Critical Care Flashcards
How can you estimate ET tube size?
Age/4+ 4
Name 5 physiologic reasons for hypoxia.
- V/Q mismatch
- Diffusion impairments
- Hypo ventilation
- Abnormal oxygen carrying capacity
- Shunt
What are the criteria for extubation?
- Reason for intubation resolved
- Normal or near normal blood gas
- Stable hemodynamics
- Intact respiratory drive
- Intact airway protective reflexes
- Good lung compliance
- Low FiO2 (40%) or low PEEP (6)
- Low rate without rapid shallow breathing
- NPO
What are the 2 principles of respiration that should be evaluated on every blood gas?
- Ventilation (pH and pCO2)
2. Oxygenation (paO2)
What features of a ventilator can you manipulate to affect ventilation ?
Ventilation = pH and pCO2
- Tidal volume
- Pressure support
- Rate
What features on a ventilator can you manipulate to affect oxygenation?
- PEEP
- FiO2
- Inspiratory time
What question should you always ask yourself when evaluating a patients blood gas?
Is this an appropriate gas given the patients respiratory rate and exam?
What are 2 devices you can use to by yourself some time in a child that may need to be intubated?
- Nasopharyngeal trumpet or oral airway
2. LMA
What is the benefit of using a nasal trumpet or oral airway?
Help relieve airway obstruction
Nasal trumpet tends to be a little bit better tolerated
What is a general tidal volume to start?
10 ml/kg
What is pressure support? What is a goal pressure support?
Pressure provides additional support to help overcome resistance of breathing with ET tube when patient is taking a spontaneous breath. Generally between 5-10
What are pressure support trials?
1-2 hours with mainly patient generated breaths and minimal settings to assess readiness to extubate
Why is PEEP helpful?
To maintain functional residual lung capacity by preventing alveolar collapse at the end of a breath
How do you assess you have an adequate tidal volume and overall ventilatory settings?
- Symmetric chest rise
- VBG
- Adequate breath sounds
What are high of PIPs? What should you do to adjust?
PIPs=peak inspiratory pressure, high if > 30
If too high:
1. recheck tidal volume (if too high can reduce)
2. Screen for airway pressure of ET tube obstruction
3. Chest ET tube position
What are the 3 common agents used for sedation for intubation. What do each of these do? What is the dose for each?
- Fentanyl-analgesic + anesthetic, 1-5 mcg/kg IV
- Versed-sedative- 0.1-0.3 mg/kg IV
- Rocuronium-paralytic-1 mg/kg IV
What is a side of effect of ketamine that can be helpful? When do you want to avoid ketamine?
- Causes tachycardia and increase BP–good for shock
- Do NOT give if worried about increased ICP
Why is atropine a useful adjunct in intubation (2 reasons)?
Anti-cholinergic drug
- Will block vagally mediated bradycardia
- Decreases oral secretions
An intubated patient is tachycardic and hypoxic. What things should you evaluate?
- Displacement of ET tube
- Obstruction of ET tube (ex mucus plug)
- Pneumothorax/effusion/atelectasis/disease progression
- Equipment failure
- Loos of TV due to air leak
Where should an ET tube terminate?
ET tube should terminate in the trachea between the vocal cords and carina
What 4 things can you do to verify ET tube placement?
- Visualized tube passing through the cords
- Look for bilateral chest movement, equal breath sounds
- Confirm end tidal CO2, condesation in ETT, O2 sats maintained
- CXR
Name 5 indications for intubation
- respiratory failure (inadequate oxygenation or ventilation
- upper airway obstruction
- inability to protect airway
- neuromuscular weakness
- hemodynamic instability
Describe BiPAP.
Mask that provide a constant, known airway pressure in between breaths (EPAP) with additional pressure assistance during inspiration (IPAP).
Name 3 benefits of CPAP
- relieve airway obstruction and dynamic collapse
- improve lung recruitment
- helps with work of breathing.
I think I need to intubate a child. What stuff do I need to have?
- ET tubes
- Stylet
- Laryngoscope and blade
- Bag and mask hooked up to O2
- Suction
- IV access
- Monitors
- Intubation meds
- End tidal CO2 detector
- tape
- Suppport peope
