- Longer EMS transport distances or an inability to adequately ventilate a patient with a bag valve mask requires a more advanced airway.
- An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate respiratory effort.
- Prepare position and oxygenate the patient with 100% Oxygen.
- Select proper endotracheal tube (ETT) (and stylet, if used), have suction ready.
- Utilize endotracheal tube introducer (Bougie®) according to Airway: Endotracheal Tube Introducer (Bougie®) Procedure.
- Using laryngoscope, visualize vocal cords (use Sellick maneuver/BURP to assist).
- Limit each intubation attempt to 30 seconds with bag valve mask between attempts.
- Visualize tube passing through vocal cords.
- Confirm and document tube placement using end-tidal CO2 monitoring or an esophageal bulb device.
- Inflate the cuff with 3-to10 mL of air; secure the tube to the patient’s face.
- Auscultate for bilaterally equal breath sounds and absence of sounds over the epigastrium. If you are unsure of placement, remove tube and ventilate patient with bag valve mask.
- Apply waveform capnography monitor. After 3 ventilations, EtCO2 should be greater than 10 or comparable to pre-intubation values. If less than 10, check for adequate circulation, equipment, and ventilatory rate. If EtCO2 is still less than 10 without physiologic explanation, remove the ETT and ventilate by bag valve mask.
- Consider using a blind insertion airway device if intubation efforts are unsuccessful.
- Apply end tidal carbon dioxide monitor (waveform capnography) and record readings on scene, en route to the hospital, and at the hospital.
- Document ETT size, time, result (success), and placement location by the centimeter marks at either the patient’s teeth or lips on/with the patient care report (PCR). Document all devices used to confirm initial tube placement. In addition, document positive or negative breath sounds before and after each movement of the patient.
- It is required that the airway be monitored continuously through waveform capnography and pulse oximetry.