ENDOTRACHEAL INTUBATION

LEVEL: Paramedic

1. All intubations MUST have initial, en route, and at transfer of care End-Tidal CO₂ detection/capnography performed and recorded on the PCR. 2. All intubation attempts MUST be documented on the PCR.

Indications:
This procedure may be performed on any patient in whom attempts at basic airway and ventilatory support are unsuccessful AND who has at least one of the following:
A.  Hypoxia
B.  Respiratory arrest/failure
C.  Inability to maintain airway patency

Contraindications:
Absolute Contraindications: None

Relative Contraindications:
A.  Presence of gag reflex
B.  Suspected narcotic overdose/hypoglycemia prior to administration or Naloxone/Glucose 50%

Adjunctive Therapy:
If patient is 12 years of age or greater, administer Etomidate 0.3 mg/kg IV/IO for induction.

☎  
If patient is less than 12 years of age, administer Midazolam 0.1 mg/kg/ IV/IN/IO titrated to effect. Maximum single dose: 5 mg. Must be given slowly over a period of 3-5 minutes. Additional pediatric doses by telemetry physician order only.

Ketamine can be used for all patients for induction: 2.0 mg/kg IV/IO or 4.0 mg/kg IM.

.
☎  
Maintain patient sedation.
A. Midazolam 0.1 mg/kg IV/IN may repeat every 5 minutes at 0.05mg/KG IV/IN/IM
OR
B. Ketamine 2mg/KG IV or 4mg/kg IM; contact medical control for additional doses

Check and prepare the
extraglottic airway
device prior to insertion

Key procedural considerations:
A.  Position head properly.
B.  Insert blade while displacing tongue and elevate mandible with laryngoscope.
C.  Introduce ET tube and advance to proper depth.
D.  Inflate cuff to proper pressure and disconnect syringe.
E.  Ventilate patient and confirm proper placement.
F.  Verify proper tube placement by secondary confirmation such as capnography or colorimetric device.
G.  Secure device or confirm that the device remains properly secured.

LEVEL: Paramedic

Nasotracheal Intubation:
Contraindications:
A.  Apnea or near-apnea
B.  Suspected basilar skull, nasal, or midface fractures
C.  Coumadin anticoagulation therapy or hemostatic disorders
D.  Upper neck hematomas
E.  Should NOT be attempted in children
Adjunctive Therapy:
1)  Prep the nostrils with Phenylephrine 2-3 drops (or 1-2 sprays in each nostril),
    or
  Oxymetazoline 2 sprays in each nostril.

    and
2)  Lidocaine 2% lubricant.

Check and prepare the
extraglottic airway
device prior to insertion

Key procedural considerations:
A. Position patient semi-Fowler, sitting or supine.
B.  Insert lubricated ET tube into dilated nostril and advance straight back (posteriorly).
C.  Listen to end ET tube for sounds of patient’s breathing.
D.  During inhalation, smoothly advance tube through glottic opening.
E.  Inflate cuff to proper pressure and disconnect syringe.
F.  Verify proper tube placement by secondary confirmation such as capnography or colorimetric device.
G.  Secure device or confirm that the device remains properly secured.