Airway and CV assessment Flashcards
Steps when approaching unresponsive person?
- verify scene is safe
- if victim is unresponsive, shout for help - activate EMS, get AED
- if breathing is normal and there is pulse: watch for respirations and check pulse for up to 10 seconds - if breathing isn’t normal but there is a pulse - then manage airway and breathing - think about opioid overdose
- if there is no breathing and no pulse - then begin CPR and use AED ASAP
ACLS guidelines for conscious pt?
- healthcare providers should perform ACLS survey: ABC
- Airway: is it open and clear?
- breathing: is ventilation and oxygenation adequate?
circulation: what is needed to support the pulse and blood pressure?
Components of airway management?
- open airway w/ head tilt/chin lift (if no C spine concerns) - jaw thrust is adequate if C spine issues
- clear airway w/ suction (if available)
- if no resp effort, begin ventilation w/ BVM device
- insert NPA or OPA
Airway management in an unconscious pt w/ resp effort?
- admin high flow O2
- ensure no obstruction to upper airway
- insert NPA or OPA
- if suspected lower airway obstruction, perform heimlich maneuver
What is considered high flow O2?
- nasal cannula w/ flow rate of 6L/min provides 40% of FIO2
- dial a concentration or venti-masks can deliver 24-40% FIO2
- NRB masks w/ reservoirs can deliver a little less than 100% FIO2 (liter flow needs to be at least 10)
When are NPAs used?
- usually better tolerated in conscious pts vs OPAs
- can usually be used even w/ intact gag reflex
- ensure it isn’t too long or too big
- lube w/ lidocaine jelly
- can lead to epistaxis
Placement of NPA?
- outer diameter of NPA shouldn’t be larger than inner diameter of the nares
- length shouldn’t be longer than tip of pt’s nose to earlobe
When are OPAs used?
- for unconscious pts
- will often lead to emesis if gag is intact
- needs to be inserted carefully so that tongue isn’t pushed back therefore blocking the airway
- difficult or impossible to insert w/ seizing pt
- not as adequate in edentulous pts
Placement of OPA?
- proper size stretches from mouth to angle of mandible
Use of LMAs?
- rescue device after failed intubation
- can be attempted quickly while another person is preparing for cricothyroidotomy
- prehosp setting
- plan for short term intubation
- good alt to continued BVM
- can decrease aspiration risk (for pts who can’t be intubated but can be ventilated)
- allows relative isolation of trachea
- is designed to sit in pt’s hypo pharynx and cover supraglottic structures
- used in many settings: OR, ED, out of hosp care, quick to place, easy to use for inexperienced provider
- success rate for placement is nearly 100% in OR
CIs to LMA?
- can’t open mouth
- complete upper airway obstruction
Insertion of LMA?
1) select proper size: size 4 for females, 5 for males
2) inflate then deflate cuff
3) lubricate back of mask
4) pt placed in sniffing positon: may need to use sedation like versed or propofol
5) slide mask down posterior pharyngeal wall until resistance is felt
6) inflate mask w/ recommended amt of air
7) confirm tube position
Complications of LMA?
- any airway device w/ cuff can cause necrosis if cuff is overinflated
- mask tip can fold and can cause obstruction by pushing down on epiglottis
- mask tip can fold back on itself:
if mask isn’t pushed up against hard palate, if not adequately lubricated, if cuff not adequately deflated
What is a combitube - why do this?
- fxns when placed in either esophagus or trachea
- insertion doesn’t reqr neck movement
- insert blindly
- check white port for esophageal intubation
- ventilate through blue port
Rules for intubation?
- oxygenate b/f and after intubation
- intubate early
- intubate as soon as you think about it
- make sure pt isn’t DNI/DNR prior to intubation
Pros of nasotracheal intubation?
- curves with anatomy of pharynx, causes less damage to trachea, vocal cords, less likely to cause necrosis
What is RSI?
- rapidly acting sedative (induction) agent and neuromuscular blocking (paralytic) agent
- incorporates meds and techniques to minimize risk of aspiration of stomach contents
Indications for RSI?
standard of care for intubations not anticipated to be difficult
CIs to RSI?
- if anticipating difficult airway placement and inabiity to ventilate pt the paralytic agent may be CI - if given paralytic have taken away resp drive
& P’s for RSI?
- preparation
- preoxygenation
- pretreatment
- paralysis w/ induction
- protection and positioning
- placement w/ proof
- postintubation management
RSI step 1: prep?
STOP MAID
- critical to have back up plan in case you can’t secure airway:
can you use BMV?
will you have to cric?
STOP MAID mnemonic for RSI step 1: preparation?
- S: suction
- T: tools for intubation
- O: O2 source for preoxygenation and ongoing ventilation
- P: positioning
- M: monitors, including EKG, pulse Ox, BP, end tidal CO2, and esophageal detectors
- A: assistant: ambu bag w/ face mask, airway devices (ET tubes, syringes, stylets, LMA); airway assessment
- I: IV access
- D: drugs, including induction agemt, NM blocking agent, desired adjuncts
RSI: Step 2?
- preoxygenation
- admin of high flow O2
- have pt take 8 vital capacity breaths w/ O2 if able
- manual ventilation if needed but slow and easy so as to avoid excessive inflation of lungs or distension of stomach
- maintain patency of upper airway w/ NPA/OPA or positioning maneuvers
- consider head up position in obese pts
- 5L of O2 per nasal cannula during apneic period (keep pt on O2 during intubation)
RSI step 3?
- pretx
- atropine for peds to prevent vagal response (severe bradycardia):
all kids less than 1, all kids less than 5 receiving succinylcholine, older than 5 receiving 2nd dose of succinylcholine, dose 0.02 mg/kg IV, min dose 0.1 mg - lidocaine: asthma or head injury
- opioids (Fentanyl): may decrease sympathetic response to intubation in adults, don’t use in pts w/ low BP (hemodynamic compromise)***
Drugs used in RSI step 4?
- this is paralysis w/ induction
- Etomidate: head injury,increased ICP, low BP
Main NM blocking agents used in RSI?
- Succinylcholine: onset of action 45-60 sec, duration 6-10 min
CI: hyperkalemia, NM disease, ocular trauma, malignant HTN, rhabdomyolsis, stroke or burn older than 72 hr - alt agents:
Vecuronium priming dose of 0.01 mg/kg 3 min prior to intubating dose of 0.15 mg/kg IV or rocuronium 1 mg/kg IV
RSI step 5?
- protection and positioning
- cricoid pressure:
to collapse the esophagus b/t cricoid cartilage and spine to prevent regurgitation of gastric contents, may help facilitate visualization of vocal cords, may help intubator as you may be able to tell them you feel the tube - BURP: backwards, upwards, rightward (pt’s right) pressure may bring larynx into view
RSI step 6?
- placement w/ proof
- place ETT w/ direct laryngoscopy (visualize cords)
- can release cricoid pressure after tube is placed
- inflate cuff
- confirm placement of tube in proper position by:
- end tidal CO2 monitor
- ausculation of breath sounds
- esophageal intubation detection device
- CXR often can’t distinguish if in trachea or esophagus but can tell how far in tube is
Use of end tidal CO2 monitor?
- use to confirm tube placement
- purple on inhalation
- yellow on exhalation
- confirm tube position using 2 methods
RSI step 7?
- postintubation management
- secure ETT
- CXR to eval depth of ETT and assess for barotrauma
- support BP
- mechanical ventilation
- determine need for ongoing sedation or paralysis
Should a paralytic be given w/o sedation?
- NO! Bad - a pt is then paralyzed and awake
How long can a pt tolerate apnea if properly preoxygenated?
- 4 minutes of apnea w/ minimal decrease in sats
When is a cricothyroidotomy done? relatively CI in what pop?
- w/o O2 the brain dies!!
so this is done: - when a pt has failed to be oxygenated adequately (SpO2 less than 90) by all other possible methods and intubation has failed
- relatively CI in young kids due to shape of airway, may lead to subglottic stenosis:
preferred surgical airway in young kids is transtracheal ventilation using 14 g needle
Diff techniques of cricothyroidotomy?
- std technique
- rapid 4 step technique
- seldinger technique
Rapid 4 step technique of cricothyroidotomy?
1: ID cricothyroid membrane by palpation
2: make horizontal stab incision through both skin and cricothyroid membrane w/ scalpel (20 blade)
- incision 1-2 cm
3: prior to removal of scalpel, hook is placed and directed inferiorly
- caudal traction is used to stabilize larynx, hold hook in nondominant hand (don’t wan’t to lose control of airway)
4: insert tracheostomy tube into trachea, or can insert tracheal tube introducer and then slide tracheal tube over introducer
What is CV collapse?
CO=SVxHR so as CO decreases HR will increase
- hypotension causes an increase in SVR and decreased tissue perfusion
- decreased coronary perfusion = increased cardiac ischemia and further LV systolic dysfxn (decreased stroke vol) and further downward spiral
The cause of every death of CV collapse is?
- cardiac arrest
- as long as blood goes round and round and air goes in and out pt lives
What are the elements of the CV assessment?
- Vital signs
- heart tones
- JVD
- pulses (diff sites)
- skin (warm, pink, dry) vs (cold, wet, clammy, pale)
- lung sounds
- peripheral edema
- fxnl status
- general state of mood (anxiety, impending doom)
