Adams: Respiratory Emergencies

Question 1

How do you support a pt who is breathing fairly adequately?

Answer 1

Supplemental O2 (Nasal cannula or mask) and position them to maximize air exchange

Question 2

How do you support a pt w/ labored breathing?

Answer 2

CPAP (sticking your head out the window) or BiPAP

-helps ppl w/ sleep apnea

Question 3

How do you support a pt prior to intubation?

Answer 3

bag-valve mask

Turn O2 up to 15 L!

Only do this for a little bit b/c they will throw up!

Question 4

What injuries might demand airway management?

Answer 4

facial
flail chest
neck

Question 5

What illnesses can require airway management?

Answer 5

Pulmonary edema
COPD
aspiration
infection
drugs
allergic reaction (anaphpylaxis, angioedema of the tongue--> ACE inhibitors)

Question 6

What conditions leave the airway unprotected?

Answer 6

Decreased LOC: GCS hypercapnia and hypoxia

Question 7

What are the primary reasons not to intubate?

Answer 7

Adequate airway protection is present

Oxygenation by other less invasive means is possible

Pt is DNI (do not intubate)

Question 8

What are back ups to intubation?

Answer 8

combitube
king airway
laryngeal mask airway (LMA)

Question 9

What do you do if your attempts at intubation fail?

Answer 9

Cricothyroidotomy

Don’t have to worry about blood as much!

Question 10

What pts may be more difficult to intubate?

Answer 10

short neck
prominent upper incisors
receding mandible
limited jaw opening
limited cervical spine mobility

Question 11

What is RSI?

Answer 11

Rapid Sequential Intubation

Question 12

What is Succinylcholine?

Answer 12

An ULTRASHORT acting skeletal muscle relaxant that combines w/ cholinergic receptors at the motor endplate to produce flaccid paralysis

Question 13

Does succinylcholine bind more firmly than acetylcholine?

Answer 13

YES

Question 14

What is succinylcholine broken down into?

Answer 14

Pseudocholinesterases break it down into succinylmonocholine

Question 15

The depolarizing action of succinylcholine at muscle’s motor endplates is clinically visible as…

Answer 15

muscle fasciculations

Question 16

How long does it take for succinylcholine to take effect, when is the optimal time to intubate and how long does the paralysis last?

Answer 16

30-60 seconds

60-90 seconds

8-12 minutes

Question 17

What are SE of succinylcholine and how do you treat them?

Answer 17

Bradycardia- atropine

Increased:
IGP
ICP
IOP
serum K levels (if already high they can die from cardiac arrythmia)
temperature

Question 18

What is the “appearance” of someone who has been given succinylcholine?

Answer 18

eyes like a mole
moist as a slug
weak as a kitten

Question 19

What effects does succinylcholine have on muscarinic receptor and nicotinic receptors?

Answer 19

SLUD
salivation, lacrimation, urination and defecationa

Nicotinic>
striated muscle problems>
fasciculation and weakness

Question 20

What are two non-depolarizing meuromuscular blockers?

Answer 20

vecuronium

Rocuronium

Question 21

What is vecuronium?

Answer 21

Neuromuscular block
Competes for CHOLINERGIC RECEPTORS>
flaccid paralysis

Question 22

If you use vecuronium when are the ultimate intubating conditions and how long does it last?

Answer 22

2.5-3 mins

25-40 mins

recovery 45-60

Question 23

What is vecuronium metabolized by?

Answer 23

liver and kidneys

• renal failure does NOT affect recovery time
• liver failure/cirrhosis may DOUBLE recovery time

Question 24

Does vecuronium cause problematic hypotension or tachycardia?

Answer 24

no

Question 25

Why is rocuronium unique among neuromuscular blocking agents?

Answer 25

It's onset of action is almost as quick as succinylcholine

Question 26

What is rocuronium's onset time, how long does it take to cause complete paralysis and how long does it act?

Answer 26

Onset muscle relaxation- 15-20 s (Fast as succinylcholine) Complete paralysis- 45-60 s Duration of action 25-60 minutes (takes a long time to start breathing again)

Question 27

An ideal sedative has....

Answer 27

``` rapid onset (20-30 s) short half life ```

Question 28

What is an example of a classic barbiturate that isn't used any more?

Answer 28

Thiopental *causes hypotension

Question 29

What is thiopental?

Answer 29

ultrashort acting anesthetic agent w/ a rapid onset of action *also has antiepileptic properties

Question 30

When are peak concentrations of thiopental achieved in the brain?

Answer 30

w/in 30 s

Question 31

What is a SE of thiopental?

Answer 31

hypotension

Question 32

What is a non-barbiturate sedative?

Answer 32

ketamine

Question 33

What is ketamine?

Answer 33

rapid acting anesthetic that induces a DISSOCIATIVE STATE in which the pt is unaware of any sensory or painful stimuli that DOESN'T AFFECT RESPIRATORY DRIVE

Question 34

What causes ketamine's effects?

Answer 34

disruption of conduction between the thalamocortical access

Question 35

When should you use ketamine?

Answer 35

SEDATION AND ANALGESIA for children undergoing complex LACERATION REPAIRS

Question 36

What are the optimal intubating conditions, peaking time and length of Ketamine's effects?

Answer 36

30 s peak 60-90 last 5-10

Question 37

Ketamine is also mildly sympathomimetic. Why is this useful?

Answer 37

trauma and HYPOTENSIVE states (doesn't affect bp) bronchodilatory property is useful in ASTHMATICS

Question 38

What are the SE of Ketamine?

Answer 38

Emergence reactions w/ vivid imagery, hallucinations and irrational behavior. Hypertension Increase in upper airway secretion (give atropine as needed)

Question 39

How do you treat emergence reactions?

Answer 39

co administration of BEZODIAZEPINES

Question 40

When using ketamine for RSI intubation what do you use to prevent emergency reactions?

Answer 40

longer acting sedative

Question 41

What is an example of a benzodiazepine?

Answer 41

midazolam

Question 42

What is midazolam?

Answer 42

short acting CNS DEPRESSANT which also causes a LACK OF RECAL

Question 43

What SE are associated w/ midazolam?

Answer 43

slight drop in MAP

Question 44

How long does it take to achieve adequate sedation w/ midazolam?

Answer 44

2-2.5 mins

Question 45

What are two non-receptor rapid acting sedative hypnotics?

Answer 45

propofol* etomidate

Question 46

What is propofol?

Answer 46

Modified phenol that is extremely LIPOPHYLIC. IT INFILTRATES the lipid bilayer of the nerve cell's membrane and DISRUPTS NERVE CONDUCTION

Question 47

Propofol: Onset of action? Peak affect?

Answer 47

W/in ONE circulation time between heart nad brain (10-20 s w/ IV bolus) VERY SHORT ACTING Peak affect in 20-40 s

Question 48

What is unique about the offset of propofol?

Answer 48

RAPID offset Duration of action is 8 minutes or less

Question 49

What are the SE of propofol?

Answer 49

APNEA (quit breathing) Potential cardiovascular depressant> HYPOTENSION (BIGGEST ISSUE)

Question 50

What sedative is also an anti-emtic that can lower ICP and is often useful for brief procedures?

Answer 50

Propofol

Question 51

What is Etomidate?

Answer 51

An Imidazole Rapid acting hypnotic NOT related to the others.f Has NO ANALGESIC OR AMNESTIC properties but can LOWER ICP

Question 52

What is the onset of action of etomidate and how long does it last?

Answer 52

20-30 seconds last 20 mins

Question 53

What sedative is ideal for hypovolemic pts or those in hemorrhagic shock? Why?

Answer 53

etomidate Doesn't produce cardiovascular depression

Question 54

What are SE of etomidate?

Answer 54

vomiting and myoclonus

Question 55

What is an example of a typical RSI protocol?

Answer 55

-3 preoxygenate -.55 Etomidate -.45 Succinylcholine 0 intubation +30 assess tube placement 8 check pt temp (b/c of succinylcholine)

Question 56

What are the 6 steps of intubation?

Answer 56

1. Preoxygenate and prepare 2. Pretreat/prime (fentanyl) 3. Paralyze (succinylcholine or rocuronium; emotidate) 4. Intubate 5. Confirm tube placement 6. Medicate for long term management

Question 57

How do you confirm tube placement?

Answer 57

1. breath sounds in both axillae and not over stomach 2. correct PaCO2 (purple BAD) 3. Bulb suction device 4. Maintenance of PaO2 (capnography) 5. CXRAY

Question 58

A 39 y/o pt suffered from a 30% third degree burn 16 hrs ago. She is having increased respiratory difficulty and will need to be intubated. Which of the follwoing drugs is most liekly to cause potentially life-threatening arrythmia?

Answer 58

Succinylcholine *worry about elevated K

Question 59

A four year old comes in w/ a laceration to the lip. What is the best choice?

Answer 59

Ketamine IM | midazolam works but makes kids hyper

Question 60

A 65 y/o in cardiogenic shock and respiratory distress. You need to use RSI and intubate them. Most useful drug is:

Answer 60

Etomidate ketamine--don't affect bp

Question 61

A 74 y/o pt w/ afib. Need to shock them. What do you use?

Answer 61

Propofol

Question 62

Which of the following is the most appropriate intervention if you can't intubate a pt after two attempts?

Answer 62

Use a combitube

Question 63

Succinycholine SE?

Answer 63

Hyperkalemia | Muscle twitching

Question 64

Etomidate SE?

Answer 64

Muscle spasm | Adrenal suppression

Question 65

Propofol SE?

Answer 65

Hypotension

Question 66

Midazolam SE?

Answer 66

Amnesia | Hypotension

Question 67

Ketamine SE?

Answer 67

Hypertension | Increased ICP

Question 68

Rocuronium SE?

Answer 68

?