The Tale of the Perfect Intubation

Disclaimer:  This is for the critically ill patient who is not in cardiac arrest.  Follow local protocols.  However, we believe this is the perfect technique for intubation.

1.      Place the patient on a High-Flow Nasal Cannula (HFNC) on at least 15 LPM.

2.      Put a non-rebreather on the patient over the nasal cannula at 15 LPM.

3.      Begin assessment for difficult airway and prepare suction.

4.      Put a PEEP valve on the BVM.

5.      Place the BVM attached to 100% O₂ and PEEP valve over the patient’s face and remove the non-rebreather.

6.      Insert IV and begin IVF bolus running wide open, unless patient is in overt CHF.

7.      Give push-dose epinephrine at 10μg per minute if SBP <90 mmHg prior to intubation. Attempt to maintain SBP>90 mmHg at all times.  Alternative:  Start a “dirty” epinephrine drip (1 mg of code cart epi in 1 L of NS) run wide open. Typical flow rate of 18-20 gauge is 30cc/min = 30μg/min.

8.      If RR>4 and SpO₂ >93%, do not bag!  Allow three minutes for denitrogenation/pre-oxygenation prior to intubation.

9.      If RR>4 and SpO₂ <93%, do not bag!  Allow three minutes for denitrogenation/pre-oxygenation.  If SpO₂ does not come up to 93% after three minutes, increase PEEP on PEEP valve, ensure proper positioning (see below), perform jaw thrust, and consider nasal airway (NPA).  Begin bagging patient at 6 breaths per minute (not more).  If pulse ox does not increase after three minutes of denitrogenation/pre-oxygenation followed by three minutes of BVM ventilation, perform rapid sequence intubation (RSI).

10.  If RR<4 and SpO₂ >93%, ventilate at 6 breaths per minute and consider other causes, such as opioid overdose.  Consider “Rapid Sequence Airway” (supraglottic airway/iGel, decompress stomach, and gentle bagging).

11.  If RR<4 and SpO₂ <93%, ventilate at 6 breaths per minutes until saturation at least 93%, then use BVM/PEEP valve without bagging for three minutes, then perform RSI.

12.  Ensure proper positioning.  This includes the head of bed at 20° elevation with ear aligned to the sternal notch.

13.  Give ketamine at 2 mg/kg.

14.  Give succinylcholine (if not contraindicated) at 1.5 mg/kg (or 2 mg/kg if SBP <90 mmHg).  Give rocuronium at 2 mg/kg, if available, in place of succinylcholine.

15.  Give fentanyl at 3 μg/kg for patients with head trauma.

16.  Perform laryngoscopy and intubation.

17.  Give fentanyl bolus at 2 μg/kg, followed by infusion at 1.5 ug/kg/hr, or repeat bolus if infusion not accessible.

18.  Repeat ketamine at 1 mg/kg PRN.

19.  Ventilate at 6 cc/kg (if ventilator available) and elevate the head of the bed/stretcher to 30°.