Preparation The clinician should have all the necessary equipment, using the mnemonic STOP IC BARS = Suction; is turned on and is close proximity to the patients head and the rigid suction catheter has been checked by the thumb port. Tubes; of all sizes is checked with a half or full size smaller and a syringe attached to the pilot line. Oxygen; a cylinder is available that is attached to a high flow O2 reservoir bag (BVM). Pharmacology; all drugs needed for RSI, pain and sedation must be drawn up and labelled. IV; intravenous access must be established with 18G or larger and preload the patient with 5-20ml/kg of fluid to migrate the offset that the RSI drugs does to the blood pressure. Connect monitors and confirmation; such as ECG, blood pressure and pulse oximeter. Confirmation devices such as capnography and EDD. Blades, should be checked for light intensity. The clinician should also make sure that there is a Macintosh blade (size 3 and size 4) and a straight blade. A bougie must also be easily accessible during all intubation attempts. An alternate devices; this includes Airtraq and LMA fastrach. Rescue oxygenation; such as LMA and I-Gel must be within reach for incase of failed intubation attempts. Surgical cricothyrotomy for cases of failed ventilation and failed intubation scenario. Secondly, it is essential that the clinician assembles adequate personnel in the roles that they are going to participate in to assist during the process. Preoxygenation Begins with the initiation of 100% in order to de-nitrogenate the function residual capacity over 3-5 minutes with a tight-fitting facemask. BVM with positive pressure ventilation must be avoided during preoxygenation unless patients become apneic or there is ineffective spontaneous breathing because there is a risk of gastric insufflation or regurgitation. Pre-intubation optimization Drugs such as fentanyl and atropine help to mitigate the negative physiological responses to intubation. Atropine is given to infants or pediatric patients who have significant bradycardia if succinylcholine is given. Fentanyl are given to patients who have went through a recent trauma for pain or who may have a sympathetic response to the ETT tube during intubation. Paralysis and induction As an induction agent such as a potent sedative-hypnotic (etomidate) or a dissociative amnestic (ketamine) in order to induce unconsciousness. This is weight- dose based as it minimizes the side effect profile and helps to prevent exacerbating the patients underlying condition. A paralyzing agent such as succinylcholine or rocuronium can be given; however with succinylcholine it has a rapid onset and the patient can resume spontaneous ventilation if there is a failed airway situation. Positioning Placing the patient head and neck in the right position is important because this helps to achieve the best view for the glottis opening. In addition this must be done when there are no C-spine precautions. The neck must be flexed at the lower cervical spine and extended at the upper cervical spine (C1-C2); known as the sniffing position. Placement with proof A best look for intubation is done; it is important that an assistant gives the clinician the ETT correctly so that the cords are always seen to prevent time delay during the procedure. To proof that tube placement is secured is done by objective (End tidal CO2) and subjectively by auscultation; to ensure it does not sit within the right mid-stem bronchi. Post-intubation Management Obtain a post-induction vital signs early with 2.5 minute intervals to avoid critical cardiovascular complications such as cerebral stroke, angina, and myocardial infarction. It is essential that the practioner initiates positive pressure ventilation to assess lung compliance but also not to hyperventilate as this may induce barotrauma, hypotension and lead to breathe stacking especially in conditions such as bronchospasm and COPD.
