Advanced Airway Principles Flashcards
Intubation Indications
Unable to swallow
cannot ventilate/oxygenate (failed airway algorithm)
GCS <8
Expected clinical course (inhal. burns, circum. burns, anaphylaxis)
Apnea
Airway obstruction
Respiratory Failure
In respiratory failure, only one value needs to be off to indicate the need to intubate. These values include:
pH, CO2, PaO2
LEMON pneumonic
Look Evaluate 3-3-2 Mallampati (I-IV) Obstructions Neck Mobility
3-3-2 rule
3 fingers in mouth
3 fingers btw jaw and hyoid
2 fingers between hyoid and thyroid
Airway Grading
Mallampati
Mallampati I
soft palate
uvula
anterior/posterior tonsillar pillars visible
Patients with a tall, thin neck are usually graded Mallampati
I
Difficulty level of Mallampati I
none
Mallampati II
Tonsillar pillars hidden by tongue
Difficulty level of Mallampati II
none
Mallampati III
Only base of uvula seen
Difficulty level of Mallampati III
Moderate
Mallampati IV
Uvula cannot be seen
Short, fat or muscular neck
Difficulty level of Mallampati IV
Severe
Curved blade that lifts vallecula
Macintosh
Straight blade that lifts the epiglottis
Miller
Direct downward pressure on the thyroid cartilage occluding esophagus and preventing aspiration during intubation:
Sellick’s Maneuver
Do NOT release Sellick’s Maneuver or BURP until intubation is
complete
BURP pneumonic
Backward
Upward
Rightward
Pressure
FAILED AIRWAY ALGORITHM
Patient requires secured airway
3 attempts of direct laryngoscopy unsucc.
Ventilate by BVM/simple airway/blind airway
Unable to ventilate/oxygenate SaO2 >90%
Cricothyroidotomy indicated (Cric)
Gold standard of placement confirmation
Chest X-ray
Distal tip of ETT should be
2-3 cm above carina or
1” above carina or
level of T2 or T3 vertebrae
2nd most reliable confirmation method
visualization of tube passing thru cords
When inflating the distal cuff on an ETT, the pressure should be between
20-30 mmHg to prevent mucosal tissue damage (only use amt required to make good seal)
Consider saline instead of air in ETT
cuff
Tube check
Bulb placed over ETT after intubation to confirm placement
End tidal CO2
Measurement of CO2 in expired air; confirms ETT placement in trachea
Colimetric Device
one-time device that changes colors when CO2 passes through it
CapnoCheck
reusable ETCO2 device that both ETCO2 and RR (aka EMMA Emergency Capnometer)
Capnography
measures EtCO2, waveform
7 P’s pneumonic
Preparation Preoxygenate Pretreatment Paralysis with induction Protect and position Placement with proof Post intubation management
Preparation
Make sure equipment is serviceable
Preoxygenate
3-5 minutes, 10-15 LPM if possible
Pretreatment
LOAD
Paralysis with induction
Neuromuscular blockade (NMB), induction agent, and pain control
Protect and position
sniffing position
towel under patient’s shoulder blades
Placement with proof
tube passing through cords
CXR
Capnography
Post intubation management
Maintain sedation, oxygenation
LOAD pneumonic (RSI pretreatment)
Lidocaine (head/lung injury)
Opiates
Atropine for infants
Defasciculating dose
(LOAD) Lidocaine
blunts cough reflex preventing ICP increases (head/lung injury)
(LOAD) Opiates
blunts pain response
(LOAD) Atropine
prevents reflexive bradycardis in infants < 1 y/o (0.02 mg/kg)
(LOAD) Defasiculating Dose
Succinylcholine
Rocuronium
Vecuronium
