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ER 2 > Airway Management > Flashcards

Airway Management Flashcards

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1
Q

Two main reasons to intubate

A
  1. oxygenation
  2. ventilation
    (also protect airway)
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2
Q

In what situations should you intubate early

A

Dynamic airways

  • neck trauma from bullets
  • anaphylaxis/angioedema
  • thermal/caustic airway injuries
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3
Q

What is visible when you have a great view (the money shot)

A

epiglottis

vocal folds

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4
Q

Purpose of airway maneuvers

A
  • improves airflow

VERY important, get this right, everything else should be more smooth

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5
Q

Patient positioning prior to and when starting intubation

A
  • keep patient sitting up as long as possible, easier to breath unless medical reason they aren’t able (LOC, trauma, etc.)
  • supine: tongue falls posterior, soft tissue of upper airway relaxes, reduced lung capacity
  • wait until last minute to recline patient
  • want ear to sternal notch to be aligned, use padding to lift head
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6
Q

Airway maneuvers

A
  1. Head-tilt, chin-lift (no c-spine concern). More for alignment, doesn’t change airway much
  2. Jaw thrust (ok with c-spine concern). opens airway much more
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7
Q

How to deal with potential c-spine injury

A
  • airway manipulation = easy to move c-spine
  • stabilize!!!
  • manual in-line stabilization is preference
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8
Q

Airway adjuncts

A
  • OPA: no gag reflex, measure from corner of mouth to angle of mandible, insert upside down with 180 rotation into place
  • NPA: better tolerated than OPA, coat with ky, insert along floor of nares, rotate if resistance
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9
Q

Bag-valve-Mask ventilation

A
  • bag gives time to prepare for definitive airway management
  • 3 elements for success
    1. Patent airway
    2. Mask seal
    3. Proper ventilation (volume, rate, cadence)
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10
Q

BVM

- proper fit

A

over the bridge of the nose and the ridge of th chin

  • if no teeth, stick bottom part in mouth
  • if beard, use tegaderm or pacer pad over beard for better seal
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11
Q

BVM

- methods to secure mask

A
  1. C-E technique if only on person
  2. Two hand, two person: preferred (two thumbs down technique)
    * in either case, pull face into mask, don’t mash mask onto face
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12
Q

BVM

- what does ventilation depend on

A
  • volume: 400-500 mL per squeeze (bag volume 1,000 to 1,500 mL)
  • rate: <10-12 breaths/min, aim for EtCO2 35-45 mmHg
  • Cadence: constant and smooth
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13
Q

BVM

- what tool can optimize

A
  • PEEP valve
  • always use
  • recruits and stents the lungs
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14
Q

BiPAP, CPAP

- indications

A
  • COPD exacerbations with hypercapnic acidosis
  • Cardiogenic pulmonary edema
  • Great way to avoid intubation
  • Might need very mild sedative if person is confused, they may fight it
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15
Q

List the different airway options

A
  1. BVM
  2. Laryngeal mask airway (LMA)
  3. Direct laryngoscopy
  4. Video assisted direct laryngoscopy
  5. Surgical airway - cricothyrotomy
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16
Q

LMA

- overview

A
  • provides oxygenation and ventilation without entering trachea
  • does NOT protect the airway from obstruction or aspiration
  • can become dislodged
17
Q

LMA

- contraindications

A
  • gag reflex (vomiting and aspiration risk)
  • trauma/disease of oropharynx
  • foreign body obstruction
18
Q

LMA

- common indications

A
  • elective sx
  • cardiac arrest
  • failed intubation attempt, at least you can oxygenate even if can’t intubate
19
Q

iLMA

A

intubating LMA

- special opening to allow ET tube through

20
Q

Direct laryngoscopy and endotracheal intubation

- definition

A
  • direct visualization of the airway to place ET tube in trachea
  • protects airway
  • conduit for oxygenation and ventilation
21
Q

Direct laryngoscopy and endotracheal intubation

- two types of blade

A

Mac: curved

  • curve approximates tongue curve
  • tip fits the vallecula, recess at the back of the tongue, elevates the epiglottis

Miller: straight

  • more narrow, sharp curved tip
  • tip lifts the epiglottis
  • use: deep, long, anterior airways, floppy epiglottis
22
Q

Direct laryngoscopy and endotracheal intubation

- how to determine kid size

A
  • (age +16) / 4

- size of pinkie is good approximation

23
Q

Laryngoscopy technique

A
  • pt in sniffing position
  • align EAM with sternal notch
  • ramp up bed height
  • might need to still elevate pt head/flex lower neck
  • open mouth with scissor technique
  • sweep tongue to left side (hold blade in left hand)
  • advance blade, press up and away
  • If can’t find epiglottis, find the tongue and use as reference mark
  • If can’t see well, perform external laryngeal manipulation (BURP: backward, upward, rightward pressure)
  • DO NOT rotate risk or push against teeth!!
24
Q

Laryngoscopy technique

- tube placement

A
  • pass tube through cords
  • should be approx 22 cm at teeth
  • Co2 detector: yellow is golden :)
  • do not rely on misting of tube or auscultation
  • CXR to determine depth, should be 4cm above carina and below clavicle heads
25
Q

Laryngoscopy technique

- helpful tools

A
  1. Stylet: shapeable, have assistant remove it once past cords
  2. Bougie/hockey stick: can be placed blind. Place with tip anterior and place under epiglottis (clicking of trachea) then place ET tube over and remove stick
26
Q

How to know if placed correctly

A
  • end tidal flow on monitor

- Sats on monitor - O2 and CO2

27
Q

Post intubation care

A
  • secure tube, don’t let go until secure
  • elevate head 30-45 degrees
  • adequate sedation/analgesia
  • in-line suction
  • gastric tube
  • balloon pressure: 20 mmHg
28
Q

Video laryngoscopy

A
  • go to option today
29
Q

RSI

A
  • admin of induction agent and neuroMSK blocking agent to create optimal intubation conditions: max success rate and min risk of aspiration
  • used in critically ill pts
  • consider alt option if anticipate rapid desaturation, severe hypotension, anatomic challenge
30
Q

7 Ps of RSI

A 
Preparation
Preoxygenation
Pre-intubation optimization
Paralysis with induction
Protection
Placement (intubation)
Post-intubation management
31
Q

RSI

- Preparation

A
  • assess airway for potential difficulty
  • develop plan A and B
  • Assemble people, equipment, medications
32
Q

How to assess airway for potential difficulty

A

LEMON

  • Look externally
  • Evaluate 332
  • Mallampati: score based on open mouth view
  • Obstruction/obesity
  • Neck mobility
33
Q

Mnemonic for preparation

A

STOP MAID

  • suction
  • Tools
  • O2 for preoxygenation and ongoing ventilation
  • Positioning
  • Monitors
  • Assistant, Ambu, Airway devices
  • IV access
  • Drugs
34
Q

Preoxygenation

A
  • high possible concentration of O2 for min 3 minutes prior to intubation
  • create O2 reservoir, delay desaturation. “safe apnea”
  • Nasal is best delivery
35
Q

Preintubation optimization

A
  • optimize physiology (give blood, decompress pneumothorax, etc.)
  • Tx hypotension: IVF, blood products, vasopressor
36
Q

Paralysis with induction

A
  • precalculated dose of induction agent and paralytic
  • goal: 45-60 seconds desired level of sedation and paralysis
  • Ketamine is best induction option
  • Succinylcholine best paralytic
37
Q

Placement with proof

A
  • relaxation: laxity of jaw = can begin laryngoscopy
38
Q

Post intubation management

A
  • secure tube
  • CXR
  • check for complications
  • vent setup
  • long-term sedation

ER 2 (10 decks)

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