Intubation Essentials

“Before he could respond, George was called away to assist with an emergency endotracheal intubation because he was stronger than the other nurses and they needed help restraining a combative patient intoxicated on an unknown cocktail of pharmacologic agents.

After an injection of a muscle relaxant, they forced a tube down the patient’s windpipe, and they monitored him closely because an overdose could lead to respiratory paralysis and asphyxiation.”

This text was sent recently, with a request to comment, which suggested a need to better explain endotracheal intubation.

First, the term,

  • endo = in
  • trachea = windpipe
  • intubate = insert a tube into the airway (or really other orifices (orifi?) like a urethra, but we won’t go there…)

Second, why would we want to do such a thing?  There are two main reasons, (1) the patient cannot breathe for themselves and we need to put them on a ventilator – this could be from something going wrong in their head (trauma, stroke, drugs), or intentional (general anesthesia for surgery) or (2) to protect a patient’s airway, for example a stroke patient whose gag reflex is impaired. Without airway protection, stomach contents might end up in their lungs.

Third, how is this accomplished? If you’ve ever had something “go down the wrong pipe,” you know we don’t willingly let a tube go through our vocal cords and into our windpipe. The gag reflex is there for a reason, and generally pretty effective. If the patient is already unconscious, often we can proceed with little or no medication, but for the majority, we first almost always have an IV, then we give at least two drugs: one to put the brain to sleep (propofol, pentothal=thiopental, ketamine, others) then a second drug to paralyze the muscles so the vocal cords don’t slam shut when we touch them (succinylcholine or any of a number of “non-depolarizing muscle relaxants”). The downside of these drugs? The patient will definitely stop breathing, so if we can’t breathe for them for some reason…you get the picture.

Within a minute or two, we can easily open the patient’s mouth, insert a laryngoscope (metal blade pictured below), lift the patient’s lower jaw to allow direct visualization of their vocal cords (upside-down ‘V’ in image on right),

and slip in a breathing tube.  (Image from Anesthesia Key https://aneskey.com)

In reference to the text above, we don’t do this on a combative patient, until they’ve become non-combative, with medications. So the nurse might hold the patient down for IV placement, or for an intramuscular injection of a sedative, but not for the intubation itself.

Though “emergency endotracheal intubation” is not wrong, it’s not what we say.  Just “emergency intubation” will do, or “They need to intubate.”

We don’t give the muscle relaxant until the patient is asleep, otherwise they’re awake and paralyzed – not much more terrifying in my imagination. And we don’t “force” a tube into an airway.

Lastly, we don’t then monitor for respiratory paralysis and asphyxiation at this point. He’s already intubated and will be placed on a ventilator. We CAUSED respiratory paralysis with our muscle relaxant – though it is likely short-lived. And he can’t asphyxiate unless we really screw up – turn off the ventilator, override all the safety mechanisms and figure out a way to hook up something other than oxygen, etc.

So if you want a character to be intubated, or to perform an intubation, these are the steps. You can learn much from the internet, but I’m also happy to read it over…

 

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