AIRWAY MANAGEMENT Flashcards
MANAGEMENT
6 P’s OF RSI
Preparaton
Pre-Oxygenation
Pretreatment
Paralysis with Induction
Positioning
Place the tube with proof
Post-intubation management
PREPARATION
“STATICS”
Suction: wide bore suction with second suction available
Tube: Endotracheal Tube (F: 7.0-7.5, M: 7.5-8.0)
Airway Adjuncts: OPA, LMA
Airway Pharmacology:
* Induction Agent: Ketamine, Propofol
* Paralytic Agent: Rocuronium
* Pressors: Phenylephrine
* Fentanyl
Tape
Introducer (stylet)
Circuit: Cardiac, Vent, BVM with a PEEP valve
Capnography: End-tidal C02 Device (colorimetric vs. quantitative)
Connections
Scope: Laryngoscope – direct vs. video (no. Mack 3 or 4; 7.5 mm – F, 8 mm – M)
Sp02
PRE-OXYGENATE
Breath 100% 02 for 3-5 minutes
High flow (15 L/m) 02 via nasal cannula during laryngoscopy
PRETREATMENT
Anxiety: +/- 1-2 mg Midazolam
Cardiovascular Disease: 1-3 mcg / kg Fentanyl ~ 3 minutes prior to induction to mitigate sympathetic discharge
Elevated ICP: 1-3 mcg / kg Fentanyl to mitigate sympathetic discharge
Reactive Airway Disease: Salbutamol 4 puff OR 2.5 mg nebulizer
Low evidence for Lidocaine
PARALYSIS WITH INDUCTION
Ketamine 1-2 mg / kg IV
OR
Propofol 1-2 mg / kg IV
THEN
Succinylcholine 1-2 mg/kg
Rocuronium 0.6 - 1.2 mg / kg
THEN
OR
Ketamine: 100 mg IV, 1 mg / kg
Rocuronium 100 mg
Phenylephrine 100 mcg IV q 1 min PRN for post intubation hypotension
POSITION
Position patient into sniffing position: ears line up with the notch
Open mouth: achieved when mandible translates
Blade Insertion: accomplished when 1” of blade is in midline of mouth
Find epiglottis: accomplished when sliver of epiglottis is seen
Perform ELM: this is accomlished when valeculla become a space
Seat blade: epiglottis pops up
Visualize posterior notch
Pass tube: intruduce ETT into the right side of the patient’s mouth, visualize the tip superior to notch
Remove the stylet
Inflate cuff then confirm end tidal CO2
21 cm in females
23 cm in males
PLACEMENT
ETC02 after 6 breaths:
Calorimetric - Yellow
End-tidal capnometry
Chest rise
Auscultation
Tube Misting
Post intubation CXR
POST-INTUBATION MANAGEMENT
Continuous ETC02
Mechanical Ventilation
CXR
Analgesia & Sedation:
Propofol: 10 - 50 mcg / kg / min, 30 mcg / kg / min most common
Fentanyl: 10 - 50 mcg / king / min, 30 mcg / kg /. min most commone
Rocuronium: 50 - 100 mg q 45 min
Further resuscitation:
Phenylephrine 100 mcg IV q 1 min PRN for post intubation hypotension
DOCUMENTATION
INDICATIONS FOR ADVANCED AIRWAY
Failure to oxygenate
Failure to ventilate
Failure to Protect the Airway (ie decreased LOC, drug overdose)
Provide Patency (ie obstruction, epiglottitis, thermal burns, anaphylaxis,)
Predicted Deterioration
LARYNGOSCOPY EXAMINATION
Look externally: habitus, GCS/ Altered LOC, external signs of trauma / burns
Temporomandibular Joint Mobility and Manidbular Protrusion - Class 1 - 4
Mouth opening and Mallampati Classification - 3 finger breadth mouth opening, Mallampati 1 - 4
Dentition: Dentures, dentition (loose caps, crowns, missing teeth)
Thyromental Distance: 3,2,1 guideline - 3 finger breadths from chin to hyoid bone, 2 finger breadths from the hyoid bone to the thyroid cartilage
Atlanto-occipital extension
PREDICTORS FOR DIFFICULT BVM VENTILATION
B - beard or other mask seal issues
O - obesity
O - older
T - toothless
S - Snoring, Stiffness
PREDICTORS FOR DIFFICULT EXTRA GLOTTIC DEVICE
M - mouth opening limited
O - obstructing pathology
D - displacement, distortion, disrupted airway
S - stiff lungs or chest wall
PREDICTORS FOR NON-REASSURING AIRWAY
Long upper incisors
Maxillary overbite
Mallampati 3 & 4
Stiff mandibular space
Short thyromental distance
Limited neck extension
Limited mouth opening
Short thick neck
AIRWAY MANAGEMENT PLAN
Plan A: Attempted direct laryngoscopy ± bougie assist
Plan B: Video laryngoscopy
Plan C: LMA and call for additional assistance
Plan D: if failed airway with a can’t intubate, can’t ventilate situation exists, surgical
cricothyroidotomy.
CONTRAINDICATIONS TO RSI
Anticipated difficult airway, especially difficult BVM
Inadequate clinician familiarity with technique
Unnecessary (i.e. the patient is in cardiac arrest)
MALLAMPATI CLASSES
Class I: soft palate, uvula, fauces, pillars visible
Class II: soft palate, uvula, fauces visible
Class III: soft palate, base of uvula visible
Class IV: only hard palate visible
CORMACK LEHANE GRADES
Grade 1 - Full view of the glottis
Grade 2a - Partial View of the Glottis with view of the arytenoids and cords
Grade 2 b - only the arytenoids are seen
Grade 3 - only the epiglottis is seen
Grade 4 - neither the glottis or epiglottis seen
INDICATIONS FOR NMBA’s
Intubation is likely to be successfull
Oxygenation can be maintained with BVM or EGD if the patient desaturates during the attempt
A forced to act scenario
FAILED AIRWAY CRITERIA
Definition:
>/3 intubation attempts by and experienced operator
Sp02 falling despite BMV or EGD
Impossible intubation after a single attempt
Can’t intubate, can’t ventilate = CRIC
TROUBLESHOOTING
5 MANAGEMENT STRATEGIES FOR BVM FAILS
- Ensure proper technique is being used (two-handed)
- Oral airways and nasal airways should be inserted
- Ensure proper mask size and excellent seal maintained
- Cricoid pressure should be released
- Insert a supraglottic airway (i.e. LMA) if the above fail
3 MANAGEMENT STRATEGIES FOR INTUBATION FAILS
BURP (Backwards, upwards and rightwards pressure)
Tracheal Tube Introducer
Video Laryngoscopy
FAILED AIRWAY CRITERIA
Definition:
>/3 intubation attempts by and experienced operator
Sp02 falling despite BMV or EGD
Impossible intubation after a single attempt
Can’t intubate, can’t ventilate = CRIC
CRASH AIRWAY
Cardiopulmonary arrest or near state of arrest and is likely to be unresponsive to direct laryngoscopy
Straight to intubation
If unable to intubate:
BVM
THEN
Succinylcholine 1-2 mg / kg
THEN
Reattempt intubation up to >/ 3 times with experienced operator
CRICOTHYROIDOTOMY
Equipment:
Scalpel
Artery forceps
Bougie
Size 6 ETT
Technique:
Extend the neck to make anatomy easier to palpate (“laryngeal handshake”)
Stabilize thyroid cartilage with non-dominant hand.
Hold scalpel with dominant hand, can rest on sternum for support.
Make a 4cm vertical incision over cricothyroid membrane. (may extend from mandible to
sternum if you can’t palpate the anatomy)
Palpate the cricothyroid membrane ± blunt dissect with forceps until membrane is
visible.
Make a horizontal incision through the cricothyroid membrane.
Dilate with a gloved little finger
Pass a bougie alongside the finger into the trachea
Confirm bougie placement with finger (should also get holdup at the carina ± sensation
of tracheal rings).
Pass ETT over the bougie. May need to corkscrew the ETT to advance. Advance the
ETT until the cuff is no longer visible.
Hold the ETT in place and remove the bougie.
Confirm placement with ETCO2 + adjunctive measures (CXR, misting, chest rise, etc).
Connect to BVM!
