Emergency Oral Endotracheal Intubation
Oral endotracheal intubation is a procedure that utilizes an instrument called a laryngoscope to visualize the opening of the trachea directly in order to pass a plastic breathing tube through the mouth and into the trachea. Rapid sequence intubation (RSI) is a procedure whereby medications are administered to sedate and paralyze a patient to allow a medical professional to perform oral endotracheal intubation more easily. These medications remove the patient’s reflex to gag when an object is placed at the back of the mouth as well as paralyze the muscles in the body. This allows the mouth and neck to move more easily, improving visualization during the procedure.
Preoxygenation of a patient is used to provide additional oxygen in a patient’s lungs prior to and in-between intubation attempts. Preoxygenating allows the patient to maintain oxygen saturation (SaO2) greater than or equal to 90% for a longer period of time during an intubation attempt. Preoxygenation often involves ventilating the patient with a BVM in order to restore their SaO2 to near-100%. This process typically takes 1–2 minutes to accomplish. If an intubation attempt is unsuccessful, the patient is typically ventilated prior to a subsequent attempt. Absent a countervailing reason, an intubation attempt should be completed before a patient’s SaO2 drops below 90%.
The required standard of care is to attempt intubation no more than three times before utilizing another airway device, for example, a COMBITUBE. Prehospital airway management has been extensively studied. With each subsequent attempt at oral endotracheal intubation, it is less likely that the specific attempt will be successful. The use of a different device/technique is recommended after either the second attempt or the third attempt, depending on the study.
Endotracheal intubation medical expert witness specialties include otolaryngology, emergency medicine, head and neck surgery, pediatric otolaryngology, critical care medicine, and pediatric critical care medicine.