Endotracheal Intubation & ER Board Exam Questions

Prepared by: JO-ANNE KAREN SERDENA BSN-34TH

Definition
Endotracheal intubation is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in patients who are unconscious or unable to breathe on their own. Oxygen, anesthetics, or other gaseous medications can be delivered through the tube.

Purpose
Specifically, endotracheal intubation is used for the following conditions: respiratory arrest respiratory failure airway obstruction need for prolonged ventilatory support Class III or IV hemorrhage with poor perfusion severe flail chest or pulmonary contusion multiple trauma, head injury and abnormal mental status inhalation injury with erythema/edema of the vocal cords protection from aspiration

CONTRAINDICATIONS: 1.AWAKE PATIENT. 2. AIRWAY CAN BE MANAGED LESS INVASIVELY. EQUIPMENTS: 1. IV ACCESS, EKG, PULSE OX MONITORS. 2. SUCTION APPARATUS. 3. OROPHARYNGEAL, NASOPHARYNGEAL AIRWAYS. 4. NON- REBREATHER MASK. 5. OXYGEN. 6. BAG VALVE MASK. 7. APPROPRIATE SIZE ENDOTRACHEAL TUBE (7.5 MM ADULT, CHILD = DIAMETER OF LITTLE FINGER); WITH STYLET AND 10CC SYRINGE. 8. LARYNGOSCOPE BLADE AND HANDLE (APPROPRIATE SIZE). 9. TAPE.

Endotracheal tube and laryngoscope sizes:

Age:
Tube size: Blade size: Preemie Neonate 6 mo. 2.5 3-3.5 3.5-4 1-2 yr. 4-5 4-6 yr. 5-5.5 8-12 yr. 6-7 Adult 7.5-8.5

0-1

1-2

2-3

4-5

Preparation
For endotracheal intubation, the patient is placed on the operating table lying on the back with a pillow under the head. The anesthesiologist wears gloves, a gown and goggles. General anesthesia is administered to the patient before starting intubation. Confirm that intubation equipment is functional. Assess the patient for difficult airway (see Difficult Airway Assessment section below for recommended method). If the patient meets criteria for difficult airway, rapid sequence intubation (RSI) may be inappropriate. Nonparalysis procedures may be an alternative. Establish intravenous access.

 Draw up essential drugs and determine sequence of administration (induction agent immediately followed by paralytic agent). Review possible contraindications to medications. Attach necessary monitoring equipment. Check endotracheal (ET) tube cuff for leak. Ensure functioning light bulb on laryngoscope blade.

Preoxygenation Administer 100% oxygen via a nonrebreather mask for 3 minutes for nitrogen washout. This is done without positive pressure ventilation using a tight seal. Though rarely possible in the emergent situation, the patient can take 8 vital capacity (as deep as possible) breaths of 100% oxygen. Studies have shown this can prevent apnea-induced desaturation for 3-5 minutes.[36] Assist ventilation with bag-valve-mask (BVM) system only if needed to obtain oxygen saturation 90%. Pretreatment Consider administration of drugs to mitigate the adverse effects associated with intubation. See Anesthesia for more information.

Paralysis with induction Administer a rapidly-acting induction agent to produce loss of consciousness. Administer a neuromuscular blocking agent immediately after the induction agent. These medications should be administered as an intravenous push.

Positioning
In cases of trauma in which cervical spine injury is suspected and not yet ruled out, intubation must be performed without movement of the head. Immobilization is best provided by an experienced assistant. In cases in which cervical injury is not a concern, proper head positioning greatly improves visualization.

In the neutral position, the oral, pharyngeal, and laryngeal axes are not aligned to permit adequate visualization of the glottic opening (see image below). Proper alignment of the axes for tracheal intubation.

 Proper alignment of the axes for tracheal intubation. Place the patient in the sniffing position for adequate visualization; flex the neck and extend the head. This position helps to align the axes and facilitates visualization of the glottic opening. Recent studies have shown that simple head extension alone (without neck flexion) was as effective as the sniffing position in facilitating endotracheal intubation.[35] Aspiration

Procedure:
Assess airway note landmarks, swelling, deformities. Remove dentures. Assess tongue size, dental obstruction, visibility of oropharynx, degree of neck mobility. - Maintain cervical spine stability as necessary. Open airway: suction or manually extract foreign material. Chin lift, jaw thrust. Heimlich maneuver as needed. Use artificial airways if needed: oropharyngeal, nasopharyngeal. (See Figure 1)

 Preoxygenate with 100% non-rebreather or bag-valvemask. Keep pulse ox greater than 95% at all times. Position patient into sniffing position if possible; restrain as necessary. Standing at the supine patients head, gentle insert laryngoscope blade with left hand. Use suction as necessary with right hand. (See Figure 2) Visualize glottic opening/vocal cords. Advance ETT with right hand through cords. (See Figure 3) Remove stylet. Inflate ETT cuff with 5 10 cc air via syringe. Ventilate with bag and oxygen. Confirm tube placement with chest auscultation, CO2 monitor and chest x-ray.

Secure tube with tape.

 To begin the procedure, an anesthesiologist opens the patient's mouth by separating the lips and pulling on the upper jaw with the index finger. Holding a laryngoscope in the left hand, he or she inserts it into the mouth of the patient with the blade directed to the right tonsil. Once the right tonsil is reached, the laryngoscope is swept to the midline, keeping the tongue on the left to bring the epiglottis into view. The laryngoscope blade is then advanced until it reaches the angle between the base of the tongue and the epiglottis. Next, the laryngoscope is lifted upwards towards the chest and away from the nose to bring the vocal cords into view. Often an assistant has to press on the trachea to provide a direct view of the larynx. The anesthesiologist then takes the endotracheal tube, made of flexible plastic, in the right hand and starts inserting it through the mouth opening. The tube is inserted through the cords to the point that the cuff rests just below the cords. Finally, the cuff is inflated to provide a minimal leak when the bag is squeezed. Using a stethoscope , the anesthesiologist listens for breathing sounds to ensure correct placement of the tube.

Placement with proof

Visualize the ET tube passing through the vocal cords. Confirm tube placement.
Observe color change on a qualitative endtidal carbon dioxide device. Use the 5-point auscultation method: Listen over each lateral lung field, the left axilla, and the left supraclavicular region for good breath sounds. No air movement should occur over the stomach.

Two pilot studies have shown that ultrasonography can reliably detect passage of a tracheal tube into either the trachea or esophagus without inadvertent ventilation of the stomach.

Postintubation management Secure the ET tube into place. Initiate mechanical ventilation. Obtain a chest radiograph.
Assess pulmonary status. Note this modality does not confirm placement; rather, it assesses the height above the carina. Ensure that mainstem intubation has not occurred.

Administer appropriate analgesic and sedative agents for patient comfort, to decrease O2 demand, and to decrease ICP.

Complications
Esophageal intubation Iatrogenic induction of an obstructive airway Right mainstem intubation Pneumothorax Dental trauma Postintubation pneumonia Vocal cord avulsion Failure to intubate Hypotension

ER Board Exam Questions

1.The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10-year-old with lacerations of the face B. A 15-year-old with sternal bruises C. A 34-year-old with a fractured femur D. A 50-year-old with dislocation of the elbow

 Answer B is correct. The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10-year-old with lacerations might look bad but is not in distress. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well.

2. The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A.You will need to lay flat during the exam. B. You need to empty your bladder before the procedure. C.You will be asleep during the procedure. D.The doctor will inject a medication to treat your illness during the procedure.

 Answer B is correct. The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances).

3.A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct? A.Use a magnet to remove the object. B.Rinse the eye thoroughly with saline. C.Cover both eyes with paper cups. D.Patch the affected eye only.

 Answer C is correct. Covering both eyes prevents consensual movement of the affected eye. The nurse should not attempt to remove the object from the eye because this might cause trauma, as stated in answer A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also does.

4.The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A.Peaked P wave B.Elevated ST segment C.Inverted T wave D.Prolonged QT interval

 Answer D is correct. Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine.

 5. Which clients can be assigned to share a room in the emergency department during the disaster? A.The schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis B.The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

 Answer B is correct. Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The clients in answer A need to be placed in separate rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents.

Thank You!