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INTRODUCTION

Tracheal intubation is a cornerstone of emergency airway management, creating a direct conduit to the trachea, allowing airway patency, aiding oxygenation and ventilation, and preventing aspiration. Intubation may also be needed to safely allow sedation or paralysis needed in critically ill patients requiring diagnostic or therapeutic interventions. Intubation is one component of the spectrum of emergency airway interventions. Supraglottic airways and the conversion of a supraglottic airway to an endotracheal tube (ETT) are discussed in Chapter 28, “Noninvasive Airway Management and Supraglottic Airways.”

PREPARATION

Proper preparation is key to successful intubation. Table 29A-1 lists emergency airway equipment needed at the bedside before beginning intubation. Have basic airway, intubation, rescue, and surgical airway equipment immediately accessible, ideally in the same cart with other airway management equipment. If treating a child, have enough and appropriately sized pediatric airway devices accessible (see Chapter 113, “Intubation and Ventilation in Infants and Children”).

TABLE 29A-1Equipment Needed for Airway Management

Key starting tasks are imperative: Ensure ongoing cardiac rhythm monitoring with continuous displays of the heart rate, blood pressure, oxygen saturation, and end-tidal capnography. Establish IV access and appropriate fluids.

Raise the patient to the level of the operator’s xiphoid (Figure 29A-1). Although ventilation and intubation are typically performed with the patient fully supine, positioning the patient so that the external ear is aligned with the sternal notch may improve glottis visualization (Figure 29A-2). Refrain from applying padding under the shoulders or neck as this position is suboptimal for facilitating emergency intubation. A more upright position for intubation may be necessary if the patient cannot lay supine—for example, the patient with severe pulmonary edema or morbid obesity (Figure 29A-3).

FIGURE 29A-1.

Correct patient-stretcher height, so that the patient’s head is just below the intubator’s xiphoid. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. Figure 22.14. Photo contributor: Lawrence B. Stack, MD.]

FIGURE 29A-2.

Patient positioning for optimal laryngoscopy. ...

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