Airway Management

Adequate anesthesia is critical for intubation in the awake patient.

If you have time, lidocaine 4% at 5 ml by hand-held nebulizer facilitates intubation by blocking the gag reflex and providing excellent topical anesthesia.

In nasal intubation, cetacaine-lidocaine spray and lidocaine jelly are helpful.

Nasal intubation.

Simple to do blindly.

Contraindicated in bleeding disorders or where you might want to use thrombolytics. Also contraindicated in basilar skull fracture and midface trauma.

The patient must be breathing to use this technique.

Almost all patients intubated nasally develop a sinusitis and should be given antibiotics if prolonged intubation is required.

Rapid Sequence Intubation (RSI)

Before you try this technique, be sure that you are able to control the airway, since the patient will be paralyzed and unable to breathe for himself or herself.

Indications. Acute intracranial lesions, some overdoses, status epilepticus, combative trauma patients where behavior threatens life, possible cervical spine fracture where immobilization not possible because of delirium, etc.

Drug side effects.

Succinylcholine.

Bradycardia

Increased intraocular and intracranial pressure

Contraindicated in penetrating globe trauma

Increased gastric pressure and emesis

Rarely hyperthermia

Vecuronium has almost no known side effects.

RSI using a depolarizing agent.

Time (minutes)

-3.00 Preoxygenate, IV lines, monitor, oximetry, equipment including that for emergency surgical airway control

-2.00 Lidocaine 1 mg/kg (100 mg*)1

-1.45 Atropine 0.01 mg/kg (0.5 mg*)2

-1.00 Vecuronium 0.01 mg/kg (1 mg*)3 prevents fasciculation

-1.00 Begin Sellick maneuver (cricothyroid pressure to prevent vomiting and aspiration)

-0.55 Midazolam 0.1 mg/kg (7 mg*)4

-0.45 Succinylcholine 1.5 mg/kg (100 mg*)5

0.00 Intubation

+0.30 Assess tube placement

+8.0 Check patient's temperature

RSI using nondepolarizing agent.

Time (minutes) to intubation

-3.00 Preoxygenate, IV lines, monitor, oximetry, equipment

-2.00 Lidocaine 1 mg/kg (100 mg*) 1

-1.45 Atropine 0.01 mg/kg (0.5 mg*)2

-1.00 Vecuronium 0.10 mg/kg (10 mg*)

-1.00 Begin Sellick maneuver

-0.55 Midazolam 0.1 mg/kg (7 mg*)4

0.00 Intubation

+0.30 Assess tube placement

*Usual adult dosage.

1May be omitted in non-head injury cases.

2May be omitted in adults if no preexistent bradycardia.

3May use pancuronium (same dose).

4May use thiopental 3 to 5 mg/kg (300 mg*).

5Dose in children is 1.5 to 2 mg/kg.