title: "Endotracheal Intubation"
Endotracheal Intubation
Intubation secures a definitive airway. RSI (Rapid Sequence Intubation) is the standard technique for emergency intubation in patients with full stomach.
Indications
| Category | Examples |
|---|---|
| Failure to oxygenate | Refractory hypoxia despite supplemental O₂ |
| Failure to ventilate | Respiratory failure, fatigue, ↓ GCS |
| Failure to protect airway | GCS ≤8, absent gag, aspiration risk |
| Anticipated course | Burns, angioedema, deterioration expected |
| Procedural | Surgery, imaging, transport |
Pre-Intubation Assessment
Predict Difficult Airway: LEMON
LEMON - Difficult Airway Predictors
- L - Look externally (facial trauma, obesity, short neck)
- E - Evaluate 3-3-2 (mouth opening, hyomental, thyromental distance)
- M - Mallampati score (I-IV, higher = harder)
- O - Obstruction (stridor, tumour, epiglottitis)
- N - Neck mobility (c-spine, ankylosing spondylitis)
Equipment Preparation
- Suction - working, within reach
- Oxygen - preoxygenate, backup supply
- Airway adjuncts - OPA, NPA, bougie, LMA
- Laryngoscope - check light, blade size (Mac 3-4 adult)
- ETT - size 7-8 for adults, cuff tested, stylet if needed
- Monitoring - SpO₂, ETCO₂, BP, ECG
- Drugs - induction agent, paralytic, vasopressors ready
Rapid Sequence Intubation (RSI)
RSI = preoxygenation → induction → paralysis → intubation (no bag-mask ventilation between drugs and tube)
The 7 Ps of RSI
- Preparation - equipment, drugs, team, backup plan
- Preoxygenation - 3-5 min 100% O₂, denitrogenate lungs
- Pretreatment - fentanyl (blunt pressor response), consider atropine in children
- Paralysis with induction - give simultaneously
- Protection - cricoid pressure (Sellick's) - controversial
- Placement - laryngoscopy and tube insertion
- Post-intubation - confirm placement, secure tube, ventilate
Drug Choices
| Drug | Dose | Onset | Notes |
|---|---|---|---|
| Propofol | 1-2 mg/kg | 30s | ↓ BP, avoid in shock |
| Ketamine | 1-2 mg/kg | 60s | Maintains BP, bronchodilator |
| Rocuronium | 1.2 mg/kg | 60s | Non-depolarising, sugammadex reversal |
| Suxamethonium | 1.5 mg/kg | 45s | Depolarising, short-acting, ↑K⁺ risk |
Clinical Pearl
Ketamine is the induction agent of choice in hypotensive patients and asthmatics. Avoid in severe hypertension or psychosis.
Confirming Tube Placement
Warning
Oesophageal intubation kills. Confirm with ETCO₂ waveform - the gold standard.
| Method | Reliability |
|---|---|
| ETCO₂ waveform | Gold standard - continuous square wave |
| Direct visualisation | See tube pass through cords |
| Chest rise | Bilateral and equal |
| Auscultation | Breath sounds bilateral, no gastric gurgling |
| Misting in tube | Suggests tracheal (not reliable alone) |
| CXR | Confirms depth, tip at T2-T4, 2-4cm above carina |
Failed Intubation Drill
If unable to intubate after 2-3 attempts:
- Maintain oxygenation - bag-mask ventilation
- Call for help - senior, anaesthetics, ENT
- Supraglottic airway - insert LMA/iGel
- Can't intubate, can't oxygenate (CICO) → Emergency front-of-neck access (cricothyroidotomy)
Source: CC Bible; ANZCOR airway/resuscitation guidance; local RSI/airway checklist.
Test Your Knowledge
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GCS
6↓↓
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Which is the gold standard for confirming correct ETT (Endotracheal Tube) placement?
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Sources
- CC Bible
- ANZCOR airway/resuscitation guidance
- Local RSI/airway checklist