Advanced Airway / RSI Flashcards
Indications for Intubation
♦ Unable to Swallow / Ventilate Oxygenate
♦ GCS < 8
♦ Inhalation Burns / Circumferential Burns
♦ Anaphylaxis
♦ Apnea / Obstruction
♦ Respiratory Failure
Respiratory Failure =
♦pH < 7.2
♦ CO2 > 55
♦ PaO2 < 60
*only one value needs to be off to indicate the need to intubate*
Intubation Visualization Aids
♦ Selick’s Maneuver = Direct downward pressure on the thyroid cartilage, occludes the esophagus
♦ BURP = Backward, Upward, Rightward Pressure
**Do NOT Release Until Intubation is Complete**
Failed Airway Algotithm
♦ Patient Requires Secured Airway
♦ 3 Attempts of Direct Laryngoscopy Unsucessful
♦ Ventilate Pt by BVM/Simple Airway/Blind Airway
♦ Unable to Ventilate/Oxygenate SaO2 > 90%
♦ Cricothyroidotomy Indicated (Cric)
Placement Confirmation
♦ Chest XR - Gold Standard
♦ Distal tip of ETT should be 2-3cm above the carina or 1” above the carina Level of the T2 or T3 vertebrae
♦ Next most reliable confirmation method - visualization of tube passing through cords
***Distal cuff on ETT should be between 20-30 mmHg to prevent damage (*25)
(use only enough air required to make good seal)
7 P’s for RSI Success
Preparation - make sure equipment is servicable
Preoxygenate - 3-5 minutes, passive oxygenation via NC 10-15 + LPM
Pretreatment - LOAD medications if required
Paralysis w/ induction - Induction agent, paralytic, and pain control
Protect / Position - Ear to sternal notch, ramping, pad behind shoulders for pediatrics
Placement w/ proof - Visual confirmation, capnography, chest x-ray
Post Intubation Management - Maintain sedation and pain control, oxygenation, etc
LOAD (RSI Pretreatment)
Lidocaine - blunts the cough reflex preventing ICP increase
Opiates - Blunts the pain response
Atropine - Prevents reflex bradycardia in infants < 1 y/o
Defasiculating Dose - 1/10 dose of Rocuronium or Vecuronium
Succinylcholine (Anectine)
(pharmacodynamics)
Depolarizing neuro muscular blocking agent
depolarizes motor endplates at myoneural junction, leading to sustained flaccid paralysis
(stimulates muscle depolarization but remains bound to the receptor, preventing it from repolarizing and being triggered again)
Malignant Hyperthermia
Masseter Spasm (lockjaw)
Sustained tetanic musscle contractions
Rapid increase in temp (can be as high as 110 degrees)
Increased ETCO2
Tachycardia / HTN
Treat with Dantrolene Sodium
_**Do NOT give *calcium channel blockers*, you will kill this pt**_
Vecuronium (Norcuron)
(pharmacodynamics
Nondepolarizing neuromuscular blocking agent
Blocks acetycholine from binding to motor endplate receptors, inhibiting depolarization
(has slower onset and longer duration)
Rocuronium (Zemuron)
(pharmacodynamics)
Nondepolarizing Paralytic
Blocks acetylcholine from binding to the motor endplate receptors, inhibiting depolarization
(has slower onset and longer duration)
Etomidate (Amidate)
(pharmacodynamics)
Depresses the reticular activating system by stimulating GABA receptors
Depresses CNS function
Decreases oxygen cosumption and cerebral blood flow (ideal for ^ ICP)
Induction Agents (sedation)
Midazolam (Versed)
Used for sedation/anxiolysis with anterograde amnesia
Useful in seizures
Dose varies on intended use (protocols)
2.5-5 mg IV
Use lowest dose possible to achieve desired result
Do not use with other benzodiazepines
Flumazenil (Romazicon) is the reversal
Ketamine (Ketalar)
Pharmacodynamics
PCP derivative
Ketamine is a non-competitive NMDA receptor antagonist and dissociative, amnestic, analgesic, anesthetic agent.
Ketamine has a variety of effects, including: anesthesia, analgesia, hallucinogen, and sympathetic stimulation
Produces a rapid profound anesthetic or dissociative state
Ketamine is a Potent Bronchodilator,
Morphine
(Pharmacodynamics)
Binds with opiod receptors in the CNS preventing painful impulse transmission producing analgesia
reduces preload,reduces afterload which may lead to decreases in myocardial oxygen demand.
Fentanyl (Sublimaze)
(pharmacodynamics)
Synthetic Opiod Analgesic
(70-100 x more powerful than morphine)
Binds with ophoid receptors in the CNS, preventing painful impulse transmission
Ketamine (Ketalar)
(onset and duration)
IV = 30 sec / duration 5-10 min
IM = 3-4 min / duration 12-25min
(sedative effects can persist for 45 min - 2.5 hours)
Ketamine (Ketalar)
(side effects)
Elevates HR and B/P shortly after administration (typically return to baseline within 15 min)
Increased cerebral blood flow and metabolism
Increased salivary secreations
(atropine 0.4-0.6 IV Slow IVP before induction)
Emergence reactions –> tachycardia, ^b/p, nystagmus, and attempts at swallowing
(treat with benzos)
Rapid admin associated with respiratory depression, apnea, and higher than usual spikes in B/P. (Give IV/IM over 60 sec)
Ketamine (Ketalar)
(Contraindications)
< 3 mo of age
Known Schizophrenia
Severe HTN
Ketamine (Ketalar)
(Indications Adult)
Induction 2 mg/kg slow IO/IV push.
May repeat bolus of 1 mg/kg every 10 minutes
Post Intubation/Ventilation For mechanically ventilated patients, consider a continuous infusion of 1 mg/kg/hr, after the initial loading dose of 1 mg/kg
Pain Management/Sedation 0.1-0.5 mg/kg Sedation/Behavioral 4 mg/kg IM
Ketamine (Ketalar)
(Indications Pediatric)
Induction 2 mg/kg slow IO/IV push.
May repeat bolus of 1 mg/ kg every 10 minutes
Pain Management/Sedation 0.1-0.5 mg/kg IV/IO 1 mg/kg IN
Sedation/Behavioral 4 mg/kg IM
Morphine
(onset and duration)
IV = 10 minutes with a duration of action 3-5 hours.
Morphine
(Indications)
Pain Management
Pulmonary Edema
Morphine
(Contraindications)
Avoid use with hypotension
Avoid in the presence of RV/ Inferior wall MI
Morphine
(side effects)
Hypotension, AMS, Nausea/ vomiting, and respiratory depression
Morphine
(adult dose)
0.1 mg/kg (up to 5 mg) IM/ IO/IV.
SBP must be > 90 mm Hg.
May repeat dose once to a max of 10 mg
*Higher doses may be required for patients with burn injuries
Morphine
(pediatric dose)
0.1 mg/kg (up to 5 mg) IM/ IO/IV.
SBP must be > 90 mm Hg.
May repeat dose once to a max of 10 mg
*Higher doses may be required for patients with burn injuries
Fentanyl (Sublimaze)
(onset and duration)
IV = onset 90 sec, duration 30 min
Fentanyl (Sublimaze)
(Indications)
Airway: Rapid Sequence Intubation
Breathing: Use of Mechanical Ventilator
Acute Coronary Syndrome
Pain Management
Fentanyl (Sublimaze)
(contraindications)
Bronchial asthma,
concomitant MAO inhibitors,
myasthenia gravis
Fentanyl (Sublimaze)
(side effects)
Muscle rigidity, (tight chest)
respiratory depression,
bradycardia and hypotension
myoclonic movements,
tachycardia,
vein irritation,
dermatitis / flushing
urinary retention
Fentanyl (Sublimaze)
(adult dose)
♦ 1 mcg/kg IM/IO/IV/IN
♦ Maximum 100 mcg
⇒ May repeat dose at 1 mcg/kg
Etomidate (Amidate)
(onset and duration)
Peak effect = 1 minute
Duration 4-10 minutes
Etomidate (Amidate)
(indications)
Airway: Rapid Sequence Intubation – for induction
(procedural sedation)
Etomidate (Amidate)
(contraindications)
Adrenal Insufficiency,
Sepsis
Etomidate (Amidate)
(side effects)
Respiratory depression,
venous pain, (use larger vessels)
skeletal muscle movement (myoclonus)
N/V on emergence
Uncontrolled eye movements
Hiccups
Apnea
Impaired cortisol synthesis
Etomidate (Amidate)
(adult dose)
0.3 mg/kg IV push over 30 seconds
Maximum dose of 40 mg
Etomidate (Amidate)
(pediatric dose)
0.3 mg/kg IV push over 30 seconds
Maximum dose of 40 mg
Succinylcholine (Anectine)
(onset and duration)
Onset 30-45 sec / duration 4-6 min
Succinylcholine (Anectine)
(indications)
Airway: Rapid Sequence Intubation
Skeletal muscle relaxation Facilitate management of patients undergoing mechanical ventilation
Succinylcholine (Anectine)
(contraindications)
Malignant hyperthermia
Skeletal muscle myopathies
Penetrating eye injury
Acute crush injuries
Acute Spinal cord injuries
Chronic renal failure (hyperkalemia)
Relative - Closed head injuries (med induced ICP)
Succinylcholine (Anectine)
(side effects)
Cardiac arrhythmias,
Increased intraocular pressure,
Muscle Fasciculation
Malignant Hyperthermia
Hypotension/Hypertension
Hyperkalemia
Bradycardia/Tachycardia
Increased ICP
Longer than normal duration of action to pt’s exposed to acetylcholinesterase inhibitors found in nerve agents and pesticides
Succinylcholine (Anectine)
(adult dose)
2 mg/kg IO/IV over 30 seconds
Maximum dose of 200 mg
Succinylcholine (Anectine)
(pediatric dose)
2 mg/kg IO/IV over 30 seconds
Maximum dose of 200 mg
Vecuronium (Norcuron)
(onset and duration)
♦ onset = 2.5 - 3 min
♦ duration = 25 - 40 min
(complete recovery 45-65 min after initial bolus dose)
Manufactored as a powder and must be reconstituted with compatible diluent
Vecuronium (Norcuron)
(indications)
Airway: Rapid Sequence Intubation
Facilitates endotracheal intubation by paralysis of skeletal muscle
Breathing: Use of Mechanical Ventilator
To increase pulmonary compliance during mechanical ventilation
Vecuronium (Norcuron)
(adult dose)
0.1 mg/kg IO/IV over 30 – 60 seconds
Maximum dose of 10 mg
Vecuronium (Norcuron)
(pediatric dose)
0.1 mg/kg IO/IV over 30 – 60 seconds
Maximum dose of 10 mg
Rocuronium (Zemuron)
(indications)
Airway: Rapid Sequence Intubation
Facilitates endotracheal intubation by paralysis of skeletal muscle
Breathing: Use of Mechanical Ventilator
to increase pulmonary compliance during mechanical ventilation
Rocuronium (Zemuron)
(side effects)
Hypotension,
Hypertension,
Increased pulmonary vascular resistance
Rocuronium (Zemuron)
(adult dose)
1 mg/kg IO/IV
Maximum dose of 100 mg
Rocuronium (Zemuron)
(pediatric dose)
1 mg/kg IO/IV
Maximum dose of 100 mg
Ideal/Predicted Body Weight
(Males)
50 + 2.3 [height in inches - 60]
= Ideal/Predicted Body Weight
Ideal/Predicted Body Weight
(Female)
45.5 + 2.3 [height in inches - 60]
= Ideal/Predicted Body Weight
Ketamine
(Adult dose for RSI)
2 mg/kg SLOW IO/IV (Maximum dose of 200mg)
May repeat bolus of 1 mg/kg IV/IO post intubation every 10 minutes as needed or infuse at 1mg/kg/hr after the initial loading dose.
Ketamine should not be used as an induction agent for infants < 3 months old, patients with a known history of schizophrenia, or in patients with severe uncontrolled hypertension.
Effects Succinlycholine has on K+
Normal muscle releases enough potassium during succinylcholine-induced depolarization to raise serum potassium by 0.5 mEq/L. Although this is usually insignificant in patients with normal baseline potassium levels, a life-threatening potassium elevation is possible in patients with burn injury, massive trauma, neurological disorders, and several other conditions.
