Airway Flashcards
What is GCS validated in and best evidence used for?
GCS has well established use in trauma patients where a GCS of 8 is an indication to intubate to prevent secondary injury (hypoxemia, hypercarbia) in the trauma patient.
- GCS
With pre-oxygenation with nasal prongs when you crank the knob past 15L/min what is the max amount of flow can you get?
30-45 L/min flow!
As per EmCrit:
Pre-oxygenate with flow 30-45L/min
after paralysis
Turn flow down to 15 L/min for apneic oxygenation.
What is your approach to RSI intubation (8 P’s)
Preparation: Room, airway equipment, suction, monitor, IV access
Personnel: RT
Pre-oxygenation: NRB mask for spontaneously breathing patient, ventilate if hypoxic
Positioning
Plan A
Plan B: ?emergency airway
Paralysis
Post intubation management/confirm placement, Vent settings
For an RSI what is the dose for: (avg 80 kg)
- Propofol
- Ketamine IV
- Ketamine IM
- Etomidate
- Propofol: 1.5-2 mg/kg (120mg)
- Ketamine IV: 1.5 mg/kg (120 mg)
- Ketamine IM: 3 mg/kg (240 mg)
- Etomidate IV: 0.3 mg/kg (24 mg)
For an RSI what is the paralytic dose for Suxx and Roc?
assume 80 kg
Succ: 1.5 mg/kg = 120 mg
Rocc: 1.2 mg/kg = 96 mg (standard dose nonRSI is 0.6mg/kg)
What are indications for intubation?
- Failure to ventilate
- Failure to oxygenate - needing positive pressure to improve oxygenation
- Failure to maintain airway (secretions, decr GCS)
- Anticipated clinical course (OR, inevitable airway compromise)
- Evidence of neck, airway or vascular injury (similar to pt 4)
What factors assist in predicting difficult larygnoscopy? (5)
LEMON
Look externally for signs of difficult intubation (by gestalt, c-spine)
Evaluate the “3-3-2 rule”
(pt’s fingers - 3 fingers between incisors, 3 fingers submandibular space, 2 fingers from cricoid to floor of mandible ‘thyroid-hyoid distance)
Mallampati
Obstruction or obesity
Neck mobility
How do you evaluate for difficult BVM?
MOANS Mask seal (beard) Obesity/obstruction Age No teeth Stiffness (to ventilation - stiff lungs)
BOOTS Beard Obese Old Toothless Snoring
How do you evaluate for difficult insertion and use of an extraglottic device?
RODS Restricted mouth opening Obstruction or obestity Deformity of anatomy (wont get good esophageal seal and indirect oxygenation..) Stiffness (to ventilation)
How do you evaluate for a difficult Cricothryoidotomy?
SMART Surgery Mass (abcess, hematoma) Access/Anatomy distorted (obesity, edema) Radiation Trauma (distortion, subQ air)
In an RSI, what is the purpose of pre-oxygenation?
It washes out the nitrogen in the alveoli/ functional residual capacity of the pt so that they will have a longer ability to be apneic without getting hypoxic.
Even in an unconscious patient, why do we use induction agents?
- Enhances effect of paralytic and improves intubating conditions because it is being done at the earliest phase of the neuromuscular blockade.
- May help attenuate response to airway manipulation
What are 5 contraindications for NIPPV?
- Inability to protect airway or clear secretions.
- Impaired consciousness (including agitated/uncooperative patients).
- Cardiac or respiratory arrest.
- Hemodynamic instability.
- Facial surgery/trauma/deformity.
- Pneumothorax.
- Upper airway obstruction.
- Complicated multi-organ failure.
- Recent esophageal anastomosis
In which conditions is there strong evidence for the use of NIPPV?
intermediate evidence? weak evidence?
- Severe COPDE
- CHF - cardiogenic pulmonary edema
- Respiratory failure in the immunocompromised
Intermediate evidence: Asthma, Community-acquired pneumonia, DNR/DNI patients.
Weak evidence: Trauma, Neuromuscular diseases (e.g., myasthenia gravis), Cystic fibrosis.
Trouble shooting with difficult airway with failed intubation (BBBARS)
Best Look Laryngoscopy Bougie Blade exchange Alternative (Video largynoscopy) Rescue (Supraglottic/LMA) Surigical (Cricothyroidotomy)
