Adams: Respiratory Emergencies Flashcards
How do you support a pt who is breathing fairly adequately?
Supplemental O2 (Nasal cannula or mask) and position them to maximize air exchange
How do you support a pt w/ labored breathing?
CPAP (sticking your head out the window) or BiPAP
-helps ppl w/ sleep apnea
How do you support a pt prior to intubation?
bag-valve mask
Turn O2 up to 15 L!
Only do this for a little bit b/c they will throw up!
What injuries might demand airway management?
facial
flail chest
neck
What illnesses can require airway management?
Pulmonary edema COPD aspiration infection drugs allergic reaction (anaphpylaxis, angioedema of the tongue--> ACE inhibitors)
What conditions leave the airway unprotected?
Decreased LOC: GCS hypercapnia and hypoxia
What are the primary reasons not to intubate?
Adequate airway protection is present
Oxygenation by other less invasive means is possible
Pt is DNI (do not intubate)
What are back ups to intubation?
combitube
king airway
laryngeal mask airway (LMA)
What do you do if your attempts at intubation fail?
Cricothyroidotomy
Don’t have to worry about blood as much!
What pts may be more difficult to intubate?
short neck prominent upper incisors receding mandible limited jaw opening limited cervical spine mobility
What is RSI?
Rapid Sequential Intubation
What is Succinylcholine?
An ULTRASHORT acting skeletal muscle relaxant that combines w/ cholinergic receptors at the motor endplate to produce flaccid paralysis
Does succinylcholine bind more firmly than acetylcholine?
YES
What is succinylcholine broken down into?
Pseudocholinesterases break it down into succinylmonocholine
The depolarizing action of succinylcholine at muscle’s motor endplates is clinically visible as…
muscle fasciculations
How long does it take for succinylcholine to take effect, when is the optimal time to intubate and how long does the paralysis last?
30-60 seconds
60-90 seconds
8-12 minutes
What are SE of succinylcholine and how do you treat them?
Bradycardia- atropine
Increased: IGP ICP IOP serum K levels (if already high they can die from cardiac arrythmia) temperature
What is the “appearance” of someone who has been given succinylcholine?
eyes like a mole
moist as a slug
weak as a kitten
What effects does succinylcholine have on muscarinic receptor and nicotinic receptors?
SLUD
salivation, lacrimation, urination and defecationa
Nicotinic>
striated muscle problems>
fasciculation and weakness
What are two non-depolarizing meuromuscular blockers?
vecuronium
Rocuronium
What is vecuronium?
Neuromuscular block
Competes for CHOLINERGIC RECEPTORS>
flaccid paralysis
If you use vecuronium when are the ultimate intubating conditions and how long does it last?
2.5-3 mins
25-40 mins
recovery 45-60
What is vecuronium metabolized by?
liver and kidneys
- renal failure does NOT affect recovery time
- liver failure/cirrhosis may DOUBLE recovery time
Does vecuronium cause problematic hypotension or tachycardia?
no
Why is rocuronium unique among neuromuscular blocking agents?
It’s onset of action is almost as quick as succinylcholine
What is rocuronium’s onset time, how long does it take to cause complete paralysis and how long does it act?
Onset muscle relaxation- 15-20 s (Fast as succinylcholine)
Complete paralysis- 45-60 s
Duration of action 25-60 minutes (takes a long time to start breathing again)
An ideal sedative has….
rapid onset (20-30 s) short half life
What is an example of a classic barbiturate that isn’t used any more?
Thiopental
*causes hypotension
What is thiopental?
ultrashort acting anesthetic agent w/ a rapid onset of action
*also has antiepileptic properties
When are peak concentrations of thiopental achieved in the brain?
w/in 30 s
What is a SE of thiopental?
hypotension
What is a non-barbiturate sedative?
ketamine
What is ketamine?
rapid acting anesthetic that induces a DISSOCIATIVE STATE in which the pt is unaware of any sensory or painful stimuli that DOESN’T AFFECT RESPIRATORY DRIVE
What causes ketamine’s effects?
disruption of conduction between the thalamocortical access
When should you use ketamine?
SEDATION AND ANALGESIA for children undergoing complex LACERATION REPAIRS
What are the optimal intubating conditions, peaking time and length of Ketamine’s effects?
30 s
peak 60-90
last 5-10
Ketamine is also mildly sympathomimetic. Why is this useful?
trauma and HYPOTENSIVE states (doesn’t affect bp)
bronchodilatory property is useful in ASTHMATICS
What are the SE of Ketamine?
Emergence reactions w/ vivid imagery, hallucinations and irrational behavior.
Hypertension
Increase in upper airway secretion (give atropine as needed)
How do you treat emergence reactions?
co administration of BEZODIAZEPINES
When using ketamine for RSI intubation what do you use to prevent emergency reactions?
longer acting sedative
What is an example of a benzodiazepine?
midazolam
What is midazolam?
short acting CNS DEPRESSANT which also causes a LACK OF RECAL
What SE are associated w/ midazolam?
slight drop in MAP
How long does it take to achieve adequate sedation w/ midazolam?
2-2.5 mins
What are two non-receptor rapid acting sedative hypnotics?
propofol*
etomidate
What is propofol?
Modified phenol that is extremely LIPOPHYLIC. IT INFILTRATES the lipid bilayer of the nerve cell’s membrane and DISRUPTS NERVE CONDUCTION
Propofol:
Onset of action?
Peak affect?
W/in ONE circulation time between heart nad brain (10-20 s w/ IV bolus) VERY SHORT ACTING
Peak affect in 20-40 s
What is unique about the offset of propofol?
RAPID offset
Duration of action is 8 minutes or less
What are the SE of propofol?
APNEA (quit breathing)
Potential cardiovascular depressant> HYPOTENSION (BIGGEST ISSUE)
What sedative is also an anti-emtic that can lower ICP and is often useful for brief procedures?
Propofol
What is Etomidate?
An Imidazole
Rapid acting hypnotic NOT related to the others.f
Has NO ANALGESIC OR AMNESTIC properties
but can LOWER ICP
What is the onset of action of etomidate and how long does it last?
20-30 seconds
last 20 mins
What sedative is ideal for hypovolemic pts or those in hemorrhagic shock? Why?
etomidate
Doesn’t produce cardiovascular depression
What are SE of etomidate?
vomiting and myoclonus
What is an example of a typical RSI protocol?
-3 preoxygenate
-.55 Etomidate
-.45 Succinylcholine
0 intubation
+30 assess tube placement
8 check pt temp (b/c of succinylcholine)
What are the 6 steps of intubation?
- Preoxygenate and prepare
- Pretreat/prime (fentanyl)
- Paralyze (succinylcholine or rocuronium; emotidate)
- Intubate
- Confirm tube placement
- Medicate for long term management
How do you confirm tube placement?
- breath sounds in both axillae and not over stomach
- correct PaCO2 (purple BAD)
- Bulb suction device
- Maintenance of PaO2 (capnography)
- CXRAY
A 39 y/o pt suffered from a 30% third degree burn 16 hrs ago. She is having increased respiratory difficulty and will need to be intubated. Which of the follwoing drugs is most liekly to cause potentially life-threatening arrythmia?
Succinylcholine
*worry about elevated K
A four year old comes in w/ a laceration to the lip. What is the best choice?
Ketamine IM
midazolam works but makes kids hyper
A 65 y/o in cardiogenic shock and respiratory distress. You need to use RSI and intubate them. Most useful drug is:
Etomidate
ketamine–don’t affect bp
A 74 y/o pt w/ afib. Need to shock them. What do you use?
Propofol
Which of the following is the most appropriate intervention if you can’t intubate a pt after two attempts?
Use a combitube
Succinycholine SE?
Hyperkalemia
Muscle twitching
Etomidate SE?
Muscle spasm
Adrenal suppression
Propofol SE?
Hypotension
Midazolam SE?
Amnesia
Hypotension
Ketamine SE?
Hypertension
Increased ICP
Rocuronium SE?
?
