Alexander app1 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Appendix 1
Endotracheal
Intubation

• The Advanced EMT integrates complex
knowledge of anatomy, physiology, and
pathophysiology into assessment to develop and
implement a treatment plan with the goal of
ensuring a patent airway, adequate mechanical
ventilation, and respiration for patients of all ages.
Note: Endotracheal intubation is beyond the scope of practice expected
of Advanced EMTs at the national level. However, some states may
include endotracheal intubation in the Advanced EMT scope of practice.
As with all skills, you may perform endotracheal intubation only if it is
allowed in your scope of practice, you have been trained properly, and it
is approved by your medical director to do so.
Advanced EMT
Education Standard

1. Explain the indications, contraindications, and
complications associated with oral endotracheal
intubation.
2. Identify the anatomic landmarks used for proper
endotracheal tube placement.
3. Identify the required and adjunctive equipment for
endotracheal intubation.
4. Perform oral endotracheal intubation under instructor
supervision.
5. Discuss current trends and controversies in prehospital
endotracheal intubation.
Objectives

• Secures the patient’s airway with proper
placement
• Isolates the airway for ventilation and avoids
complication of gastric distention
• Prevents aspiration of fluids around the tube
• Requires extensive training and regular practice
– Proficiency should be maintained.
Endotracheal Intubation (1 of 14)

• Necessary equipment:
– Laryngoscope
– Endotracheal tube with a malleable stylet
– 10 mL syringe
– Suction device
– Securing device (commercial or tape)
– Stethoscope
– Placement confirmation device

• Laryngoscope
– Lifts the tongue and epiglottis for visualization of the
glottis
– Two parts: handle and blade
 MacIntosh (curved blade)
– Lifts the epiglottis indirectly with insertion into the vallecula, lifting
anteriorly exposing the glottis
 Miller (straight blade)
– Lifts the epiglottis directly by placement beneath it and lifting to
expose the glottis
– Preferred blade for pediatric patients

Figure A1-2
The base of the laryngoscope blade attaches to the top of the handle.

Figure A1-3
The laryngoscope blade light source is activated by lifting the blade.

• Laryngoscope blade positioning

Figure A1-4
The tip of the curved blade is inserted into the vallecula and lifted.

Figure A1-5
The straight blade is used to lift the epiglottis directly by placing the tip beneath it and lifting.

• Endotracheal tube
– Flexible, translucent, single lumen tube
– 12 to 32 cm in length, 2.5 to 9.0 mm diameter
– Standard 15 mm adapter at proximal end
– Distal end can be cuffed or uncuffed (pediatric)
– Pilot balloon reflects inflation status of the cuff

Figure A1-6
Endotracheal tube (ETT) and syringe.

• Stylet
– Malleable, plastic coated wire used to mold the tip of
the endotracheal tube at a slight angle
– Should be recessed 1–2 cm inside the tube
 Otherwise could cause injury to the airway tissues
• 10 mL syringe
– Used to inflate the cuff, providing a seal within the
trachea
 Air volume dependent on size of the tube and patient

• Suction unit
– Used to remove oral secretions, vomitus, or blood
potentially before and after intubation
• Securing device
– Once the ET tube is placed, it must be secured to
prevent dislodgement.
– Some type of bite block should be used to prevent
patient from biting the tube and obstructing air flow.

• Minimum of three methods:
– Visualization of the tip passing through the glottic
opening
– Auscultation of breath sounds bilaterally with ventilation
with a BVM
– Capnometry or esophageal detector device (EDD)
 Capnometry is considered to be the most reliable.

• Anatomy
– Epiglottis
– Vallecula
– Arytenoid cartilage
– Vocal cords

• Anatomic landmarks

Figure A1-9
The glottis visualized through laryngoscopy. Note the landmarks: the epiglottis, arytenoid
cartilage, and vocal cords. (© Gastrolab/Science Source)

• Indications
– Failure to maintain and protect his own airway
 GCS score of 8 or less?
– Consider airway control for the patient
– Failure to ventilate or oxygenate
 Signs of respiratory failure present?
– CPAP, O2, BVM not adequate
– Poor clinical outcome
 Anticipation of patient’s condition deteriorating?
– Potential for laryngeal edema to occlude airway

• Complications
– Hypoxia
 Limit each intubation attempt to no more than 30 seconds.
– Equipment malfunction
 Test your equipment at the beginning of each shift to ensure
proper working condition with blades and handle.
– Damage to teeth and soft tissues
 Rough handling and improper lifting of the laryngoscope can
cause damage.
– Lift the blade and handle as one unit toward the patient’s feet; do
not use the teeth as a fulcrum.

• Complications (continued)
– Esophageal intubation
 Leads to life-threatening hypoxia and gastric distention if not
immediately recognized
– Endobronchial intubation
 Leads to ventilation-perfusion mismatch

• Patient with no suspected spine injury
– Place the patient supine with the head in a “sniffing
position.”
– Insert an adjunct and preoxygenate with high-flow
oxygen.
– Gather and inspect equipment.
– Visualize the airway structures with insertion of the
laryngoscope blade.
– Insert the ET tube, inflate, ventilate, and verify
placement.
– Secure the ET tube.

Scan A1-1 (1 of 8)
Endotracheal Intubation in a Patient with No Spine Injury
1. Ventilate the patient.

Scan A1-1 (2 of 8)
2. Prepare the equipment.

Scan A1-1 (3 of 8)
3. Apply Sellick’s maneuver and insert the laryngoscope with the head slightly
hyperextended into the sniffing position.

Scan A1-1 (4 of 8)
4. Visualize the larynx and insert the endotracheal tube.

Scan A1-1 (5 of 8)
5. Inflate the cuff, ventilate, and auscultate.

Scan A1-1 (6 of 8)
6. Confirm placement with an ETCO2 detector.

Scan A1-1 (7 of 8)
7. Secure the tube.

Scan A1-1 (8 of 8)
8. Reconfirm endotracheal tube placement.

• Patient with suspected spine injury
– A neutral, in-line position of the patient’s head must be
maintained throughout the procedure.
– Follow the same procedural steps for visualization,
insertion, ventilation, verification, and securing the ET
tube in place.
– Apply a cervical collar to the patient.
Endotracheal Intubation

Scan A1-2 (1 of 5)
Endotracheal Intubation in a Patient with Suspected Spine
Injury
1. Ventilate the patient and manually stabilize the cervical spine, maintaining the head and
neck in neutral alignment.

Scan A1-2 (2 of 5)
Injury
2. Apply Sellick’s maneuver and intubate.

Scan A1-2 (3 of 5)
Injury
3. Ventilate the patient and confirm placement.

Scan A1-2 (4 of 5)
Injury
4. Secure the endotracheal tube and place a cervical collar.

Scan A1-2 (5 of 5)
Injury
5. Reconfirm placement.

Alexander app1 lecture

Recommended

Recommended

More Related Content

What's hot

What's hot (9)

Similar to Alexander app1 lecture

Similar to Alexander app1 lecture (20)

More from corynava00

More from corynava00 (20)

Recently uploaded

Recently uploaded (20)

Alexander app1 lecture