Airway

Question 1

what are examples of dynamic airways

Answer 1

bullets -neck trauma
bites - anaphylaxis, angioedema
burns - thermal and caustic airway injuries

Question 2

ABC in the decision to intubate

Answer 2

Airway
Breathing
Circulation
Disability
Expected Course
Feral

Question 3

Airway signs prompting intubation and causes

Answer 3

mouth and neck infections, tumors, foriegn bodies, bleeds
stridor, phonation, swallowing, secretions, dyspnea

Question 4

breathing signs and causes prompting intubation

Answer 4

failure to oxygenate or ventilate
often amenable to medical an non-invasive therapies
think Non-Invasive Ventilation

Question 5

Criculation causes and signs to intubate

Answer 5

supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis

Question 6

what disabilities would lead you to intubate

Answer 6

CNS catastrophes and CNS depression, ongoing seizures and weakness
*avoid gag - assess the ability to swallow and handle secretions for neuromuscular weakness: FVC < 12mL/kg and NIF < 20 cm H2O
vomiting in the obtunded patient is particular concern

Question 7

expected course that will prompt the decision to intubate

Answer 7

anticipated decline, transfer to radiology or another institution

Question 8

feral decision to intubate

Answer 8

need for prompt, aggressive sedation to protect patient and others
*especially with potential or undiagnosed medical instability

Question 9

RSI intubation considers

Answer 9

peri-arrest
dynamic airway already deteriorating
upper GI bleed
bowel obstruction
vomiting

Question 10

Awake intubation consideration

Answer 10

stable GI bleed requiring endoscopy
slowly progressing NM weakness requiring transfer
fixed flexion deformity of the neck
cannot open mouth

Question 11

how can you use local anesthesia for an awake intubation

Answer 11

dry
nebulize
atomize
topicalize

Question 12

Awake intubation - IV sedation options

Answer 12

ketamine**
versed
fentanyl
dexmedetomidine

Question 13

how do you set the table for laryngscopy

Answer 13

ear to sternal notch
equipment is ready: suction under right shoulder
assistant pulls right mouth corner

Question 14

how can you optimize the patient’s head

Answer 14

place your right hand under the patient’s head and do sniff and head tilt

Question 15

how can you optimize the larynx

Answer 15

using your right hand to maneuver the thyroid cartilage into optimal position

Question 16

the black stripe on the bougie tells you what

Answer 16

25 cm - at lips mid trachea in an adult male

Question 17

considerations for etomidate for RSI

Answer 17

safe choice in most situations
adrenal suppresion
lowers seizure threshold

Question 18

considerations for ketamine for intubation

Answer 18

reactive airways
IM RSI
hypotension/sepsis
*Avoid if HTN/tachycardia is undesirable
*Contraindicated in high ICP
*hyper sympathetic delirium

Question 19

problems with succinycholine

Answer 19

rhabdomyolysis
existing hyperkalemiaa
Multiple sclerosis ALS
muscular dystrophies / inheritied myopathies
denervating injuries > 72 hours old (stroke, spinal cord injury)
burns > 72 hours old
tetanus, botulism, and other endotoxin infection
severe infections > 72 hours old (especially intra-abdominal)
immobilization
predisposition to MH
bradycardia
fasciculations - increased ICP

Question 20

if you want to give Roc for RSI what type of dose range do you need to give

Answer 20

1.6 - 2 mg/kg provided excellent intubating conditions at 40 seconds

Question 21

duration of action of succinycholine

Answer 21

5-10 minutes

Question 22

duration of action of rocuronium

Answer 22

30-90 minutes

Question 23

physiologic killers with intubation

Answer 23

hypotension (SBP =< 90)
hypoxemia
metabolic acidosis

Question 24

strategies to mitigate hypotension before intubation

Answer 24

2 proximal PIVs or Its
judacious bolus of IVF wide open or pressor support
shoot for BP higher than normal before intubation (SBP>140 mmHg)

Question 25

What dose of rocuronium has a similar onset of 45 seconds like succinylcholine 2 mg/kg IV

Answer 25

rocuronium 1.6 mg/kg

Question 26

do shock patients require a decreased dissociative dose of ketamine for RSI

Answer 26

Yes, reduce the dose to 0.5 mg/kg IV
may require a subsequent dose of 0.5 mg/kg

Question 27

Options for push dose pressors

Answer 27

epinephrine
phenylephrine
vasopressin** (easiest drug to dilute)

Question 28

how would make your push dose vaso

Answer 28

20 units/1 mL Vaso + 19cc of NS in a 20cc syringe -> 1unit/mL

Question 29

how to mitigate desaturations during efforts to intubate

Answer 29

NC at 15LPM + NRB at 15LPM
keep a PEEP valve close

Question 30

if youre unable to get a O2 saturation greater than 95% what pathologies are you considering

Answer 30

Lung Shunt Physiology pulmonary edema, PNE

Question 31

What is a DSI used for and how is it done

Answer 31

delayed sequence intubation is used for uncooperative or combative patient
give procedural sedation for the procedure of prexygenation
-Ketamine 0.5-1 mg/kg
once preoxygenated paralyze -> apneic oxygenation -> intubate

Question 32

what is BUHE

Answer 32

back up head elevated

Question 33

pH kills - try to avoid intubation if at all possible. how can you optimize the patient beforehand

Answer 33

consider short trial of NIPPV while you correct the cause of metabolic acidosis

Question 34

A patient in severe metabolic acidosis who is tachypneic will bicarb help the patient?

Answer 34

no it’ll make the patient more acidotic and can lead to cardiac dysrhythmias

Question 35

high aspiration risk patients and considerations

Answer 35

upper GI bleed, bowel obstruction, pre-induction vomiting

consider NGT prior to intubation, intubate in semi-upright position, bag early but slightly less early

Question 36

difficult airway strategies

Answer 36

initiate rescue maneuvers such as ventilation and cricothyrotomy early so that the patient has enough reserve to allow for calm and effective execution

BVM with three airways in, two hands down replace BVM with LMA ventilation

make the bougie part of your routine