Intubation

Indications: 1) increased ICP, 2) ventilatory failure, 3) oxygenation failure, 4) airway protection, 5) intensive pulmonary toilet, 6) decreased WOB as in septic shock

Supplies: think SALT!
 
- Suction
 
- A-mbu bag
 
- L-aryngoscope (0 for babies, 1 for infants/toddlers, 2 for >2yo, macintosh for teenager)
 
- T-tube and tape

ETT size= age +16/4 for uncuffed subtract 0.5 for cuffed tube

Medicines:
 
1. Atropine 0.01 mg/kg IV(min 0.1 mg; max 0.5 mg child, 1 mg adol) <8y/o
  
• blocks bradycardia mediated by vagal stimulation, decreases secretions

2. Sedative  Etomidate-0.3 mg/kg IV
 
- Ultra short acting
 
- duration10-15 min
 
- SE: myoclonic activity, cortisol suppression

Versed 0.1 mg /kg IV
 
- minimal myocardial/cardiovasc SE
 
- amnesia
 
- onset of action 60-90 sec

Ketamine 2 mg/kg IV/IM
 
- drug of choice in asthma
 
- stimulates heart, good for hemodynamically unstable patients
 
- causes dissociate state (like PCP)
 
- SE; Laryngospasm, nystagmus, increased secretions, elev BP/HR, emergence phenomenom, hallucinatins, increased IOP, vomiting
 
- CI: Head trauma, increased ICP, open globe injury

3. Muscle Relaxant
 
Rocuronium 1.0 mg/kg IV
 
- non-depolirizing
 
- shorter duration than vecuronium

Vecuronium 0.1 mg/kg IV (for ongoing paralysis)
 
- non-depolirizing
 
- duration of action 30 min

Rapid Sequence Intubation:
 
1. MSOAP (monitors, suction, oxygen, airway equipment, pharmacy/position/personnel)
 
2. If concerned about increased ICP, give Lidocaine 1 mg/kg IV
 
3. Atropine(under 8 years of age)
 
4. Cricoid pressure
 
5. Sedative-à flush, à paralyzing agent
 
6. Intubate and release cricoid pressure only after ETT in place or if difficulty visualizing cords

Sedation after Intubation:

Purpose: To provide additional sedation, analgesia, and/or neuromuscular
blockade in order to maintain ETT placement to facilitate continued
oxygenation and ventilation in an intubated patient.

Commonly used medications are:
 
Sedation
   
Midazolam (Versed):
   
Adult and Peds dose: 0.1 mg/Kg IV

Analgesia
 
Fentanyl
 
Adult and Peds: 2 mcg/kg IV,
 
- may repeat every 15-20 min PRN