Daniel F. Danzl
Confirmation, and Complications of. Intubation
Nasotracheal .Intubation Digital Intubation Transillumination
Fiberoptic. Assistance Retrograde. .Tracheal ..Intubation Rapid-Sequence Intubation
Nondepolarizing ..Agents Strategies
Airway integrity, assurance of oxygenation, ventilation, and prevention of aspiration are the mainstays of emergency airway management. The indications for tracheal intubation in the emergency setting most commonly include correction of hypoxia or hypercarbia, prevention of impending hypoventilation, and assuring maintenance of a patent airway. Secondary indications include provision of a route for resuscitative medication administration and to permit temporizing paralysis during diagnostic testing. This chapter reviews tracheal intubation techniques to establish an airway and ventilate a patient after basic maneuvers have been utilized.
The most reliable means to ensure a patent airway, provide oxygenation and ventilation, and prevent aspiration is endotracheal intubation. Many unconscious and even conscious patients may be unable to spontaneously clear the airway of secretions, may require mechanical ventilation, may have aspirated, or may lack protective airway reflexes.
The clinical assessment of oxygenation and ventilation is often unreliable in a chaotic ED. Continuous noninvasive bedside monitoring of arterial oxygen saturation by oximetry is helpful. Isolated oximetry, however, does not assess the status of alveolar ventilation. Capnography does allow estimation of the Pa co2 based on the waveform display of the end-tidal Paco2. Capnometry refers to the numerical display. In combination, both of these noninvasive modalities affect decisions regarding tracheal intubation.
One should take the time to evaluate the upper airway anatomy. Examination of the teeth, size of the oral cavity, thyromental distance, mobility and posterior depth of the mandible, and neck mobility may point to a difficult airway. The normal adult mouth opening measures three finger breadths. The alert, sober patient may be asked to open the mouth as widely as possible and point the tongue in the examiner's direction. The ease of laryngoscopy correlates well with the examiner's ability to visualize the soft palate, uvula, and faucial pillars (see " Difficult. . . Airway," below).
While calling for an assistant, check and arrange the necessary equipment. The appropriate-size tube and an additional tube (0.5 to 1 mm in size smaller) should be selected and the cuff checked for air leaks with a 10-mL syringe. Selecting a tube of the proper diameter is essential ( Table,""). The second hole at the end of the tube above the bevel is called Murphy's eye. This permits some uninterrupted airflow if the tip is occluded.
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