Advanced Airway / RSI Flashcards by Eric Hayes

Indications for Intubation

♦ Unable to Swallow / Ventilate Oxygenate

♦ GCS < 8

♦ Inhalation Burns / Circumferential Burns

♦ Anaphylaxis

♦ Apnea / Obstruction

♦ Respiratory Failure

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Respiratory Failure =

♦pH < 7.2

♦ CO2 > 55

♦ PaO2 < 60

*only one value needs to be off to indicate the need to intubate*

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Intubation Visualization Aids

♦ Selick’s Maneuver = Direct downward pressure on the thyroid cartilage, occludes the esophagus

♦ BURP = Backward, Upward, Rightward Pressure

**Do NOT Release Until Intubation is Complete**

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Failed Airway Algotithm

♦ Patient Requires Secured Airway

♦ 3 Attempts of Direct Laryngoscopy Unsucessful

♦ Ventilate Pt by BVM/Simple Airway/Blind Airway

♦ Unable to Ventilate/Oxygenate SaO2 > 90%

♦ Cricothyroidotomy Indicated (Cric)

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Placement Confirmation

♦ Chest XR - Gold Standard

♦ Distal tip of ETT should be 2-3cm above the carina or 1” above the carina Level of the T2 or T3 vertebrae

♦ Next most reliable confirmation method - visualization of tube passing through cords

***Distal cuff on ETT should be between 20-30 mmHg to prevent damage (*25)

(use only enough air required to make good seal)

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7 P’s for RSI Success

Preparation - make sure equipment is servicable

Preoxygenate - 3-5 minutes, passive oxygenation via NC 10-15 + LPM

Pretreatment - LOAD medications if required

Paralysis w/ induction - Induction agent, paralytic, and pain control

Protect / Position - Ear to sternal notch, ramping, pad behind shoulders for pediatrics

Placement w/ proof - Visual confirmation, capnography, chest x-ray

Post Intubation Management - Maintain sedation and pain control, oxygenation, etc

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LOAD (RSI Pretreatment)

Lidocaine - blunts the cough reflex preventing ICP increase

Opiates - Blunts the pain response

Atropine - Prevents reflex bradycardia in infants < 1 y/o

Defasiculating Dose - 1/10 dose of Rocuronium or Vecuronium

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Succinylcholine (Anectine)

(pharmacodynamics)

Depolarizing neuro muscular blocking agent

depolarizes motor endplates at myoneural junction, leading to sustained flaccid paralysis

(stimulates muscle depolarization but remains bound to the receptor, preventing it from repolarizing and being triggered again)

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Malignant Hyperthermia

Masseter Spasm (lockjaw)

Sustained tetanic musscle contractions

Rapid increase in temp (can be as high as 110 degrees)

Increased ETCO2

Tachycardia / HTN

Treat with Dantrolene Sodium

_**Do NOT give *calcium channel blockers*, you will kill this pt**_

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Vecuronium (Norcuron)

(pharmacodynamics

Nondepolarizing neuromuscular blocking agent

Blocks acetycholine from binding to motor endplate receptors, inhibiting depolarization

(has slower onset and longer duration)

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Rocuronium (Zemuron)

(pharmacodynamics)

Nondepolarizing Paralytic

Blocks acetylcholine from binding to the motor endplate receptors, inhibiting depolarization

(has slower onset and longer duration)

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Etomidate (Amidate)

(pharmacodynamics)

Depresses the reticular activating system by stimulating GABA receptors

Depresses CNS function

Decreases oxygen cosumption and cerebral blood flow (ideal for ^ ICP)

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Induction Agents (sedation)

Midazolam (Versed)

Used for sedation/anxiolysis with anterograde amnesia

Useful in seizures

Dose varies on intended use (protocols)

2.5-5 mg IV

Use lowest dose possible to achieve desired result

Do not use with other benzodiazepines

Flumazenil (Romazicon) is the reversal

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Ketamine (Ketalar)

Pharmacodynamics

PCP derivative

Ketamine is a non-competitive NMDA receptor antagonist and dissociative, amnestic, analgesic, anesthetic agent.

Ketamine has a variety of effects, including: anesthesia, analgesia, hallucinogen, and sympathetic stimulation

Produces a rapid profound anesthetic or dissociative state

Ketamine is a Potent Bronchodilator,

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Morphine

(Pharmacodynamics)

Binds with opiod receptors in the CNS preventing painful impulse transmission producing analgesia

reduces preload,reduces afterload which may lead to decreases in myocardial oxygen demand.

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Fentanyl (Sublimaze)

(pharmacodynamics)

Synthetic Opiod Analgesic

(70-100 x more powerful than morphine)

Binds with ophoid receptors in the CNS, preventing painful impulse transmission

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Ketamine (Ketalar)

(onset and duration)

IV = 30 sec / duration 5-10 min

IM = 3-4 min / duration 12-25min

(sedative effects can persist for 45 min - 2.5 hours)

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Ketamine (Ketalar)

(side effects)

Elevates HR and B/P shortly after administration (typically return to baseline within 15 min)

Increased cerebral blood flow and metabolism

Increased salivary secreations

(atropine 0.4-0.6 IV Slow IVP before induction)

Emergence reactions –> tachycardia, ^b/p, nystagmus, and attempts at swallowing

(treat with benzos)

Rapid admin associated with respiratory depression, apnea, and higher than usual spikes in B/P. (Give IV/IM over 60 sec)

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Ketamine (Ketalar)

(Contraindications)

< 3 mo of age

Known Schizophrenia

Severe HTN

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Ketamine (Ketalar)

(Indications Adult)

Induction 2 mg/kg slow IO/IV push.

May repeat bolus of 1 mg/kg every 10 minutes

Post Intubation/Ventilation For mechanically ventilated patients, consider a continuous infusion of 1 mg/kg/hr, after the initial loading dose of 1 mg/kg

Pain Management/Sedation 0.1-0.5 mg/kg Sedation/Behavioral 4 mg/kg IM

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Ketamine (Ketalar)

(Indications Pediatric)

Induction 2 mg/kg slow IO/IV push.

May repeat bolus of 1 mg/ kg every 10 minutes

Pain Management/Sedation 0.1-0.5 mg/kg IV/IO 1 mg/kg IN

Sedation/Behavioral 4 mg/kg IM

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Morphine

(onset and duration)

IV = 10 minutes with a duration of action 3-5 hours.

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Morphine

(Indications)

Pain Management

Pulmonary Edema

Morphine

(Contraindications)

Avoid use with hypotension

Avoid in the presence of RV/ Inferior wall MI

**Morphine** **(side effects)**

Hypotension, AMS, Nausea/ vomiting, and respiratory depression

**Morphine** **(adult dose)**

0.1 mg/kg (up to 5 mg) IM/ IO/IV. SBP must be \> 90 mm Hg. May repeat dose once to a max of 10 mg \***Higher doses** may be required for patients with burn injuries

**Morphine** **(pediatric dose)**

0.1 mg/kg (up to 5 mg) IM/ IO/IV. SBP must be \> 90 mm Hg. May repeat dose once to a max of 10 mg **\*Higher doses** may be required for patients with burn injuries

**Fentanyl (Sublimaze)** **(onset and duration)**

IV = onset 90 sec, duration 30 min

**Fentanyl (Sublimaze)** **(Indications)**

Airway: Rapid Sequence Intubation Breathing: Use of Mechanical Ventilator Acute Coronary Syndrome Pain Management

**Fentanyl (Sublimaze)** **(contraindications)**

Bronchial asthma, concomitant MAO inhibitors, myasthenia gravis

**Fentanyl (Sublimaze)** **(side effects)**

Muscle rigidity, (tight chest) respiratory depression, bradycardia and hypotension myoclonic movements, tachycardia, vein irritation, dermatitis / flushing urinary retention

**Fentanyl (Sublimaze)** **(adult dose)**

♦ **1 mcg/kg** IM/IO/IV/IN ♦ **Maximum 100 mcg** ⇒ **May repeat dose at 1 mcg/kg**

**Etomidate (Amidate)** **(onset and duration)**

Peak effect = 1 minute Duration 4-10 minutes

**Etomidate (Amidate)** **(indications)**

Airway: Rapid Sequence Intubation – for induction (procedural sedation)

**Etomidate (Amidate)** **(contraindications)**

Adrenal Insufficiency, ## Footnote **Sepsis**

**Etomidate (Amidate)** **(side effects)**

Respiratory depression, venous pain, (use larger vessels) skeletal muscle movement (myoclonus) N/V on emergence Uncontrolled eye movements Hiccups Apnea Impaired cortisol synthesis

**Etomidate (Amidate)** **(adult dose)**

0.3 mg/kg IV push over 30 seconds **Maximum** dose of **_40 mg_**

**Etomidate (Amidate)** **(pediatric dose)**

0.3 mg/kg IV push over 30 seconds **Maximum** dose of **40 mg**

**Succinylcholine (Anectine)** **(onset and duration)**

Onset 30-45 sec / duration 4-6 min

**Succinylcholine (Anectine)** **(indications)**

Airway: Rapid Sequence Intubation Skeletal muscle relaxation Facilitate management of patients undergoing mechanical ventilation

**Succinylcholine (Anectine)** **(contraindications)**

Malignant hyperthermia Skeletal muscle myopathies Penetrating eye injury Acute crush injuries Acute Spinal cord injuries Chronic renal failure (hyperkalemia) Relative - Closed head injuries (med induced ICP)

**Succinylcholine (Anectine)** **(side effects)**

Cardiac arrhythmias, Increased intraocular pressure, Muscle Fasciculation Malignant Hyperthermia Hypotension/Hypertension Hyperkalemia Bradycardia/Tachycardia Increased ICP Longer than normal duration of action to pt's exposed to acetylcholinesterase inhibitors found in nerve agents and pesticides

**Succinylcholine (Anectine)** **(adult dose)**

2 mg/kg IO/IV over 30 seconds **Maximum dose** of 200 mg

**Succinylcholine (Anectine)** **(pediatric dose)**

2 mg/kg IO/IV over 30 seconds **Maximum dose** of 200 mg

**Vecuronium (Norcuron)** **(onset and duration)**

♦ **onset** = 2.5 - 3 min ♦ **duration** = 25 - 40 min (complete recovery 45-65 min after initial bolus dose) Manufactored as a powder and must be reconstituted with compatible diluent

**Vecuronium (Norcuron)** **(indications)**

**Airway**: Rapid Sequence Intubation Facilitates endotracheal intubation by paralysis of skeletal muscle **Breathing**: Use of Mechanical Ventilator To increase pulmonary compliance during mechanical ventilation

**Vecuronium (Norcuron)** **(adult dose)**

0.1 mg/kg IO/IV over 30 – 60 seconds **Maximum dose** of 10 mg

**Vecuronium (Norcuron)** **(pediatric dose)**

0.1 mg/kg IO/IV over 30 – 60 seconds **Maximum dose** of 10 mg

**Rocuronium (Zemuron)** **(indications)**

**Airway**: Rapid Sequence Intubation Facilitates endotracheal intubation by paralysis of skeletal muscle **Breathing**: Use of Mechanical Ventilator to increase pulmonary compliance during mechanical ventilation

**Rocuronium (Zemuron)** **(side effects)**

Hypotension, Hypertension, Increased pulmonary vascular resistance

**Rocuronium (Zemuron)** **(adult dose)**

1 mg/kg IO/IV **Maximum dose** of 100 mg

**Rocuronium (Zemuron)** **(pediatric dose)**

1 mg/kg IO/IV **Maximum dose** of 100 mg

**Ideal/Predicted Body Weight** **(Males)**

50 + 2.3 [height in inches - 60] = Ideal/Predicted Body Weight

**Ideal/Predicted Body Weight** **(Female)**

45.5 + 2.3 [height in inches - 60] = Ideal/Predicted Body Weight

**Ketamine** **(Adult dose for RSI)**

2 mg/kg SLOW IO/IV (**Maximum** dose of 200mg) May repeat bolus of 1 mg/kg IV/IO post intubation every 10 minutes as needed or infuse at 1mg/kg/hr after the initial loading dose. **Ketamine should not be used as an induction agent for infants \< 3 months old, patients with a known history of schizophrenia, or in patients with severe uncontrolled hypertension.**

**Effects Succinlycholine has on K+**

Normal muscle releases enough potassium during succinylcholine-induced depolarization to **raise serum potassium by 0.5 mEq/L**. Although this is usually insignificant in patients with normal baseline potassium levels, a **life-threatening potassium elevation is possible in patients with burn injury, massive trauma, neurological disorders, and several other conditions.**