Airway Management Flashcards
(117 cards)
1
Q
Amount of people without gag reflex
A
12-25%
2
Q
Causes of impending upper airway obstruction (6)
A
- Facial burns
- Severe Angioedema
- Penetrating Neck Trauma
- Expanding Hematoma
- Foreign Body
- Epiglottis
3
Q
When to intubate (4)
A
- Failure to maintain patent airway
- Loss of protective reflexes
- Failure to adequately oxygenate or ventilate
- Anticipated clinical deterioration
4
Q
When possibly not intubate with GCS <8
A
Rapidly reversible cause (i.e. hypoglycemia, opioid overdose)
5
Q
Causes of hypercapnia (2)
A
- Diminished central respiratory drive
- CNS injury
- sedatives
- alcohol - Peripheral process
- Guillain Barre
- Myasthenia gravis
- Muscular dystrophy
6
Q
When expect anticipated clinical deterioration with need to intubate? (4)
A
- Status epilepticus
- Poly-trauma (+head inj)
- TCA overdose
- Tiring asthmatic
7
Q
Are airway adjuncts (OPA or NPA) temporary or permanent measures?
A
Temporary
8
Q
Contraindications for OPA
A
gag reflex
9
Q
OPA sizing
A
Mouth to angle of the mandible
10
Q
OPA placement for peds
A
- Compress tongue with depressor
2. Advance device without inversion
11
Q
NPA sizing
A
Nares to angle of mandible
12
Q
Contraindications for NPA
A
Midface or basilar skull fx
13
Q
Should pop off valves be used in ped BVM use?
A
No
14
Q
Minimum volume of bag for peds BVM
A
450mL
15
Q
Appropriate volume for BVM?
A
Achieves chest rise
16
Q
O2 flow for BVM
A
15L/min
17
Q
Which technique is preferred with BVM?
A
Two-handed
18
Q
What to do if suspect air trapping while BVM?
A
stop bagging and squeeze chest to help patient exhale
19
Q
Make sure to remove these to protect airway
A
dentures
20
Q
What if pt has a beard while BVM?
A
use lubricating KY jelly
21
Q
Normal ET tube size for adult male
A
7.5- to 9.0-mm
22
Q
Normal ET tube size for adult female
A
7.0- to 8.0-mm
23
Q
How much smaller is a type for nasal intubation?
A
0.5-1.0 mm
24
Q
Peds ET tube size (cuffed & uncuffed)
A
Uncuffed
(age/4)+4
Cuffed
(age/4)+3.5
or estimated from Broselow tape
25
Ped cuff pressure
< 20cm H2O
26
Macintosh vs Miller blades
```
Macintosh
-curved
-lifts epiglottis via hyoepiglottic ligament
Miller
-straight
-preferred in peds (especially < 3yo)
```
27
Laryngoscope blade sizing based on age
Premature infants: 0
Normal infants: 1
Older children: 2
Adults: 3-4
28
Best single means of confirming ET tube placement?
End-tidal CO2 after 6 manual breaths
29
What is the positive ETco2 color?
Yellow
30
What gives false positive ETco2?
1. Tube in supraglottic region
2. Gastric distention
3. Immediately following sodium bicarb administration
31
What causes false negative ETco2?
Poor pulm perfusion (cardiac arrest, massive pulm embolism)
in cardiac arrest, CO2 >2% = correct placement
32
When is using the bougie helpful?
1. when can visualize the arytenoids or epiglottis
| 2. cord opening is narrow
33
At what distance will you typically hit the carina when using a bougie?
27-30 cm
34
BURP
Backward, Upward, Rightward Pressure
35
ET Tube Depth for males, females and children
Male: 23 cm
Female: 21 cm
Children: 3 x ET tube size
36
Gold standard to confirm ET tube placement
Fiberoptic visualization of tracheal rings through ET tube
37
Esophageal detector device
No resistance or bulb inflates = tracheal intubation
| Resistance = esophageal intubation
38
Causes of postintubation hypotension (3)
1. PTX
2. Decreased venous return from PPV
3. Drop in peripheral resistance from induction and paralysis
39
6 P's of rapid sequence intubation
```
Preparation
Preoxygenation
Pretreatment
Paralysis with induction
Placement of tube
Postintubation management
```
40
When to consider RSI pretreatment (PREMED)
```
Pediatric (<10 yo)
Reactive Airway Disease
Elevated ICP
MI
Elevated BP
Dissection
```
41
What are the pretreatment medications?
Lidocaine, fentanyl, and atropine
42
Pretreatment used in reactive airway disease
Lidocaine (mitigate bronchospasm)
43
Pretreatment used in MI/CAD
Fentanyl (mitigate tachycardic response)
44
Pretreatment for elevated ICP
Lidocaine
45
Pretreatment in peds (<10 yo)
Atropine (symptomatic bradycardia)
46
When should pretreatment medications be administered?
3 min prior to induction meds
47
Mechanism of Lidocaine
Lower ICP
| Lower bronchospamstic response to intubation
48
Indication for Lidocaine
Lower ICP
Raise intraocular pressure
Reactive airway disease
49
Dosing for Lidocaine
1.5 mg/kg
50
Mechanism of Fentanyl
Lower sympathetic response to intubation
51
Indication for Fentanyl
Lower ICP
Intracranial bleed or aneurysm
Heart disease
Aortic dissection
52
Dosing for Fentanyl
3 micro-g/kg
53
Mechanism for Atropine
May lower symptomatic bradycardia due to enhanced vagal tone from laryngoscopy
Lower bronchorrhea due to ketamine
54
Indication for Atropine
<10 yo
55
Dosing for Atropine
0.02 mg/kg
56
Why should ketamine be used with caution in patients with known CAD?
causes tachycardia -> demand ischemia
57
Reversal of nondepolarizing neuromuscular blockade
Edrophonium (0.5-1mg/kg IV) given after administration of atropine (0.01 mg/kg IV) once partial motor activity has been regained
58
Class of drug - Etomidate
imidazole derivative
59
Class of drug - Ketamine
PCP derivative
60
Class of drug - Midazolam
benzo
61
Class of drug - Propofol
GABA agonist
62
Benefit - Etomidate
Lower ICP
| Hermodynamically neutral
63
Benefit - Ketamine
```
Bronchodilator
Dissociative amnesia
Short acting
Preserves respiratory drive (awake intubation)
Safe in head injury
```
64
Benefit - Midazolam
Lower ICP
| Anticonvulsant effects
65
Benefit - Propofol
Lower ICP
Lower Airway Resistance
Short onset and duration of action
66
Side Effects - Etomidate
Brief clonus
| Lowers cortisol
67
Side Effects - Ketamine
Increases secretions
Increases HR
Emergence phenomenon
68
Side Effects - Midazolam
Negative inotropy -> lowers BP
69
Side Effects - Propofol
Negative inotropy, vasodilation -> lowers BP
| Apnea
70
Dosing - Etomidate
0.3 mg/kg
71
Dosing - Ketamine
1-2 mg/kg
72
Dosing - Midazolam
0.1-0.2 mg/kg
73
Dosing - Propofol
1.5-3 mg/kg
74
When should you avoid using succinylcholine?
Hyperkalemia
75
Things that increase risk of succinylcholine-induced hyperkalemia
1. Neuromuscular diseases
- ALS, MS, muscular dystrophy, myasthenia gravis
2. Skeletal muscle denervation
- Stroke, spinal cord injury
3. Major burns
4. Prolonged abdominal sepsis >5 days
5. Malignant hyperthermia hx
6. ESRD
7. Crush injury
76
Depolarizing vs Nondepolarizing Agents
```
Depolarizing
-Succinylcholine
Nondepolarizing
-Vecuronium
-Rocuronium
```
77
Onset - Succinylcholine
45-60s
78
Onset - Vecuronium
2-4min
79
Onset - Rocuronium
1-3min
80
Duration - Succinylcholine
5-9min
81
Duration - Vecuronium
40-60min
82
Duration - Rocuronium
30-45min
83
Complications - Succinylcholine
1. Hyperkalemia
2. Fasciculations
3. Trismus/masseter spasm
4. Increased ICP/IOP
5. Malignant Hyperthermia
6. Prolonged action if low pseudocholinesterase activity
84
Complications - Vecuronium
Prolonged action in obese/elderly/hepatorenal dysfunction
85
Complications - Rocuronium
Tachycardia
86
Dosing - Succinylcholine
1.5 mg/kg
87
Dosing - Vecuronium
0.1 mg/kg
88
Dosing - Rocuronium
1 mg/kg
89
Postintubation management
1. Confirm tube placement with ETco2 and auscultation
2. Sedate with benzos or propofol and provide analgesia with opioid
3. Paralyze only if necessary
90
What ages of children typically have adult airway proportions?
8-10 yrs
91
Difficult bag mask pt (BAG'EM)
```
BMI (obese)
Airtight seal (beard, facial trauma)
Geriatric
Edentulous
Mobility (decreased neck mobility or pulm compliance)
```
92
How to overcome large occiput for airway management?
Towel under thorax
93
Characteristics of peds vs adult airway (4)
1. Anterior/superior larynx
2. Large/floppy epiglottis
3. Large tongue
4. High O2 consumption
94
Typical length of infant trachea
5cm
95
Typical length of 18mo trachea
7cm
96
Typical length of adult trachea
12cm
97
How to calculate placement of tube in peds?
Depth at teeth + 3 x ET tube size
98
Mallampati Score 1
soft palate, uvula, fauces, tonsillar pillars
99
Mallampati Score 2
soft palate, uvula, fauces
100
Mallampati Score 3
soft palate, base of uvula
101
Mallampati Score 4
hard palate only
102
Difficult Cricothyrotomy (SLICE)
```
Surgery/radiation
Large neck (or short)
Infection
Cancer
Expanding hematoma
```
103
what is an awake intubation?
Sedation without paralysis
104
how to perform an awake intubation?
1. Administer local airway anesthetic (4% lidocaine or topical benzocaine at base of tongue )
2. Sedated with ketamine (10-20 mg per dose)
3. Intubate
105
contraindications to blind nasotracheal intubation (6)
1. Less than 10 years old
2. Mid face trauma or basilar skull fracture
3. Increased intracranial pressure
4. Anticoagulation/thrombolysis
5. Combative patient
6. Apnea
106
which we should bevel face during nasotracheal intubation?
The septum
107
What is the typical depth of the ETT for male and females in nasotracheal intubation?
28 cm for males
| 26 cm for females
108
how is inserting a GlideScope C-MAC laryngoscope different?
Insert blade midline without sweeping tongue
109
how much do you inflate LMA cuff?
20-40 mL air
110
What are the sizes of the Combitube or KING LT supraglottic airways
37F: Small adults/large child
41F: Larger adults
111
Which port of Combitube is ventilation given?
Longer (blue) connector (may do it through shorter/clear tube if think ventilating stomach)
112
What is the surgical airway of choice in children < 10-12 years old?
Needle cricothyrotomy
113
What needle should be use for needle cricothyrotomy?
12 to 14-gauge
114
How to oxygenate using needle cricothyrotomy?
Deliver 100% O2 for 1 sec, then release for 4 seconds to allow for expiration using jet-ventilation system
115
What size ETT should be used for cricothyrotomy?
5.5 or 6.0 cuffed ET tube
116
How are the incisions oriented for cricothyrotomy?
1. Vertical incision through skin
| 2. Horizontal incision through cricothyroid membrane
117
Should you do abdominal thrusts in a patient who is speaking or coughing?
No, urge them to continue coughing
