Airway assessment (cont.) Flashcards
When deciding to intubate, what are some examples of dynamic airways?
- Bullets: neck trauma
- Bites: anaphylaxis/angioedema
- Burns: thermal and caustic airway injuries
What are some other considerations in deciding to intubate (6)?
- Airway: mouth and neck infections, tummors, foreign bodies, bleeds (i.e stridor, phonation, swallowing, SOB, secretions)
- Breating: failure of oxygenation or ventilation
- Circulation: supoorting tissue oxygen delivery by unloading the muscles of respiration (i.e sepsis)
- Disability: CNS catastrophes and CNS depression, ongoing seizures, weakness
- Expected course: anticipated decline, transfer to radiology or other institution
- Feral: need for prompt, aggressive sedation to protect pt/others
(4) things to consider when determining RSI vs awake intubation
- Urgency:
- Difficult airway features
- Vomiting risk
- Sympatholysis risk/apnea risk
Describe the “awake technique” for intubation.
“Dry, nebulize, atomize, topicalize”
Laryngoscopy - How do we “set the table”? (3) things.
- Ear to sternal notch
- Equipment is ready: suction under right
- Shoulder assistant pulls right mouth corner
After “setting the table” what are the remaining steps to successful laryngoscopy?
- Find the epiglottis: advance from the right
- Optimize the head: using right hand, perform sniff and head tilt
- Seat the blade: either in vallecula or on the epiglottis (then lift)
**Ventilate pt before subsequent attempts
If using a bougie, what measurement is the black strip at the lips?
25 cm. Mid trachea in an adult male
What is the reversal agent for rocuronium?
Sugammadex
True or False: Succs wears off on its own without a reversal agent?
True
What are some contraindications & side effects to using Succs?
Contraindications:
- Rhabdo
- Existing hyperkalemia
- MS, ALS
- Muscular dystrophies
- Denervating injuries >72hrs old (i.e stroke, spinal cord injuries)
- Burns >72hrs old
- Exotoxin infections (tetanus, botulism)
- Severe infections (i.e intraabdominal)
- Immobilization (including pts found down)
Side effects:
1. Predisposition to MH
2. Bradycardia
3. Fasciculations: increased ICP, myalgias, masseter spasms (desat)
True or false: the only real contraindication/side effect of Roc is a true allergy?
True. Recall the most common anaphylactic reaction is from NMBs.
What are the (3) conditions that increase the risk for cardiac arrest after intubation?
- Hypotension
- Hypoxemia
- Metabolic acidosis
What should be the induction agent of choice in shock patients?
Ketamine. It gives simultaneous sympathetic surge and pain control.
What should be the paralytic agent of choice?
Rocuronium
True or false: dose sedation high and paralytics low
False. Dose paralytics high and sedation low. Keep in mind sedation will always impact a patients sympathetic drive.
What are (3) ways we can augment a pts O2 sats while securing an airway?
- NC at 15LPM + BVM 15LPM + PEEP valve 5-15cmH20
- Procedural sedation for preoxygenation (Ketamine 0.5-1mg/kg)
- BUHE: back up head elevated
*If O2 sats don’t improve consider underlying causes & treatments - i.e pulmonary edema (lasix), PNA
True or False: we want to intubate acidotic pts as quickly as possible
False: we should try to avoid it if possible. Consider short trial of non-invasive positive pressure ventilation while trying to correct acidosis.
How can we use the ventilator to preoxygenate the pt (include settings)?
- Mask
- SIMV + PSV; VT 8ml/kg; FiO2 100%; Pressure support 5-10cmH20; PEEP 5
What are some special considerations with high aspiration risk patients - upper GIB, bowel obstruction, pre-induction vomitting?
- NGT prior to intubation
- Intubate in semi-upright position
