Intubation Guideline

Personnel

  • Skilled assistance is mandatory; where possible a team of 4 is required.

  • "Intubator" who controls and co-ordinates the procedure.

  • "Drug administration"

  • A person to apply in-line traction where the stability of the cervical spine is unclear.

  • "Cricoid Pressure"

      • Cricoid pressure is recommended in all emergency situations and should be applied at the commencement of induction.

      • Cricoid pressure may distort the larynx so that intubation is made more difficult.  It should be modified at the discretion of the Intubator, and requires an understanding of the procedure.

 

Drugs:

  • Induction agent:

      • eg;  Etomidate (0.2mg/kg, 10-20mgs is recommended), or midazolam and morphine or Fentanyl
  • Muscle Relaxant

    • Suxamethonium 1-2mg/kg (100mg)

    • Consider rocuronium 1-2mg/kg (50-100mg) if suxamethonium contra-indicated, eg;

        • Burns patients >48 post injury

        • Spinal injury patients where spasticity is present

        • Chronic neuromuscular disease (Myasthenia Gravis, GBS)

        • Hyperkalaemic states

  • Miscellaneous Drugs

    • Atropine 0.6 – 1.2mg

    • Adrenaline 10ml of 1:10 000 solution

    • Ephedrine 30mgs in 10mls normal saline

  • Procedure – Rapid sequence induction and Orotracheal intubation

      • Pre-oxygenate for 3-4 minutes with 100% oxygen.  Patients receiving non-invasive ventilation should continue on this form of ventilation until the point of induction, and a PEEP valve applied to the AMBU-bag mask assembly.

      • Administer induction agent and suxamethonium

      • Apply cricoid pressure

      • Intubation under direct visualization

      • Inflate ETT cuff until there is no air leak during ventilation

      • Confirm ETT placement with capnographs and chest auscultation with normal ventilation

      • Release cricoid pressure (once tube position confirmed)

      • Secure ETT at correct length

      • Do not cut ETT

      • Connect patient to ventilator

      • Ensure adequate sedation and analgesia to cover period of muscle relaxant and continue as indicted by clinical scenario

      • Insert naso-/-orogastric tube if not already present

      • If ongoing relaxant required use pancuronium or rocuronium

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Page last reviewed: 13 May 2014
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