Airway Skills Flashcards by Nathan Wheeler

List the indications for Digital Intubation

Cramped quarters, awkward position, poor lighting, upright patient, inability to visualize vocal cords, copious oral secretions or vomitus, suspected cervical spine trauma, laryngoscope unavailable or malfunctioning

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List the contraindications for Digital Intubation

Gag reflex, inability to open mouth due to trauma, fracture, dislocation or pathologic condition

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List complications for Digital Intubation

Trauma to airway, being bitten, esophageal intubation, right mainstream bronchial intubation

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List the indications for Nasotracheal Intubation

Awake intubation technique, long term intubation, laryngoscope unavailable or malfunctioning, laryngoscopy not possible, unable to open mouth

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List the contraindications for Nasotracheal Intubation

Apnea, basilar skull fractures, CSF rhinorrhea, foreign body in the upper airway, severe facial fractures, inability to pass tube through nostril

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List the relative contraindications for Nasotracheal Intubation

Bleeding disorders, Combative patient

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List complications for Nasotracheal Intubation

Epistaxis, Increased ICP, esophageal intubation, hypoxia, submucosal dissection, nasotracheal trauma, infections

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List the indications for Endotracheal Intubation

Inability to protect/maintain airway or inadequate ventilation (not reversible), blood gases
indicate need for intubation (decompensation)

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List the contraindications for Endotracheal Intubation

Intact gag reflex, caustic ingestion, esophageal disease/trauma, tracheal fracture or disruption,
Do Not Resuscitate (DNR)/Do Not Intubate (DNI) orders

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List complications for Endotracheal Intubation

Esophageal intubation, bronchial intubation, dental/pharyngeal/ airway trauma, inadequate ventilation, laryngospasm, aspiration/vomiting of gastric contents, hypertension

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How long should you preoxygenate someone before endotracheal intubation? How?

Pre-oxygenate the patient for 2 - 3 minutes with BVM and high flow nasal cannula (both at 15 LPM)

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What does BURP stand for? When is it used?

Backwards, upwards, rightwards, posterior pressure. It applies pressure to the thyroid cartilage to bring the vocal cords into view during intubation.

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What is a percutaneous cricothyrotomy?

AKA Needle Cricothyrotomy. When you cric using a 14-16g IV cath, and then connect to a 3mL syringe (without plunger) and a 15mm BVM connector robbed from a #7 ETT tube. #MacGyver

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What are the indications for a percutaneous (needle) cricothyrotomy?

Inability to intubate/unsuccessful intubation, airway obstruction, temporary airway

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List the contraindications for a percutaneous cricothyrotomy

Ability to secure an airway by other means, larynx/cricoid/trachea trauma

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List complications of a percutaneous (needle) cricothyrotomy

Hemorrhage, barotrauma, subcutaneous emphysema, infection, tracheal/esophageal injury, cannula misplacement, bleeding

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At what angle do you insert the cath in a percutaneous (needle) cricothyrotomy?

Stabilize the larynx and insert the needle into the cricothyroid membrane at a 45 degree angle toward the feet.

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List the indications for a cricothyrotomy

Failed airway/inability to oxygenate, airway obstruction, temporary airway

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List the contraindications for a cricothyrotomy

Ability to secure an airway by other means, inability to landmark, child younger than 8

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List the complications for cricothyrotomy

Incorrect/ unsuccessful tube placement, tracheal/esophageal injury/swelling/trauma, asphyxia,
hemorrhage, infection, subcutaneous emphysema, tube occlusion

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How big of an incision do you make for a cricothyrotomy? Where?

1-2 cm vertical incision over the cricothyroid membrane then puncture the cricothyroid membrane and make a horizontal cut 1 cm in each direction from the
midline, using the index finger as a guide.

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What are the indications for a needle thoracostomy (AKA needle decompression)?

Tension pneumothorax with at least 2/3 of signs:

Respiratory distress/ central cyanosis
Loss of radial pulse
Decreasing level of consciousness

What are the contraindications for a needle thoracostomy?

None in presence of tension pneumothorax

What are some complications with needle thoracostomy?

Failure to decompress/improper placement, bleeding, pneumothorax, lung laceration, infection

Where do you insert the decompression needle anteriorly? How?

Insert the decompression needle into the second intercostal space at a 90 °angle to the superior border of the third rib, advancing until air released. Hold needle in place, advance catheter to the hub and remove needle. Cover with a commercial one-way valve.

What are the indications for a mechanical ventilator?

Patient transport (prolonged transport requiring accurate ventilation settings)

What are some complications with mechanical ventilation?

Hypotension, barotraumas, lung injury/infections/sepsis, patient anxiety, malfunctioning equipment/alarms, displaced tube

How long should you monitor a patient on a ventilator prior to initiating transport?

Closely monitor the patient and ventilator for at least 10 minutes prior to transporting to ensure adequate ventilation. Adjust parameters as needed as per blood gases.

Your patient is on a ventilator and not responding appropriately. What do you do?

The patient should be taken off the ventilator immediately and connected to an alternate method of ventilation. If patient is still not responding appropriately, assess DOPEGS.

What are the ideal bodyweight formulas?

Male: 50 + [(Height in inches – 60) x 2.3] Female: 45.5 + [(Height in inches -60) x 2.3] Male: 88 - (Height in cm x 0.9) Female: 92 - (Height in cm x 0.9)

What should the respirator rate be set at with a ventilator? (generally speaking and not without exception)

Adult, 16-18 Child, 14 to 24 Infant, 20 to 40

What should tidal volume be set at on a ventilator?

Standard Range: 6 - 8 ml/kg Lung protective: 4 to 6 ml/kg *Ideal bodyweight used for each calculation

What is the sensitivity for Ptrig usually set to?

-1 cmH20

How should PEEP be set?

Generally start with 5 cmH20 and work up from there.

Where should the high PAW alarm limit be set on a ventilator?

Set 10 cmH20 higher than the peak inspiratory pressure

What should also be connected to a ventilator breathing circuit?

Ensure there is an HME (Heat and Moisture Exchanger) and a side stream ETC02 between the ventilator breathing circuit and the patient.

What are some complications to look for when monitoring chest tubes?

Tube pulled out/blockage, air leaks, airway obstruction, atelectasis, pneumothorax/tension pneumothorax, infection, bleeding.

What suggests a leakage in a chest tube system?

Persistent, unexplained bubbling at the water seal chamber.

How do you handle a suspected leak in a chest tube system?

Clamp the tube as close to the patient as possible using padded clamps for 1-2 seconds. If the bubbling stops, the leak is on the patient side. Remove the clamp and ensure the chest tube has not been dislodged and attempt to make a better seal at the insertion site. If the bubbling continues, the leak is on the chest drainage system side. Seal all connections with tape.

What are the indications for use of a bougie tube?

Difficult airway or high LEMON score, inability to view/swollen cords

List the contraindications for use of a bougie tube.

Gag reflex, inability to open mouth due trauma, fracture, dislocation or pathologic condition

What are some complications with use of a bogie tube?

Tracheal/esophageal injury/perforation, bleeding, infection

What are the suction settings for Suction beyond oropharynx (endotracheal tube suctioning)?

Adult: 120mmHg Pediatric: 80-120mmHg Neonate: 80-100mmHg

How long should endotracheal suctioning be limited to?

Adult: 15 seconds in an adult Pediatric: 10 second Infant: 5 seconds *Apply intermittent suction while withdrawing and rotating catheter

What should be put down the ETT tube prior to suctioning?

3 - 5 ml of sterile water

What does LEMON stand for? Predictors for difficult Laryngoscopy

``` Look - beard, anatomy, obesity, etc. Evaluate the 332 rule Mallampati - scored 1 to 4 Obstruction - foreign body, trauma, etc. Neck Mobility - normal ROM? C-collar? ```

What does BONES stand for? Predictors of difficult BVM

``` B - Beards O - Obesity, Old patient, Obstruction N - Neck stiffness, mass & trauma or No Teeth E - Expecting (late pregnancy) S - Snores, stridor, stiff lungs ```

What does RODS stand for? Predictors for difficult Supraglottic Device Placement or Function

R - Restricted mouth opening O - Obstruction D - Distorted / displaced airway S - Stiff Lungs, chest, neck or Severe bronchospasm

What does SHORT stand for? Predictors of possible difficult Surgical Airway

``` S - Surgery to the neck H - Hematoma O - Obesity R - Radiation T - Trauma ```

What does DOPEGS stand for? Patient deteriorating once advanced airway is in place

D Dislodged tube - airway is in the esophagus, oropharynx or Drugs (pt not adequately sedated) O Obstruction - airway is obstructed or Oxygen (patient not receiving enough O2) P Pneumothorax E Equipment - malfunction G Gastric inflation S Stacking of breaths (air trapping)

What is the Tidal Volume (tV) setting on a ventilator?

The amount to be delivered with each breath and calculated using ideal body weight. Standard Range: 6 - 8 ml/kg Lung protective: 4 to 6 ml/kg

Ventilation rate with chest compressions and an advance airway in place?

10 bpm *According to the "Commonly used Airway management Mnemonics, Calculations and Figures" handout.

Ventilation rate with a pulse for rescue breathing

12 bpm *According to the "Commonly used Airway management Mnemonics, Calculations and Figures" handout.