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Resuscitation > Airway > Flashcards

Airway Flashcards

1
Q

Correct ETT position on CXR:

A

5cm above carina (+-2)
T2-T4
Between medial clavicles

(In neutral head position)

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2
Q

10 Ps of RSI:

A

Plan
Prepare
Protect Cspine
Position
Preoxygenate
Premeds
Paralysis (and induction)
Placement
Proof
Post-tube care

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3
Q

SOAPME:

A

Equipment for RSI:

Suction
Oxygen
Airway stuff
Pharmacy
Monitoring
End tidal CO2

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4
Q

Standard ETT sizes:

A

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

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5
Q

Depth of ETT insertion (cm):

A

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

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6
Q

Paediatric blade size:

A

*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)

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7
Q

Methods for ETT confirmation:

A
  • 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
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8
Q

Sux adverse effects/ contraindications:

A

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

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9
Q

Rocuronium:

A

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.

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10
Q

Propofol:

A

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.

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11
Q

Ketamine dosing and onset/ duration:

A

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

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12
Q

Ketamine pros and cons:

A

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

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13
Q

Etomidate, dose and characteristics:

A

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)

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14
Q

Thiopentone:

A

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

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15
Q

What is delayed sequence intubation? When is it used?

A

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)

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16
Q

Preoxygenation:
- Devices and flow rates
- Duration
- Goals

A

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.

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17
Q

Usual O2 consumption during apnoea (healthy)?

A

3ml/kg/minute

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18
Q

Safe apnoea time:
- Without preox
- With preox

A

Preoxygenation extends safe apnoea time from:

1 minute …. to 8 minutes (healthy)

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19
Q

Factors that reduce safe apnoea time:

A
  • Poor preoxygenation/denitrogenation
  • Airway occlusion (atelectasis)
  • Shunt physiology
  • O2 demand (sepsis, pregnancy, obesity, critical illness, sux fasciculations, fever)
20
Q

Pretreatment options in RSI:
- Doses
- Indications

A

No evidence to support use these are OPTIONAL

Lignocaine top, or 1.5mg/kg IV
- Blunt airway reactivity (eg. Asthma)
- Prevent sympathetic spike (eg. Head injury, dissection)

Atropine 20microg/kg IV
- Prevent brady in kids

Fentanyl
- 2-3 microg/kg IV
- Prevent sympathetic spike
- Propofol sparing
- Give over 60secs to reduce rigid/resp depr

21
Q

Risk factors for difficult laryngoscope/ intubation:

A

LEMON

Look externally
Evaluate 3-3-2
Mallampati
Obstruction (upper airway)
Neck mobility

Look externally: micrognathia, bull neck, missing teeth, etc.

22
Q

3-3-2 rule for airway:

A

3 fingers between incisors
3 fingers chin to neck (hyoid)
2 fingers hyoid to thyroid cartilage
*patient’s own fingers

23
Q

Mallampati score:

A

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

24
Q

Cormack-Lehane grading:

A

View of glottic structures on laryngoscopy:

I- Full glottis
II- Partial glottis
a- Partial cords
b- Arytenoids only
III- Epiglottis only
IV- Pharynx only

25
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 “
26
Indications for intubation:
Failure to oxygenate Failure to ventilate Failure to maintain airway Any of the above predicted (incl. transport) Humane (eg. severe burns) To facilitate: - Paralysis - Cooling - Reduced metabolic rate - Hyperventilation (Eg. Head injury, NMS, serotonin syndrome) *Behavioural control
27
Risk factors for difficult BVM:
MOANS Mask seal/ Male/ Mallampati Obese Age >55 No teeth Stiff / snores
28
Risk factors for difficult LMA:
RODS Reduced mouth opening Obstruction Deranged anatomy Stiff lungs/ (c)Spine
29
Risk factors for difficult Cric:
SMART Surgery Access/ anatomy (eg. Obesity, fixed neck) Mass (eg. Haematoma, abscess) Radiation Tumour
30
Post intubation hypoxia: causes and approach
**DOPES** Dislodged tube, disconnection Obstruction (secretions, mucus plug) Patient (LUNGS: PTx, bronchospasm, pulm oedema, atelectasis, stacking, CHEST: rigidity, SHUNT: PE) Equipment (incl. O2 supply, chest drain) Stacking Disconnect 100% FiO2 via BVM - Easy = equip (or PE) - Diff = ETT or patient (incl chest drain) No chest movement- likely ETT - Check ETCO2 - Suction/ bougie - Check position: laryngoscopy (poor), bronchoscopy, CXR - Replace. Okay chest movement- likely PATIENT - Examine chest movement, breath sounds, anaphylaxis signs, CXR/gas
31
Post intubation hypotension: causes and approach
**AH SHITE** Anaphylaxis , acidosis Heart- tamponade, pulm HTN Stacking (disconnect, lower RR, lower i time, lower VT, control tachypnoea- analgesia, paralysis) Hypovolaemia (lower PEEP, bolus) Induction agent Tension Electrolytes Slow culprit infusions. Consider: bolus, pressor. Examine patient: chest movement, hyperinflation, signs of anaphylaxis. Bedside echo/IVC. CXR. If stacking suspected, check flow/vol graph, and expiratory hold. Manage PRN.
32
Management of airway transection:
Intubation attempts must be AT OR BELOW LEVEL OF INJURY. Intubate trachea directly through open wound, if able. Stabilise distal trachea with forceps (recoil likely, partic below cric) Consider STERNOTOMY to find trachea.
33
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.
34
CICO alternatives/ options:
FRONT OF NECK (needle cric- jet vent or O2, surg cric, trache) Fibreoptic Blind/ digital intubation Nasal intubation Retrograde intubation
35
Surgical cricothyroidotomy:
AVOID IN CHILDREN <10 (if poss) - Local with adrenaline (control bleed) - Sterile set up/ skin prep - Ketamine sedation …. if time. - **Laryngeal handshake** to *identify anatomy* - Then **stabilise from above** with non dom hand- use index finger to palpate CTM - **Stabilise scalpel hand on sternum** - 4cm **VERTICAL incision** to skin/subcut (extend as needed) - **Blunt dissect** to membrane (artery forceps) - **HORIZONTAL stab** through. **Extend to side, 180 DEGREE TURN, extend to other side.** - Insert **finger** - Insert **bougie, feel rings** - **Size 6 ETT** over bougie - Confirm placement CONTRAINDICATIONS: - Children <10 (failure, subglottic stenosis, larynx trauma) - Airway trauma at or below CTM - Less invasive means available
36
Jet ventilation:
Main risk is BAROTRAUMA. Careful inflation pressures, and long expiration. Upper airway must be at least partially patent to allow for expiration. <20mmHg preschool <30mmHg child 50mmHg adults IE 1:5 RR 12
37
Tracheostomy general:
Tracheostomy (patent airway above) vs laryngectomy (O2 to face futile) 7 days = stoma mature (safe to remove tube) Anatomy: - Trache - Inner tube - +\- cuff - +\- speaking valve ALL BLEEDING IS BAD. Even a small bleed can ‘herald’ a pending massive haemorrhage from tracheoinnominate fistula. ALL need bronchoscopy in OT.
38
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.
39
ED extubation:
Airway grade 1 or 2 No intracranial concerns On minimal settings: - FiO2 <40% - PEEP 5 or less Wean sedation. Put vent on minimally supported, spont mode (eg. 10/5 or less) Check if: - Following commands - Raise head off bed, hold arm in air 15secs - RR<30, sats >95% - Strong cough *Can maintain this for 30mins min* Ensure pH, biochem, asp risk etc. all optimised ____________ 100% O2 Difficult airway trolley and plan Suction Deflate Pull out on cough Onto HFNP or 6L NP _____________ Complications: - Post ext stridor (Adren neb) - Aspiration - Brochospasm - Resp failure - Negative pressure APO - Hypotension - Sore throat, cough
40
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
41
Choking BLS algorithm:
42
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 _______
43
MODIFIER: RSI in Pulmonary HTN
*Reduce PVR and optimise RV function* **Optimise oxygenation**, DSI if required, but *don't use PEEP/NIV* if poss (preload). Could bag without PEEP, and careful VT. **Avoid hypercarbia** as above, hyperventilate. **Support preload** —> Normal sinus rhythm, rate --> Avoid hypoTN (inopressor) --> Avoid PEEP/NIV —> Diuretic vs small fluid bolus **Optimise RV function** - Dobutamine - Don’t use pressor alone without inotrope (afterload) **Use HD neutral induction** (eg. ketamine, etomidate) After care: - **+- Nitric** for pulmonary vasodilation - Avoid permissive hypercarbia.
44
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
45
DIFFICULT AIRWAY:
**OPTIMISED RSI:** - Get help - Most experienced operator - Optimise preoxygenation/ safe apnoea time and positioning - Best chance equipment: —> CMAC, Bougie. Have D blade available (+ stylet-loaded tube) - Use external laryngeal manipulation. - Be **scrubbed and ready for FONA** *(“dual set up”)* OTHER OPTIONS: *Awake and unparalysed is safest*: 1- **Awake fibreoptic** 2- **Primary, awake FONA** under local 3- **Ketamine, lignocaine spray and LOOK** first *(if difficult ++, see above)*

Resuscitation (10 decks)

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