Airway and Breathing

Question 1

What three categories/ reasons to intervene on the airway?

Answer 1

1. Obtain or maintain their airway
2. Oxygenation or ventilation issue
   3.Clincal progression of emergency

Question 2

What is NODSAT?

Answer 2

Nasal cannula @5lpm while ventilating with a bvm @15lpm

Question 3

How do you measure a OPA?

Answer 3

Corner of mouth to ear lobe

Question 4

How do you measure a NPA?

Answer 4

From tip of nose to the tragus of ear

Question 5

At what Sat’s do you provide supplemental o2? (In most cases)

Answer 5

<94%

Question 6

What is PEEP? When do you use it?What are the contraindications?

Answer 6

-Positive End Expiratory Pressure
-Pt.’s that remain hypoxic even after high flow o2 and ventilatory support
-Contraindicated in: cardiac arrest, >12 YOA when SBP <90mmHg, <12 Systolic blood pressure ≤ lower limit for age range as per pediatric vital signs, suspected pneumo, traumatic cause of respiratory issues

Question 7

What PEEP do you start with? What is the max?

Answer 7

start with 5cmH2O and max is 10cmH2O

Question 8

When is a SGA indicated?

Answer 8

When a pt. is unable to protect their airways due to unconsciousness

Question 9

What are the contraindications for a SGA?

Answer 9

-inabilities to place the device due to difficulties with mouth opening
-Known or suspected FBAO
-Trauma to trachea, neck or oropharynx
-Caustic ingestion
-Active vomiting

Question 10

what is CPAP?

Answer 10

Continuous Positive Airway Pressure

Question 11

When is CPAP indicated?

Answer 11

-Able to maintain their own airway, with no vomiting
-13 and older
-Resp rate >24, Sats of <94% even when on 02
-Asthma, Pneumonia, Submersion injuries, COPD

Question 12

When is CPAP contraindicated?

Answer 12

Patient age 12 years and less
Decreased level of consciousness, or inability to follow commands
Respiratory arrest or hypoventilation
Patients who are in imminent or actual respiratory failure (i.e., whose respirations are slow, feature shallow tidal volumes, and whose level of consciousness is falling) are not candidates for CPAP; these patients must be ventilated with a bag-valve mask (and may benefit from PEEP use)
Unable to fit mask to patient’s face
Vomiting or any other risk of aspiration
Traumatic cause of respiratory distress
Tracheostomy
Suspected or known pneumothorax
Systolic blood pressure < 90 mmHg

Question 13

Awake intubation Indicators?

Answer 13

1. Patients with predicted difficult airway anatomy
2. Predicted difficult physiology
3. You must call clinical prior to intubation

Question 14

What are the procedures of the awake intubation?

Answer 14

-call clinicall to discuss plan
-Bring sats of pt. to the highest you can get (usually above 94%)
-NODSAT placed (Nasal cannula at 5lpm)
-500ml’s N/S bolus (for adults, 10ml/kg for children)
-Induction agents: Ketamine, fentanyl, midaz
-Lidocaine for topical anesthetic of cords (spray as you go approach)
-DL or VL approach (VL has a higher rate of first pass succes)

Question 15

What is the procedure of confirming tube is placed correctly in the trachea?

Answer 15

There has to be 2 of the following to confirm placement:
1. See the tube pass the cords
2. End tidal wave form (not just the number, actual wave form)
3. Auscultation of stomach for air entry (this is a bad sign and confirms tube was placed in esophagus)
4. Auscultation of lungs to confirm air entry/ Right main stem

Question 16

What is the anesthetic induction plan?

Answer 16

Based upon 4 criteria:
1. Amnesia
2. Analgesia
3. Autonomic Stability
4. Areflexia

Question 17

What is shock index?

Answer 17

Greater than 1 or equal to:
- HR is equal to or greater then the SBP

Less then 1:
- HR is less then SBP

Shock index is a standard to indicate that the pt. is compensating for shock, comparing HR to SBP.

Question 18

Ketamine Dosing for induction

Answer 18

Shock index of greater than or equal to 1:
-1mg/kg for induction
-half the amount for induction for maintence every 10-15mins

Question 19

Fentanyl Dosing for induction

Answer 19

50-100mcg for induction and maintenance every 10-15mins

Question 20

Phenylephrine dosing for periintubation

Answer 20

100mcg every 3-5 mins to maintain SBP >90mmHg
Greater than 500mcg Clinicall is required to give more

Question 21

The dosing for all meds that could be used? (the diagram off BCEHS Handbook)

Answer 21

Question 22

SOAPME

Answer 22

1. Suction
2. O2
3. Airway equipment (DL/VL, different size blades, ET tube with 10cc, lube, back up option, bougie, stylet.
4. Pharmacology
5. Monitor and thresholds set
6. End tidal

Question 23

When is surgical airways indicated?

Answer 23

When the pt. is unable to be ventilated or oxygentiated by other means.

Question 24

What methods are used for surgical airways?

Answer 24

1. > or equal then 12 years of age:Bougie-assisted cricothyrotomy using a scalpel, bougie and 6 tube
2. < 12 years of age: Needle cricothyrotomy

Question 25

Contraindications for surgical airways?

Answer 25

Inability to landmark

Question 26

Do you ventilate or start compressions when you find a pulseless pt.?

Answer 26

Unconscious patients should have their breathing and circulation assessed concurrently. If the patient is found to be pulseless, immediately begin chest compressions and attach a defibrillator – do not attempt to ventilate these patients prior to beginning CPR. In cardiac arrest, the lack of a patent airway is significantly less important than the need to establish circulation.

Question 27

When do you provide abdominal thrusts?

Answer 27

When the pt. has a fully obstructed airway and still conscious

Question 28

At what age do you perform back blows and chest compressions? What is the ratio?

Answer 28

<1 year of age, 5 back blows followed by 5 chest compression, then look in mouth for FB to remove, follow this until dislodged or unconscious.

Question 29

What characteristics are accompanied in a bronchoconstriction pathology?

Answer 29

wheezing coughing airway inflammation I:E ratio that increase on the expiratory phase due to air trapping

Question 30

What is the progression of treatments for status asthmaticus?

Answer 30

1. O2 2. Salbutamol 3. Ipratropium 4. Dex (Clinicall consult required) 5. IM EPI 6.IV EPI 7. Mag 8. CPAP 9. Intubation

Question 31

WHIPS

Answer 31

Worst you ever had it? Hospitalized for this? Infections/ ICU stays for your bronchospasms Puffer use? Steroid use?

Question 31

BREATHE

Answer 31

Bacterial infection Reactive airway Embolism (PE) Anaphalyxsis Tension Pneumo Heart Failure Electrical excitation of the heart

Question 32

What portions does croup and epiglottitis inflame?

Answer 32

the upper airways causing narrowing, this is especially concerning for pediatric population

Question 33

What is the main difference between croup and epiglottitis?

Answer 33

drooling! of the pt. This is highly indicative of epiglottitis Barking cough like a seal is highly indicative of croup

Question 34

Treatments for croup?

Answer 34

5mg EPI in 5ml nebulized over 15mins Dex (Clinicall consult required) Antipyresis - 15mg/kg tylenol

Question 35

WELLS Criteria

Answer 35

Clinical signs of a DVT PE is the most likely HR >100 Immobilization for 3 days or more or surgery in the last 4 weeks Previous Dx. of DVT or PE Hemoptysis Malignancy within the last 6 months

Question 36

Virchows Triad

Answer 36

Hypercoagulability Endothelial injury to Blood vessels Stasis of blood flow