Page 40 - PJ MED OPS Handbook 8th Ed

b. Check light on laryngoscope.
c. Ensure availability of suction.
3. Lubricate distal end of tube with water soluble lubricant (viscous lidocaine can be used).
4. Stop pre-oxygenation.
a. Make an attempt less than 30 seconds, if failed, remove laryngoscope and ventilate the pa-
tient for 1 minute. Repeat attempt to visualize cords unless there is obvious severe edema, or
excess blood or secretions that cannot be suctioned.
b. Make no more than 2 attempts before reverting to maintain BVM, placing SGA or performing
surgical airway. Avoid prolonged attempts. If you cannot visualize the vocal cords immedi-
ately, come back out of the airway, bag the patient to re-oxygenate and attempt again.
c. When cords are visualized, advance the ETT cuffed balloon beyond cords. Inflate cuff and
ventilate. If using bougie, place bougie first with visual confirmation of passing the vocal
cords, and tactile feedback of feeling the tracheal rings.
5. Confirm proper tube placement:
a. Auscultate over stomach and both lung fields.
b. Attach capnometer and document CO2 reading.
c. If proper tube placement can’t be confirmed, reposition or remove tube as necessary.
d. Secure tube once proper placement confirmed.
e. Reconfirm position of tube by auscultation and capnometry every time the patient is moved
Also monitor pulse oximetry. If patient begins to desaturate, check tube for DOPE: Displace-
ment; Obstruction (blood, mucus); Pneumothorax; Equipment (disconnection, power failure,
etc.).

PJ PEARLS:
When performing intubation use the following 4 steps:
1. Scissor the mouth open by applying pressure to the molars via the thumb and middle
finger.
2. Put the laryngoscope blade on the right side of the patient’s mouth and sweep the tongue
to the left as you go.
3. Progressive visualization of structures: Insert just the tip of the blade first and incremen-
tally place it forward until you see the tip of the epiglottis. Then place the blade in front of
the epiglottis (in the vallecula) so it stays on the tongue. Continue to slowly advance (and
lift up) it so you next see the arytenoid cartilages, the “knuckles” in back of the airway, and
then the entire airway (the upside down “V”, the V being the pale vocal cords.
4. Pass the tube under direct visualization of it going through the vocal cords.

NOTE: If you only see a portion of the airway, insert the bougie, feel the tracheal cartilages,
pass an ET tube over the bougie to the appropriate depth and withdraw the bougie.

38 n Pararescue Medical Operations Handbook / 8th Edition