Advanced Airway Principles

Question 1

Respiratory Failure ABG Values

Answer 1

pH < 7.2

CO2 > 55

PaO2 < 60

Question 2

Indications for Intubation

Answer 2

• Inability to Swallow
• Can’t Ventilate/Oxygenate
• GCS < 8
• Expected Clinical Course
• Apnea
• Obstruction
• Respiratory Failure

Question 3

LEMON Mnemonic

Answer 3

• Look
• Evaluate 3-3-2
• Mallampati (I-IV)
• Obstructions
• Neck Mobility

Question 4

3-3-2 Rule

Answer 4

3 Fingers in Mouth

3 Fingers Between Jaw and Hyoid

2 Fingers Between Hyoid and Thyroid

Question 5

Mallampati Scale

Answer 5

I - soft palate, uvula, anterio/posterior tonsillar pillars visible

II - Tonsilar pillars hidden by tongue

III - Only the base of the uvula can be seen

IV - Uvula cannot be seen

Question 6

Sellick’s Manuever

Answer 6

Direct downward pressure on the thyroid cartilage, occludes esophagus and prevents aspiration during intubation.

Question 7

BURP Manuever

Answer 7

Backward, Upwards, Rightwards Pressure

Question 8

CXR Intubation Confirmation

Answer 8

Distal tip of ETT 2-3cm superior to the carina or level of the T2-T3 vertebrae

Question 9

7P’s for Intubation

Answer 9

Preparation

Preoxygenation

Pretreatment

Paralysis with Induction

Protect and Position

Placement with proof

Post Intubation Management

Question 10

LOAD Mnemonic

(RSI Pretreatment)

Answer 10

Lidocaine - blunts the cough reflex preventing ICP increase

Opiates - blunts the pain response

Atropine - for invants, prevents reflex bradycardia

Defasiculating Dose - use succinylcholine, rocuronium, or vecuronium

Question 11

Succinylcholine

Answer 11

• Depolarizing NMB
• Dose 1-2mg/kg
• 1-2min onset, 4-6min duratino
• Can cause hyperkalemia
• Can cause malignant hyperthermia

Question 12

Malignant Hyperthermia S/Sx

Answer 12

• Masseter spasm/trismus
• Sustained tetanic muscle contractions
• Rapid increase in temperature
• Increased ETCO2
• Tachycardia/HTN
• Mixed Acidosis

Question 13

Malignant Hyperthermia Tx

Answer 13

Dantrolene Sodium (Dantrene)

3.0mg/kg

DO NOT GIVE calcium channel blockers - malignant hyperthermia caused by problem with Ca removal from cells

Question 14

Vecuronium (Norcuron)

Answer 14

• Non-Depolarizing NMB
• Slow onset, long acting
• Defasiculating doses reduces increased ICP during intubation
• Onset 4-6min, duration 30-45min
• 0.04-0.06mg/kg if after Sux
• Maintenance 0.01-0.015mg/kg IVP 2-45min PRN

Question 15

Rocuronium (Zemeron)

Answer 15

• Non-Depolarizing NMB
• Defasiculating dose can reduce increased ICP during intubatin
• Onset 4-6min, duration 30-45min
• Dosing 0.1-0.2mg/kg IV q20-30min

Question 16

Etomidate (Amidate)

Answer 16

• Induction agent
• 0.3mg/kg
• 30sec onset, 3-12min duration
• Causes almost no change in BP or CO
• NO analgesic properties
• CI - adrenal suppression (sepsis or Addison’s)

Question 17

Midazolam (Versed)

Answer 17

• Sedation/anxiolysis with retrograde amnesia
• BDZ
• 2.5-5mg IV
• Onset 60-90sec, 15-30min duration
• Do not use with other BDZs

Question 18

Propofol (Diprivan)

Answer 18

• Hypnotic with no analgesic properties
• Dose varies but typically 1.5mg/kg IV
• Onset 15-45sec, 5-10min duration
• Decreases CPP and MAP

Question 19

Ketamine (Ketalar)

Answer 19

• Hypnotic, Analgesic, Amnesic
• 1mg/kg IV, 2mg/kg IM
• Onset 45-60sec, Duration 11-17min
• Used to stop pain impulses
• Potent bronchodilator
• May increase airway secretions
• Caan have hallucinations upon awakening

Question 20

Morphine

Answer 20

• Opioid analgesic
• 2-5mg IV/IM/IO
• Onset within minutes, duration 2-3 hours
• Avoid in head injury and respiratory depression
• Causes hypotension, nausea, flushing

Question 21

Fentanyl

Answer 21

• Opioid Analgesic
• 50-100mcg IV q2h PRN
• Onset 1-2min, 45-60min duration
• Avoid with increased ICP, hypoventilation, hypotension, and bradycardia