Airway Flashcards
what are examples of dynamic airways
bullets -neck trauma
bites - anaphylaxis, angioedema
burns - thermal and caustic airway injuries
ABC in the decision to intubate
Airway
Breathing
Circulation
Disability
Expected Course
Feral
Airway signs prompting intubation and causes
mouth and neck infections, tumors, foriegn bodies, bleeds
stridor, phonation, swallowing, secretions, dyspnea
breathing signs and causes prompting intubation
failure to oxygenate or ventilate
often amenable to medical an non-invasive therapies
think Non-Invasive Ventilation
Criculation causes and signs to intubate
supporting tissue oxygen delivery by unloading the muscles of respiration
sepsis
what disabilities would lead you to intubate
CNS catastrophes and CNS depression, ongoing seizures and weakness
*avoid gag - assess the ability to swallow and handle secretions for neuromuscular weakness: FVC < 12mL/kg and NIF < 20 cm H2O
vomiting in the obtunded patient is particular concern
expected course that will prompt the decision to intubate
anticipated decline, transfer to radiology or another institution
feral decision to intubate
need for prompt, aggressive sedation to protect patient and others
*especially with potential or undiagnosed medical instability
RSI intubation considers
peri-arrest
dynamic airway already deteriorating
upper GI bleed
bowel obstruction
vomiting
Awake intubation consideration
stable GI bleed requiring endoscopy
slowly progressing NM weakness requiring transfer
fixed flexion deformity of the neck
cannot open mouth
how can you use local anesthesia for an awake intubation
dry
nebulize
atomize
topicalize
Awake intubation - IV sedation options
ketamine**
versed
fentanyl
dexmedetomidine
how do you set the table for laryngscopy
ear to sternal notch
equipment is ready: suction under right shoulder
assistant pulls right mouth corner
how can you optimize the patient’s head
place your right hand under the patient’s head and do sniff and head tilt
how can you optimize the larynx
using your right hand to maneuver the thyroid cartilage into optimal position
the black stripe on the bougie tells you what
25 cm - at lips mid trachea in an adult male
considerations for etomidate for RSI
safe choice in most situations
adrenal suppresion
lowers seizure threshold
considerations for ketamine for intubation
reactive airways
IM RSI
hypotension/sepsis
*Avoid if HTN/tachycardia is undesirable
*Contraindicated in high ICP
*hyper sympathetic delirium
problems with succinycholine
rhabdomyolysis
existing hyperkalemiaa
Multiple sclerosis ALS
muscular dystrophies / inheritied myopathies
denervating injuries > 72 hours old (stroke, spinal cord injury)
burns > 72 hours old
tetanus, botulism, and other endotoxin infection
severe infections > 72 hours old (especially intra-abdominal)
immobilization
predisposition to MH
bradycardia
fasciculations - increased ICP
if you want to give Roc for RSI what type of dose range do you need to give
1.6 - 2 mg/kg provided excellent intubating conditions at 40 seconds
duration of action of succinycholine
5-10 minutes
duration of action of rocuronium
30-90 minutes
physiologic killers with intubation
hypotension (SBP =< 90)
hypoxemia
metabolic acidosis
strategies to mitigate hypotension before intubation
2 proximal PIVs or Its
judacious bolus of IVF wide open or pressor support
shoot for BP higher than normal before intubation (SBP>140 mmHg)
What dose of rocuronium has a similar onset of 45 seconds like succinylcholine 2 mg/kg IV
rocuronium 1.6 mg/kg
do shock patients require a decreased dissociative dose of ketamine for RSI
Yes, reduce the dose to 0.5 mg/kg IV
may require a subsequent dose of 0.5 mg/kg
Options for push dose pressors
epinephrine
phenylephrine
vasopressin** (easiest drug to dilute)
how would make your push dose vaso
20 units/1 mL Vaso + 19cc of NS in a 20cc syringe -> 1unit/mL
how to mitigate desaturations during efforts to intubate
NC at 15LPM + NRB at 15LPM
keep a PEEP valve close
if youre unable to get a O2 saturation greater than 95% what pathologies are you considering
Lung Shunt Physiology pulmonary edema, PNE
What is a DSI used for and how is it done
delayed sequence intubation is used for uncooperative or combative patient
give procedural sedation for the procedure of prexygenation
-Ketamine 0.5-1 mg/kg
once preoxygenated paralyze -> apneic oxygenation -> intubate
what is BUHE
back up head elevated
pH kills - try to avoid intubation if at all possible. how can you optimize the patient beforehand
consider short trial of NIPPV while you correct the cause of metabolic acidosis
A patient in severe metabolic acidosis who is tachypneic will bicarb help the patient?
no it’ll make the patient more acidotic and can lead to cardiac dysrhythmias
high aspiration risk patients and considerations
upper GI bleed, bowel obstruction, pre-induction vomiting
consider NGT prior to intubation, intubate in semi-upright position, bag early but slightly less early
difficult airway strategies
initiate rescue maneuvers such as ventilation and cricothyrotomy early so that the patient has enough reserve to allow for calm and effective execution
BVM with three airways in, two hands down replace BVM with LMA ventilation
make the bougie part of your routine
