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EQUIPMENTS

• Oxygen tubing

• Suction source and catheter

• AMBU BAG ( Assisted Manual Breathing Unit )

• Bag valve mask

• Clear face mask various size and shape

• Oropharyngeal airway

• Nasopharyngeal airway

• Pulse oximeter , CO2 Detector

• Endotracheal tubes various size ; Laryngoscope blade and handles

• Syringes , Magills forceps

• Stylets

• Lubrican jelly

• Alternative or rescue devices : Laryngeal mask airway , intubating laryngeal mask airway , combitube

• Surgical rescue equipmen : surgical cricothyroidotomy kit.

• Medication for topical airway anasthesia , sedation or RSI.

PREREQUISTES

• Make sure that your laryngoscope is locked into position and that the incandescent light on the blade tip functions. Also make sure that you have several alternate blades available in case the one you have chosen does not allow for visualization of the cords.

• Examine the endotracheal tube. Make sure that the cuff inflates by using a 10-mL syringe to inflate the cuff and then detach the syringe to ensure that the cuff pressure is maintained. Be sure to deflate deflate the cuff after testing it.

• Ensure a functioning suction unit to clear the airway in case of unexpected blood, emesis or secretions.

• Ensure that you have tape within your reach to secure the tube once it is in place.

• The patient should be thoroughly preoxygenated before intubation ideally several minutes .

  Hypoxia develops more quickly in children , pregnant women and patients in other hyperdynamic state.

POSITION

Popitoz Sniffing Position: It is commonly used position. Here a small foam sheets or pillow (10cm) is used to maintain a cervical flexion and a small degree of atlanto-occipital extension.

Aim is to keep the oral , pharyngeal as well as laryngeal axis in line.

TECHNIQUE

• The laryngoscope is held in the left hand and an ETT or suction apparatus is held in the right.

• Any dentures, any obscuring blood , secretion and vomitus is to be removed by a suction using the right hand.

• The blade is inserted to the right corner of patients mouth. If a macintosh blade is used the flanges will push the tongue to the left of oropharynx but if inserted directly down the middle ,tongue can force the line of sight posteriorly , which is a common reason for putative 'anterior larynx'.

• After visualisation of epiglottis the macintosh blade is placed in the vallecula and the epiglottis is lifted indirectly off the larynx owing to the traction on the frenulum. The handle is pulled at an angle of 90 to the blade( pull the handle in the direction of the blade).

• The tube is advanced until the cuff disappears below the cords. The correct placement of the tube is about 2cm above the carina. From corner of the mouth , this location is approximately 23cm in men and 21 cm in women. The base of pilot tube(the tube with adapter to inflate the cuff) is usually at the level of the teeth.

• To avoid ischemia of tracheal mucosa , cuff pressure should be kept below 40 cmH₂0 & minimal intracuff pressure to prevent aspiration is 25 cmH₂0

• DRUGS
  Etomidate	0.3mg/kg IV	Neutral on BP , Decrease ICP , IOP ; Myoclonic jerk , seizures , vomiting , decrease in levels of cortisol.
  Propofol	0.5 – 1.5mg/kg IV	Antiemetic , Anticonvulsant , decrease in ICP. No analgesic effect , decrease BP , Apnea.
  Ketamine	1 -2 mg/kg IV	Bronchodilator , Dissosciative amnesia , Analgesia Increase secretions , Increase BP ,Emergence phenomenon.
  Fentanyl	3mcg/kg IV	Elevated ICP , Cardiac ischemia , Aortic dissection Respiratory depression, Hypotension, Chest wall rigidity.

 Updated on 21/12/2013

Reference :Tintinalli