Advanced_Intubation_for_Residents and learners.

intubation

1. Advanced Intubation for Residents High-yield overview for emergency and critical care clinicians

2. Learning Objectives • Review key principles of rapid sequence intubation (RSI) • Recognize predictors of a difficult airway • Master techniques and optimization strategies • Understand pharmacologic options and dosing • Apply troubleshooting and rescue methods effectively

3. Preparation & Setup • Perform airway assessment: Mallampati, neck mobility, jaw opening • Assemble equipment: laryngoscope (video/direct), ETT, stylet, bougie, suction • Confirm suction and oxygen source working • Ensure backup plan: LMA, cricothyrotomy kit, second operator

4. Preoxygenation • Goal: prolong safe apnea time (denitrogenation) • Use 100% O₂ via nonrebreather or BVM with PEEP valve • For critically ill: consider NIV or HFNC (15 L/min+) • Apneic oxygenation: nasal cannula 15 L/min during attempt

5. Induction Agents • Etomidate: 0.3 mg/kg (hemodynamically stable, minimal BP drop) • Ketamine: 1–2 mg/kg (bronchodilator, supports BP, ↑ secretions) • Propofol: 1–2 mg/kg (reduces BP, use cautiously in shock) • Midazolam: slower onset, not preferred for RSI

6. Paralytic Agents • Succinylcholine: 1–1.5 mg/kg (onset 45s, duration 5–10 min) • Rocuronium: 1.0–1.2 mg/kg (onset 45–60s, duration 30–60 min) • Succinylcholine contraindications: hyperkalemia, burns, paralysis, neuromuscular disease • Rocuronium preferred for most ICU/ED intubations

7. Optimization During Intubation • Position: ear-to-sternal notch, sniffing position if no c-spine injury • Apply external laryngeal manipulation (BURP) if poor view • Limit attempts to <30 seconds • Confirm visualizing cords before passing tube • If difficulty: switch technique early (VL → DL or vice versa)

8. Troubleshooting Failed First Pass • Reoxygenate between attempts (BVM with PEEP or HFNC) • Reassess position, blade size, suction, and secretions • Use bougie: tactile clicks and hold-up sign confirm tracheal entry • Change operator or device if repeated difficulty

9. Rescue & Difficult Airway • If cannot intubate but can ventilate → use supraglottic airway (LMA, i-gel) • If cannot ventilate nor intubate → perform surgical airway (cricothyrotomy) • Have a clear 'Plan B' before first attempt • Early call for anesthesia or ENT if complex anatomy

10. Confirmation & Post-Intubation • Primary confirmation: end-tidal CO₂ waveform • Secondary: chest rise, bilateral breath sounds, no gastric sounds • Secure tube at 22–24 cm (men), 20–22 cm (women) • Post-intubation sedation: propofol, midazolam, fentanyl infusion

11. Common Complications • Desaturation (most common) → preoxygenate, limit apnea • Hypotension → consider fluid bolus, push-dose pressors • Esophageal or right mainstem intubation → always confirm ETCO₂ • Aspiration, dental trauma, airway swelling

12. Key Takeaways • Preparation and anticipation are the foundation of success • Prioritize oxygenation over speed or first-pass success • Choose agents based on hemodynamic profile • Always have a backup airway plan and equipment ready • Practice improves speed, safety, and confidence