Tracheal Intubation

Question 1

Remarks on hemodynamics prior intubation

Answer 1

Try to normalize patient heart rate and BP, and try to optimize oxygen saturation prior to drug administration and laryngoscopy; peri-intubation cardiac arrest is likely if ANY of these parameters is abnormal

Question 2

Elevating the head of the patient ______ degrees may improve preoxygenation

Answer 2

20 to 30

Question 3

how to perform the scissor motion in opening the patient’s mouth during intubation

Answer 3

press caudally on the patient’s lower incisors with the operator’s thumb and cranially on the patient’s upper incisors with the operator’s index finger

Question 4

TRUE or FALSE
The tip of the stylet may extend beyond the end of the ETT or exit the Murphy eye

Answer 4

FALSE
The tip of the stylet must not extend beyond the end of the ETT or exit the Murphy eye

Question 5

How to lift the epiglottis

Answer 5

Lift the epiglottis:
directly with the straight blade (Miller) or
indirectly with the curved blade (Macintosh)

Question 6

Remarks on correct tube placement

Answer 6

Correct tube placement is a minimum of 2 cm above the carina (approx 23 cm at the incisors in men and 21 cm in women)

Question 7

inflate the balloon with ____ mL of air

Answer 7

5-7 mL of air
Check the cuff pressure to avoid tracheal injury from pressure (target 25-40 cm H2O)

Question 8

Best method for confirming successful endotracheal tube placement

Answer 8

Directly visualizing the tube between the vocal cords.

Others:
Listen for bilateral breath sounds and the absence of epigastric sounds
Tube condensation
Confirm placement with capnography or colorimetric CO2 detector

Question 9

Multiple intubation attempts are associated with adverse events including cardiac arrest. To minimize desaturation, limit each intubation attempt (insertion of blade) to:

Answer 9

no more than 30 seconds.

Question 10

Remarks on intubation patients in extremis or with anticipated difficulty

Answer 10

first-pass success is more vital; have the most experienced person perform intubation in these sitations

Question 11

expected color change of colorimetric CO2 detectors

Answer 11

yellow to purple with carbon dioxide exposure

Question 12

Clear, regular waveforms or CO2 measurement _____ mm Hg correlating with exhalations suggest proper ETT placement

Answer 12

CO2 >30 mm Hg

Question 13

remarks on UTZ in confirming ETT placement

Answer 13

Confirms endo-tracheal placement, but does NOT rule out mainstem bronchus intubation

Question 14

this UTZ sign likely suggests esophageal intubation

Answer 14

“double track sign”

Question 15

remarks on CXR in confirming ETT placement

Answer 15

Confrims vertical positioning of ETT (rules out mainstem bronchus intubation), but does NOT reliably distinguish ETT placement in the trachea from the esophagus

Question 16

Epinephrine dose in hypotension after intubation or sedation

Answer 16

5-20 mcg/bolus dose over 20-30s every 2-5 mins as needed

Question 17

remarks on Etomidate as induction agent

Answer 17

a nonbarbiturate hypnotic
protects from myocardial and cerebral ischemia
causes minimal histamine release
causes little hemodynamic depression

Question 18

Do not use succinylcholine in patients with suspected preexisting

Answer 18

significant hyperkalemia (especially renal failure),
myopathies,
or myasthenia gravis

Question 19

video laryngoscopy (VL) vs traditional laryngoscopy

Answer 19

in contrast to traditional laryngoscopy, a midline insertion approach is preferred and a tongue sweep is NOT needed with VL

Question 20

Poor flexible fiberoptic laryngoscopy (FFL) candidates

Answer 20

patients needing an immediate airway,
with near-complete obstruction,
with large bleeding or vomitus,
and who cannot be ventilated to maintain saturation

Question 21

the typical optimal depth of nasotracheal tube placement is

Answer 21

28 cm at the nares in men
and 26 cm at the nares in women

Question 22

In the presence of major anatomic barriers (tumor, trauma, obesity, difficult anatomy), consider:

Answer 22

deferring RSI, preserving the patient’s natural respiratory drive and protective airway reflexes

Question 23

What is the LEMON method of airway assessment?

Answer 23

Look externally - facial trauma, large incisors, beard, large tongue
Evaluate the 3-3-2 rule
Mallampati ≥3
Obstruction [internall] - epiglottitis, peritonsillar abscess, trauma
Neck mobility

Question 24

Discuss the 3-3-2 rule

Answer 24

To allow for alignment of the pharyngeal, laryngeal, and oral axes and therefore simple intubation, observe the following relationshiops:

Incisor opening distance: ≥3 fingerbreadths
Hyoid-mental distance: ≥3 fingerbreadths
Thyroid [notch]-to-mouth [floor] distance: ≥2 fingerbreadths

Question 25

Some tips in unanticipated intubation difficulty

Answer 25

1. Stay calm 2. Call for help 3. Plan and communicate the **next two steps** 4. Alter airway techniques with each attempt 5. Let RSI medications wear off 6. Use noninvasive airway measures