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Emed 4 > AW management > Flashcards

AW management Flashcards

1
Q

2 classes of AW management techniques

A

Noninvasive vs Invasive

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2
Q

Types of noninvasive AWs?

A

Passive oxygenation
Bag-valve mask ventilation
Supraglottic airways
Noninvasive positive-pressure ventilation

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3
Q

Types of invasive AWs?

A

Endotracheal intubation
Cricothyroidotomy
Transcutaneous needle jet ventilation
Tracheostomy

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4
Q

Types of AW obstruction

A

Fx - Unconscious pt

Mechanical - FOB

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5
Q

Respiratory failure characteristics?

A

Hypoventiliation and hypoxia

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6
Q

Hypoventiliation is?

A

inadequate CO2 excretion

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7
Q

Hypoxia is?

A

inadequate alveolar O2 content

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8
Q

S/S of respiratory failure?

A 
Weakness
Fatigue
Chest pain
SOB
ABNL breath sounds
Increased work of breath
AMS
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9
Q

Prolonged Respiratory failure (hypoventiliation/hypoxia) can present with?

A

AMS

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10
Q

ABNL breath sound findings w/ respiratory failure?

A

Audible wheezing
Stridor
Silent chest

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11
Q

Respiratory failure - Signs of increased work of breath

A 
Dyspnea
Tachypnea
Hyperpnea/Hypopnea
Accessory muscle use
Cyanosis
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12
Q

Classifications of respiratory failure?

A

Type 1 - hypoxia w/out hypercapnia

Type 2 - Hypoxia w/ hypercapnia

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13
Q

Type 1 respiratory failure - Notes

A

Hypoxia w/out hypercapnia
Afx oxygenation but not ventilation (Ex - PNA, PE)
TXT - optimizing oxygenation

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14
Q

Type 2 respiratory failure - Notes

A

Hypoxia w/ hypercapnia
Afx affect ventilation (COPD)
TXT - optimizing oxygenation & supporting ventilation

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15
Q

Performing BVM difficult situations

A 
MOANS
M- Mask seal
O- Obesity/obstruction
A- Age - >55yo
N- No neeth
S- Stiff lungs/chest wall
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16
Q

Performing Supraglottic AW difficult situations

A 
RODS
R- Restricted mouth opening
O- Obesity/obstruction
D- Disrupted/distorted AW
S- Stiff lungs or cervical spine
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17
Q

O2 delivery of - Nasal cannulae

A

O2 flow- 2-5L

Fio2 - 20-40%

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18
Q

O2 delivery of - Simple face mask

A

O2 flow- 6-10L

Fio2 - 40-60%

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19
Q

O2 delivery of - Non-rebreather mask

A

O2 flow- 10-15L

Fio2 - Near 100%

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20
Q

Fio2 is

A

Inhaled fraction of O2

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21
Q

Preperation of AW placement - pt position for upper AW obstruction who is unconscious?

A

Extend neck w/ anterior displacement of mandible

Add forward neck flexion by placing folding towel under occiput (sniffing position)

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22
Q

OPA - Notes

A

PVTs tongue base from occluding hypopharynx

Indications - comatose/deeply obtunded pt w/out gag reflex

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23
Q

NPA - Notes

A

Displaces soft palate and posterior tongue

Indicated if Pt has intact gag reflex W/OUT midface trauma

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24
Q

BVM - Notes

A

PVT re-inhalation of exhaled air

Delivers 75% o2

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25
Q

NIPPV - Notes

A

Reduces work of breathing via face/nasal mask
Doesn’t use ET tube
Augments spontaneous respiration
Reqs cooperative pt w/ protective AW reflex and intact ventilatory efforts

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26
Q

NIPPV settings?

A

CPAP- continuous POS AW pressure

BiPAP- bilevel POS AW pressure

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27
Q

NIPPV CI’s

A 
absent/agonal effort
absent/impaired gag reflex
severe maxillofacial trauma
basilar skull Fx
life threatening epistaxis
bullous lung dz
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28
Q

NIPPV use circulation consideration?

A

HOTN - Positive pressure will worsen it

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29
Q

NIPPV reduces work of breathing by 60% via

A 
Pulmonary compliance
Recruits/stabilize collapsed aveoli
Shifts Pulm edema into vasculature
Improves cardiac fx
Increases tidal volume/min vent
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30
Q

NIPPV complications

A 
Mask seal
Pt discomfort
Aspiration (rare)
Air trapping
Pulm barotrauma
Anxiety/agitation (claustrophobic)
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31
Q

Supraglottic - notes

A

Placed in Oropharynx
-Oxygenates and vent w/out ET tube
Best for short periods
Indicated - apneic/unconscious pts.

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32
Q

Supraglottic - AWs

A

Shiley - esophageal tracheal AW
King Laryngeal Tube (King LT)
Laryngeal Mask Airway (LMA)

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33
Q

Shiley - esophageal tracheal AW - Notes

A

Double-lumen tube inserted blindly
Proximal cuff seals pharyngeal
Distal cuff seals esophagus

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34
Q

King Laryngeal Tube (King LT) - Notes

A

MC - (95% of the time)
Single lumen - inserted blindly
Proximal cuff seals post oropharynx
Distal cuff occludes esophagus

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35
Q

Laryngeal Mask Airway - (LMA) - Notes

A

Placed blindly
occludes structures around larynx
Single cuff

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36
Q

Shiley/King LT - complications

A

Hypoxia - ventilating incorrect port
Esophageal perforation
Aspiration pneumonia
Tongue engorgement (King LT)

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37
Q

Laryngeal Mask Airway - (LMA) - complications

A

Partial/complete AW obstruction

Aspiration of gastric contents

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38
Q

RSI (mechanical ventilation) is?

A

sequential administration of an induction agent and NMBA for endotracheal intubation

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39
Q

Pts not ideal for RSI?

A

Deeply comatose

Cardiac/Respiratory arrest

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40
Q

Mechanical ventilation indications?

A 
Failure to protect AW
Failure to O2 or Ventilate
Clinical anticipation course
- GCS <8
- Deterioration
- Transport
- Impending AW compromise
(Facial burns, Fxs, expanding pharyngeal hematoma)
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41
Q

RSI preperation reqs

A 
Clinical assessment
Pulse Ox
Capnography
Expected course
Equipment
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42
Q

MIller blade - Notes

A

Straight
Lifts epiglottis to visualize larynx
Easier if pt has smaller central incisors

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43
Q

Macintosh blade - Notes

A

Curved
Placed in vallecula- indirectly lifts epiglottis off larynx
Less trauma
Less likely to stimulate AW reflex

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44
Q

RSI position?

A

Sniffing position - aligns oropharyngeal-laryngeal axis
Ear horizontally aligned w/ sternal notch
Reposition if initial attempts fail

45
Q

RSI - preoxygenation purpose

A 
Begin ASAP (PVTs possible hypoxia w/ O2 reservoir)
-displaces nitrogen in aveoli
46
Q

RSI - preoxygenation method

A

100% O2 for 3m using NRB mask 15 L/min

47
Q

Is using a nasal cannula OK for RSI preoxygenation?

A

No

48
Q

RSI pretreatment - purpose

A

Attenuate adverse physiologic responses to laryngoscopy/intubation

49
Q

When should RSI pretreatment begin?

A

3-5m prior RSI

50
Q

Possible adverse effects of RSI?

A

Reflex sympath response (BAD - ICP/MI/Aortic dissect)
Resp - Laryngospasm, cough, bronchospasm
Children- Vagal responses

51
Q

RSI Pretreatment agents

A

Lidocaine
Fentanyl
Atropine

52
Q

RSI Pretreatment - Lidocaine indications

A

Elevated ICP
Bronchospasm
Asthma

53
Q

RSI Pretreatment - Fentanyl indications

A

Elevated ICP
Cardiac ischemia
Aortic dissection

54
Q

RSI Pretreatment - Atropine indications

A

Children <5 y with bradycardia
Children <10 y receiving succinylcholine + bradycardia
Adults - Bradycardia from repeat succinylcholine

55
Q

Will pretreating children w/ atropine universally PVT bradycardia?

A

NO

56
Q

RSI - Induction Agents

A

Etomidate
Propofol
Ketamine

57
Q

Etomidate - onset/duration

A

<1m / 10-20m

58
Q

Propofol - onset/duration

A

20-40s / 8-15m

59
Q

Ketamine - onset/duration

A

1m / 10-20m

60
Q

Benefits of Etomidate

A

↓ ICP
↓ Intraocular pressure
Neutral BP

61
Q

Benefits of Propofol

A

Antiemetic
Anticonvulsant
↓ ICP

62
Q

Benefits of Ketamine

A

Bronchodilator
“Dissociative” amnesia
Analgesia

63
Q

SEs/Caveats of Etomidate

A

Myoclonic jerking/seizures and vomiting in awake pts
No analgesia
↓ Cortisol

64
Q

SEs/Caveats of Propofol

A

Apnea
↓ BP
No analgesia

65
Q

SEs/Caveats of Ketamine

A

↑ Secretions
↑ BP
Emergence phenomenon

66
Q

Etomidate - NOTES

A

Nonbarbituate hypnotic
Not an analgesic
Does not blunt sympathetic response to intubation

67
Q

Propofol - NOTES

A

Sedative with anticonvulsant & antiemetic properties

Not an analgesic

68
Q

Ketamine - NOTES

A

Dissociative agent
Analgesia & amnesia
Preserves respiratory drive (ideal for awake intubation)

69
Q

Depolarizing NMBA

A

Succinylcholine

70
Q

Nondepolarizing NMBA

A

Rocuronium, Vecuronium

71
Q

RSI - Paralytic agents

A

Succinylcholine - Depo (Short acting)
Rocuronium - Non-depo (intermediate/long)
Vecuronium - Non-depo (intermediate/long)

72
Q

Succinylcholine MOA

A

High affinity for cholinergic receptors of the motor end plate and are resistant to acetylcholinesterase

73
Q

Rocuronium, Vecuronium MOA

A

Compete w/ Ach for cholinergic receptors and can be antagonized by anticholinesterase agents

74
Q

Purpose of paralytic agents?

A

NMBA can facilitate tracheal intubation, improve mechanical ventilation, & help control intracranial HTN

75
Q

Are paralytic agents anxiolytics or analgesics?

A

No

76
Q

Prior to admin paralytic agents ensure?

A

Sedation during initial paralysis to avoid patient awareness

77
Q

Rocuronium - onset/duration

A

1-3m / 30-45m

78
Q

Vecuronium - onset/duration

A

2-4m / 25-40m or 60-120m depending on dose

79
Q

Succinylcholine - onset/duration

A

45-60s / 5-9m

80
Q

Rocuronium - comments

A

Tachycardia

MC alternative to succinylcholine for RSI

81
Q

Vecuronium - comments

A

Hepatorenal dysfx, old, DM = prolonged recovery

82
Q

Succinylcholine - comments

A

Best intubation conditions in the shortest amount of time

83
Q

Succinylcholine can cause kyperkalemia in what pts?

A 
>5d old injuries -
-Burns
-Denervation injury
-Significant crush injury
-Severe infection
Preexisting - Myopathies
84
Q

Succinylcholine complications and CI’s

A

Fasciculations
Transient pressure INC w/ intragastric, intraocular, ICP
Masseter spasm alone
Malignant hyperthermia
Bradycardia
Prolonged apnea w/ pseudocholinesterase deficiency Myasthenia gravis

85
Q

After ETT insertion perform?

A

Confirm placement

Suction tracheobronchial tree w/ lubricated, soft, curved tip cath

86
Q

Complications of improper RSI ETT placement?

A 
Hypoxia/hypoxemia
Dysrhythmia
HOTN
Pulmonic collapse
Direct mucosal injury
87
Q

Doubt correct placement of ETT RSI?

A

Take it out and try again

88
Q

Most reliable way to confirm placement? Follow w/?

A

Direct visualization passing vocal cords

Not 100% accurate checks

  • Auscultate chest/epigastric
  • check condensation
  • chest expansion
89
Q

Labs to assess confirmed placement?

A

Expired (end-tidal) carbon dioxide (ET co2) via Capnometers/capnographs

90
Q

After RSI intubation - what imagins to order for confirmation?

A

CXR - locate Bad = ETT in mainstem bronchus/esophagus

91
Q

Is CXR full proof to reliably distinguish ETT placement?

A

No

92
Q

RSI complications?

A 
Esophageal/mainstem bronchus intubation
Tube displacement or obstruction
ETT cuff leaks or displacement
Arytenoid cartilage avulsion
Pyriform sinus intubation
Pharyngeal-esophageal perforation
Subglottic stenosis
93
Q

Alternate AW management methods?

A 
Nasotracheal intubation
Digital intubation
Transillumination
Fiberoptic laryngoscopy
Indirect fiberoptic laryngoscopes
Video laryngoscopy
Retrograde tracheal intubation
Extraglottic devices
94
Q

Nasotracheal intubation alternate AW method - NOTES

A

Indicated if Laryngoscopy, cricothrotomy and NMBA problematic
Use Topical nasal vasoconstrictor anesthetic
ETT is smaller

95
Q

Digital intubation alternate AW method - NOTES

A

Useful when anatomy cannot be seen with a laryngoscope

Patient must be in deep coma, arrest, or blockaded

96
Q

Transillumination alternate AW method - NOTES

A

Lighted stylet
Helps to confirm placement/position
Useful when laryngoscopy is anatomically impossible

97
Q

Fiberoptic laryngoscopy alternate AW method - NOTES

A

Useful when vocal cords are not visualized

Relative CI

98
Q

Indirect fiberoptic laryngoscopes alternate AW method - NOTES

A

Incorporates fiberoptics into a laryngoscope
Good w/
-difficult airways
-immobilized necks
-w/ reduced oral openings
-anterior larynx anatomy
No diagnostic capabilities like direct fiberoptics

99
Q

Video laryngoscopy alternate AW method - NOTES

A

Enhanced visualization
Useful in pts w/ small mouths, difficult AW or restricted cervical mobility
Shared visualization and recording

100
Q

Retrograde tracheal intubation alternate AW method - NOTES

A

Useful w/ cervical & mandibular ankylosis or upper AW masses
Landmarks are that of a cricothyrotomy
Guidewire technique
Time consuming procedure - rarely used in ED

101
Q

Nasotracheal intubation alternate AW method - Process?

A

Advance along nasal floor w/ bevel toward septum
Steady gentle pressure or slow rotation
Once near occiput rotate until max airflow is heard
Advance at initiation of inspiration
Presence of vocal sounds = failed attempt
Advance ETT to correct depth at the nares
Standard post-intubation confirmation checks

102
Q

Difficult AW means?

A

Can maintain O2 sat > 90% even w/ optimal position/adjuncts

103
Q

Failed AW means?

A

3 unsuccessful attempts at intubation by experienced operator

104
Q

Difficult BVM for AW obstacles?

A 
Facial hair
Obesity
Edentulous patient
Advanced age
Snoring
105
Q

Mallampati III has a failure rate of?

A

5% pts

106
Q

Mallampati IV has a failure rate of?

A

20% pts

107
Q

3 common ventilator methods?

A 
Continuous mechanical ventilation (MC in OR)
Assist control (A/C) (perfer w/ pts in resp distress)
Synchronized intermittent mandatory ventilation (SIMV)
108
Q

Is extubation performed in ED?

A

No - rarely

Emed 4 (10 decks)

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