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4.assignment On Endo Tube

This document outlines the procedure for endotracheal intubation by an Advanced Health Practitioner. It defines endotracheal intubation and its purposes. It describes the necessary materials, patient preparation, steps to perform the procedure, assessment of proper placement, follow up care, documentation, and requirements to achieve initial competency. The Advanced Health Practitioner must demonstrate understanding, observe the attending physician perform it 10 times, and then perform it 10 times under direct supervision before being signed off.

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santosh kumar
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47 views

4.assignment On Endo Tube

This document outlines the procedure for endotracheal intubation by an Advanced Health Practitioner. It defines endotracheal intubation and its purposes. It describes the necessary materials, patient preparation, steps to perform the procedure, assessment of proper placement, follow up care, documentation, and requirements to achieve initial competency. The Advanced Health Practitioner must demonstrate understanding, observe the attending physician perform it 10 times, and then perform it 10 times under direct supervision before being signed off.

Uploaded by

santosh kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ENDOTRACHEAL INTUBATION

Definition:
This protocol covers the task of endotracheal intubation placement by an Advanced Health
Practitioner. The purpose of this standardized procedure is to allow the Advanced Health
Practitioner to safely place an endotracheal tube when needed. An endotracheal tube may be
needed in routine (preoperative placement, non-urgent placement and urgent case scenarios.

II. Background Information

A. Setting - The setting (inpatient vs outpatient) and population (adults vs pediatrics) for
the Advanced Health Practitioner (AHP) is determined by the approval of the privileges
requested on the AHP Privilege Request Form. This particular procedure is for adults
only.
B. Supervision - The necessity of the procedure will be determined by the Advanced
Health Practitioner in verbal collaboration with the attending physician. The attending
physician is the supervising physician for this procedure. Direct supervision will not be
necessary once competency is determined, as provided for in the procedure. At that time,
general or indirect supervision is acceptable. The Advanced Health Practitioner will
notify the physician immediately upon being involved in any emergency or resuscitative
events or under the following circumstances:
1. Patient decompensation or intolerance to the procedure
2. Bleeding that is not resolved
3. Outcome of the procedure other than expected
C. Indications
Endotracheal intubation may be indicated but not limited to maintaining a patent airway,
facilitating oxygenation and ventilation, reducing the risk of aspiration, and assisting in
the removal of secretions.
D. Precautions/contraindications:
Practitioners performing intubation should be able to rescue patients whose airway is
difficult to intubate. Proper cardiovascular monitoring as well as provisions for managing
difficult airways must be in place. Patients with a history of or anticipated difficult
endotracheal intubation or patients with significant respiratory or hemodynamic
instability will be intubated in collaboration with an anesthesiologist.

III. Materials STANDARDIZED PROCEDURE

ENDOTRACHEALINTUBATIOIN (Adults) The following materials may be used during


endotracheal tube placement-

1. Laryngoscope blades, typically starting with Mac 3


2. Laryngoscope handle, checked for sufficient battery power
3. Proper size cuffed endotracheal tube with 10ml syringe and stylet
4. Jackson Reese resuscitation circuit
5. Ambubag
6. Proper size face mask
7. Proper size nasopharynge
8. Proper size oral airway al airway
9. End tidal CO2
10. Oral suction apparatus
11. Stethoscope
12. Appropriate hemodynamic and oxygen saturation monitoring equipment
13. IV access
14. Supplemental oxygen
15. Appropriate sedating, vasoactive, and reversal agents
16. Appropriate ETT securing device / materials IV.

Procedure-
A. Pre-treatment evaluation: Assess clinical necessity for intubation. If informed
consent is indicated this must be granted before sedation begins. A directed history
and physical should be performed that includes:-
1. Relevant history of acute and chronic diseases
2. Clarification of code status
3. History of prior intubation
4. Physical exam with attention to anatomical defects of the airway and evidence of
respiratory compromise
5. Current medications and allergies
6. Time of last oral intake
7. Assess airway using Mallampati classification, extent of mouth opening,
thyromental distance, palate width, and neck mobility

B. Set up- Gather all necessary materials and notify Respiratory Therapist to set up
ventilator
C. Patient preparation-

1. Explain procedure to patient and acquire consent unless emergency


2. Explain procedure to family members if they are present
3. Assess for sufficient IV access and attachment appropriate cardiovascular and
respiratory monitoring equipment
4. Position patient in sniffing position. Use blankets as ramps if patient requires
additional aligning of oral, pharyngeal, and laryngeal axes.
D. Performing the procedure:

STANDARDIZED PROCEDURE ENDOTRACHEALINTUBATIOIN (Adults)

1. Wash hands and don personal protective equipment.


2. Check equipment and check endotracheal cuff for leaks.
3. Insert stylet into endotracheal tube.
4. Attach blade to battery base and assess light function. Have backup blades of different
type and sizes available.
5. Preoxygenate with 100% O2 using ambubag or Jackson-Reese circuit for 3- 5 minutes to
wash out residual nitrogen gas.
6. If necessary administer appropriate sedatives or opioids.
7. Have an assistant apply cricoid pressure.
8. Assess for ability to mask ventilate.
9. If appropriate administer appropriate neuromuscular blockade and assess for clinical
effect.
10. Grasp the laryngoscope in the left hand.
11. Open the patients’ mouth with the cross finger technique e laryngoscope in the left hand.
12. Slowly insert the blade into the right side of the patient’s mouth using it to push the
tongue to the left. Advance the blade inward and midline toward the base of the tongue.
13. The tip of the curved blade should be placed in front of the epiglottis in the valecula. The
tip of the straight blade should be placed under the epiglottis. Apply pressure caudally
and upward with the handle at a 45 degree angle to the bed.
14. Lift the handle until the vocal cords are visualized ensuring that the blade or handle is not
levered against the incisors.
15. Grasp the ETT tube with stylet inserted in the right hand.
16. Gently insert the ETT along the right side of the mouth under direct visualization of the
vocal cords until the cuff is no longer visible.
17. Firmly hold the ETT in place, withdraw the blade, remove the stylet, and inflate the ETT
cuff with 5-10ml of air.
18. Attach end tidal CO2 monitor and Jackson-Reese circuit to the ETT and give positive
pressure breaths.
19. Assess for proper placement of ETT by end tidal CO2 waveform, fogging in ETT,
bilateral breath sounds, symmetric chest movement, and absence of breath sounds over
the epigastrum, as well as return to baseline vital signs.
20. If assessment indicates that the ETT is not placed in the trachea, deflate the cuff and
remove the ETT. Resume mask ventilation with 100% O2. Consult with ICU fellow or
anesthesia staff on strategy to reattempt intubation.
21. If breath sounds are absent on the left, deflate the cuff and withdraw the ETT 1-2cm and
evaluate for correct placement.
22. Palpate the suprasternal notch feeling for the ETT cuff.
23. Attach the secure the ETT with tape or appropriate device.
24. Attach the ETT to the mechanical ventilator.
25. Order and review STAT portable CXR to evaluate the location of the tip of the ETT.
26. Order and review arterial blood gas 30 minutes post intubation.

STANDARDIZED PROCEDURE ENDOTRACHEAL INTUBATIOIN (Adults)

Follow-up treatment
1. Order and review STAT portable CXR to evaluate the location of the tip of the ETT.
2. . Order and review arterial blood gas 30 minutes post intubation.
A. Documentation is in the electronic medical record
1. Documentation of the pretreatment evaluation and any abnormal physical findings

2 Record the time out, indication for the procedure, procedure, type and size of tube
used, method used, EBL, the outcome, how the patient tolerated the procedure,
medications (drug, dose, route, & time) given, complications, and the plan in the
note. Clinical events may also require an event or progress note. The patients’
primary service should be notified of the intubation if they are not already aware

B. All abnormal or unexpected findings are reviewed with the supervising


physician. VI. Competency Assessment A. Initial Competence

1. The Advanced Health Practitioner will be instructed on the efficacy and the
indications of this therapy and demonstrate understanding of such.
2. . The Advanced Health Practitioner will demonstrate knowledge of the following:
a. Medical indication and contraindications of endotracheal intubation b. Risks
and benefits of the procedure c. Related anatomy and physiology d. Consent
process (if applicable) e. Steps in performing the procedure f. Documentation of
the procedure g. Ability to interpret results and implications in management.
3. . Advanced Health Practitioner will observe the supervising (attending) physician
perform each procedure a minimum of ten times in its entirety.
4. . The Advanced Health Practitioner will perform the procedure a minimum of ten
times under direct supervision of the supervising (attending) physician.

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