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Flashcards in AIRWAY Deck (49):
1

General anesthetic two principal mechanisms

Increase in inhibition through activity at GABA receptors (benzos, barbs, propofol, etomidate, isoflurane, enflurane, halothane) and
Decreased excitation through NMDA receptors (ketamine, nitrous oxide, xenon)

2

Onset of unconsciousness in all induction agents minus midaz

30 seconds

3

Dosing of induction agents should be based on

LBW, decreasing to IBW if pt is hemodynamically compromised
Fatties 0.3 of excess body weight (TBW-IBW) added to IBW
1/2-1/3 in oldies due to extra fat, less muscle, less ability to compensate

4

Etomidate pharmacology

Hypnotic, no analgesic properties. Second most hemodynamically stable (next to ketamine)
Increases GABA. Attenuates ICP by decreasing CBF and CMRO2 (cerebral metabolic rate for oxygen)
Hemodynamically stable so preservers CPP
No histamine release
No bronchodilatory effect

5

Etomidate indications

Good for hemodynamic instability, or ICP because of decreased CMRO2 and CPP.
Pregnancy category C
Not FDA approved for peds but still probably okay for peds

6

Etomidate doses

0.3mg/kg
0.2mg/kg in hemodynamic compromised pts
Fatties do 0.3mg/kg plus 30% of TWB-IBW

7

Etomidate adverse

Pain on injection
Myoclonic movements (don't matter but look like a seizure)
Blockage of 11-B hydroxylase decreases serum cortisol and aldosterone

8

T1/2A and T1/2B

Distribution half life and elimination half life

9

Etomidate pharmacology

Onset 15-45 seconds
T1/2A 2-4 minutes
Duration 3-12 minutes
T1/2B 2-5 hours

10

Ketamine pharmacology

Onset 45-60 seconds
T1/2A 11-17 minutes
Duration 10-20 minutes
T1/2B 2-3 hours

11

Clonus

a series of involuntary, rhythmic, muscular contractions and relaxations.

12

Failed airway definition (3 things)

Failure to maintain acceptable O2 during or after one or more failed laryngoscopy attempts
Three failed attempts by an experienced provider even with proper oxygenation
Single best attempt at tubing fails in the "forced to act" scenario

13

Cormack and Lehane

Visualizing larynx during laryngoscopy. 3 and 4 are correlated with failed intubation
Grade 1 - Visualization of entire glotic aperture
Grade 2 - visualization of posterior portion of the cords or arytenoids
Grade 3 - only epiglottis visible
Grade 4 - No glottic structures visible

14

Cromack and Lehane Grade 2a/2b

2a shows an portion of the cords and 2b shows only arytenoids (2b airways behave more like 3)

15

LEMON

For identifying difficult intubations
Look externally
Evaluate 3-3-2
Mallampati score
Obstruction/Obesity
Neck mobility

16

L in LEMON

Look externally, if an airway looks difficult it probably is.
Overall feeling, things like lower facial disruption, bleeding, obese, agitated, short neck, small mouth etc.

17

E in LEMON

Evaluate 3-3-2. Based on angles for proper alignment to create a direct line of site.
Based on mouth opening wide enough for visualization, long enough mandible for tongue to be displaced, glottis is a sufficient distance caudad to the base of the tongue that cords can be visualized

18

Ludwigs angina

rare skin infection that occurs on the floor of the mouth, underneath the tongue. This bacterial infection often occurs after a tooth abscess, which is a collection of pus in the center of a tooth. It can also follow other mouth infections or injuries.

19

M in LEMON

Mallampati score
Class I and II are easy, IV may fail more than 10% of the time.

20

Mallampati class I

Soft palate, uvala, facues, pillars - no difficulty

21

Mallamapti class II

Soft palate, uvala, facues - no difficulty

22

Mallamapti class III

Soft palate, base of uvala - moderate difficulty

23

Mallampati IV

Hard palate only, severe difficulty

24

O in LEMON

Obstruction/obesity
Muffled voice (hot potato), difficulty swallowing, stridor, sensation of dyspnea are 4 cardinal upper airway obstruction signs.
Stridor and sensation of dyspnea being most worrisome.

25

Stridor

<50% of normal airway caliber or diamater of less than 4.5mm

26

N in LEMON

Neck mobility. C-spine or ankylosing spondylitis, RA.

27

Difficult BMV acronym

Radiation/restriction
Obesity/obstruction/obstructive sleep apnea
Mask seal/Mallampati/Male sex
Age
No Teeth

28

R in ROMAN

Radiation tx to neck is one of strongest predictors of difficult BMV
Restrictive airway disease pts (COPD) or pulmonary edema, ARDS, pneumonia

29

O in ROMAN

Fatties/preggos difficult to bag from resistance on diaphragm.
Angioedema, ludwig angina, abscesses, epilglottits

30

M in ROMAN

Mask seal/mallampati/male
Beards (try jelly but not too much to make the whole face slippery) Male sex and mallampati 3 or 4 are predictors of difficult BVM

31

A in ROMAN

Over 55 tougher from loss of muscle and tissue tone.

32

N in roman

No teeth. Leave dentures in if possible, use gauze in the cheeks or roll lower lip down toward chin and use inner mucosal surface as contact point for bottom of mask

33

Reasons to tube

Failure of airway protection
Failure of ventilation or oxygenation
Anticipated clinical course

34

7ps

Preparation
Preox
Pretube optimization
Paralysis with induction
Positioning
Placement with proof
Post tube management

35

LMA

1. Test cuff on flat surface, make sure no wrinkles then lube
2. Open airway with head tilt or jaw lift
3. Press back of LMA against hard palate as you slide it in,
4. If leaking, ensure head and neck alignment correct, withdraw device 6cm (cuff stays inflated) and reinsert (this frees a folded or trapped epiglottis)
Sizes 3 40-50
4 50-70
5 >70kg

36

King tube

Insert until 15/22 bag connector touches incisors, inflate, slowly withdraw while bagging.
Walls says 1-2cm more after

37

SMART acronym

Surgery
Mass
Access/Anatomy
Radiation
Trauma

38

Cric

Be on dominant hand side
Locate laryngeal prominence
1 finger below is cricothyroid membrane, find dent
R hand Incise skin 2cm vertical
Re identify membrane
1cm horizontal
L hand hook
R hand insert tube
Inflate and confirm

39

DOPE

Displacement
Obstruction
Pneumothorax
Equipment

40

Prep

Assess difficulty
Prepare backups
Lines
Draw drugs
Equipment

41

Preoxygen

8 vital breaths or
NRB and NC 3 mins
Fatties preox sitting up

42

Etomidate dose for keeping down

0.3mg/kg
0.2mg/kg if unstable
IBW plus 30% of excess weight

43

Ketamine dose

1.5mg/kg more can cause myocardial depression and hypotension if catechol depleted

44

Atropine dose

0.01mg/kg for drying effect for awake tubing

45

Propofol dose

1.5mg/kg
1/2 to 1/3 reduction in compromised oldies

46

Midaz

0.3mg/kg

47

Fentanyl

3-5mcg/kg

48

Ketamine to keep them down

1mg/kg q 10

49

Roc to keep down

0.5mg/kg q 20 prn