Intubation

Step 1: Reasons for intubation include pending surgery, respiratory distress, poor ventilation, or failure to protect airway from oral secretions. Consent is necessary if intubation is elective and not the result of an emergency situation. 

Step 2: Place your patient on 100% oxygen while you gather supplies. Supplies include mask with face shield, gloves, glidescope, suction catheter, ambubag, intubation blade, and endotrachial tube with stylet and RSI (Rapid Sequence Intubation) kit. For patients with a lower to normal/low blood pressure, have norepinephrine primed and ready to be administered. 

Step 3: Once ready to begin, have the patient boosted to the top of the bed and place a rolled towel under their neck with no pillow support for their head. For larger patients, it may be helpful to place a pillow under their shoulders to help extend the patient's neck. You will be at the head of the bed with your equipment. 

Step 4: With 100% oxygen still on the patient, begin intubation induction. Vital signs should be set to every 3 minutes at a minimum. Induction can be completed with Etomidate, Ketamine, or Propofol. 

Etomidate 0.3 mg/kg IV push. Generally 20 mg IV for small to average patients, 30 mg IV push for larger patients 

Propofol 1.5 mg/kg. IV push. May be the better choice for patients actively having seizure activity with reactive airway disease. 

Ketamine 1.5 mg/kg. Can cause transient hypertension, making this of consideration for patients being intubated with shock. 

Step 5: After about 20-30 seconds, all of the above medications should be taking effect and you will be initiating neuromuscular blockade to prevent cough/gag during intubation. This will be IV push. 

Rocuronium 1 mg/kg IV push.  Commonly 50, 75, or 100 mg doses are used. 

Succinylcholine 1.5 mg/kg IV push Can cause potassium elevation and should not be used with hyperkalemia or malignant hyperthermia. 

Step 6: Once patient is both sedated and paralyzed (there breathing will stop as the paralytic begins to work), gently open the patient's mouth with your fingers and insert the glidescope camera. This should slide over the patients tongue at which point you will lift the scope upwards and expose the patient's trachea. Suction any secretions that are present and insert the endotracheal tube through the now visualized vocal cords. The stylet will need to be removed from the ETT during insertion. 

Step 7: Remove the glidescope while holding the ETT in place to ensure it does not migrate out. Confirm placement with both auscultation to both lungs and CO2 detection. RT will assist with securing the tube and the patient can be placed on mechanical ventilation if placement is confirmed. 

Step 8: Confirm final position of ETT with bedside Stat Chest X-ray. 3-6 cm above the carina is generally accepted, although this does vary slightly by provider.