Airway Flashcards
Correct ETT position on CXR:
5cm above carina (+-2)
T2-T4
Between medial clavicles
(In neutral head position)
10 Ps of RSI:
Plan
Prepare
Protect Cspine
Position
Preoxygenate
Premeds
Paralysis (and induction)
Placement
Proof
Post-tube care
SOAPME:
Equipment for RSI:
Suction
Oxygen
Airway stuff
Pharmacy
Monitoring
End tidal CO2
Standard ETT sizes:
Female 7–7.5 (6.5 if pregnant)
Male 8-8.5
Child (<10yo) age/4 + 4 uncuffed (down 1 size for cuffed)
Neonate: gestation/ 10
Depth of ETT insertion (cm):
Easiest = TRIPLE THE ETT SIZE
Neonates: weight (kg) + 6
Children >1: age/2 + 12
Adults: 21 females, 23 males
Measurement read at central incisors/alveolar ridge
Paediatric blade size:
*measure the same as a Guedel
Miller up to age 2, Macintosh above age 2:
00 prem
0 neonate
1 at 1yo
2 at 2yo
3 at grade 3 (age 9)
4 at 14
(3 or 4 for adult)
Methods for ETT confirmation:
- Visualised through cords
- Clinical: chest rise, ausc, spo2 improvement
- Fogging
- ETCO2 with uniform, non-dwindling waveform capnography (less accurate on arrested pt)
- Oesophageal detector device (not great, will miss 20%)
- CXR
- Bronchoscopy
Sux adverse effects/ contraindications:
Hyperkalaemia
Bradycardia
Increased O2 consumption (poss lower safe apnoea time)
Raised ICP/ intraocular/ intragastric
—> ICP RISE IS NONSIGNIFICANT
Sux apnoea (no serum cholinesterases)
Malignant hyperthermia
Less effective in myaesthenia
Contraindications:
HyperK or at risk of it:
-Renal failure, crush, burns >72h, neuromuscular stuff: myopathies/MS/MG/stroke or SCI >72h,
- Personal or FHx of sux apnoea, malignant hyperT
Rocuronium:
Non-depol NM blocker
Onset 60seconds, duration 30mins
Dose in RSI: 1.2mg/kg IV (ideal weight)
Pros: rapid onset, safe and simple, reversible (suggamadex or neostigmine + atropine/glyco)
Adverse effects: allergy
Contraindications: allergy
At above dose, onset just as rapid as roc. No fasciculations so doesn’t consume O2/ marginally better safe apnoea time. None of the contraindications/ adverse/ complex decisions off sux. Cheaper.
Propofol:
Potentiates GABA for spinal inhibition
Soybean/ egg/ lipid emulsion
Onset: 30secs. Duration: 10mins.
Induction: 1.5- 3mg/kg IV ideal body weight (upper end for infants, alcoholics)
Procedural sedation: 0.5-1mg/kg and titrate
Infusion: 4-12mg/kg/hour and titrate
Bolus: 0.5mg/kg
Pros: cheap, rapid on/off, familiar. Bronchodilator, anticonvulsant, antiemetic, lowers ICP.
Adverse: bradycardia, negative inotropy, hypotension, reduced cerebral perfusion, propofol infusion syndrome if >4mg>48hours.
Ketamine dosing and onset/ duration:
Ideal body weight.
Analgesia (subdissociative):
- 0.1 - 0.3 mg/kg IV. Repeat after 10-30mins PRN.
- 0.1mg/kg/hr infusion
Procedural sedation:
- 1 - 1.5mg/kg IV. Repeat 0.5mg/kg after 15mins PRN
- 4mg/kg IM. Repeat 2mg/kg after 15mins PRN.
Induction:
- 2mg/kg IV
- 10mg/kg IM
Infusion for sedation:
- 2mg/kg/hr and titrate
Onset of induction:
60secs IV, 5 mins IM
Duration:
10mins IV, 30mins IM
Ketamine pros and cons:
IM option
Rapid onset, good procedural duration
Analgesic/ anxiolytic/ amnesic
Brochodilating
Maintained resp/ airway reflexes
No hypotension
Can’t use <6mo
—> caution up to 12mo, neurodev)
Laryngospasm
—> (0.3%, RF: asthma, URTI, passive smoke. Mostly infants. Can preTx with lignocaine)
ICP elevation
Spike in PR/BP/CO
—> caution in heart dis)
Emergence delirium/ recovery agitation (—> more so teens/adults)
Hypersalivation
Vomiting
(—> teens/adults usually in recovery phase)
Resp depr/apnoea only in 0.4%
NOTHING IS DOSE-DEPENDENT
Etomidate, dose and characteristics:
0.3mg/kg IV
Rapid
Haemodynamically neutral
Preserved resp
Lowers ICP (but keeps SBP/CPP)
Vomiting ++ (“vomidate “)
Myoclonus
Focal seizure
Adrenal suppression (can’t use in sepsis)
Thiopentone:
3-7mg/kg IV for induction (can also be PR)
Onset very rapid
Lasts 15mins
Good for the brain! (Reduces brain O2 demand, reduces CO2 effect in brain, decreases ICP, anticonvulsant)
Bad for the CVS! (Negative inotrope, bradycardia, hypotension)
CAN ONLY USE SUX (not vec or roc)
Carson: needed sedation, neuroprotection and anticonvulsant all at once, was HD stable
What is delayed sequence intubation? When is it used?
It is procedural sedation, when the procedure is preoxygenation.
Ideally with ketamine to preserve resps (etomidate is alternative).
Used when:
- Patient not compliant with preoxygenation
- Another procedure required prior to tube that won’t be tolerated (eg. NGT in GI haemorrhage)
Preoxygenation:
- Devices and flow rates
- Duration
- Goals
Always nasal prongs, 4L/min 100% (APNOEIC ox)
1- NRBM, 15L, 100%
2- HFNP 60L, 100%
*don’t forget NGT
3-BVM, >15L, 100%, good seal and PEEP. If poor effort.
4- CPAP, 100%
Minimum 3 minutes. If patient critical, don’t persist beyond 3-4 mins ….. crack on.
Usual O2 consumption during apnoea (healthy)?
3ml/kg/minute
Safe apnoea time:
- Without preox
- With preox
Preoxygenation extends safe apnoea time from:
1 minute …. to 8 minutes (healthy)
3-3-2 rule for airway:
3 fingers between incisors
3 fingers chin to neck (hyoid)
2 fingers hyoid to thyroid cartilage
*patient’s own fingers
Mallampati score:
Visual, pre-laryngoscopy view of posterior oropharyngeal structures, to predict difficult airway.
I- Whole soft palate incl full uvula with a gap, fauces and pillars behind
II- No pillars
III- Only base of uvula
IV- Only hard palate
III and IV considered risky airways
IV has up to 10% failure rate
Not great sensitivity, doesn’t reliably correlate with blade grade
Cormack-Lehane grading:
View of glottic structures on laryngoscopy:
I- Full glottis
II- Partial glottis
a- Partial cords
b- Arytenoids only
III- Epiglottis only
IV- Pharynx only
Vortex approach:
Guidance in failed airway
Keep coming back to green (if able) via rescue device between attempts
Only reattempt a lifeline (up to 3x) if changing/ optimising something
Use in conjunction with diff airway algorithm: eg.
“Plan A- video scope by me
Fail —> BVM and reox
Plan B- video scope by boss
Fail —> BVM and reox. Call anaesthetics.
Plan C- LMA
Plan D- surgical “
Needle cricothyroidotomy:
For CICO situations. Bridging only, no ventilation.
Can do as cric, OR as tracheostomy.
- 14G CANNULA CONNECTED TO 5ml SYRINGE WITH 2ml SALINE
- Insert 45 DEGREES, CAUDALLY (down)
- ASPIRATE as advance
- Once bubbles, confirm can aspirate entire syringe and plunger stays up
- Cannulate
- Recheck aspiration with another saline- filled syringe
- Attach passive O2 flow OR jet ventilation
WHILST getting ready for A) OT or B) Seldinger conversion to minitrach/ size 6 tube.
Management of failing tracheostomy:
- Apply O2 to FACE AND TRACHE
- REMOVE INNER TUBE, speaking valve.
- Attempt SUCTION CATHETER. If passes, patent. Suction/ humidify/ saline nebs.
- DEFLATE CUFF
If not resolved- airway emergency.
- REMOVE TRACHEOSTOMY.
- O2 TO STOMA HOLE (via LMA, paeds face mask)
- If not breathing, ventilate via face while covering stoma, or via stoma while covering face.
1- TUBE FROM BELOW (stoma). Using FIBREOPTICS, ideally.
2- Tube from above (likely difficult ++)
3- Usual back up if all is failing: cric.
Laryngospasm management:
- STOP procedure
- SUCTION
- 100% O2
- Jaw thrust with LARSONS POINT pressure (in and forward)
- CPAP via BMV with peep valve and pop-off held shut
- DEEPEN sedation (propofol bolus 0.5-1mg/kg)
- PARALYSE (eg. SUX 4mg/kg IM - short action)
- INTUBATE
Complications incl:
- Negative pressure APO
Choking BLS algorithm:
Inhaled foreign body management:
Effective cough:
- Adopt position, encourage cough
- Take to OT
Ineffective cough:
- 5 chest thrusts, 5 back blows
- Try to visualise FB, remove with Macgills if seen (DONT blind sweep)
- Repeat PRN
Unresponsive:
- CPR
- At each ‘breath’, Laryngoscopy, remove FB with Macgills if seen
Further steps:
- FB above cords: cric
- FB below cords: R main intubation, pull back, lie R side down
- If can’t intubate, force FB distal with PPV
_______
Management of a tracheostomy bleed?
ANY bleed (even a drop) needs admission and bronchoscopy.
Tracheinominate fistula –> life threat.
Remove all
Hook finger in and compress vessel firmly against sternal notch
