Airway Pharm

Question 1

Goal of RSI?

Answer 1

Rapidly induce anesthesia and paralysis to optimize intubating conditions

Question 2

Anesthetize

Answer 2

To give drugs to a patient so that no pain can be felt

Question 3

Indications for intubation

Answer 3

FAILURE TO OXYGENATE
FAILURE TO VENTILATE
Inabilty to protect airways(AMS, secretions, pending airway obstruction)
Expected clinical course

Question 4

Absolute contraindications to RSI

Answer 4

Total airway obstruction
Total loss of anatomic landmarks

Question 5

Relative contraindications to RSI

Answer 5

Difficult Airways with unlikely backup
Apneic and unconscious patient
Physiologic parameters (hypoxia, hypotension)
Lack of skill

Question 6

Why are sedatives used in RSI?

Answer 6

-To reduce a patient’s anxiety
-Induce amnesia
-Limit awareness of procedure
-Minimize responsiveness to stimulation/procedure.

Question 7

Complications of sedatives in RSI

Answer 7

Incomplete amnesia (under dosed sedation)
Loss of protective airway reflexes
Respiratory Depression
Airway obstruction
Hypotension

Question 8

What kind of patient receives a sedative during emergency intubation

Answer 8

Patients who need aggressive airway management but are too responsive to tolerate intubation

Question 9

What are the 2 major classes commonly used in airway management?

Answer 9

Sedative Hypnotics and Analgesics

Question 10

Primary contraindication for sedatives

Answer 10

Hypersensitivity

Question 11

What flavors do sedative hypnotics come in?

Answer 11

Benzos, narcotivs, nonbarbiturates

Question 12

Pros an cons of benzodiazepines for sedation

Answer 12

Pros:
Muscle relaxation
Sedation
Anterograde amnesia
Cons:
Large dose necessary
Resp depression
Hypotension

Question 13

What is the reversal agent for benzodiazepines?

Answer 13

Flumazenil(Romazicon)

Question 14

Tell me all about Versed

Answer 14

It’s a benzodiazepine
Dose: 0.05-0.1 mg/kg, for RSI it’s 0.1-0.2 mg/kg
Onset: 60-90 s
Duration: 10-30 min
Not great for RSI due to 10-25% in MAP and lack of analgesia, acceptable for post-intubation continuous sedation
drawbacks: Resp depression, apnea, hypotension, agitation

Question 15

How do benzos work?

Answer 15

They bind to the BZD receptor in CNS, GABA agonist, causing inhibitory effect on neurol excitation

Question 16

Tell me about ketamine for sedation

Answer 16

It’s a dissociative anesthetic
NMDA receptor antagonist, blocks transmission of impulses in the limbic system and cortex
Dose: 1-2 mg/kg
Onset: 20-30 s
Duration: 10-20 min
Good for all RSI except cardiac, HTN,
Drawbacks: Increased secretions, emergence reaction, can drop BP in critically sick

Question 17

Push ketamine fast?

Answer 17

Absolutely not unless you want resp depression and laryngospasm

Question 18

Sympathomimetic

Answer 18

Stimulates sympathetic nervous system

Question 19

Is fentanyl alone a sedative?

Answer 19

No it’s an adjunct used with another one for pts with head injury, cardiac demand, or aortic dissection

Question 20

Tell about how you’ll use fentanyl for sedation

Answer 20

Dose: 1 mcg/kg as adjunct, 3 mcg/kg for pretreatment
Onset: <60 s
Duration: 30-60 min
Drawbacks: Hypotension, resp depression, vomiting, bradycardia

Question 21

When to use Etomidate?

Answer 21

Amidate should be used when you want something fast with a short duration in patients with ACS, Increased ICP, Borderline hypotension/hypovolemia

Question 22

side effects of amidate

Answer 22

Etomidate will:
have little effect on pulse, BP, and ICP
No histamine release
Myoclonus

Question 23

Tell me about the use of etomidate in RSI

Answer 23

Amidate
Dose: 0.3 mg/kg
Onset: 10-15 s
Duration: 3-5 min
suitable for most situations but does lower the seizure threshold
Drawbacks: adrenal suppression and insufficiency with multiple does

Question 24

Propofol for sedation

Answer 24

Sedative hypnotic
Dose: 0.5-1.5 mg/kg followed by 0.5 mg/kg every 2-3 min as needed
Onset: 15-30 s
duration: 5-10 min
SIGNIFICANT HYPOTENSION

Question 25

Why use a paralytic?

Answer 25

Laryngospasm Trismus Reduce Aspiration Risk Muscle Relaxation to Optimize Glottic View

Question 26

Trismus

Answer 26

Spasms

Question 27

Paralytics convert

Answer 27

a breathing patient with a marginal airway into an apneic patient with no airway

Question 28

What to watch out for when using a paralytic?

Answer 28

Patients appear asleep or unresponsive, but are not! No effect on LOC

Question 29

Tell me all about succinylcholine chloride in RSI?

Answer 29

Anectine Depolarizing neuromuscular blocking agent typically used as an initial paralytic Dose: 1-1.5 mg/kg Onset: 45-60 s Duration: 5-9 min(12 min until full resp) Contraindictions: hyperK, malignant hyperthermia, burns, myopathy, renal failure, crush injuries Side effects: fasciculations, hyper K, brady in peds

Question 30

When are nondepolarizing neuromuscular blocking agents ideal?

Answer 30

When pt needs paralysis for extended period of time Need to manage other conditions

Question 31

Tell me about Rocuronium for RSI

Answer 31

Nondepolarizing Dose: 0.6-1.2 mg/kg Onset: 30-60s Duration: 30+ min

Question 32

Tell me about vecuronium for RSI

Answer 32

Nondepolarizing Dose: 0.1 mg/kg Onset: 120-180 s Duration 45-60 min

Question 33

What reverses vecuronium

Answer 33

Sugammadex

Question 34

Roles in RSI

Answer 34

Airway proceduralist Airway assistant Drug administrator

Question 35

IE SOAP MEADE

Answer 35

Inquiry about allergies Explain the procedure Suction ready Oxygen Airway prep and redundencies Pharm prep Monitor prep and vitals Equipment Difficult airway determination Evaluate cric landmarks

Question 36

O2 sat goal for RSI

Answer 36

100%

Question 37

AOL

Answer 37

Atropine 0.02 mg/kg for brady in peds Opioid: 3 mcg/kg for TBI, ACS, aortic dissection, or subarachnoid hemorrhage Lidocaine: 1.5 mg/kg for TBI, decrease airway reactivity in asthma

Question 38

If O2 sats drop below 94% then what?

Answer 38

Terminate and oxygenate for 3 min BVM w/ 1 second breaths just enough to make chest rise