# Elective Endotracheal Intubation

## Overview

This module describes the elective endotracheal intubation of patients without risk factors for aspiration, where techniques minimising time between induction and intubation are less critical than in Rapid Sequence Induction.

## Indications

Fasted patients with no risk factors for aspiration requiring:

## Contraindications

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to give you medication to make you sleep for a procedure. I have to protect your airway while you are asleep, so I will put a tube down your throat, through which I will give you oxygen for breathing.”

### What can my patient expect?

“You will be asleep, so you will not feel anything when I insert the tube. Your throat may feel a bit dry or sore and you may have a hoarse voice when you wake up. This should go away quickly.”

### What is my patient’s role?

“It’s very important that you tell me honestly when last you ate, and whether you have used any recreational drugs. Tell me if you have allergies or any medical conditions. Try to stay relaxed as I give you the medication putting you to sleep.”

## Preparation

This procedure requires an assistant, and:

A difficult airway trolley should also be available with supraglottic airways (LMA).

## Site & Positioning

The patient should be in the “sniffing” position, with the ear aligned to the sternal notch. This may require building a ramp with pillows and blankets to raise the patient’s head.

## Procedure

Use medical asepsis with non-sterile gloves. Wear N95 masks as for aerosol-generating procedures.

## Troubleshooting

I can’t visualise the cords.

Always re-oxygenate the patient between attempts, providing breaths with the BVMR/ventilator. Call for a senior. If not able to oxygenate, consider a supraglottic airway.

To optimise visualisation, position the patient with ear in line with sternal notch.

I can’t oxygenate the patient with BVMR/ventilator breaths.

I can’t oxygenate the patient, and intubation or difficult airway devices have failed or are unavailable.

This is a can't intubate-can't oxygenate scenario, and front of neck access may be indicated.

I’m not sure how to draw up ketamine.

Ketamine is available in different concentrations; 10, 50, and 100 mg/ml. It is easiest to work with a 10 mg/ml solution, which comes as a 20 ml vial and can be used undiluted. If you have a 50 mg/ml vial (comes in a 10 ml vial), draw up 2 ml in a 10 ml syringe and add 8 ml of normal saline, making a 10 mg/ml solution.

For the 100 mg/ml solution (comes in a 10 ml vial), draw up 1 ml ketamine and add 9 ml normal saline in a 10 ml syringe, making a 10 mg/ml solution. For a 70 kg patient, you may need to draw up two 10 ml syringes, or one 20 ml syringe with 2 ml of ketamine.

Diluting high concentrations of ketamine is safe practice and avoids accidental misdosing.

## Risks

## References