Airway Flashcards
What are indications for intubation?
Unable to swallow
Cannot ventilate/oxygenate (failed airway algorithm)
GCS is less than 8
Expected clinical course as a result of inhalation burns, circumferential neck or chest burns, or anaphylaxis
Apnea
Airway obstruction
Respiratory failure (pH less than 7.2, CO2 greater than 55, PaO2 less than 60)
What is the LEMON acronym for intubation?
Look Evaluate 3-3-2 Mallampati (1-4) Obstructions Neck Mobility
What is the Mallampati Airway Grading Scale?
Mallampati I: Soft palate, uvula, anterior/posterior tonsillar pillars visible (tall thin neck/no difficulty)
Mallampati II: Tonsillar Pillars hidden by tongue (no difficulty)
Mallampati III: Only the vase of the uvula can be seen (Moderate difficulty)
Mallampati IV: Uvula cannot be seen (short, fat or muscular neck/severe difficulty)
How are the Macintosh and Miller laryngoscope blades different?
Macintosh: curved blade used to lift the vallecula
Miller: straight blade used to lift the epiglottis
What are the airway visualization aid methods?
Sellick’s Maneuver: Direct downward pressure on the thyroid cartilage occluding the esophagus and prevents aspiration during intubation
BURP: Backward Upward Rightward Pressure
What is the Failed Airway Algorithm?
Patient requires a secured airway
3 attempts of direct laryngoscopy unsuccessful
Ventilate patient with BVM
Unable to ventilate/oxygenate SaO2 greater than 90%
Cricothyroidotomy indicated
How can ET tune placement be confirmed?
Chest X Ray is the gold standard (distal tip should be 2-3 cm or 1” above carina or level of T2/T3 vertebrae
Visualization of tube passing through the cords is the next best method
Bulb tube check: attached bulb will not re-inflate if tube is in esophagus
ETCO2: if ETT is in trachea there will be CO2 in expired air
What are the 7 P’s of Intubation?
Preparation Preoxygenate Pretreatment Paralysis with induction Protect and position Placement with proof Post intubation management
What is the LOAD acronym for RSI pretreatment?
Lidocaine
Opiates
Atropine
Defasiculating dose
What differentiates the 3 main neuromuscular blockers?
Succinylcholine (Anectine): depolarizing neuromuscular blocker that causes fasiculations has a short onset and duration. Dose is 1-2mg/kg. Contraindications include Hyperkalemia, crush injuries, eye injuries, narrow angle glaucoma, history of malignant hyperthermia, burns for greater than 24 hours, any nervous system disorder. Known to lead to malignant hyperthermia which is treated with 3mg/kg Dantrolene
Vecuronium (Nocuron): non depolarizing neuromuscular blocking agents which does not cause fasiculations. Often used after succinylcholine to maintain paralysis. Defasiculating dose reduces intubation ICP increase. Longer onset and duration. Dose 0.04-0.06mg/kg after succinylcholine. Only one of 3 which does not require refrigeration.
Rocuronium (Zemeron): non depolarizing neuromuscular blocking agents which does not cause fasiculations. Often used after succinylcholine to maintain paralysis. Defasiculating dose reduces intubation ICP increase. Longer onset and duration. Dose 0.1-0.2mg/kg every 20-30 min maintenance
What are the 3 main sedation induction agents?
Etomidate (Amidate): preferred for awake sedation due to short onset and duration. Minimal change in BP and CO. There are no analgesic properties. Vomiting can occur when waking up. Contraindications include some adrenal suppression occurs so do not use in septic shock or Addison’s disease
Midazolam (Versed): used for sedation by helping to forget an event ever happened (anterograde amnesia) and for seizures. Flumazenil (Romazicon) is reversal agent.
Propofol (Diprivan): Hypnotic with no analgesic properties. Dose is average 1.5mg/kg IV. Decreases CPP and MAP. Not used in head injury or or for hemodynamically unstable pts
What are the 3 main analgesic induction agents?
Ketamine (Ketalar): Hypnotic analgesic amnesic used to stop pain impulses. Potent bronchodilator. Does not dry airway secretions, can increase them in which case 0.01 mg/kg IV Atropine or 0.3mg IV Scopolamine slowly. Hallucinations can occur upon waking.
Morphine: Opioid analgesic. Avoid in patients with head injury or respiratory depression. Hypotension, nausea, and flushing can occur.
Fentanyl: Opioid analgesic that is 100x more powerful than morphine. Avoid in patients with increased ICP, hypoventilations, hypotension, and bradycardia. Chest wall rigidity can occur.
How do tidal volume, inspiratory reserve volume, exploratory reserve volume, vital capacity, residual volume, total lung capacity, and dead space relate to each other?
Tidal volume is how much air the patient breathes in a regular breath. Inspiratory reserve volume is the amount of air that can be forcefully inhaled in addition to the tidal volume breath. Exploratory reserve volume is the amount of air that can be forcefully exhaled after a tidal volume breath. These three components together are the vital capacity. Add on to this the residual volume or the amount of air remaining in the respiratory system after that exploratory reserve volume and you have the total lung capacity. Dead space is simply the term for all the airway surfaces not a part of the gas exchange process which is approximately 2ml/kg.
What are the two classifications of chemoreceptors?
Central chemoreceptors are located in the medulla/pons and its response is dictated by H and CO2 levels
Peripheral chemoreceptors are located in the aortic arch/carotid bodies. Their response is dictated by CO2, O2, and H levels.
What is the Fick Formula?
A measurement of cardiac output based on the principle that oxygen uptake by the lungs is equal to O2 delivery for the sake of determining how much O2 a person is using
