NORTH COAST EMERGENCY MEDICAL SERVICES Policy # 5318

POLICIES AND PROCEDURES

Subject: Medical Direction

Associated Policies: 01/16/98

I. Indications:

A. Respiratory insufficiency.

II. Therapeutic Effects:

A. Isolates the trachea and permits complete control of the airway

B. Prevents gastric distension.

C. Provides direct route for suctioning of respiratory passages.

D. Permits administration of medications via endotracheal tube.

Medications that can be administered:

1. Epinephrine.

2. Atropine.

3. Narcan.

4. Lidocaine.

III. Contraindications:

A. Absolute:

1. None.

B. Relative:

1. Severe pharyngeal or esophageal burns: thermal or caustic.

2. Possible epiglottis.

IV. Equipment:

A. Adult and pediatric laryngoscopes.

B. Adult and pediatric endotracheal tubes (2.5-9.0mm).

C. tape or other device for securing tube

D. Inserting stylets.

E. 10 ml syringe.

F. Bag-Valve-Mask.

G. Adult and pediatric Magill forceps.

H. Suction device.

I. Stethoscope.

J. Additional Equipment (Optional):

1. CO2 Detector Device-Adult and Pediatric

V. Adverse Effects:

A. Hypoxia.

B. Esophageal or right main stem bronchus-intubation.

C. Aspiration during the procedure.

D. Vagal stimulation with severe bradychardia and hypotension.

E. Laryngospasm.

F. Vocal cord damage.

G. Displacement of a cervical fracture and paralysis.

H. Complete obstruction of airway in epiglottis.

VI. Procedure

A. Insertion:

1. Ensure that the equipment is working and that suction is available

2. Select appropriate size ET tube:

3. Adult: Average adult sizes of 7.0, 7.5 and 8.0 uncuffed tubes.

4. Pediatric and infant sizes can be determined using:

a. Resuscitation tape should be about the same size as the child’s small fingernail. Pediatric tubes should not be cuffed, or if cuffed, it should not be inflated.

5. Insert stylet and bend ET tube into a "Lazy J". If a stylet is used, the distal end should be recessed from the tip of the tube.

6. Position patient:

a. Medical patient: Sniffing position. Facilitate this position for a child or infant by placing towel roll under shoulders.

b. Trauma patient: Neutral position with inline axial stabilization.

7. Hyperventilate the patient.

8. Grasp laryngoscope in the left hand and ET tube in the right.

9. Exert traction upward along the axis of the laryngoscope handle until glottic opening is exposed. Do not use top teeth as a fulcrum.

10. Insert ET tube into the trachea.

11. Inflate cuff in adult patient with 10cc air.

12. Remove syringe and stylet, maintaining tube position.

13. Ventilate patient and watch for chest rise, auscultate lung fields and epigastic area.

14. If CO2 Detector is used

a. Determine correct size device. (Do not use Adult CO2 detector on a patient less than 15kg).

b. Place on ET tube and hyperventilate patient.

c. Observe CO2 Detector for appropriate color change.

15. Note tube position and secure tube in place with tape or ET tube hold device.

16. Reassess ventilations, watch for chest rise and auscultate lung fields.

B. Indications for Extubation:

1. No chest rise with ventilation.

2. Absent breath sounds.

3. Presence of epigastric ventilation sounds.

4. Purple color on CO2 detector with exhaustion for patient with a pulse.

5. Consider extubation on the patient who has return of spontaneous respirations, who has regained consciousness, and who is coughing, gagging and struggling against the ET tube.

C. Extubation Procedure:

1. Turn patient on side and suction oropharynx.

2. If cuff was used, deflate cuff completely.

3. Withdraw ET tube rapidly at end-inspiratory phase while suctioning oropharynx.