Chapter 6

For patients who require orotracheal intubation, digital (tactile) intubation is an alternative airway technique. This procedure involves using the index and middle fingers as a guide to blindly place the endotracheal tube into the larynx. Digital tracheal intubation has been demonstrated to be a safe, simple, and rapid method.1 It should be considered as a secondary method of intubation when other methods prove difficult or impossible.1 It is particularly suited for prehospital and aeromedical use, where equipment and alternate intubation techniques are limited or unavailable. One study demonstrated an 88 percent success rate among paramedics who intubated with this technique.2

For this procedure, the only two significant anatomic structures that the intubator will encounter are the tongue and the epiglottis. The epiglottis is the cartilaginous structure that is located at the root of the tongue and serves as a valve over the superior aperture of the larynx during the act of swallowing.3

Digital orotracheal intubation is an ideal alternative technique for intubating the comatose or chemically paralyzed patient when other more conventional methods for intubation have failed. In particular, this procedure is useful when oral secretions or blood inhibit the direct visualization of the upper airway.1 Since this technique involves minimal movement of the head and neck, it may be a suitable method for intubating patients with known or suspected cervical spine injuries. Digital intubation may be a useful procedure for paramedics and aeromedical personnel in the out-of-hospital setting, when trapped patients require intubation but are not in a position for more conventional methods.2 It is an alternative technique for out-of-hospital intubation where other techniques and equipment are unavailable or limited. This procedure also has been performed successfully in intubating neonates.4

There are no absolute contraindications to digital intubation. The main danger of this procedure is to the health care worker performing the intubation, who is at risk for having his or her fingers bitten by the patient. This technique should not be performed on any patient who is awake or semiconscious. It should be performed only on patients who are paralyzed or unconscious. A relative contraindication would be performing this procedure on a patient with multiple fractured teeth that may abrade or cut the intubator’s fingers.

• Endotracheal tubes, various sizes
• Wire stylet, malleable (optional)
• 10 mL syringe
• Water-soluble lubricant or anesthetic jelly
• Bag-valve device
• Oxygen source and tubing
• Gauze, 4×4 squares

Endotracheal intubation in the Emergency Department is commonly performed on an emergent or urgent basis. If there is time, the risks, benefits, and complications of the procedure should be explained to the patient and/or the patient’s representative.

The use of gloves, a bite block, and gauze over the teeth as guards are recommended when performing this procedure. The patient should be lying supine. If the patient has sustained a concerning mechanism of injury, the cervical spine should be immobilized. An ...

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