Intubation

7 P's mnemonic

• Plan
• Preparation
• Protect the C-spine
• Positioning
• Preoxygenation
• Pretreatment
• Paralysis and induction
• Protection and positioning: BURP
• Placement with proof
• Postintubation management

Preparation

• Predicting difficult intubation (LEMON)
  • Look for difficulty
  • Evaluate with 3-3-2 rule (mouth opening, neck-to-chin, and neck-to-thyroid)
  • Mallampati
  • Obstruction: swelling, foreign objects, obesity
  • Neck mobility
• Gathering equipment (SOAPME)
  • Suction
  • Scope & backup glide-scope with blade
  • Oxygen
  • Airways
    • ETT (7.5 in general; 7 for small women, 8 for large men), with stilette
    • Oral airway
  • Preoxygenation
  • Monitors and Medications, including premedication, induction, paralysis, and phenylephrine/vasopresors
  • ETCO2 detector

Preoxygenation

• 100% O2 ideally with some deep breathing

Pretreatment

• Short-acting analgesic to blunt the sympathetic response
  • Fentanyl 3mcg/kg (~180mcg) IV given over 30 to 60 seconds
• Alpha-adrenergic for BP support
  • Phenylephrine 50 to 200 mcg

Paralysis and induction

Induction

• Etomidate 0.3mcg/kg (~18mcg) IV push
  • GABA-ergic
  • Time to effect 15 to 45 seconds and duration of action 3 to 12 minutes
  • Best in hypotension (has no effect on BP)
  • Concern for adrenal suppression
• Midazolam 0.1 to 0.3 mg/kg (~12mg) IV push
  • GABA-ergic
  • Time to effect 30 to 60 seconds and duration of action of 15 to 30 minutes
  • Drops MAP by 10 to 25%
• Ketamine 1 to 2 mg/kg (~100mg) IV push
  • NMDA-ergic and stimulates catecholamine release
  • Time to effect 45 to 60 seconds and duration of action of 10 to 20 minutes
  • Provides some analgesia as well
  • Preserves respiratory drive
  • Preserves blood pressure
  • Concern for reemergence phenomenon (disturbing dreams)
• Propofol 1.5 to 3 mg/kg (~120mg) IV
  • GABA-ergic
  • Time to effect 15 to 45 seconds and duration of action of 5 to 10 minutes
  • Decreases MAP by 10mmHg

Paralysis

• Succinylcholine 1-2 mg/kg (usual dose 100 mg)
  • Depolarising
  • Side effects include hyperkalemia and malignant hyperthermia
• Rocuronium 0.6-1.2 mg/kg IBW
  • Non-depolarising