Intubation

Describe intubation

Achieved by performing direct laryngoscopy. A flexible plastic tube is passed through the oropharynx and glottis, and directly into the trachea. This enables the clinician to maintain a secure and patent airway for adequate ventilation.

Patient positioning for intubation

"Sniffing position" by using head extension and head elevation to align the patient's external auditory meatus with the sternal notch, with the face parallel to the ceiling. This: - Optimises the oral, pharyngeal, and laryngeal axis of the upper airway. - Improves laryngeal exposure - Maximises dimensions of the hypopharyngeal space - Maximises upper airway patency - Improves the mechanics of ventilation (both with spontaneous breathing (patients in respiratory distress naturally adopt this position) and with mask ventilation). Process: - Adults: 4-6cm of occipital padding - Obesity: significant ramping or padding (under upper torso, shoulders, neck, and occiput) - Neonates: shoulder padding - Paediatrics: usually in this alignment whilst laying supine but shoulder packing may be required Head extension notes: - Achieved by elevating the occiput to achieve: • Cervical (neck) flexion of 35 degrees relative to the chest/torso • Head extension at the atlantooccipital joint (situated between the cervical spine and base of the skull) of 15 degrees between the facial and horizontal plane. - Hyperextension of the neck (i.e. extreme atlanto-occipital extension) causes posterior displacement of the tongue and epiglottis, which narrows the upper airway. This worsens the view during laryngoscopy, and increases the force needed to expose the larynx, which can injure the spine. Head elevation notes: - In an adult, pack underneath the head with 4-6cm of towels (for normal adults) to cause the face to be plane parallel to the ceiling. - Radiographic reports show that increasing head elevation may be safer than increasing atlanto-occipital extensions in situations of poor laryngeal exposure, due to the risk of neurological injury from overaggressive head and neck extension during laryngoscopy (particularly central cord syndrome). For this reason, it has been suggested that if standard positioning needs to be modified, any additional extension should be avoided, and instead additional head elevation should be attempted. - Contraindicated in cervical spine immobilization - Obese patients require a huge amount of head elevation. Multiple pillows may be required - this is known as 'ramping'. This may be difficult to achieve prehospitally, but moving the patient onto the stretcher may assist with ramping. In massive obesity, this position lengthens the apnoeac time period to critical hypoxia, and shortens the time needed with mask ventilation to return to normal oxygen saturation. - Paediatrics: techniques to achieve the sniffing position in children will differ depending on the age of the child. Elevation of the occiput is usually necessary due to its relatively large size.

Describe the intubation procedure

- Intubation should occur with chest compressions in place, or when chest compressions are paused for a rhythm check. Chest compressions should only be paused for the minimum time necessary (no more than 3sec) to perform intubation - Equipment set up (CRAILS) - Discuss failed intubation plan with crew. Designate an airway assistant, ensure the whole team knows the plan, and have checklists ready - Positioning: sniffing - Check the mouth and pharynx, and perform a finger sweep if any foreign bodies are present. Remove dentures and dental appliances - Insert OPA correctly, and preoxygenate preferably using the two person technique via BVM (e.g. 100% O2 for 2-3mins) - Stop ventilations and remove OPA - Open the mouth as widely as possible - Laryngoscopy: • Hold in left hand • Insert into the right of the mouth, and sweep the tongue to the left • Advance the tip of the blade until you see the epiglottis, whilst not fulcruming against the teeth or lips: (a) MacIntosh blade: place the tip of the blade into the vallecula space, and apply additional lift along the longitudinal axis. This will displace the tongue out of the submandibular space, and will depress the hyoepiglottic ligament to lift the epiglottis out of view (b) Miller blade (for neonates and small paediatrics): pass posteriorly to the epiglottis, and directly lift it out of view • Apply lift along the longitudinal axis of the laryngoscope handle - Identify structures: • The posterior cartilages and interarytenoid notch (these structures make up the posterior border of the glottis and seperate the tracheal inlet from the oesophagus) • Visualise the vocal cords if possible (if not possible, passing the bougie anterior to the posterior cartilages and interarytenoid notch structures will facilitate intubation) - Insert bougie/ETT: • Bougie first: ask an assistant to pass you the bougie in your right hand. Always maintain visualisation of the cords and maintain laryngoscopy as this ensures the tongue remains displaced, thereby maximising successful intubation. Insert the bougie by passing it under the epiglottis in the midline and upwards into the glottis. Ask an assistant to 'rail road' the ETT over the bougie • ETT first: slide it down the groove of the blade and through the cords. Use a 90-degree anti-clockwise rotation to prevent the beveled tip of the ETT from getting caught in the arytenoids - Pass ETT until the first black line (closest to the cuff) is just pass the vocal cords. Ask the assistant to remove the bougie - Holding the ETT in place (to reduce risk of dislodgement): • Remove the laryngoscope • Note the length at lips • Inflate the cuff: (a) 5ml syringe: use 3-5ml of air. The minimum amount of air should be present in order to provide a seal: remove air from the cuff until a small leak is heard during PPV, then add 1-2ml of air until the leak can no longer be heard (b) Pressure syringe: 20-30cmH20. (c) This prevents air leak, and aspiration. High pressure within the cuff may cause mucousal ischaemia, with subsequent tracheal injury, leading to tracheal stenosis which may cause significant morbidity. The pressure threshold for mucousal ischaemia is lower in shocked patients. • Connect circuit and perform confirmation checks - Successful: • Secure the ETT • Reassess length at lips to ensure this has not moved whilst securing the ETT • Consult post intubation checklist (if in CA, use this if the patient develops sustained ROSC) • Reconfirm ETT placement with head movement or patient movement. • Document intervention correctly with appropriate details on the ePRF - Unsuccessful (unable to intubate within 30sec of beginning laryngoscopy, severe desaturation occurs during laryngoscopy, or there is oesophageal intubation): failed intubation drill

Cautions

1). Airway trauma (including chemical or thermal injury) 2). Trismus 3). Intact gag reflex 4). Extensive facial trauma that would impede the ability to perform laryngoscopy 5). Distorted anatomy due to a preexisting condition (e.g. tumours, trauma)

Principles of ventilation

1). Avoid hyperventilation. This: - Increases intrathoracic pressure, which decreases venous return and thus the blood flow achieved during CPR - Hypocarbia, which causes reflex cerebral vasoconstriction and thus decreased CPP) 2). Avoid overinflation. Remember that a normal adult breathes in approx 500ml of air, and a BVM is capable of delivering 1600ml of air. Overinflation causes: - Increases risk of gastric inflation - Increases intrathoracic pressure, which decreases venous return and thus the blood flow achieved during CPR 3). Stay focused. Easy to become distracted by other things.

Contraindications

1). Capnography is unavailable (continuous capnography is compulsory for all patients intubated with an ETT, including those in cardiac arrest) 2). GCS >3 3). GCS 3 with effective airway and/or breathing (risk outweighs benefit)

Post intubation checklist

1). Confirm placement with capnography. Note the EtCO2 and waveform 2). Examine for signs of bronchial intubation and adjust the ETT depth if required 3). Secure the ETT and note the length at lips 4). Measure vital signs 5). Administer sedation and analgesia in combination with neuromuscular blockade if required 6). Check the O2 supply 7). Check the ETT cuff. Ensure the minimum amount of air required to provide a seal 8). Ensure BVM is immediately available if a mechanical ventilator is being used.

Potential complications associated with ETT placement?

1). Failed intubation 2). Oesophageal intubation 3). Right main stem bronchus intubation (breath sounds should be heard bilaterally with proper tube placement. If they are only unilateral or diminished/absent over one hemithorax, withdraw the tube 2-3cm, but also consider the possibility of pneumothorax, haemothorax, pleural effusion, or obstruction) 4). Trauma to the upper airway: • Perforation/laceration to upper oesophagus, vocal cords (particularly if the tube is too big), or larynx • Dental or soft tissue trauma 5). Dislodgment of the ETT 6). Transient hypoxia or hypercarbia from prolonged intubation attempts. Other (not in CPG's): 7). Laryngospasm (particularly in choking patient's). This is a very rare complication. Revert back to an LMA, paralytic drugs, bougie, smaller ETT, or cricothyroidotomy 8). Neurological injury (particularly central cord syndrome) has been reported following overaggressive head/neck extension during laryngoscopy 9). Dysrhythmias (rare): - Intubation may induce sympathetic stimulation and increases in plasma catecholamines (causing increase HR, CO, BP, glucose levels) with subsequent ventricular arrythmias - Bradycardia (rare in an adult (unless raised ICP is also present, as intubation further raises ICP which in turn increases vagotonicity) - although vagal dominance has been reported in adults, it is more common in paediatrics) - Dysrhythmias are also associated with hypoxia (underlying or caused by intubation), or underlying myocardial ischaemia, electrolyte imbalances 10). HTN: a consequence of an imbalance between sedation and stimulation (intubation). Associated with: • Repeated ETT attempts (high risk) • Myocardial ischaemia • Re-rupture of aneurysmal subarachnoid haemorrhage • Poor outcomes in patient's with severe TBI • Male sex • Ketamine administration • Neuromuscular blockade (incidence decreases with use of sedation) 11). Hypotension due to raised intrathoracic pressures associated with high ventilatory rates

Post intubation confirmation checks

CELARA: Cords: visualising the passage of the ETT between the cords. EtCO2: - Waveform present - Capnography >5mmHg for the 4-6 breaths must occur. Consider that oesophageal intubation with stomach contents containing CO2 (e.g. drinks containing CO2, BCPR) will cause EtCO2 to be detectable for the first 2-4 breaths, and then rapidly fall <5mmHg. ETT must be removed even if you think a technical error is causing the EtCO2 to be <5mmHg as the risk of unrecognised oesophageal intubation is too high Length at lips: Should be assessed immediately after intubation, and once the ETT has been secured: - Adult male: 23cm - Adult female: 21cm - Newborn: (weight in kg + 6) - Newborn to 1 year: (ETT size x 3) - >1 year: (age in years ÷ 2) + 12. Auscultation: Abdomen/epigastric area first (air entry will be clearer during the first ventilation, but will diminish with more ventilations), right lung, then left Rise and fall of the chest. Assess for manual ventilation compliance.

Equipment and set up acronym for intubation

CRAILS. Circuit: - BVM - PEEP - Filter - EtCO2 - Cobbs connector - O2 tubing - O2 supply (with sufficient amount available) Rescue airways: - BVM with a selection of face masks - Forceps - OPA - NPA - LMA - Cricothyroidotomy kit Airway adjunct and holder: - ETT: • Check the cuff: inflate and deflate • Size if based on patient height and weight • Always have a smaller and bigger size available • Adult male: 7-8mm, 23cm at lips • Adult female: 6-7mm, 21cm at lips • New born: 3-4mm, (weight in kg + 6)cm at lips • Newborn to 1 year: 3-4mm, (ETT size x 3)cm at lips • >1 year: (age in years + 4) + 3.5mm ETT, (age in years ÷ 2) + 12cm at lips • Note: smaller ETT sizes are easier to insert, but larges ETT sizes have less airway resistance, allow for better suctioning, and decrease WOB. - Thomas tube holder Introducer: - Stylet: helps the tube conform to the airway, and may facilitate insertion into the larynx and trachea. Improper stylet shaping may make intubation difficult even if the larynx is well sighted. What you shouldn't do: • The stylet should not extend to the tip of the tube, as this makes the tip too rigid and prevents the tube from sliding into the trachea • Arcuate (curved) stylet shape can cause oesophageal intubation by blocking the line of site and obscuring the tip as it approaches the target, and minor rotational change whilst holding the arcuate tube causes the distal tip to move significantly, which can easily cause the tip to rotate past the right aryepiglottic fold, missing the larynx entirely • The use of stylets have been associated with pharyngeal or laryngeal trauma. - Bougie: should be inserted via the side of the mouth rather than down the centre, so that the rotation of the bougie provides better control of the tip in the vertical plane. Laryngoscope: - Check the light - Have a size below ready (don't worry about a size above) - Macintosh (curved) • 4 is the appropriate first choice for an average sized adult. • 3 is appropriate for a large paediatric • The tip of this blade is positioned in the vallecula, anterior to the epiglottis, lifting it up, in order to visualise the vocal cords and the glottis in between them • It minimises trauma to the teeth • Does not come in contact with the epiglottis (decreasing epiglottic trauma and decreased vagal stimulation) • Particularly advantageous to displace the tongue out of the submandibular space, which allows for more room in the oropharynx for passage of an ETT. - Miller (straight): • For neonates and small paediatrics • Size 0 (premature) • Size 4 (average adult requires size 2-3). • Blade is inserted so that the tip lies beneath the laryngeal surface of the epiglottis. The epiglottis is then lifted to expose the vocal cords. • Provides excellent exposure of the glottic opening, but a smaller passageway through the oropharynx and hypopharynx. Lubricant Suction, syringe, stethoscope, safety glasses: - Suction: • Check to ensure it's working • Yankauer handle positioned on the right side of the patient's head - Syringe: • Pressure syringe: check that this is calibrated to 0, or • 5ml syringe available

Considerations during paediatric intubation

Challenges identified during paediatric intubation: - Body fluids obstructing laryngeal view, which highlights the importance of airway suctioning in procedural process - Tube dislodgement which may be attributable to shorter tracheal anatomy - Some complications may be directly attributable to the underlying acute medical process (e.g. aspiration) - Deep tube placement into a mainstem bronchus - Intubation may contribute to: • Hypoxia (particularly because paediatrics desaturate faster than adults) • Arrhythmia, particularly bradycardia (due to direct stimulation of the epiglottis which is innervated by the vagus nerve and paediatrics have vagal overdominance. This is seen more in hypoxic patients). • Cardiovascular instability. Anatomical differences (2-6 years is the transition phase between paediatric and adult anatomy): - Occiput is large in proportion to the rest of the head. In neonates in the supine position, this results in natural head flexion that compresses the soft upper airway passages - The vocal cords are more anterior and superior - The tongue is proportionally larger. During conditions of low airway tone, the tongue falls back against the posterior pharyngeal wall, and contributes to airway turbulence and upper airway obstruction - The mandible and oral cavity are smaller - The trachea is shorter and narrower - The soft tissues are more fragile - The narrowest part of the airway is the cricoid cartilage - The epiglottis is large and floppy (described as a horseshoe shape, as opposed to a leaf in an adult). This changes to adult anatomy around 8 years. Lifting the epiglottis out of view using a miller blade is often better than using a mac blade, because the epiglottis may obstruct laryngeal view when using the latter blade.

Troubleshooting difficulty during ETT ventilation acronym

DOPES: for troubleshooting an apparent issue in ventilation/oxygenation post intubation, that may help identify technical problems. This is more for mechanical ventilation, but is also applicable for manual ventilation. Dislodgement of the ETT: assess for: - Inadvertent extubation: poor EtCO2 waveform with no or low EtCO2. Troubleshoot: BVM and reintubate - Right main stem bronchus intubation: asymmetric chest rise or breath sounds. Troubleshoot: adjust ETT length at lips - Oesophageal intubation: poor EtCO2 waveform with no or low EtCO2, SpO2 <90%, bradycardia, no chest rise, bubbling on auscultation of stomach. Troubleshoot: extube, BVM, reintubate Obstruction of the ETT or circuit/tubing may be indicated by decreased chest rise and breath sounds, SpO2 <90%, abnormal EtCO2 waveform, increased resistance to ventilation. This may be caused by: - ETT kinked - ETT obstructed with secretions, by passing a suction catheter or bougie down the ETT - Patient biting the tube - Circuit/tubing obstructed or kinked. - Troubleshooting: suction, and if no improvement, then extubate. BVM, then reintubate. Pneumothorax or tension pneumothorax (spontaneous or induced). Compromises gas exchange and may decrease CO. Assess for: - Hx or trauma - Signs of chest trauma - Aggressive PPV - Sx of pneumothorax (e.g. (auscultation, percussion, asymmetrical chest rise, shock, JVD, tracheal deviation - O2 sats <90% - Troubleshoot: FT - Consider other causes of abnormal lung function e.g. pulmonary oedema, bronchospasm, and aspiration Equipment problem: indicated by SpO2 <90%: - Air leak around the ETT cuff - Pop off valve activated on the BVM - O2 tubing disconnected - O2 tank empty - Ventilator settings. - Troubleshoot: check equipment, starting from the patient, working backwards through the equipment. Check the ventilator and settings, the circuit/tubing (ensuring all connections are secure), and check the oxygen and power supply. Stacked breaths (i.e. dynamic hyperinflation), however this is only associated with use of a mechanical ventilator. If this does occur, disconnect the ventilator for 20-30sec to allow for full expiration.

Benefits of ETT placement?

ETT is the gold standard in advanced airway management, and certain clinical conditions may mandate ETT placement. When protective airway reflexes are absent and frequent suctioning is required to maintain patency, the introduction of an ETT is key to ongoing airway management for effective ventilation and protection from aspiration. When compared to SGA, ETT has been shown to be associated with improved outcomes after OHCA, including increased chance of ROSC, survival to hospital admission, and neurologically intact survival to hospital discharge. Benefits: 1). Secures, obtains and maintains a patent airway 2). Prevent aspiration of vomit and/or bodily fluids 3). Able to control CO2 levels by controlling ventilation 4). Monitor EtCO2, which gives an idea of gas exchange and acid/base balance, which is a particularly helpful indicator of blood flow achieved during CPR 5). Improves oxygenation by allowing provision of PEEP via ETT 6). Allows for continuous compressions to occur (if CPR is in progress) without interruptions for ventilations

Post intubation management

For patients that have been intubated with an ETT and if ETT placement has been confirmed with capnography. If the patient was intubated during cardiac arrest, this section should only be used if sustained ROSC occurs. - Ventilate 10/min (once every 6s) (drowning and asthma: 6/min) - Ventilate to an ETCO2 of 35-45mmHg (TBI as primary clinical problem: 30-35mmHg) - Post intubation sedation/analgesia and neuromuscular blockade if the patient has been intubated without RSI and is showing clinically significant signs of movement: • Biting the tube • Coughing (may raise ICP, particularly in patients with TBI) • Gagging (may raise ICP, particularly in patients with TBI) • Lacrimation • Spike in EtCO2 (fastest and most reliable indicator) • Curare cleft • Agitation (e.g. hypertension, tachycardia, lacrimation, sudden spike in EtCO2 (fastest and most reliable indicator), curare cleft) • Shivering (increases oxygen consumption and temperature, which is of particular concern post cardiac arrest) • SNS stimulation: tachycardia, HTN. - Signs of shock: fentanyl/ketamine - No signs of shock: fentanyl/midazolam - Neuromuscular blockade: • 50-≤80kg: 50mg • >80kg: 100mg • Paediatrics: 1mg/kg • Repeat as required • Avoid neuromuscular blockade in adults with very poor prognosis, wherever feasible. • Halve the dose if the pt has a chronic condition of muscle weakness - NaCl if there are signs of hypovolaemia, hypotension or poor perfusion: • Adults: 1L • Paeds: 20ml/kg • One further bolus if required. - Metaraminol IV in addition to NaCl if the patient remains hypotensive: • Adults: infusion pump (administer an initial bolus of 0.5-1mg IV. Start the infusion at 2mg/hr and adjust the rate as required. The patient is likely to require ~2-3mg/hr). Bolus (0.5-1mg IV every 5-10mins as required) • Paediatric: bolus 0.01-0.02mg/kg IV every 5-10mins as required - Consider IV adrenaline if the BP is unresponsive to metaraminol, or if the patient is hypotensive and bradycardic: • Adult: infusion pump (start at 0.5mg/hr, and adjust as required). Infusion (1mg/1L (1:1,000,000 solution - 0.01mg/ml) start at 2 drops/sec and adjust rate as required). Bolus (10ml (0.01mg) of a 1:1,000,000 solution (0.01mg/ml) every 1-2mins as required). • Paediatrics 5-14yo: infusion pump (start at 0.25mg/hr, and adjust as required). Infusion (1mg/1L (1:1,000,000 solution - 0.01mg/ml) start at 1 drop/sec and adjust rate as required). Bolus (0.0002mg/kg of a 1:1,000,000 solution (0.01mg/ml) every 1-2mins as required). • Paediatrics <5yo: bolus (0.0002mg/kg of a 1:1,000,000 solution (0.01mg/ml) every 1-2mins as required). - Re-confirm placement frequently, and with every movement.

Risks of ETT placement?

For the majority of unconscious patients not in cardiac arrest, the risks of intubation without RSI outweigh the benefits, hence why intubation without RSI must only occur if the patient is GCS 3 with ineffective breathing. CPG risks include: 1). Inadvertent hyperventilation post intubation, at rates >10/min. This may raise intrathoracic pressure, leading to point 2 2). Reduced CO due to raised intrathoracic pressure which reduces venous return to the heart, with a subsequent reduction in CO, which leads to point 3 3). Reduced blood flow during CPR (due to raised intrathoracic pressure) if hyperventilation occurs (rates >10/min). This risk exists with SGA devices too 4). Unacceptable interruption and pauses in chest compressions during CA. These pauses are detrimental to achieving the necessary CPP associated with successful ROSC. 5). Hypoxia and hypercarbia during laryngoscopy secondary to failed or prolonged attempts 6). Raised ICP during laryngoscopy 7). Unrecognised oesophageal intubation

Intubation: - Indications (without RSI) - Why it is only reserved for this circumstance - Provide examples

Intubation without RSI must only occur if the patient is: 1). GCS 3 with ineffective breathing. If you intubate a GCS 3 patient with adequate airway/breathing then the risk outweighs the benefit. Intubation in the latter setting may cause vagal stimulation therefore leading to bradycardia and decreased brain perfusion. You may also provoke a SNS response, which will lead to tachycardia, HTN, and increased ICP. Examples: - Cardiac arrest: • Primary: not a priority during the initial stages of CA, but if ROSC hasn't occurred within 10mins, consider replacing the LMA with an ETT provided that this doesn't cause an unnecessary pause in chest compressions • Respiratory arrest (e.g. drowning, choking): high priority. An ETT should be placed early if ROSC is not achieved within the first few mins - Significant vomiting - Ventilation via OPA/LMA is inadequate, then an ETT should be placed provided that this doesn't cause an unnecessary pause in chest compressions.

Predicting difficulty acronym

LEMON Look externally at the features that may effect intubation: - Restricted/small mouth opening - Teeth: large, loose, overbite - Short neck - Small mandible - Beards - Facial fractures - Bleeding - Large tongue e.g. Downs syndrome. - Angioedema Evaluate 3, 3, 2 rule: - Oral access: upper and lower incisors should equal 3 pt fingers. This indicates how much the mouth will open to visualise past the tongue with both the blade and the tube in the opening - Mandibular space: distance between the chin and the hyoid bone should equal 3 pt fingers. The size of the mandible must be long enough to allow for the tongue to be displaced into the submandibular space - Mandible: the distance from the the floor of the mouth to the thyroid cartilage should equal 2 pt fingers. Indicates that the larynx is far enough away from the base of the tongue so that it can be seen, but not so far away that it cannot be seen. Mallampati score: Visibility of the oropharyngeal structures (i.e. in order of what is seen during the best (1) to worst (4) class score: soft palate, faucial pillars (the arches over the tonsils), uvula, hard palate). However, this is not useful prehospitally because it requires a conscious patient to open their mouth in the sitting position. Instead, use the Cormack-Lehane grading score: determines glottis visibility under direct laryngoscopy, prior to passing the ETT. Important to know so that troubleshooting can take place prior to any further intubation attempts are made after the initial view. Grade scores: - Grade I: visualisation of the entire glottic aperture (i.e. hole) - Grade II: visualisation of the arytenoid cartilages (cuneiform and corniculate) or posterior portion of the glottic aperture - Grade III: visualisation of the epiglottis only - Grade IV: visualisation of the tongue and soft palate only. Obstruction (functional, pathological, mechanical), obesity and obstetrics. Neck immobility: may limit the ability to position the head appropriately e.g: - Akolysing spondylitis (a form of spinal arthritis) - Rheumatoid arthritis - Spinal/cervical spine trauma - Elderly (e.g. with kyphosis) - Cervical fusion - C spine trauma

What is the failed intubation drill?

Look at the check list! Basically: preoxygenate with BVM and high flow O2 whilst systematically analysing the likely cause of failure. On second attempt, an aspect of technique must be adapted/changed to improve success (e.g. positioning, blade size, ETT size, external manipulation (BURP or OELM), a more experienced clinician - base this off the Cormack-Lehane score).

Describe external manipulation

Performed by the laryngoscopist, or by an assistant. It is not the same as cricoid pressure. BURP: - Backwards, upwards, rightwards pressure applied to the larynx by an assistant. - Has been shown to significantly improve glottic visualisation during laryngoscopy. OELM (optimal external laryngeal manipulation): - By the laryngoscopist has been shown to be more advantageous than BURP by an assistant, because it allows the operator to have immediate feedback and quickly determine which movements are required to provide an optimal view for intubation - Movements can include BURP, but can also involve any movements that improve visualisation of the glottis (e.g. firm downward pressure on the thyroid cartilage, that is in the opposite direction to the force of lift with the laryngoscope to maximise laryngeal view). - Firm downward pressure moves the vocal cords posteriorly, into the line of sight of the laryngoscopist. During laryngoscopy, downward pressure helps to drive the tip of the Macintosh blade into the hyoepiglottic ligament, further lifting the epiglottis out of view - When an optimal view has been achieved, an assistant can hold the larynx in this position whilst the ETT is placed.

Doses and dilution for sedation

Signs of shock: - 200mcg fentanyl and 200mg ketamine, diluted to a total of 20ml. This solution contains 10mcg/1ml fentanyl and 10mg/1ml ketamine (draw up the medicines the exact same in adults and paediatrics). - Adult: 5ml (50mcg fentanyl and 50mg ketamine) of the solution IV every 15-30mins - Paediatrics: 1mcg/kg fentanyl and 1mg/kg ketamine IV every 15-30mins - Titrate the frequency to the clinical signs of the patient's level of sedation. No signs of shock: - 100mcg fentanyl and 10mg midazolam, diluted to a total of 10ml. This solution contains 10mcg/ml fentanyl and 1mg/ml midazolam (draw up the medicines the exact same in adults and paediatrics) - Adult: 1-2ml (10-20mcg fentanyl and 1-2mg midazolam) every 5-15mins - Paediatrics: 0.5mcg/kg fentanyl and 0.05mg/kg midazolam - Titrate the frequency to the clinical signs of the patient's level of sedation.

Describe cricoid pressure

The technique involves the application of pressure to the cricoid cartilage at the neck, thereby occluding the oesophagus which passes directly behind it. This technique is used during intubation to reduce the risk of regurgitation in high vomiting risk situations.