilation of the Intubated Pt
ETT checks with each Pt movement
Provide circulatory support if hypotension present
Use colourimetric capnometry if capnography fails
Suction ETT and oropharynx
Insert OG/NG tube
Ventilate tidal volume 10ml / per kg, EtCO2 30 - 35mmHg if appropriate to Pt condition
Disconnect and hold ETT during transfers
Specific instructions as per General Care of the Intubated Pt
   
General Care
Reconfirm tracheal placement using EtCO2 after every Pt movement. Disconnect and hold ETT during all transfers.
If electronic capnography fails after intubation, use colourimetric capnometry.
Suction ETT and oropharynx in all Pts.
If time permits, insert orogastric or nasogastric tube, aspirate and connect to drainage bag. The orogastric route must be used in head or facial trauma.
Ventilate using 100% oxygen and tidal volume of 10 ml/kg. Aim to maintain SpO2 >95% and EtCO2 at 30 - 35mmHg (except asthma / COPD where a higher EtCO2 may be permitted, tricyclic OD where the target is 20 - 25mmHg, and DKA where the EtCO2 should be maintained at the level detected immediately post-intubation, with a max. of 25mmHg).
Document all checks and observations made to confirm correct ETT placement.