Airway Management and CV Collapse

Question 1

LMA Contraindications

Answer 1

Cannot open mouth

Complete upper airway obstruction

Question 2

LMA Complications

Answer 2

Necrosis with overinflation of cuff

-even more likely in kids

Mask tip can fold down and obstruct by pushing down the epiglottis

Mask tip can fold back on itself - mask not inserted, inflated, or lubricated properly

Question 3

Intubation Rules

Answer 3

Oxygenate before and after ventilation

Intubate early - as soon as you think about it

Make sure patient is not DNI/DNR beforehand

Question 4

Nasotracheal Intubation

Answer 4

Tube is more stable

Causes less damage to vocal cords and trachea

Less necrosis damage to posterior wall

More difficult procedure to master

Kids are more prone to intubation vagal response

Question 5

Rapid Sequence Intubation (RSI) & Contraindications

Answer 5

Rapidly acting sedative agent with neuromuscular blocking agent

Incorporates medications and techniques to minimize aspiration risk of stomach contents

If anticipating difficult placement and inability to ventilate patient - paralytic agent may be contraindicated

Have to ventilate patient once you give the paralytic

Question 6

RSI - 7 P’s

Answer 6

Preparation

Preoxygenation

Pretreatment

Paralysis with induction

Protection and positioning

Placement with proof

Postintubation management

Question 7

Preparation - STOP MAID

Answer 7

Suction

Tools for intubation

Oxygen

Positioning

Monitors

Assistant

IV access

Drugs

Question 9

Pretreatment

Answer 9

Fentanyl - decrease sympathetic response to intubation

-CI w/ hemodynamic compromise

Lidocaine - for asthma or head injury

Atropine - for pediatrics, prevent vagal response; also for severe bradycardia

Question 10

Inducers - sedation

Answer 10

Versed - for status epilepticus; benzo; amnesic properties

Etomidate - for head injury, ICP, BP, epilepsy, shock

Ketamine - shock, kids; CI w/ status epilepticus

Propofol - use w/ severe bronchospasm if hemodynamically stable

Thiopental - for status epilepticus; CI w/ Hx bronchospasm - causes histamine release

Question 11

Induction Drugs for Status Epilepticus

Answer 11

Versed

Thiopental

Ketamine is CI

Question 12

Paralytics

Answer 12

Succinylcholine - 45-60 sec onset, duration 6-10 minutes

-CI: hyperkalemia, neuromuscular disease, ocular trauma, malignant hyperthermia, rhabdomyolysis, stroke or burn >72 hrs old

Vecuronium/Rocuronium - have to give priming dose

Question 13

Protection and Positioning - BURP

Answer 13

Backwards, Upwards, Rightward (Pt’s right) pressure to bring larynx into view

Cricoid Pressure to collapse esophagus and prevent regurge

Question 14

RSI PEARLS

Answer 14

Give sedation with the paralytic

Preoxygenation - if done proper, pt can tolerate up to 4 minutes apnea

Always have a backup plan

Can sedate and look at cords before giving paralytic

Question 15

Cricothyroidotomy

Answer 15

Can go horizontally or vertically

Lots of vasculature around

Relatively contraindicated in young children due to shape of airway

• may lead to subglottic stenosis

Preferred surgical airway for young kids is transtracheal ventilation with a 14g

Question 16

Rapid 4 Step Cricothyroidotomy

Answer 16

Step 1: Identify cricothyroid membrane by palpation

Step 2: Make horizontal stab incision through skin and membrane 1-2 cm long

Step 3: Hook incision before removing scalpel with caudal traction to stabilize the larynx

Step 4: Insert tracheostomy tube

Question 17

Cardiovascular Collapse

Answer 17

Cardiac Output (CO) = Stroke volume (SV) x HR

As output decrease, HR increases

HOTN causes an increase in systemic vascular resistance and decreased tissue perfusion