Indications for performing endotracheal intubation

• Poor respiratory drive

• Questionable airway patency

• Hypoxia

• Hypercarbia

• Reduced GCS (>8)

• Airway compromise

• Airway protection

• Airway maintenance during a cardiac arrest

• Respiratory failure/arrest

• Respiratory acidosis

• Major trauma requiring multiple interventions 

Contra-Indications

• Major maxillofacial injuries (Consider surgical airway)

Preparation

• Intravenous access

• Hemodynamic monitoring

• Stethoscope

• Pulse & NIBP monitoring

• Capnography (ETCO2)

• Suction

• Rapid sequence intubation medications (if requiring sedation)

• Defibrillator

• BVM

• OPA/NPA/IGel

9Ps:

• Plan

• Preparation (drugs, equipment, people, place)

• Protect the cervical spine

• Positioning (some do this after paralysis and induction)

• Preoxygenation

• Pretreatment (optional; e.g. atropine, fentanyl and lignocaine)

• Paralysis and Induction

• Placement with proof

• Postintubation management

Intubation Sequence

• The intubator will position themselves at the airway and pre-oxygenate the patient using the prepared airway circuit firmly applying the face-mask

• The team will rapidly run through either the RSI checklist

• Intubator or a delegated clinician will challenge

• Support clinician will respond

• The chosen induction agent(s) and muscle relaxants will be administered by the doctor or a delegated clinician

• Upon onset of apnoea the intubator may gently ventilate the patient using an oropharyngeal airway (or iGel device if it was already in situ) until they attempt laryngoscopy - waiting at least 60 seconds after the administration of rocuronium

• A laryngoscope is used to pass a bougie through the cords, over which an appropriately sized endotracheal tube is 'rail-roaded' into position

• Apnoeic time during laryngoscopy should not exceed 30 seconds - the support clinician should announce the time elapsed at 20 seconds and again at 30 seconds

• Connect the prepared airway circuit and confirm successful intubation using waveform capnography.

• In the event that intubation is not successful on first attempt, the failed intubation algorithm should be followed (See Appendix 3)

Indications for performing a scalpel cricothyroidotomy

• Can't intubate, can't oxygenate (CICO)

• Swelling or trauma to the face or neck making endotracheal intubation impossible

• e.g. burns, facial fractures, angioedema

• Inadequate airway access e.g. entrapments

• Progressive airway occlusion in a casualty with face and neck trauma or swelling, where the practitioner is unable to undertake pre-hospital RSI

• Scalpel cricothyroidotomy equipment should be available to hand for all PHEA cases and unpacked as part of the PHEA preparation process when it is anticipated that an airway will be particularly difficult including patients with;

• Airway trauma

• Difficult anatomy

• Burns to face and neck precluding jaw movement

• Possible airway burns

• Angioedema

• Patients with severe facial injury may look alarming and difficult to intubate. However, the vast majority can be intubated in the normal way using the PHEA SOP. Pre-oxygenation and induction of anaesthesia should however be performed in the position where they are most comfortable and can maintain their own airway. Suction (with a back-up) should be readily available.

Equipment

• Scalpel (Number 10 blade)

• Bougie

• Tube (cuffed 6.0mm)

Palpable cricothyroid membrane

1. Transverse stab incision through the cricothyroid membrane

2. Turn the blade through 90 degrees

3. Slide the tip of the bougie along the blade into the trachea

4. Railroad lubricated 6.0mm cuffed tracheal tube into the trachea

5. Ventilate, inflate the cuff and confirm the position with capnography/auscultation

6. Secure tube

Impalpable cricothyroid membrane

1. Make an 8-10cm vertical skin incision

2. Use blunt dissection with the fingers of both hands to separate tissues

3. Identify and stabilise the larynx

4. Proceed with the technique for palpable cricothyroid membrane as above 

If the patient is conscious use sedation (e.g. ketamine or midazolam) and/or infiltration of local anaesthetic across the front area of the neck.