Advanced Airway Management Flashcards
Name three medications to paralyse the patient during intubation
Suxamethonium, Rocuronium and vecuronium
Name 6 induction agents that are commonly used during intubation
Ketamine, thiopental, midazolam, fentanyl, etomidate and propofol
In which groups is pretreatment mostly done during intubation?
Pediatrics
People deemed as high risk of intubation response
What is the drug of choice for pretreatment during intubation?
Fentanyl or lignocaine(adults only)
Name three medications that can be considered for the patient post intubation care
Analgesia, sedation and long term paralytics(not routine?
List five important things to monitor during the post intubation care
- ABG/VBG
- Saturation of oxygen with pulse oximetry
- EKG for 3 leads
- Monitor blood pressure non invasively or invasively
- Chest X ray for Endotracheal tube placement
Capnography if it is available
List 6 conditions/factors that limits the effectiveness of pulse oximetry.
- Hypothermia
- Hypovolemia/hypotension
- High ambient light
- Nail polish
- Carbon monoxide poisoning
- Cardiac arrest
What is the value of the ETCO2 capnometry attached at the end of intubation as a proof of intubation?
Tells us about ventilation, perfusion and metabolism by measuring oxygen
How do you confirm that the tube has been placed correctly?
Attach ETCO2 as an objective measure of proof of placement
Once Endotracheal tube is inserted, you inflate the cuff with either a 10 ml syringe or cuff manometer
Check the measurements of the ET tube at the teeth or lips and note it down
Check for chest rise and fall then auscultate the lung fields and epigastric
Secure the ETT
6 complications of endotracheal intubation
Infections-Pneumonia
Bronchospasm/laryngospasm
Stomach/oesophageal intubation
Trauma: lip, mouth, teeth, airway or vocal cords
Tension Pneumothorax
Right main bronchus intubation
What are the 4 common causes of drop in sats during/just after intubation?
Displacement of endotracheal tube either to the right main bronchus or oesophagus
Obstruction of ETT/circuit
Pneumothorax
Equipment failure
Stomach full of air especially in children
Outline the step ladder of intubation that is used to guide what to do next if one method fails?
Laryngoscope guided endotracheal tube insertion=>supraglottic airway=>final attempt at face mask ventilation=>cricothyroidotomy
What is a measure of failure to oxygenate?
Hypoxia/hypoxemia
What indicates failure to ventilate
Hupercapnia
Indications for active airway intervention
Respiratory Failure: persistent and or worsening hypoxia, severe hypercarbia/respiratory
acidosis.
Airway Protection: absent gag, depressed level of consciousness, excess secretions.
Impending or existing airway obstruction: mass, infection, angioedema, foreign matter or excess secretions, etc.
Facilitation of further studies or to protect the airway during transport when
deterioration may be anticipated.
What are the signs of respiratory failure?(3)
Failure to oxygenate:Persistent or worsening hypoxia
Failure to ventilate:Hypercarbia and respiratory acidosis
In select patients who are awake and alert, noninvasive positive pressure ventilation (BiPAP) may be an option to delay or prevent intubation in the setting of hypoxic or hypercapneic respiratory failure.
3 features suggestive of inability to protect airway
Decreased level of consciousness GCS<8
Absent gag reflex or absent or weak cough reflex
Excess secretions
If the patient can tolerate the insertion of an oropharyngeal airway, are they able to protect their airway?
No, they can’t that is why they can tolerate it(their level of consciousness is too low)
When a patient has decreased level of consciousness that they cannot protect their airways, what three things should be considered before providing active intubation?
Treat reversible or Transient causes of decreased level of consciousness
1. Hypoglycemia
2. Opioid overdose
3. Post ictal state
List three clinical manifestations of hypercapnia
Somnolence
Decreased level of consciousness
Agitations
List 5 situations in which intubation can be considered even though the patient is not in respiratory failure but there is anticipated deterioration expected.
Anaphylaxis
Angioedema
Severe burns or smoke inhalation
Penetrating neck trauma with an expanding neck hematoma
Epiglottis and deep face neck infections
This can be done prior to transfer
Name at least one situation where intubation can be indicated to facilitate medical evaluation.
A trauma patient who may be agitated or combative
These patients often require
emergent CT imaging as part of their initial workup. If they require sedation to
facilitate adequate imaging or procedures, intubation may be required for airway
protection
Is airway management only intubation?
It can be as simple as providing supplemental oxygen or repositioning the patient
What are the first steps in management of someone who is hypoxic but can protect their airway?
Supplementary oxygen via nasal prong then simple facemask then partial rebreather mask then non rebreather mask then non invasive positive pressure ventilation(BiPAP/BVM)
What is the most common cause of
airway obstruction in the semiconscious or unconscious patient?
Loss of muscle tone causing the tongue and soft tissue to occlude airway
That is why it is important to position the patients well.
Absolute contraindications of non invasive positive pressure ventilation (4)
coma, cardiac arrest, respiratory
arrest and any condition warranting immediate intubation
Indication of NIPPV
COPD
Cardiogenic pulmonary oedema
severe respiratory acidosis,
hypoxia, dyspnea, tachypnea and increased work of breathing
Relative contraindications of NIPPV(5)
Eviidence of airway obstruction,
Cardiac instability (shock requiring pressors,
ventricular dysrhythmias),
GI bleeding,
Inability to protect airway, and
status epilepticus.
Indication for crash intubation
Indicated in pulseless, and apneic patients, often without the use of preoxygenation or medications
What is defined as urgent intubation
refer to patients needing intubation within minutes rather than seconds and do allow for the use of preoxygenation and induction medication.
What is the best way to confirm endotracheal tube placement?
Watching the ETT pass through the vocal cords
Other methods include CXR, auscultation of the lung and epigastrium and end tidal CO2 measurements through a ETCO2 capnometry
What is RSI?
Rapid sequence intubation (RSI) is a method that attempts to simultaneously sedate and paralyze a patient while creating optimum intubating conditions. The major goal is to leave the airway unprotected for the shortest time possible
The procedure assumes that the patient may have a full stomach and is at great risk of vomiting
and aspiration.
Features that makes bag valve ventilation or oral tracheal intubation difficult to perform(4)
Long beards
Short thick neck
Recessed chin
Large tongue
What is the MALLAMPITI SCORE?
Score for predicting intubation difficulty that is assessed by asking the patient to stick their tongue out while opening their mouth widely which allows for the posterior pharynx to be seen visibly and divided into 4 classes
What is class 1 mallampati?
full visibility of the tonsils, uvula, and soft palate.
The more limited class three and class-four views may be associated with difficult intubations.
List 6 materials needed for imtubation
Suction
Oxygen
Airway adjuncts
Pharmacology
Monitoring equipment
IV line
Name two commonly used laryngoscope blades.
Curved Macintosh blade and the straight Miller
blade
What is done during the pre oxygenation phase of RSI?
Give high flow O2 every 3-5 minutes
It should be started when one is even considering the need for active airway management.
Can pre oxygenation be done in an apneic patient?
Pre-oxygenating with high-flow oxygen requires that the patient is breathing. If the patient is apneic, studies have shown that 8 full-volume
BVM ventilations over 1 minute are equivalent.
What is the aim of the pre treatment phase of rapid sequence intubation and state how it is done.
Used in people with raised intracranial pressure to reduce the effect of manipulation of airway on the intracranial pressure(Manipulation is associated with increase in intracranial pressure)
Meds: fentanyl followed by lidocaine(all started a few minutes before induction) and a defasciculating dose of the paralytic agent
What is the most commonly used induction agent in the emergency unit?
Etomidate
Why it: It is rapidly sedating and hemodynamically neutral. It is also thought to be cerebral protective.
State the adverse effect of etomidate.
Transient adrenal suppression thus many avoid it in septic shock and septic patients
When is ketamine preferred over etomidate during intubation?3
Anaphylatoc shock
Status asthmaticus
Sepsis
Note: Ketamine is a derivative of PCP and acts as a dissociative agent.
Why is ketamine preferred over etomidate in status asthmaticus, anaphylactic shock and sepsis?
It leaves airway reflexes protected and does not induce apnea. Additionally, it has bronchodilatory and analgesic properties.
What is the adverse effect of thiopental and propofoll?
Hypotension
What is the absolute contraindication of ketamine usage in intubation?
History of coronary artery disease
Name a paralytic agent that should be avoided in people with Hyperkalemia.
Succinylcholine
List contraindications of succinylcholine
Hyperkalemia,
Neuromuscular disorders,
Rhabdomyolysis/crash injuries
How should the patient be positioned during intubation?
The proper head position in adults is the “sniffing” position, with the base of the neck flexed forward and the head hyperextended.
When done properly, the patient ear should be at the level of the sternum
State how the patient should be positioned before and after administration of induction agents.
Prior: Head should be at the very end of the bed and the bed height should be adequate for the operator
After: Once induction agents are given, firm
downward pressure to the cricoid cartilage (known as the Sellick maneuver)
NOTE: RECENT STUDIES SHOW THIS MAY NOT BE NECESSARY
What is the best way to prove the ETT is placed correctly and what are the other options available.
Seeing it pass through the vocal cord
Others: Auscultation of the lungs and epigastrium
Chest X-ray however it cannot differentiate if it is in the trachea or oesophagus
ETCO2 capnometry (End tidal CO2 changes)
Fogging of the tube
