Mx of the newly intubated patient in ED - post-intubation

immediate tasks

  • initial confirmation of successful intubation of the trachea
    • end-tidal CO2 (EtCO2) determination (either colorimetric or quantitative) is the most accurate means of confirming ETT placement in most circumstances and should be used for every intubation
      • EtCO2 methods may not be useful in patients in cardiac arrest if CO2 is not detected
    • traditional clinical indicators as below cannot be relied upon alone:
      • visualization of the ETT through the cords
      • misting of the tube with ventilation
      • auscultation of breath sounds over the lung fields
    • check that ETT has not been inserted too far and has gone into R main bronchus:
      • most adults should have a lip level of ~21cm
      • check for breath sounds on L chest
      • CXR confirmation once NGT has been placed
  • inflate ETT cuff
  • check cuff pressure and ensure no air leak
  • ventilate patient
    • initially via bag unless ventilator has been set up prior
  • secure tube
  • commence ongoing sedation infusion
  • consider longer acting muscle relaxant
  • CXR to confirm ETT depth, NGT position and evidence of pneumothorax or aspiration
  • blood gases to confirm adequate ventilation

hypotension post-intubation


  • persisting hypotension from induction agents
  • hypotensive effect of sedative infusion
    • consider changing from propofol to morphine/midazolam
    • paralysis is often followed by a period of hypotension, consider iv fluid bolus +/- metaraminol (Aramine)
  • reduced venous return from mechanical ventilation
    • check airway pressures and PEEP
    • patients with obstructive airways disease such as asthma need prolonged expiratory phase and slow respiratory rate to avoid excessive pressures do not cause impaired venous return and asystole
  • tension pneumothorax due to mechanical ventilation
  • reduced venous return from intra-abdominal gas due to BVM ventilation or ETT cuff failure
    • ensure NGT is placed, draining and correctly position in stomach
    • re-check ETT cuff for air leak
  • underlying hypovolaemia
    • give iv fluids, or if blood loss, give blood transfusion
  • cardiac ischaemia
  • depletion of endogenous catecholamines in the critically ill patient
  • could it be due to underlying disease process causing the shocked hypotensive patient

declining oxygen saturation

  • re-check ETT placement
    • check EtCO2 trace and level
  • re-check ETT depth
  • re-check ETT cuff air leak
  • abrupt changes in the airway pressure in a patient receiving volume limited ventilation, or in tidal volumes in a patient receiving pressure limited ventilation, should prompt an immediate search for a cause of an acute change in compliance
    • is the endotracheal tube obstructed
      • suction it
    • is there a tension pneumothorax caused by mechanical ventilation
    • is there a tense air-filled abdomen splinting the chest
      • ensure NGT position, draining and no air leaks from ETT cuff
    • is patient fighting against ventilation
      • ensure adequate sedation +/- paralysis
  • when in doubt, take patient off ventilator and hand ventilate with bag to better assess situation
  • those with bronchospasm need this treated

Mx of the ventilated patient

  • ongoing sedation infusion
    • eg. morphine/midazolam infusion or propofol infusion
  • consider longer acting muscle relaxant
    • neuro-muscular blockers such as bolus dose vecuronium 10mg for adults
    • consider particularly prior to inter-hospital transfer
  • lung protective ventilator settings
  • head up 30-45°
  • warmed humidified air (HME filter)
  • suction including mouth
    • at least hourly
  • stress ulcer prevention
  • DVT prophylaxis
  • treat underlying illness
    • eg. nebulisers if asthma/exacerbation COPD
post-intubation.txt · Last modified: 2016/03/28 09:14 (external edit)