1. Failure to protect airway:First steps to try to re-establish a patent airway

- reposition- chin lift- jaw thrust- OPA/NPA

2. Failure to O2/ventilate: clinical assessment of this includes?

pulse ox +/- capnographygeneral pt status (LOC)ventilatory pattern

3. examples of expected clinical course to deteriorate:

- oerdose/intoxication of certain meds-septic shock-mult tarumatic injuries-penetrating neck trauma

1. Airway Flashcards by Tegan Turner

3 decisions to intubate

cannot protect airway 2. cannot ventilate or o2 3. clinical course to deterioriate

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Failure to protect airway: First steps to try to re-establish a patent airway

reposition - chin lift - jaw thrust - OPA/NPA

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Failure to protect airway: what is a reliable way to determine this?

if cannot swallow or handle secretions

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Failure to protect airway: PE of this?

can they phonate? LOC secretions

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Failure to O2/ventilate: clinical assessment of this includes?

pulse ox +/- capnography general pt status (LOC) ventilatory pattern

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Failure to O2/ventilate: when can you use cpap/bipap? (ie 2 conditions these may be helpful)

copd HF

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examples of expected clinical course to deteriorate:

oerdose/intoxication of certain meds -septic shock -mult tarumatic injuries -penetrating neck trauma

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Preintubation planning - plans need to be made for what 4 different ways of managing airway?

BMV 2. Intubation 3. SGA (extraglottic device) 4. Intubation ETT

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Patients with refractory hypoxemia or severe metaboli acidosis that may be intolerant to brief periods of apnea: what approach may be preferred?

awake intubation

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What is a double set up?

intubation and cric

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Difficult direct laryngoscopy: LEMON stands for?

Look externally (gestalt) Evaluate 3-3-2 Mallampati Obstruction or obesity RF Neck mobility

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When I intubate, what scale am I using to describe my findings?

Cormack Lehane

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Intubating: grade 1 view

see epiglottis, VC and arytenoids

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Intubating: grade 2 view

can see epiglottis, VC and arytenoids but smaller space to put the tube through

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Intubating: grade 3 view

see epiglottis, arytenoids NO VC or hole to put tube through

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Intubating: grade 4 view

See epiglottis but no VC, arytenoids or hole to put tube through

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Difficult intubation: Look externally: what might give you gestalt this is more difficult?

-bruised/bloody face -c collar

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Difficult intubation: Evaulate 3-3-2 what does this stand for?

geometry for direct ideal: three OWN (but in practice we use ours) fingers between open incisors, along roof of mandible beginning at mentum and 2 from laryngeal prominence under chin

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Difficult intubation: Evaulate 3-3-2 - what might make more difficult?

receding mandible or high riding larynx

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Difficult intubation: Obstruction/Obesity: conditions?

epiglottitis head and neck ca ludwig angina neck hematoma glottic swelling glottic polyps

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Difficult intubation: Obstruction/Obesity: what is helpful to assess this?

voice - hoarse/not obesity so bmi

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Difficult intubation: neck mobility: assessment?

chin to chest and extension

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Difficult intubation: neck mobility: conditions that may impair this?

RA ank spond

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Difficult intubation: LEMON +s - s stands for?

starting o2 sat - lower = sh apnea time

Difficult BMV - ROMAN mneumonic?

Radiation or resistance to ventilation
Obstruction/obesity/OSA
Mallampati, male, mask seal
Aged
No teeth

RODS mneumonic for Difficult EGD placement:

Restricted mouth open and or R to ventilation
Obstruction/obesity/OSA
Distorted anatomy
Short thyromental distance

Difficult BMV: Examples of R in ROMAN

-asthma, copd, ards, h+n rads

What age is consistent with difficult BMV?

>55

Teeth out to ___, teeth in to __

intubate
ventilate

Difficult cric: SMART stands for?

surgery
mass (abscess/hematoma)
acess/anatomy (obese, edema)
rads
tumor

What is the rate of grade 3 and 4 views for intubation?

<5% of grade 3

Grade 2 is divided into a and b - what does this mean?

a. arytenoids and portion vc seend
2b. only arytenoids seen

In one review of emergency adult inpatient intubations, as many as __% were considered difficult (grade 3 or 4 CL direct view or more than three attempts required

How to confirm an ETT?

- etco2
-colormetric change purple to yellow *persistence >6 breaths = yay
-pocus over cric
-aspiration??
-bougie
-auscultation of lungs fields
-pulse ox
-cxr

What patients are considered crash airways?

agonal
near death
circultory collapse

How can a crash airway be supplemented?

succ 2mg/kg IV

Why give higher dose of succ in crash intubation?

poor circulation impairs delivery so more to be faster

What %o2 should be used to abort event of intubation?

Potentially difficult airway, potentially don't use which drugs?

NMBA

Difficult airway - cases to consider awake intubation management?

- R HF
- refractory hypoxemia
-sev metabolic acidosis

What is a forced to act scenario in airway?

permits RSI, even in a highly difficult airway situation in which the operator is not confident of the success of laryngoscopy or of sustaining oxygenation. This usually occurs in the setting of a rapidly deteriorating patient with an obviously difficult airway and a presumed clinical trajectory of imminent arrest or airway obstruction. Although this is not yet a crash airway situation, the oper- ator is forced to act—that is, there is a need to act immediately to intu- bate before orotracheal intubation quickly becomes impossible or the patient arrests.

**Therefore, in the difficult airway algorithm, the first determination is whether the operator is forced to act. If so, RSI drugs are given, a best attempt at laryngoscopy is undertaken, and, if intubation is not suc- cessful, the airway is considered failed, and the operator moves imme- diately to the failed airway algorithm.

Why choose around 93% for ceasing trial of intubation?

because this represents the point at which hemoglobin undergoes a conformational change, more readily releases oxygen, and increases the pace of further desaturation.

How to prepare for an awake intubation?

1. dry with glycopyrolate
2. lidocaine neb/atomized
3. ketamine

What is RSI:

simultaneous admin of sedative/induction agent and NMBA after reox and cardiopulm optimization for trach intubation

For patients considered at high risk for desaturation during RSI, use of ? between induction and intubation is a reasonable approach as long as the patient is not believed to be at high risk for aspiration (i.e., active upper gastrointestinal bleeding, emesis prior to intubation).

careful, controlled mask ventilation

7 Ps of RSI:

1. prep
2. preox
3. preintub optimiz
4.paralysis with induction
5. position
6. place tube
7. post care

7 Ps of RSI: 1. Prep - goal?

deNirogenation of alveoli and formation of o2 rich reservoir within lung's FRC

7 Ps of RSI: 1. Prep - traditional method?

100% for 3L at 15L/min through NRB

7 Ps of RSI: 1. Prep - how much o2 actually gets to pt?

fio2 room 65% so about 50-60% etco2 in pt

7 Ps of RSI: 1. Prep - flush o2 capability - how?

40-70L/min incr fio2 andetco2
use when possible
fully open o2 valve atb wall

7 Ps of RSI: 1. Prep - how much time does a moderately ill 70kg person have til desat?

6 mins

7 Ps of RSI: 1. Prep - patients with lung disease may not be getting about 93% with initial steps, what can you do to increase alveolar recruitment, reduce shunting, increase etco2?

BIPAP

7 Ps of RSI: 1. Prep - if time, what additionally to O2 can help increase preox with high flow or?

+ 8 VC breaths

7 Ps of RSI: 1. Prep - what is the concept behind apneic o2?

aventilatory mass flow - cont o2 during apneic face constatly diffuses alveolar o2 into pulmonary ciruclation to create natural gradient for o2 from upper airway to gas exchanging lung portions

7 Ps of RSI: 2. Preintubation optimization - physiologic areas to fix pre - what are 3

HOP killers
hypotension
oxygen
ph - acidosis

7 Ps of RSI: 4. paralysis with induction: dose succ vs roc

1.5mg/kg succ vs 1.2mg/kg roc

7 Ps of RSI: 5. positioning - basics?

head extension
flexion of neck

7 Ps of RSI: 6. placeemnt of tube -how long to wait post NMBA?

45-60s

7 Ps of RSI: 6. tube - easiest way to test if relaxed enough to try to pass?

mandible movement should be easy adn absence m tone

No ongoing bleeding or hypotension: what to give post ETT to keep people sedated?

propofol 0.05-0.1mg/kg/min IV

Delayed sequence intubation - what is this?

max preox by dissoc dose ketamine 1-2mg/kg IB bolis as procedural sedation

Delayed sequence intubation with ketamine risks?

apnea

Awake oral intubation: what is this?

sedative and topical agents to manage difficult airway without a NM blockade

Awake oral intubation: how to achieve topical anesthesia

paste, spray, neb or local anesthetic nerve block

Awake oral intubation: sedative of choice?

ketamine

Awake oral intubation: ketamine dose?

0.25-0.5mg/kg IV q10min aliquots titrate to avoid apnea

what is dexmedatomidine?

centrally acting alpha receptor blocker

Awake oral intubation: can use dexmetatomidine for aqake airway eval - recommended dose?

1mg/kg IB infused over 5-10 mins

The arrested or near-death patient may not require pharmacologic agents for intubation, but even an arrested patient may retain suf- ficient muscle tone to render intubation difficult. If the glottis is not adequately visualized, administration of a single dose of ? alone may facilitate laryngoscopy (

succinylcho- line

What is a Neuromuscular blocking agent?

highly water soluble quarternary ammonium compound mimicing ach

does Neuromuscular blocking agent cross bbb or placenta?

no - due to water solubility

NMBA 2 main classes ?

depol and nondepol agents

how does succinlcholine work?

bind noncompetitive with Ach at motor endplate to cause sustained depol of myocytes so they can't be further stim by ach
noncompetitivie + depol

how does roc work?

nbma competitive with nondepol - binds Ach receptors to prevent access to ach and prevent muscle activity

**Succinylcholine is a combination of two molecules of ACh. Succinylcholine is rapidly hydrolyzed by plasma pseudo- cholinesterase to succinylmonocholine, which is a weak NMBA, and then to succinic acid and choline, which have no NMBA activity. Pseudocholinesterase is not present at the motor end plate and exerts its effects systemically before the succinylcholine reaches the ACh receptor. Only a small amount of the succinylcholine administered survives to reach the motor end plate. Succinylcholine is active at the motor end plate until it diffuses away.

Succinylcholine: onset to action?

45s

Succinylcholine: length of action?

6-10 mins

Succinylcholine: full recovery

15 mins

Succinylcholine: cardiovascular effects

binds all ach so:
- negative chronotrope - sinus brady
- risk of vfib and asystole

Succinylcholine: MSK effects

fasiculations during onset of paralysis in 90%
m pain 50% of people

Succinylcholine: electrolyte concern?

hyperkalemia

Succinylcholine: how does it cause hyperkalemia?

upregulation of post syaptive m membrane
incr density and change in subtype of m surface
ach receptors primarily k ion channels so can have massive efflux of K

Succinylcholine: contraindicated in which patients at risk of hyperK from burns?

early as 3d post burn, does not become sign until 5d

Succinylcholine: m disorders for which its CI?

MS
ALS
duchenne

Succinylcholine: stroke/SC injury - why risky to give?

upreg of receptors

safe once 6mo post insult

Conditions assoc with hyperk after succ administration?

burns >10% bsa >5d after injury
crush injury (as above)
denervation via stroke/sc injury
NM disease (als, md, ms)
intraabdo sepsis

Succinylcholine: what m may spasm specifically?

masseter

Succinylcholine: if masseter continues to spasm, concern for what disease?

malignant hyperthermia

Succinylcholine: risk of malignant hyperthermia: treatment?

1. stop succ
2. dantrolene 1-2.5mg/kg IV q5min to max of 10mg/kg IV
3. passive cooling

Malignant hyperthermia: what is this?

syndrome of rapid temp rise and rhabdo

Competitive NMBA aminosteroid agent ex

roc
vecuronium
pancuronium

Rocuronium: onset to action

60s

Rocuronium: lasts?

45 mins

Rocuronium: reversal agent?

sugammadex

Rocuronium: prior reversal drug before suggammadex?

neostigmine

Paralysis after intubation with roc - example?

sedating dose of a benzodiazepine, such as midazolam (0.1 mg/kg IV), combined with an opioid analgesic, such as fentanyl (0.5 to 1 μg/kg IV) or morphine (0.1 to 0.2 mg/kg IV bolus), is required to improve patient comfort and decrease sympathetic response to the ETT.

Etomidate: induction dose

0.3mg/kg IV

Etomidate: why use in elevated ICP?

decr ICP, cerebral blood flow and metabolic rate without affecting systemic MAP and cerebral perfusion pressure

Etomidate: may cause brief m__

myoclonus

Etomidate: risk of using this?

reduce serum cortisol and blunt adrenal response ACTH

Etomidate: with risk of adrenal cortisol blunting - when to worry about use in which pt?

sepsis

Ketamine: onset to action

30s

Ketamine: peak

1min

Ketamine: duration of action

10-15 mins

Ketamine: key use in what kinds of intubation?

awake

Ketamine: helpful for pt with severe a__ or hemodynamic ____

asthma
instability

In pt with profound refractory shock or those with depressed myocardial contraction, catecholamine depletion, what to do with ketamine?

reduce to 50% usual dose

Does ketamine cause raised ICP?

nah

What pt should NOT have ketamine used?

TBI WITH elevated BP (if normal or low BP then ok) - risk of release catechol and incr BP

Emergence phenomenon with ketamine: what is this?

scary nightmares within first 3 awares of waking

Emergence phenomenon with ketamine: RF

adults
women
larger dose
personality risk

Emergence phenomenon with ketamine: how to manage?

supportive + benzo postintub

Propofol for induction:what receptor does it stimulate?

gaba

Propofol for induction: who to use in?

pt with elevated ICP as lowers
also lowers cerebral o2 use

Propofol for induction: risks

vasodilates, myocardial depression - can cause hypotension

Propofol for induction: usual induction dose

1.5mg/kg IV

Propofol for induction: lower dose for elderly, hemodyn compromise or poor cardiovascular reserve

<1.5mg/kg IV

Propofol for induction: avoid in people with which allergies?

soybean oil
lecithin

Propofol for induction: likely safe in pt with __ allergy

egg

Propofol for induction: pain at site - how to decrease this?

pretx iv lido

*The usual induction dose for midazolam is 0.2 to 0.3 mg/kg IV. At a dose of 0.3 mg/kg IV, midazolam produces loss of consciousness in approximately 30 seconds (but may take up to 120 seconds) and has a clinical duration of 15 to 20 minutes. Midazolam is a negative inotrope and should be used with caution in hemodynamically compromised and older patients, for whom the dose can be reduced to 0.1 or 0.05 mg/kg. Onset is slower at these reduced doses.

**Dexmedetomidine (Precedex) has gained popularity as a solo agent, or in combination with benzodiazepines, for procedural sedation and awake intubation but is not used for induction during RSI given its slow loading rate. The typical loading dose is 1 mg/kg IV over 5 to 10 minutes. At therapeutic levels, it has a minimal effect on the respiratory drive or protective airway reflexes, but its use is limited by bradycardia and hypotension.

Status asthmaticus recommend intubation technqiue:

RSI

Status asthmaticus if difficult airway, recommend?

awake intub

Status asthmaticus - what med as IV drip can help?

epi

Status asthmaticus risk of what if not allowing for prolonged expiration?

breath stacking --> barotrauma

Status asthmaticus - bronchocontrisction with ETT what med can help mediate this?

lidocaine

Status asthmaticus induction agent of choice?

ketamne

Reflexive release of catecholamines post ETT: which conditions to look out for?

hypertensive emergencies
elev ICP

Reflexive release of catecholamines post ETT: how to manage?

fent (3 microgram per kg) given over 60s and esmolol can blunt

Reflexive release of catecholamines post ETT: recommended CPP to watch for in pt with elevated ICP?

map 100

Reflexive release of catecholamines post ETT: recommended pre tx drug in pt with elevated ICP?

3 microgram/kg

Shock sn RSI 3 key principles:

vol resus with fluid/blood
reduced dose of inducton agent
peri intubation pressor

Hypot and requirng ETT: NE recommendations

Norepinephrine should be initiated early (5 to 10 mcg/min IV) and titrated quickly upward by reassessing the patient’s blood pres- sure every 3 to 5 minutes and escalating the norepinephrine by 5 mcg/ min if the MAP remains at or less than 60 mm Hg.

Recommendations for intubating with injury to Cspine?

- VL and hyperangulated blade

When to use a flexible intubating scope?

diff airway with distorted upper airway anatomy - angioedmea, blunt neck trauma

How to do a cric?

can;t intubate can't ventilate:
1. palpate cricothyroid membrane
2. 10 scalpel vertically then horizontal
3. finger in
4. bougie in
5. 6 ETT overtop

When is a cricothyrotomy relatively contraindicated?

disorted neck anatomy
infection over site
coagulopathy

1. Which of the following is considered unreliable for assessing the need to establish an artificial airway?
a. Absence of a gag reflex
b. Absence of swallowing on command

c. Level of consciousness
d. Patient’s ability to phonate
e. Pooling of secretions in the oropharynx

4. In which of the following conditions is succinylcholine contraindi- cated?

a. Acute burn <5 days
b. Acute head injury secondary to motor vehicle accident c. Acute spinal cord injury <5 days
d. Renal failure with a serum potassium level of 4.7 mEq/L e. Multiple sclerosis

2. Which of the following is the most reliable overall method for con- firmation of correct tube placement after endotracheal intubation? a. Chest and gastric auscultation
b. Chest radiography

c. Detection of colorimetric or quantitative end-tidal carbon diox- ide (ETco2)

d. Measurement of exhaled volume

5. Which of the following provides the highest ETo2 after 3 minutes of ambient pressure tidal volume breathing?
a. Nonrebreather mask with oxygen flow at 15 L/min
b High-flow nasal cannula

c. Nonrebreather facemask at flush rate oxygen (40 to 90 L/min)

d. Venturi mask

Until how long after an acute burn is succinylcholine considered

safe to use for RSI? a. 30 minutes
b. 12 hours
c. 24 hours

d. 48 hours

e. 5days

3. During rapid sequence intubation (RSI) of a hypotensive blunt

abdominal trauma patient, which of the following will mitigate the risk of circulatory collapse during emergency airway management if performed before medications are administered?
a. Central venous access

b. Choosing propofol instead of ketamine for induction
c. Resuscitating with packed red cells
d. Obtaining an abdominal computed tomography (CT) scan to

better characterize the degree of bleeding

1. Airway Flashcards

(160 cards)