Airway Assessment Part 2 (that 2023 didn't make) Flashcards
Practice labeling these structures
What two things can be caused by overinflation of an ett cuff?
- Tracheoesophageal fistula
- subglottic stenosis
What is micrognathia?
A condition in which the lower jaw is significantly smaller than normal. Similar to “recessed” jaw
What drug class can enlarge the tongue?
ACE-I’s. Angioedema effects
How can we treat an enlarged tongue caused by angioedema?
FFP, TXA
Why is it more difficult to ventilate an edentulous patient?
Soft tissue where the teeth used to be can be obstructive. These patients may need an OPA during bag-mask ventilation
What anatomical structure does the ear have to be level with in the sniffing position?
The sternal notch
What is the frequency (%) of seeing a CL-1?
68-74%
What is the frequency (%) of seeing a CL-2?
24-30%
What is the frequency (%) of seeing a CL-3?
1.2-1.6%
What is the frequency (%) of seeing a CL-4?
Very rare
Criteria associated with difficult mask ventilation:
OBESE
O: obesity, BMI >30
B: beard
E: edentulous
S: snorer, OSA
E: Elderly, age >55
*** Mallampati 3 or 4 when at least TWO of these criteria are met
Criteria associated with difficult intubation:
LEMONS
L- look. Abnormal face, trauma, unusual anatomy
E- evaluate. 3-3-2 rule.
M- mallampati score
O- obstruction, obesity
N- neck mobility
What is the 3-3-2 rule?
3 finger breadths inter incisor gap
3 fingers thyromental distance
2 fingers thyromandibular junction
What 5 criteria, if met, will necessitate an “awake” intubation?
- suspected difficult laryngoscopy
-suspected difficult ventilation with face mask/supraglottic airway
-significant increased risk of aspiration
-increased risk of rapid desaturation
-suspected difficult emergency invasive airway
What is the most difficult part of doing a cricothyrotomy?
Deciding to do it (kinda a serious card)
If the patient is not yet crashing after intubation attempts and using a BVM is difficult to ventilate the patient, what tool do you try in order to ventilate your patient?
LMA; you should probably have called for help after the unsuccessful intubation attempts
If unable to adequately ventilate your patient using an LMA, what must be considered next?
- cricothyrotomy
-praying to Jesus
What could you consider if an LMA IS adequate enough for ventilating your patient?
-If appropriate, maybe an LMA will get your patient through the case
-……. if not, consider waking up your patient
RSI vs. Awake intubation:
peri arrest
dynamic airway
deteriorating
RSI
Problems associated with rocuronium use:
None, bitch
RSI vs. awake intubation:
stable GI bleed requiring endoscopy with a progressive neuromuscular weakness
Awake
RSI vs. awake intubation
upper GI bleed, bowel obstruction, vomiting in ED
RSI
RSI vs. awake intubation
fixed flexion deformity of the neck, cannot open mouth
awake
Problems associated with succinylcholine use:
rhabdo, hyperkalemia, MS, ALS, muscular dystrophies, burns, crash injury, immobilization, etc.
Predispositions to malignant hyperthermia, bradycardia, fasciculations, increased ICP/IOP
What conditions would probably necessitate early intubation?
Airway -
-“dynamic airways”….. bullets, bites, burns: ie neck trauma, anaphylaxis/angioedema, thermal or caustic airway injuries
A- mouth and neck injections, tumors, foreign bodies causing stridor, phonation abnormalities, swallowing difficulty, excess secretions, dyspnea
What conditions would probably necessitate early intubation?
Breathing
Failure of oxygenation or ventilation
What conditions would probably necessitate early intubation?
Circulation
supporting tissue oxygen delivery by unloading the muscles of respiration
Ex: sepsis
What conditions would probably necessitate early intubation?
Disability
CNS catastrophes and CNS depression, ongoing seizures, weakness
What conditions would probably necessitate early intubation?
Expected Course
Anticipated decline, transfer to radiology or another institution
What conditions would probably necessitate early intubation?
Feral
need for prompt, aggressive sedation to protect patient/others.
Which two anticholinergics can you use for drying secretions for an awake intubation? What are the doses? Which is preferred?
Glycopyrolate 0.2 mg
Atropine 0.01 mg/kg
*** Glyco is preferred
Is nebulized lidocaine or viscous lidocaine preferred? What is the dose of the preferred lidocaine?
Nebulized lidocaine. 4cc of 4% or 8cc of 2%
How can you confirm proper tracheal placement with a bougie?
The coude tip will “scrape” or “bounce” against the tracheal rings, confirming correct placement to the operator.
Why can it be difficult to ventilate your patient after they have received a high dose of opioid?
s/e: rigid chest with high dose of opioids
What are some of, if not all, contraindications to succinylcholine?
- Rhabdo
- Hyperkalemia
-Muscular dystrophies - denervating injuries
- predisposition to malignant hyperthermia
- crush injury
- masseter spasm
What is the duration of action for both succinylcholine and rocuronium?
Sux: 5-10 minutes
Rocuronium: 30-90 minutes
What three conditions should scare you when you need to intubate someone?
- hypotension
- hypoxemia
- metabolic acidosis
If hypotension is a concern, what should be your SBP goal before intubating, if possible?
SBP > 140 mmHg
What does the term “sedatives low, paralytics high” mean?
We may have to adjust our dosing of induction agents secondary to a patient’s pathophysiology.
Example: someone who is septic would probably need an induction agent like ketamine (SNS stimulating properties) and a relatively high dose of rocuronium (distributive shock hinders Vd of any drug) in order to more safely intubate a patient like this.
What are the three push-dose pressors we will carry around?
-Epinephrine
- Phenylephrine
- Vasopressin
Which push-dose pressor is typically the agent-of-choice?
Epinephrine
Which push-dose pressor will shock patients respond best to?
Vasopressin
Which pressor is a pure alpha agonist?
Phenylephrine
What does the acronym NO DESAT mean? What is its purpose?
Nasal Oxygen During Efforts Securing A Tube
- hyperoxygenating the patient via NC and BVM or NRB in between trying to get an ett placed is important to do!
What is “Intervention One” when implementing NO DESAT for your patient?
NC 15 L/min, BVM 15 L/min, PEEP valve 5-15 cmH2o.
Do you need to ventilate your patient using a BVM if they’re spontaneously breathing during a NO DESAT maneuver?
No
What if you’re doing a NO DESAT and you can’t get your patient’s SpO2 above 95%?
Consider shunt physiology and use apneic CPAP recruitment
What is “Intervention Two?”
Cooperate Before Intubate
- used for the uncooperative or combative patient
What is the step-by-step process of Cooperate Before Intubate?
- ketamine 1mg/kg IV
- pre-oxygenate
- paralyze
- apneic oxygenation
- intubate
What is “Intervention Three: BUHE”?
Back Up, Head Elevated
- an intervention to consider to avoid intubation-related complications in comparison to standard supine position
What is VAPOX? What mode do you set the ventilator to?
Ventilator Assisted Pre-Oxygenation
SIMV+PSV
What ventilator settings do you use in VAPOX?
Vt: 8 mL/kg IBW
FiO2: 100%
Pressure Support: 5-10 cmH2o
PEEP: 5
Respiratory Rate: 0
Inspiratory flow rate: 30 lpm
