RSI

Question 1

What are the main reasons a patient emerges from anesthesia?

Answer 1

Discontinuation of anesthetic agents (versed, fent, volatiles), stimulation (verbal, noxious), and rising CO₂ levels which trigger spontaneous ventilation

Question 2

What is the primary objective of RSI?

Answer 2

Prevent pulmonary aspiration

Question 3

How does rapid sequence induction (RSI) reduce the risk of aspiration?

Answer 3

By minimizing the time between loss of airway reflexes and securing the airway, and by using cricoid pressure to occlude the esophagus.

Question 4

Name indications for RSI (think anyone who’s at risk for aspiration)

Answer 4

Trauma
Esophageal obstruction
NPO guidelines not followed
Acute abdomen and bowel obstruction
Active GI bleed or upper airway bleed
Pregnancy
Abdominal mass or ascites
Severe GERD
N/V

Question 5

What is the purpose of cricoid pressure during RSI?

Answer 5

To compress the esophagus against the cervical vertebrae

Question 6

Is the cricoid pressure maneuver (Sellick’s maneuver) always effective?

Answer 6

No—it may impair glottic view and 75% of people have an esophagus to the right of the trachea

Question 7

What are major problems with cricoid pressure during intubation?

Answer 7

Improper pressure can worsen glottic view, making intubation harder

If the patient vomits, cricoid pressure can increase the risk of esophageal rupture**

Question 8

What are some contraindications to cric pressure?

Answer 8

Airway trauma
Lack of properly trained assistant
Fractured larynx or cricoid
Active vomiting
Esophageal foreign body near cricoid
Esophageal disease
Cervical fracture near C6

Question 9

Name complications of intubation

Answer 9

Dental trauma, esophageal intubation, laryngospasm, bronchospasm, right mainstem intubation, vocal cord injury

Question 10

What is the most common cause of death related to airway management?

Answer 10

Pulmonary aspiration

Question 11

When does bronchospasm occur?

Answer 11

During intubation or extubation

Question 12

What increases the risk of bronchospasm?

Answer 12

Patients with reactive airway disease (RAD) like asthma, COPD

Question 13

What are signs of bronchospasm during anesthesia?

Answer 13

High peak pressures, wheezing, poor bag compliance, desaturation, absence of tube fog

Question 14

How do you treat a bronchospasm?

Answer 14

100% O2
Beta 2 agonist (albuterol)
Lidocaine IV or through ETT if intubated
Deepen volatile (if intubated)
IV atropine, epi (last option)
Fentanyl

Question 15

Name extubation criteria

Answer 15

Adequate NMBA reversal (sugam)
TOF 4/4 with sustained 5 sec tetany
Vt and RR adequate to eliminate CO2
Strong hand grip
Strong cough
Sustained head lift>5 sec
Airway reflexes (swallow and tongue movement)
Maintain oxygenation/ventilation without stimulation*

Question 16

What are important questions to ask before extubation?

Answer 16

Can I maintain a patent airway? Can I reintubate if needed? Are aspiration risks reduced?

Question 17

What is the overall goal of extubation?

Answer 17

Smooth, atraumatic extubation

Question 18

When can you extubate?

Answer 18

Either while deep, or awake

Question 19

What patients would you NOT extubate deep?

Answer 19

Depends on patient history, aspiration risk, difficult intubation, OSA

Question 20

What is the purpose of giving a positive pressure breath before extubation?

Answer 20

Clears secretions and helps push them away from the vocal cords

Question 21

When should the ETT be gently removed during extubation?

Answer 21

Pull the tube on exhalation to ensure that secretions are projected away from cords

Question 22

If you pull the ETT on inhalation, what does that put the patient at risk for?

Answer 22

Laryngospasm

Question 23

What should be done immediately after removing the ETT?

Answer 23

Apply oxygen with PPV, and listen for breath sounds/mask fog

Question 24

After extubation, what could hear crowing and turbulent sounds indicate?

Answer 24

Partially obstructed airway

Question 25

What are reassuring signs after extubation?

Answer 25

Strong cough, good chest rise, audible breath sounds, alertness, purposeful movement

Question 26

What are some worrisome signs post extubation?

Answer 26

Hypoxia, hypercapnia, acidotic, agitated, hemodynamic instability, larynx and tongue edema, and increased secretions

Question 27

What is laryngospasm?

Answer 27

Reflex closure of the vocal cords causing partial or total airway obstruction

Question 28

When is laryngospasm most likely to occur?

Answer 28

During light anesthesia, especially Stage II or extubation in non-deep patients

Question 29

What are initial treatments for laryngospasm?

Answer 29

Suction secretions, jaw thrust, 100% O₂ with positive pressure, Larson’s maneuver

Question 30

What are pharmacologic treatments for laryngospasm?

Answer 30

Succinylcholine 10–20 mg, IV lidocaine

Question 31

What maneuver can break a laryngospasm by causing pain and jaw thrust?

Answer 31

Larson’s maneuver – pressure at the laryngospasm notch behind the earlobe

Question 32

What causes negative pressure pulmonary edema?

Answer 32

Strong inspiratory effort against an occluded airway like with laryngospasm or occuluded ETT (can even be from biting)

Question 33

What patient population is most at risk for NPPE?

Answer 33

Young, muscular patients***

Question 34

What are signs of NPPE?

Answer 34

Pink frothy sputum, desaturation, respiratory distress, crackles on auscultation*

Question 35

How is NPPE treated?

Answer 35

Keep them intubated, lasix, 100% FiO2, PEEP and sedation*

Question 36

What are common complications of tracheal extubation?

Answer 36

Coughing, HTN, tachycardia, glottic trauma, hypoxemia, aspiration

Question 37

How can coughing during extubation be harmful?

Answer 37

Can cause bleeding, hernia repair rupture, increased IOP or ICP

Question 38

What is the biggest sign the patient has glottic edema?

Answer 38

Stridor

Question 39

What are causes of glottic edema?

Answer 39

Repeated intubation attempts ETT too large Excessive coughing while intubated

Question 40

What are treatments for glottic edema?

Answer 40

IV steroids (Decadron), racemic epi, and humidified oxygen May need to reintubate

Question 41

What types of surgeries create high-risk extubation situations?

Answer 41

Head and neck surgeries*** ENT, oral/maxillofacial, airway tumors, cervical spine procedures

Question 42

Why are head and neck issue surgeries high-risk for extubation?

Answer 42

Altered airway anatomy, edema, bleeding risk, or limited ability to reintubate quickly

Question 43

If you have to reintubate your patient, should you use the same technique you did the first time?

Answer 43

NO! Reintubation fundamentally different from the initial intubation

Question 44

How is reintubation different from initial intubation?

Answer 44

It’s often urgent, with a compromised airway, edema, secretions, and patient instability

Question 45

What are common indications for reintubation?

Answer 45

Post-extubation respiratory failure, sustained hypoxemia, hemodynamic instability

Question 46

What is the most important thing to consider before extubating high-risk patients?

Answer 46

Can I reintubate quickly and safely if needed?

Question 47

Why is succinylcholine preferred in difficult airway scenarios?

Answer 47

Quick onset/offset allows intubation or spontaneous breathing to resume quickly if intubation fails

Question 48

What should be done when faced with a difficult airway and an urgent surgery?

Answer 48

Consider awake intubation with topical anesthesia if intubation is likely to be difficult and ventilation is not guaranteed

Question 49

What is always a safe backup plan in uncertain airways?

Answer 49

Awake fiberoptic intubation with topical anesthesia and oxygenation