ANESTHETIC AGENTS

A number of diverse drugs are routinely used in the ED to induce anesthesia prior to intubation. These include thiopental, methohexital, ketamine, etomidate, and propofol. Midazolam and fentanyl may also be used; these two agents are more commonly used at low doses as conscious sedation agents (see Analgesia and Sedation). The choice of a particular anesthetic agent depends to a great extent on the experience and training of the...

CHANGING TRACHEAL TUBES

The tracheal tube with a leaking cuff is a vexing problem, especially if the original intubation was difficult. A method of replacing the tube without losing control of the tracheal lumen is preferred. This can be achieved by passing a guide down the defective tube, withdrawing the tube while leaving the guide in place, and introducing a new tube over the guide and into the trachea.A number of different guides have been described...

GUIDED INTUBATION TECHNIQUES

Digital IntubationDigital intubation is a technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx. It is particularly well adapted to the out-of-hospital situation in which a trapped victim cannot be positioned for intubation. An out-of-hospital series of 66 digitally intubated patients demonstrated an 89% success rate.Indications and ContraindicationsDigital intubation is indicated...

NASOTRACHEAL INTUBATION

Nasotracheal intubation was first described by Magill in the 1920s and the basic technique has changed little over the years. Modifications have been described that increase the success rate and limit complications. The tube may be placed blindly or with the aid of a laryngoscope or bronchoscope. Blind nasotracheal intubation can be one of the more technically demanding airway approaches, with the outcome being heavily dependent...

MODIFIED OROTRACHEAL INTUBATION

Intubation with an Intermediate Airway in PlaceEsophageal Obturator/Gastric Tube Airway in PlaceThe unconscious patient who requires ventilatory assistance may benefit from the temporary use of the esophageal obturator airway (EOA) or similar device. Although this may be an effective means of ventilation, it is at best a temporary measure. The patient experiencing upper airway hemorrhage with the EOA in place may have oropharyngeal...

OROTRACHEAL INTUBATION

Indications and ContraindicationsAny clinical situation in which a definitive airway is necessary and limited neck motion is permissible is an indication for orotracheal intubation. Many of these situations, including cardiac arrest, airway compromise in infection and trauma, and airway obstruction are discussed in detail in Chapter 1 . Most orotracheal intubations are accomplished using a direct laryngoscope. An unstable cervical...