Operational Medicine 2001
Field Medical Service School
Student Handbook

ENDOTRACHEAL INTUBATION

FMST 0426

17 Dec 99

TERMINAL LEARNING OBJECTIVES:

1.   Given a respiratory injury in a combat environment (day and night) and the standard Field Medical Service Technician supplies and equipment, perform endotracheal intubation, per the references. (FMST.04.27)

ENABLING LEARNING OBJECTIVES:

1.   Without the aid of reference materials and given a list, identify the advantages of endotracheal intubation, per the student handbook. (FMST.04.27a)

2.   Without the aid of reference materials and given a list, identify the disadvantages of endotracheal intubation, per the student handbook. (FMST.04.27b)

3.   Without the aid of reference materials and given a list, identify the indications for endotracheal intubation, per the student handbook. (FMST.04.27c)

4.   Without the aid of reference materials and given a list, identify the contraindications for endotracheal intubation, per the student handbook. (FMST.04.27d)

5.   Without the aid of reference materials and given a list, identify the equipment required for endotracheal intubation, per the student handbook. (FMST.04.27e)

6.   Without the aid of reference materials and given a list, sequence the procedural steps for intubating with the endotracheal tube, per the student handbook. (FMST.04.27f)

7.   Without the aid of reference materials and given a FMST MOLLE Medic bag and a simulated casualty (mannequin), perform endotracheal intubation using the orotracheal route, per the student handbook. (FMST.04.27g)

OUTLINE:

A. ENDOTRACHEAL INTUBATION - THEORY

1. DEFINITION – The insertion of a tube into the trachea to allow air to enter the lungs.

2. INDICATIONS FOR ENDOTRACHEAL INTUBATION:

a. Cardiopulmonary Arrest

b. Patient in deep coma or unresponsive

c. Shallow or slow respirations (less than 8 per minute)

d. Progressive cyanosis

e. Gastric lavage / gavage

f. Surgical patients where body positioning or facial contours preclude the use of a mask

g. To prevent loss of airway at a later time, i.e. a burn patient who inhales hot gases may be intubated initially to prevent his airway from swelling shut

3. CONTRAINDICATIONS FOR ENDOTRACHEAL INTUBATION:

1. Obstruction of the upper airway due to foreign objects

2. Cervical fractures

3. The following conditions require caution before attempting to intubate:

4. Esophageal disease

5. Ingestion of caustic substances

6. Mandibular fractures

7. Laryngeal edema

8. Thermal or chemical burns

4. ADVANTAGES OF ENDOTRACHEAL INTUBATION:

1. Provides an unobstructed airway when properly placed

2. Prevents aspiration of secretions (blood, mucous, stomach / bowel contents) into the lungs

3. Can be easily maintained for a lengthy period of time

4. Decreases anatomic dead space by approximately 50%

5. Facilitates positive pressure breathing without gastric inflation

6. Facilitates body positioning and movement of the patient

7. May be utilized to pass medications

   1. Narcan

   2. Atropine

   3. Epinephrine

   4. Lidocaine

5. DISADVANTAGES OF ENDOTRACHEAL INTUBATION:

1. Need advanced training to properly perform procedure

2. Bypasses the nares function of warming and filtering the air

3. Increased incidence of trauma due to neck manipulation when spinal cord injury is suspected

4. May increase respiratory resistance

5. Improper placement

6. ENDOTRACHEAL INTUBATION

a. REQUIRED EQUIPMENT:

1. Endotracheal tube

1. Size of tube is dependent on size of patient

2. 7.5 mm is the “Universally Accepted” size for an unknown victim

3. Men are usually larger, therefore an 8.0 mm tube may be appropriate

4. Females are usually smaller, therefore a 7.0 mm tube may be appropriate

2. 10 cc Syringe – used to fill the cuff at the end of the endotracheal tube

3. Stylet – a wire inserted into the endotracheal tube in order to stiffen it during passage

4. Water soluble lubrication – KY Jelly or Surgilube

5. Stethoscope – to check for proper placement of the endotracheal tube

6. Magill forceps – May be used to help guide an endotracheal tube from the pharynx into the larynx

7. Laryngoscope handle

8. Laryngoscope blade

9.Miller blade (straight blade)

10. Macintosh blade (curved blade)

11. Oropharyngeal airway (bite block) – to prevent the patient from biting down on the endotracheal tube

12. Tape – to secure the endotracheal tube in place

13. Gloves

14. Ambu-bag – to facilitate positive pressure ventilations

15. Suction Device – to clear the airway of debris (blood, mucous, saliva)

7. PROCEDURAL STEPS:

1. Maintain the patient’s ABC’s

2. Determine that the patient requires endotracheal intubation

3. Assemble required equipment

4. Position the patient’s head – three axes, those of the mouth, the pharynx, and the trachea must be aligned to achieve direct visualization of the vocal cords

5. Sniffing Position – the head is extended and the neck is flexed

6. A folded towel may be placed under the patients shoulders and neck to assist with positioning

7. Suction the patient (no longer than 30 seconds)

8. Oxygenate patient for 1 minute with 100% Oxygen

9. Insert the laryngoscope blade and place endotracheal tube

10. Laryngoscope handle is held with the left hand

11. Insert the laryngoscope blade in the patients right side of the mouth and sweep to the center of the mouth

When a curved blade is used, the tip of the blade is advanced into the vallecula (i.e. the space between the base of the tongue and the pharyngeal surface of the of epiglottis)

When a straight blade is used, the tip of the blade is inserted under the epiglottis

12. Lift the laryngoscope blade in an upward motion

13. The handle must not be used with a prying motion, and the upper teeth must not be used as a fulcrum

14. Visualize the vocal cords

15. Using the right hand, insert the endotracheal tube until you see the cuff pass through the vocal cords. Advance the tube an additional ½ to 1 inch for proper placement.

16. Remove the laryngoscope carefully from the patients mouth

17. Remove the stylet from the endotracheal tube

** NOTE: The insertion of the endotracheal tube should be no longer than 30 seconds from the time you stop ventilating the patient until the time you remove the stylet. If you are unable to place the endotracheal tube within 30 seconds, withdraw the endotracheal tube and laryngoscope, ventilate the patient (Step f.) and start again

18. Ventilate the patient with two breaths

19. Check for proper placement with these first two ventilation’s by:

20. Observing the chest rise and fall with each ventilation:

Proper placement will cause both lungs to inflate with each ventilation

Auscultating for bilateral breath sounds:

• Breath sounds will be completely absent if placed within the esophagus. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation.

• If the tube is placed too far down the tracheal tree, a right mainstem intubation can occur. This prevents air from going into the left lung. To correct this problem, continue to ventilate patient and slowly withdraw endotracheal tube ¼ - ½ inch or until bilateral breath sounds are heard.

• Auscultating over epigastrium for gastric sounds:

• Placement of the endotracheal tube into the stomach / esophagus will produce gurgling sounds in the epigastric area. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation.

21. Inflate the endotracheal tube’s cuff with 10 cc’s of air:

22. Inflation of the balloon serves two purposes:

23. Holds tube in place

24. Acts as a barrier and prevents fluids from entering the lungs

25. Ventilate the patient with two breaths

26. Insert oropharyngeal airway

27. Ventilate the patient with two breaths

28. Tape endotracheal tube securely in place

29. Continue to ventilate patient (1 breath every 5 seconds) and suction as necessary

8. PROCEDURAL STEPS FOR THE REMOVAL OF THE ENDOTRACHEAL TUBE (EXTUBATION)

1. Determine that endotracheal intubation is no longer required

2. Patient begins spontaneous respiration’s

3. Medical Officer orders removal of endotracheal tube

4. Remove tape from endotracheal tube

5. Remove oropharyngeal airway from patient’s mouth

6. Suction the endotracheal tube, the patient’s mouth, and the patient’s posterior pharyngeal area

7. Deflate the endotracheal tube’s cuff

8. Withdraw the endotracheal tube with one smooth motion

9. Monitor the patient for signs / symptoms of respiratory distress or difficulty

REFERENCE (S):

1. EMERGENCY WAR SURGERY

2. TEXTBOOK OF ADVANCED CARDIAC LIFE SUPPORT

3. PREHOSPITAL EMERGENCY CARE AND CRISIS INTERVENTION

Field Medical Service School
Camp Pendleton, California

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Operational Medicine 2001
Health Care in Military Settings

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