Air Methods PCG's Flashcards
RSI: Indications
- Unable to maintain airway
- Unable to oxygenate or ventilate
- Expected clinical course
- Unable to facilitate safe patient transport
RSI: Contraindications
- Unable to ventilate with a BVM
RSI: Etomidate
Dose: 0.3mg/kg IV (Max of 40 mg)
Caution: in pt’s with adrenal insufficiency or sepsis
Preferred: In pt’s with Severe HTN (SBP >160)
RSI: Ketamine
Dose: 1 - 2 mg/kg IV or IM
Preferred: In pt’s with bronchospasm, shock/hypotension, sepsis, & pediatrics
Caution: pt’s with severe HTN (SBP > 160)
RSI: Rocuronium
Dose: 0.6 - 1.2 mg/kg IV (usual dose 1 mg/kg)
Caution: In pt’s with difficult airway (long-term paralysis)
RSI: Succinylcholine
Dose: 1.5 - 2 mg/kg IV
Contraindications: Hyperkalemia, Severe injury > 2 days, Spinal injury > 2 days, Burn > 24 hours, Renal failure, pseudocholinesterase deficiencies, Hx of malignant hyperthermia, neuromuscular disorders, penetrating eye injuries
RSI: Push Dose Pressors
Resuscitate with NS/LR fluid, if SBP < 90
PDP may be used 15 min before or 15 min after intubation
Medical:
Phenylephrine 200mcg IV and MR q 2 mins
Trauma:
Vasopressin 2 units IV MR q 2 mins
Needle Thoracotomy: Sites
- 4th-5th ICS anterior axillary line
2. 2nd-3rd ICS midclavicular line
Needle Thoracotomy: Indications
S/S of tension pneumothorax
- Tachycardia
- increased RR or work of breathing
- decreased SPO2
- Increased PIP and MAP in intubated pt’s
- decreased lung sounds
- decreased chest rise
- JVD
- Subcutaneous emphysema
- hypotension
- tracheal deviation
- hyper-resonance upon percussion
Needle Thoracotomy: Needle sizes
Adult: 10-14 g 3 inch catheter
Pediatric: 18 g 1 inch catheter
NPPV Settings
Initial Settings: IPAP = 10 cmH2O EPAP= 5 cm H2O FiO2= Low pressure source (LPS @ 15 lpm) Breath Rate= 0 Rise profile = 1-2 Flow termination= 40 % Time Termination= 0.7 s Turn off low pressure and Ve alarms
EZ- IO: Approved Sites
- Proximal Tibia (Adult/child/infant)
- Distal Tibia (Adult/child/infant)
- Proximal Humerus (Adult/child/infant)
- Distal Femur (Child/infant)
EZ-IO: Analgesia
Adult: Lidocaine 2% 40mg IO over 120 seconds & let sit in IO space for 60 seconds and then flush w/NS
Infant/Child: Lidocaine 2 % 0.5mg/kg to max of 40mg (follow same method as adult)
Needle Cricothyrotomy
Indications: Inability to oxygenate or ventilate the pt by any other means. Pediatric pt less than 8y/o (Surgical airway contraindicated)
Contraindications: Damage to the larynx, cricoid cartilage, or trachea -or- ability to ventilate by another means.
Manometer: ETT Cuff pressures
Adult: 20-30 cmH2O
Pediatric: 20-25 cmH2O
Should take Initial, Altitude, & Landing
Ways to verify Tracheal tube placement
- Direct Visualization
- Quantitative ETCO2 waveform (Gold Standard)
- Re-visualization
- Chest rise and fall with Lung sounds and negative epigastric sounds
- Chest x-ray
RSI: Pre-medications
Oxygen
Push-Dose Pressors
Atropine 0.02 mg/kg IV for peds < 1 y/o to max of 1mg
HEAVEN Criteria
- Hypoxemia
- Extremes of size
- Anatomic disruption/obstruction
- Vomit/blood/fluid in airway
- Exsanguination
- Neck Mobility
IBW: Calculations
[(2.3)(# inches over 5 ft) + 50 (males) or 45.5 (females)
Tidal Volume Calculation
6mL/kg of IBW
Minute Ventilation (Ve)
100mL/kg/min of IBW
Ventilation management for Acidosis
Target minute ventilation to achieve pt’s pre-intubation ETCO2
Minute Ventilation Goals:
- Adults = 9 L/min
- Pediatrics = 4-5 L/min
- Infants = 1.5-3 L/min
Ventilator Setting Confirmation
Vte: make sure Vt matches Vte
f (frequency): make sure frequency closely matches the set RR
PIP: confirm the PIP < 35 cmH2O
Pplat: Confirm Pplat is <30 cmH2O
AutoPEEP: Confirm air trapping is not occurring (AutoPEEP < 0)
IBW Calculations: Infant & Pediatric
Infants: (months of age + 9)/2
Pediatrics: (years of age x 2) + 8
Resuscitative Ventilation
- Maintain same Ve
- Vt is increased to 8-10mL/kg
- RR is decreased to around 8-10/min
- Consider decreasing PEEP to 0*
How to fix increased AutoPEEP
- Reduce RR
- Increase the expiratory time, by lowering the inspiratory time
- Consider Bronchodilators
Initial Settings for Pressure Control (PC) ventilation
Pressure Control= 15 cmH2O
PEEP = 5 cmH2O
PIP = PC + PEEP
Pressure Control should be used for what patients?
- Any pt < 10 kg
- Pt with injured, damaged, or non-compliant lungs (Pplat > 30)
ETT size for pediatrics
16 + age / 4
OG/NG tube size
- 2 x ETT size
- Measure from nose around the ear and to the stomach
Tranexamic Acid (TXA)
MOA: Prevents clot breakdown
Dose: 1g in 100mL given over 10 minutes
Inclusion: Age > 15 years, injury < 3 hours, S/S of SBP < 90mmHg or HR > 110 after 10mL/kg fluid bolus.
Cerebral Perfusion Pressure
MAP - ICP = CPP
Normal 70-90mmHg
MAP
MAP= [SBP + (2 x DBP)] /3
Hypotension: maintain MAP of 65mmHg
PACO tool
Conversion factor x psi/ flow rate = duration
Conversion factors
- Portable tank (D) = 0.16
- Aircraft tank (M) = 1.56
- Small hospital tank (E) = 0.28
Pain Management: Adult
Fentanyl 0.5 - 1 mcg/kg IV/IN MR q 3-5 min; max single dose of 100 mcg
Ketamine 0.1 - 0.25 mg/kg IV if opioids are not managing pain MR q 10 minutes
Pain Management: Pediatric
Fentanyl 0.5 - 1 mcg/kg IV/IN MR q 3-5 min; max single dose of 100 mcg
Ketamine 0.1 - 0.25 mg/kg IV if opioids are not managing pain MR q 10 minutes
ETCO2 goal for TBI
30-35 cm H2O
Hypertension parameters per disease
AAA = SBP < 110
Subarachnoid= SBP < 140
Hemorrhagic = SBP < 160
Ischemic = SBP < 180 w/ tpa & < 220 w/o tpa
Aortic Dissection = HR < 60 & SBP < 120
PIH = BP < 160/110
qSOFA score
RR > 22
Change in mental status
SBP < 100
SIRS criteria
Temp < 36 or > 38 RR > 20 ETCO2 < 29 HR > 90 WBC > 12, 000/mm3
Seizures: Treatment
- Check BGL
- RSI prn (short-term paralytic preferred)
- For active seizing or hx of multiple seizures give Versed.
- Midazolam 5 mg IV/IN or 10 mg IM repeat prn q 2-5 min
Lab Values: Sodium
135-145 mEq/L
Lab Values: Potassium
3.5- 5 mEq/L
Lab Values: Chloride
95- 105 mEq/L
Lab Values: Calcium
8.5 - 10.5 mg/dL
Blood Urea Nitrogen (BUN)
6- 23 mg/dL
Creatinine
0.6- 1.4 mg/dL
Serum Osmolality
275- 295 mOSm/kg H2O
H & H= Hgb & Hct
Hgb- 12-18 g/dL
Hct- 36-52%
Hematocrit is typically 3 x higher than your hemoglobin
Anxiety: Treatment Adult
Midazolam 2.5- 5mg IV/IM/IN MR in 3-5 minutes
or
Lorazepam 1 -2 mg IV MR in 15 minutes
Excited Delirium: Treatment Adult
Ketamine 0.5 - 1 mg/kg IV MR x 1 or 4 mg/kg IM x 1
or
Etomidate 10 mg IV x 1
King Airway Sizes
Size 0 = for a 0-1 y/o Size 1 = for a 1-2 y/o Size 2= for a 2 y/o Size 2.5 = for 25 kg Size 3= bigger than broselow or > 4 ft Size 4= for most adults 5-6 ft Size 5 = over 6 ft
