Intubation¶

Types of Intubation mangmant algo¶

Crash intubation [in cardio-pulmonary arrest ]
Difficult airwary
Failed airway mng

Crash algo¶

Difficult airway¶

Failed airway mang algo¶

Steps in Intubation¶

Preparation
medications
intubation
post-intubation seadation
resuce airway mangmnet

Items needed¶

O2 source and functioning regualtor
bag valve mask
Large suction catheter
ETT tube best size and a smaller one
BMI and Correct medication dosages

Patient Bed height in intubation¶

Patient head Position¶

why sniffing position¶

Obese pt / Pulmonary Edema pt Head position¶

In emesis patient¶

suction along side of mouth

Risk in intubation , if BP and HR are not normal¶

Peri -intubation cardiac arrest

Intubation failure¶

15% initial attempt failure
1% - 2% overall intubation failure

Intubation Failures¶

Factors of Diffuiculty Visualizing oral, pharyngeal, and tracheal axes needed for intubation.¶

Detailed Steps of Intubation¶

Can intubate without RSI

1.Rapid-sequence intubation[RSI]¶

Seqence of Drugs to increase intubation sucess rate
- Induction agent
- Neuro muscular relaxing agent

Pre-treament Drugs Before RSI¶

laryngoscopy cause ⇒ Sympathetic responses ⇒ ⇑HR,⇑BP,⇑ICP
- Worsens MI,Hemorrhagic Stroke ,aortic dissection
Laryngeal stimulation ⇒ laryngospasm, cough, and bronchospasm.

These maybe prevented by using these drugs 3-5min before RSI - Fentanyl 50mcg to 100mcg

Induction agent¶

rapid, deep sedation of limited duration, avoids hypotension, and mitigates the physiologic response to laryngoscopy and intubation

Ketamine
Midazolam
Propofol

Seadtion in ER

Neuro-muscualar Blocking drugs¶

Neuromuscular blockade eliminates protective airway reflexes . Neuromuscular blockade can facilitate tracheal intubation, improve mechanical ventilation, and help control intracranial hypertension. - No analgesic & Sedation effect, so need Sedation drugs

Complications of Succniyl-choline¶

2. Pre-oxygenation¶

Oxygen delivery methods¶

Preoxygenation displaces nitrogen from the alveoli, creating a potential oxygen reservoir that may prevent hypoxia and hypoxemia during apnea

< 70% SpO2 leads to cardiac arrest , dysarrythimias, so
- 3-min 15L/min

3.Steps in Intubation¶

Complications after ETT¶

Intubation Drugs¶

1.Ketamine¶

dissociative anesthetic state characterized by profound analgesia and amnesia
by binding to the N-methyl-D-aspartate (NMDA) receptors on postsynaptic neurons ⇒ inhibits neurotransmitter like glutamate and NDMA , causing anesthesia and amnesia
⇑ICP, ⇑HR,⇑BP,SO BAD IN HEART PATIENT
minimal to no respiratory depression
potent broncho-dilator
Increases bronchial and oral secretions
preserve protective airway reflexes in contrast to other anesthetic agents. Skeletal muscle tone is increased and results in random movements.BAD FOR Epiliptic history

Complication From Ketamine¶

-Post anesthatic { agitation, aggression, confusion, delirium, hallucinations, hysteria, nightmares, restlessness, and unpleasant sensations} - Managed with Benzodiazapines [ Midaz,propofol]

2.Etimodate¶

No Pain relief , ONLY Anesthesia{loss of Concious-ness}
By GABA modulation , hyperpolarisation and inhibition of post synaptic neurons
No cardiac effects
No ICP and CNS perfusion effects
barbiturates in patients with diminished pulmonary function. Etomidate is therefore considered to be the induction agent of choice in patients with severe cardiopulmonary disease and highrisk patients in whom maintenance of blood pressure is crucial.

Side effects of Etimodate¶

Injection site pain by propylene glycol diluent. , nausea,vomiting @ induction
Myoclonic activity from inhibtion of Cortico-thalamus
dose dependant suppression of Adrenal gland

3.Fentanyl¶

Anesthesia
Fentanyl binds to the μ (mu) opioid receptor found throughout the CNS. Activation of the opioid receptor causes hyperpolarization and inhibition of neurotransmitter release
slight { ⇓Hr,⇓Contractility, ⇓TPR} mostly no cardiovascular worseng effect
dose dependant Respiratory depression.{reduce
tidal volume and subsequent apnea}