Intubation is an advanced airway management skill that should be practiced regularly and used sparingly. As a paramedic, the advanced airway skill of intubation has been used since the Vietnam war in which army doctors had no desire to go into the jungle to intubate their badly burned soldiers, and so decided to teach their medics how to intubate. After the Vietnam War, paramedics started to think, hey, if we can do it in Vietnam, why not back home on the streets?
Senior paramedics in ambulance services all around the world have been trained and regularly use the skill of intubation to manage unconscious patients who are not longer managing their own airway, such as cardiac arrest victims and people with a GCS approaching 3.
In the past ten years researchers have started to question the appropriateness of intubation in the pre-hospital care setting after some research has indicated worse outcomes for patients who were intubated prior to arrival in hospital than patients who were manually ventilated and then intubated in hospital.
Some of the reasons highlighted for this include:
* Trauma patients were delayed on scene while the paramedics attempted to intubate (although intubation should only take 10-20 seconds the
preparation may take much longer);
* Often unclean environments in which paramedics treat their patients may lead to secondary complications such as pneumonia and later on
difficulties weening patients off the ventilators in ICU;
* Concentration on intubation over all other issues (where a patient could be manually ventilated to hospital); and
* Incorrect placement of the ETT into the oesophagus (and not diagnosed by the paramedic).
* Patients who were intubated at the scene were more commonly at the end of their potential treatment options (such as cardiac arrests and severe trauma with airway involvement);
This said and done, intubation is an excellent skill and one that I believe well and truly has a place in the pre-hospital environment. Intubation should be considered as a gold standard of airway management and securement in any patient who is unconscious without the ability to maintain their own airway.
Intubation is particularly important in patients who have:
1. Suffered a cardiac arrest, as a means of securing the airway and providing an easier relationship between chest compressions and ventilations;
2. Suffered burns to the airway, which will likely swell and occlude the airway if left untreated.
Guide on How to Intubate
So, how do we intubate a patient?
ETT insertion follows these main steps:
Always have a back up plan in case you are unable to intubate!
Maintain normal airway management and ventilation throughout procedure;
Pre-oxygenate the patient with 100% oxygen (of course, this may not be possible if the reason you are trying to intubate the patient is due to being unable to manage the airway any other way)
Position the head into the ‘sniffing’ position, in which the head is slightly raised, tilted back slightly and the chin is stretch anteriorly into a ‘sniffing’ position
Prepare the ETT equipment, including suction, ventilator (if your service is lucky enough to have one), and LMA in case the ETT fails
Laryngoscopy and visualize the vocal cords (easier said than done)
Insert ETT and inflate cuff
Attatch bag and ventilate slow deep ventilations, while auscultating the stomach first (to listen for possible gurgling sounds if you are in the oesophagus), then both axilla to ensure that you haven’t intubated
the right or left bronchus only
Attach a CO2 monitor and assess for a CO2 wave pattern (no pattern means no CO2 and indicates that the ETT is in the wrong place)
Secure ETT if correct placement is confirmed
Regularly monitor, ETT placement, equal raise and fall of the chest, equal lung sounds, CO2 wave pattern, SaO2, Skin colour of patient, heart rate, and blood pressure to ensure that the patient is still being well perfused.
More Guides on How to Intubate
Here is a video link on how to intubate:
Tips for the actual insertion process of intubating:
Visualise pushing laryngoscope away from patients’ nose. This avoids the natural tendency to lever laryngoscope on teeth. If you break teeth during intubating in a cardiac arrest there is the chance that a tooth may become dislodged and fall into the larynx (this is not a good thing);
Insert laryngoscope down right hand side of mouth and push tongue to left and out of the way. Gradually insert until cords are visible.
Alternatively insert blade all the way in (too far) and then slowly pull back until cords become visible. Push tip of laryngoscope into vallecula.
If an attempt is not successful within 30 seconds withdraw and ventilate immediately to minimise apnoea.
Holding your breath during laryngoscopy and ETT insertion will give an indication of when the patient requires ventilation (although it
may not help you concentrate and may add additional stress on your body);
When inserting tube, viewing the cords can become obstructed. This may be exacerbated by having laryngoscope blade and tube both being central and dominating the view. Try pulling laryngoscope across as far to left as possible whilst inserting the ETT from as far right as possible to open up view.
Tips of the trade for paramedics intubating:
If left side of the chest does not expand during ventilations you may have inserted the ETT into the left main bronchus
(although it is more common to accidentally go into the right main bronchus, this does sometimes occur) – if the ETT is placed correctly, assess for other causes such as tension pneumothorax and treat accordingly.
Where cardiac arrest is from an obstructed airway be careful of foreign matter remaining within the trachea and being pushed further down by
the tube, Magill’s forceps are recommended.
Don’t forget to suction (I know it’s a nuisance to clean afterwards) but there’s reason our cars are equipped with it and this is it;
If you are performing effective non-intubated ventilations then you are doing what the patient requires ;
Prolonged attempts to intubate a patient may result in hypoxic brain damage.
Hyperventilation may lead to hypocapnia (reduced carbon dioxide in the blood), also hypotension due to increased intrathoracic pressure
decreasing venous return.