Intubation Question

Editorial Team / Moderator · Jan 11, 2011

I would be familiar with the meds you have available for RSI and sedation, as well as common dosing guidelines, order of administration, what your docs like to use, etc. Be familiar with the equipment, as well as where to get at least two more of everything you'd need in a hurry!

suanna · Jan 11, 2011

EQUIPMENT! Ambu bag, ET tray, suction, ET holder, meds for sedation, easy access to meds for BP management. Set up a good dedicated IV with NS infusing quickly for sedtion that can be used for pressors if the patients BP crashes. (you don't want to be trying to figure out where to plug in your levo drip when your patients SBP is 60). A vent is always nice, unless you want to spend the next 20 min bagging. Pulse ox monitoring and a CO2 detector should be at hand. As soon as possible a Salem Sump/NG should be placed while the intubation sedation is still working and before the post intubation CXR. I always have soft restraints at hand unless you want to do it all over again with a much angrier doc in about 15 minutes.

canchaser, BSN, RN · Jan 11, 2011

THings you will need are

1.suction equipment ie yankeur,tubing to go to wall suction and WORKING suction machine. I check these at the start of the day dont wanna be in an emergrncy and the suction head doesnt work.

2. Bag and mask oxygen turned up as high as it will go.

3. Drugs the MD orders, bring extra syringes and blunt tips/needles,tape. When you draw up the drugs tape the vial to the syringe with name showing out,so if someone comes into help midway they know what is in each syringe.

4. endotrachial tube, and a laryngoscope with blade. MAke sure the light is working. towel or paper towel for Dr to wipe the nasty sputum ball on, if (s)he should get one.

5. Stethoscope to listen for breath sounds after intubation. Listen over the belly to make sure you dont hear air. Listen over the right and left lung hope you do hear air.

6. Paper towel to write notes on or someone charting for you as its going on.

7. After intubation expect the pt to be placed on Vent, expect a PCXR and also(from an ICU nurse) expect/ request a follow up blood gas in about 30 minutes to see what vent changes need made. Please dont leave the pt on the original settings.

Any one else? Im sure there's stuff I missed

rntim49 · Jan 11, 2011

This is information you should already know. :uhoh3:

**canoehead, BSN, RN** · Jan 12, 2011

Also you should have the secretary or security, or someone standing by. Someone who knows how to use the phone, or even better, can go grab a piece of equipment for you. Call around before the intubation. If the EHS base is close by, or medsurg isn't too busy, they may be willing to loan you a recorder so they get the benefit of watching the procedure.

If it has to be just you and the doc get everything ready and within reach, and verbally go through the procedure together, before you push drugs. Bring the cordless phone into the room with you, and stick some of the 2" tape on your pants leg so you can make notes on the fly. Set the monitor on auto record, plant the doc at the head of the bed with a Mayo stand, and show them where the bag, O2, suction, air syringe and tape is. You will be pushing drugs, assessing patient, cricoid pressuring, and free to scramble about the room as needed. Once the tube is in someone needs to hold it constantly until it is securely taped, the doc can hold and bag while you tape.

usalsfyre · Jan 12, 2011

The 7 P's of RSI

1. Preoxygentate. Place the patient on high concentration oxygen for at least 5 minutes. The goal is to wash out nitrogen from the patient's functional residual capacity (FRC). Alternately in the non-breathing/inadaquately breathing patient this can be done with 5-7 vital capacity (as much as you can get in) breaths.

2. Prepare. BVM connected to O2. Working laryngescope, Mac and Miller blades. Tubes the size you think you need, as well as one size larger and one size smaller. Working suction, connected correctly (test this) placed under the patient's right shoulder. Rescue airways, whatever they may be (LMA, King airway, Combitube). Surgical airway equipment. A bougie if you can get one. Good IV access (preferably two), with you med doses already calculated. Make sure the MD has assessed what he's getting into/doesn't need to g a different route.

3. Premedicate. Whatever that particular physician wants. Some people use lido for head injuries, atropine for kids, ect. I'm a fan on LARGE doses of fentanyl prior to any RSI, as a blade in your throat hurts....

4. Induce and Paralyze. Again, med sequence will be MD choice, midazolam, propofol, etomidate, and ketamine are all common choices for induction agent, neuromuscular blockers comonly used are succinylcholine, roccuronium and vecuronium. All have pros and cons, many of the will do a number on BP, so watch out. Ephedine at bedside works like a charm if too much propofol or midaz tanks a B/P. DO NOT PUSH A NMBA WITH OUT SEDATION FIRST!!! Doing so is letting you patient be fully aware while paralyzed.

5. Position and Protect. Cricoid pressure should be in place when the sedatives are pushed to prevent passive regurg. Learn about external laryngeal manipulation and the BURP (Backwards Upwards Rightward Pressure) Line the external auditory canal up with the sternal notch prior to laryngoscopy attempts, it puts the head in the optimum position for visualization.

6.Placement with confirmation. Once the tube is placed, listen for breath sounds over the epigastrium FIRST. Absence of sounds there is a good thing. Look for equal chest rise and equal breath sounds. Good SP02. ETCO2 with waveform preferably, as this is the only legal way of proving placement.

7.Post-intubation management. Secure the tube with a commercial device if it's being shipped. Hopefully a vent is available, you can do a lot of damage with a BVM. SEDATE, SEDATE, SEDATE. Remember many of the induction agents wear off quickly, "10 of vec" is not sedation, rather leaves you with an aware, paralyzed patient. Versed and propofol are common, be prepared to add a little fentanyl or morphine as having a tube between you cords hurts. NG tube to prevent aspiration. Reassess tube placement after EVERY move. Be ready with pressors, as the switch to PPV can do a number on hemodynamics, not to mention the sedatives.

Not a complete rundown by any means, just the thoughts of a guy who's been at bedside for and performed himself a couple of intubations.

RN1980 · Jan 12, 2011

lord i know exactly what you are talking about. i work prn and part time at very rual er's here in mississippi. and like yours there may not be in house resp therapy and at many times may only be 2 rn's in the er with a often young md or np. you certainly have to have your stuff wired tight at all times cause there often is no back-up. i will give the same advice as the others have given. but really open up your intubation kits and crash carts and look and take stock of where things are, be familar with your surroundings. good luck.

fromtheseaRN, BSN, RN · Jan 12, 2011

This is information you should already know.

not necessarily- we were not taught anything regarding intubation in school (how to assist, equipment needed, anything), reason given is that it is advanced practice in my state.

cacentralvalley · Jan 12, 2011

This is supposed to be a safe place to post and ask questions without being ridiculed. I don't think placing such a comment (you should already know) is supportive in any way.

veetach · Jan 12, 2011

I think you have been given some excellent advice already. One of the things I see new nurses freak out over, is the order in which to give RSI meds. You do not want your patient to be paralyzed and NOT sedated!!! Talk to the doc, find out what meds he/she will want and make sure you know which one is the sedative and which one is the paralytic.

JKL33 · Jan 12, 2011

If you haven't recently, I would recommend that you make arrangements to do a practice run at your workplace. Get your supervisor or another experienced nurse to go through ALL the motions with you....get out the appropriate equipment, review and walk-through the typical sequence of events, discuss your questions. Know where everything (every single thing) is. Review any applicable policies your institution has. Make note of the medications commonly used at your facility, and read up on them.

I agree you have received some excellent advice and tips here. I think, though, that you may feel at least a bit more comfortable if you walk through this at your workplace so that you can 'see' yourself doing what you'll need to do when the day comes. Even if this was part of your orientation, I think it's not a bad idea to re-familiarize yourself by doing it every so often so that it stays fairly fresh in your mind.

Best wishes ~