You are called to a scene of a 50 year old male who was thrown from his motorcycle on a nice fall afternoon. The man is barely alert and cannot maintain his own airway. The first responders are assisting with ventilations but he doesn’t seem to tolerate ventilations via bag valve mask. His blood pressure is 110/60, pulse rate of 50, with snoring respirations at a rate of 6 breaths a minuet that are very shallow. With an Oxygen saturation of 80%. He is extremely hypoxia and needs an advanced airway his jaw is clenched tightly and impossible to inset a tube. You decide to prepare for intubation, but first decide a dose of Versed at 1.5mg to open his clenched jaw and will take effect while you prepare all equipment. Using a jaw thrust maneuver you open his airway and visualize that an ET tube is appropriate and viable. You prepare 100mg of succinylcholine estimating the man’s weight is 100kg as a sedative. After administering the drug you will have your partner aggressively monitor vital signs. You now use a laryngoscope and blade to open the epiglottis and hold the tongue for clear visualization. You choose an 8mm diameter tube to insert and you’ve already made sure the balloon inflates with a 10ml syringe. Lubricant will assist in tube placement as well as putting a slight bend in it prior to intubation.
The tube is then slid along the right side of the mouth and visualized entering 1/2 to I inch into the vocal cords. Make sure you do not take your eyes off the vocal cords once you see them. If you need something have it passed to you by your partner. Watch the tube pass through the cords. A helpful trick is to vocalize what you see and what you are doing to ensure proper technique. The laryngoscope is removed and the balloon at the end of the tube is inflated using the syringe. Then the tube is secured to the patient with either a strap or tape. The next crucial step is confirmation of tube placement. The most accurate method of confirming tube placement is end tidal CO2. This should be measured after giving the patient three ventilations. The most common device is a detector that attaches directly to the tube and changes color to indicate the CO2 level. However, end tidal CO2 is NOT accurate for patient's in cardiac arrest. Look for chest rise and fall. Listen to lung sounds and well as the abdomen. Waveform capnography is known as ventilation vital signs and should always be used to confirm proper tube placement. Studies on wave form capnography have shown 100% sensitivity and 100% specificity in identifying correct endotracheal tube placement. It’s imperative to confirm tube placement so as not to ventilate the esophagus or a main bronchus going to only one lung. If the tube is inadvertently placed in the esophagus, adequate respirations will not occur. Brain damage, cardiac arrest, and death can occur. Aspiration of stomach contents can result in pneumonia and ARDS. Placement of the tube too deep can result in only one lung being ventilated and can result in a pneumothorax as well as inadequate ventilation. During endotracheal tube placement, damage can also occur to the teeth, the soft tissues in the back of the throat, as well as the vocal cords. All of this is happening with minimal interruptions of ventilations of course and monitor the O2 sat of this patient.