ABCDE

Question 1

MC reason that airways get obstructed

Answer 1

tongue and submandibular musculature

if you are not conscious that stuff lays on the back of your throat and blocks your airway

Question 2

when would you use a jaw thrust alone to open airway

Answer 2

if you have not witnessed injury and it could be a C spine injury

Question 3

review of what airway compramise looks like

Answer 3

• Universal choking sign
• Unconscious, deeply sedated (intoxication or medication)
• Respiratory distress, position preference (you don’t want to lie down)
• Getting sleepy while working to breathe
• Changes in level of consciousness - come in talking - now difficult to arouse •

Sedated + vomiting

• Head trauma, facial trauma
• Infection somewhere along the airway
• Burns - smoke inhalation (get edema from heat/smoke inhalation)
• Face, tongue, neck edema
• Severe bleeding from nose, mouth (flooded your airway)
• Cyanosis, shock

Question 4

inspiratory stridor indicates

Answer 4

narrowing at the glottis

Question 5

what can airway trouble sound like

Answer 5

stridor

voice changes- hoarseness and can’t get
words out

gurgling

Question 6

when would you use a nasopharyngeal airway

Answer 6

for semi-conscious pts with a gagreflex

Question 7

Nasopharyngeal Airway placement

Answer 7

tip of the nose to the tragus should be the fit

bevel to septum with lube
floor of the nose down until the opening is at the nostril

Question 8

Oropharyngeal Airway is used for

Answer 8

Use only in unconscious, unarousable patients

NOT IN A PT WITH A GAG REFLEX–> vomit

Question 9

Oropharyngeal Airway measurement

Answer 9

corner of the mouth to the angle of the jaw

Question 10

how should you be holding laryngoscopes

Answer 10

with left hand

Question 11

what should you do before intubating

Answer 11

make sure your balloon inflates but always insert with balloon deflated

Secures the airway by placing a tube in the airway space - secures a lumen

Question 12

CO2 monitor should turn what color following intubation

Answer 12

Yellow-Yes

purple= poor

Question 13

laryngoscope with straight blade

Answer 13

Miller

Question 14

laryngoscope with curved blade

Answer 14

macintosh

Question 15

indications for intubation

Answer 15

Can’t protect/maintain their own airway:
Alterations in level consciousness
Airway patency threatened
Edema, secretions, blood, infection,
trauma

Breathing indications
Failure to ventilate or oxygenate
Pulmonary, cardiac, systemic problem,
trauma

Preemptive
Threat to airway patency (consciousness), oxygenation, ventilation, aspiration

Question 16

first thing to do to prop for intubation

Answer 16

Bag Valve Mask – BVM – essential skill

Pre-intubation ventilation – 100% O2

do this right after to before putting them on a ventilator

Question 17

S.O.A.P M.E checklist

Answer 17

Suction
Oxygen
Airway equipment
Pharmacy
Monitoring Equipment

Question 18

prep for intubation

Answer 18

BVM
SOAPME
Have Plan A, Plan B, Plan C
RSI - Rapid Sequence Intubation

Question 19

RSI- What are the steps KNOW THIS

Answer 19

Pt is paralyzed to gain control; intubation easier, deals with full stomach - prevents aspiration

ii. The 7 P’s
1. Possibility of success
2. Prepare
3. Pre-oxygenation
4. Pre-treatment
5. Induction/Paralysis
6. Positioning/Protection
7. Pass it, prove it, post procedure tasks

Question 20

why should you beware of paralyzing a pt

Answer 20

Paralyzed patient = no respiratory effort

You MUST be able to adequately ventilate the patient with bag-valve-mask

Must anticipate a successful intubation or do not paralyze

Question 21

tubing the goose

Answer 21

don’t pass through the chords, pass into the esophagus

will get a shift CO2 reading
happens witt big pts, looking away

No color change, low pulse ox, no breath sounds.

Question 22

why do we get a CXR post intubation

Answer 22

to check depth NOT to see if it’s the esophagus

Question 23

what to do if you can’t see the chords very easily

Answer 23

LMA-Laryngeal Mask Airway
or Bougie

i. Supraglottic airway devices
ii. Designed for blind insertion - goal is esophagus, not trachea
iii. LMA for minor surgery common, good Plan B
Nasotracheal intubation and/or fiber optic guided

All designed to minimize risk of the failed airway-

Question 24

king tube

Answer 24

goes into the esophagus

inflate giant balloon and

Question 25

Causes of Inadequate Ventilation-i. Increased airway resistance

Answer 25

1. Airway collapse, hyper-reactivity, edema 2. Small decreases in diameter significant 3. COPD, emphysema, asthma

Question 26

Causes of Inadequate Ventilation-Decreased airway compliance

Answer 26

1. Interstitial edema and alveolar collapse | 2. Pulmonary edema, effusion, shock, sepsis, aspiration, drowning, smoke inhalation, ARDS, trauma

Question 27

Abnormalities of ventilation/perfusion

Answer 27

1. Acute left ventricular failure, pneumonia, pulmonary embolus, anemia, ARDS, etc…

Question 28

Impaired wall mechanics

Answer 28

1. Perfused but under-ventilated alveoli | 2. Pneumothorax, pneumonia, effusion, neuromuscular problems, rib fx, trauma

Question 29

Hypoventilation/hyperventilation

Answer 29

1. Poisoning, toxic overdoses, intoxication 2. Acidosis 3. Endocrine disorders 4. CNS lesions

Question 30

Inadequate Ventilation leads to

Answer 30

Leads to Hypoxia... and hypercarbia

Question 31

Hypoxia causes

Answer 31

1. Low arterial O2 tension - alveoli aren’t transferring O2 from lungs to circulation 2. Ventilation-perfusion mismatch

Question 32

Hypercarbia:

Answer 32

1. Alveolar hypoventilation 2. Increased lung “dead space” 3. Acidosis from CO2 retention 4. Altered mental status à will cause you to become sleepy and unconsciousness and will affect your breathing

Question 33

RED FLAGS of respiratory distress

Answer 33

``` • Can they talk? • How many word sentences? (<4 NOT GOOD) • Fighting for each breath - anxiety? • Tachypnec? >30/min? • Posture - tripod? Won’t lie down? • Accessory muscles? • Handling secretions? • Diaphoretic? Cyanotic? • Altered? Sleepy? • Gag reflex? • Stridor? ```

Question 34

if your pt is in respiratory distress

Answer 34

```  Give supplemental O2 now; beta-agonist now if appropriate -->bronchodilators  Prepare for definitive airway control  Vital signs, Pulse Ox  IV access, cardiac monitor  Undress  Pre-hospital hx, PE, interventions  Rapid assessment: <1 min  Focused history, PE ```

Question 35

treatment goals

Answer 35

```  Airway control  Reverse hypoxemia Supplemental O2 Improve ventilatory effort/status  Avoid/treat hypercapnea  Increase effective tidal volume  Improve alveolar ventilation  Find and treat the cause ```

Question 36

placing nasal cannula

Answer 36

tubes down

Question 37

Maybe tachypnec but full sentences, no posturing, 2-4L/min what type of O2 threapy

Answer 37

ii. Nasal cannula - no/slight distress

Question 38

Moderate distress & O2 deficit, 4-10L/min

Answer 38

iii. Face mask

Question 39

Limitations of Pulse Oximetry

Answer 39

Measures % oxygen saturation of hemoglobin in arterial blood (SaO2 measured = SpO2) Useful only if arterial O2 above 60% Hyperventilation, anemia can give false readings Pulse Ox tells us very little about adequacy of ventilation Pulse Ox tells us nothing about CO2/hypercarbia

Question 40

really important questions for red flags

Answer 40

have you had this before how long? what medications are you on and did you run out of them? associated sxs- rash, fever, cough, hemoptysis, DOE, CP, orthopnea, edema, trauma, syncope home O2? --> lung issues ever been intubated?

Question 41

ROS for SOB

Answer 41

``` rash-allergies fever cough hemoptysis DOE CP orthopnea edema trauma syncope ```

Question 42

vital sign red flags

Answer 42

a. Blood pressure Often elevated (think cardiac too) – very common Hypotension - ominous sign--> intubation Respiratory rate - tachypnea is sensitive Pulse - tachycardia common, beta agonists? Pulse – bradycardia – ominous sign Temperature - infectious process Pulse Oximetry – improvement with O2?

Question 43

PE

Answer 43

look at the bare torso --> accs muscles listen to breath sounds Cardiac exam, pulses – rhythm, m/r/g Check capillary refill time: <2secs normal. >2secs? Think shock! Abdomen – distention, ascites Eyes (pallor), mouth (tongue, thrush) neck (JVD, masses, swelling) Skin – rash, diaphoresis Extremities – edema, clubbing? Think CHF, DVT, COPD Neuro – mental status, muscle weakness

Question 44

Common Pulmonary Causes of respiratory distress

Answer 44

```  Asthma or COPD exacerbation  Pneumonia, infectious  Pleural effusion  Pneumothorax  Pulmonary embolus  Malignancy  Trauma  Rhematologic, connective tissue Dz, Sickle Cell  Pulmonary manifestations  Aspiration, foreign body ```

Question 45

Common Non-Pulmonary Causes

Answer 45

```  Acute coronary syndrome  Sepsis  CHF/pulmonary edema (pump problem)  Pericardial effusion/pericarditis  Anemia  Renal and metabolic disturbances  Environmental, toxic ingestion  Allergy, anaphylaxis  Neuromuscular  Psychiatric ```

Question 46

a. ED Diagnostics respiratory distress

Answer 46

IV, 02, monitor triple scan CXR EKG ``` LAB CBC CMP UPREG UTOX Lactic acid ```

Question 47

Case specific - consider:

Answer 47

1. Cardiac enzymes 2. D-Dimer, lower extremity ultrasound 3. ABG/VBG, PT/INR 4. Aspirin level: mixed acid base picture and first sign of aspirin tox is tachypnea 5. BNP? CHEST CT NIPPV-

Question 48

Non-invasive Positive Pressure Ventilation

Answer 48

Hypercapnic, hypoxemic respiratory failure

Question 49

d. BiPAP - “bilevel positive airway pressure”

Answer 49

i. Nasal mask | ii. Use to vary inspiratory and expiratory pressures (COPD)

Question 50

c. CPAP - “continuous positive airway pressure”

Answer 50

i. Mask over mouth/nose | ii. Continuous inspiratory/expiratory pressure (CHF)

Question 51

NIPPV can be used for

Answer 51

i. COPD exacerbations, severe asthma ii. Pulmonary edema/CHF iii. Obstructive sleep apnea iv. Post-extubation, chest trauma

Question 52

Positive Pressure Ventilation-what does it do exactly

Answer 52

i. Reduces the work of breathing ii. Maintains alveolar inflation, assists ventilation (O2 in, CO2 out) iii. Improves airway compliance iv. Reduces preload and afterload

Question 53

CI for NIPPV

Answer 53

1. Pt cannot breathe on own if mask falls off 2. Must be relatively stable, not agitated or unconscious 3. Intact face - avoid subcutaneous air

Question 54

21 YR o F partier cut her hand resisted going to the ED sleeping deeply without arousing to shake and shout ETOH .28 what are your airway issues and options

Answer 54

vomiting sedated on her back could use a nasal trumpet rescue position on side suction nearby will pull it out could put a nasal cannula

Question 55

case 2 55 yo M robbed by youths, hit in the face by the bat, can't speak or open his mouth can't speak

Answer 55

jaw is probably broken --> difficult to suction the hell out of him reevaluate need for intubation

Question 56

43 YO M brought in by ambulance from house fire

Answer 56

preemptively intubate because of worry about edematous

Question 57

lil guy with lip swelling

Answer 57

epinephrine | package for anaphylaxis