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Emergency Medicine > Emergency Medicine Airway Management and CV Collapse > Flashcards

Emergency Medicine Airway Management and CV Collapse Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

For CONCIOUS patients healthcare providers should perform the ACLS survey: What is this? 3

A

ABC

  1. Airway

Is it open and clear?

  1. Breathing

Is ventilation and oxygenation adequate?

  1. Circulation

What is needed to support the pulse and blood pressure?

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2
Q

Airway management

  1. If no C spine concern what is the first step? If there is?
  2. 2nd step?
  3. If no respiratory effort begin what?
  4. Insert what?
A
  1. Open airway with head tilt/chin lift (if no c-spine concerns), Jaw thrust is adequate if c-spine issues
  2. Clear the airway with suction (if available)
  3. If no respiratory effort, begin ventilation with bag-mask (BMV) device
  4. Insert nasopharyngeal or oropharyngeal airway
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3
Q

AIrway Management:

In unconscious patient with respiratory effort? 4

A
  1. Administer high-flow oxygen
  2. Ensure no obstruction to upper airway
  3. Insert nasopharyngeal or oropharyngeal airway
  4. If suspected lower airway obstruction, perform Heimlich maneuver
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4
Q

“High-flow” oxygen options? 3

A
  1. Nasal cannula with flow rate at 6L/min provides about 40% FIO2
  2. “Dial-A-Concentration” or venti-masks can deliver from 24-40% FIO2
  3. Non-rebreathing (NRB) masks with reservoirs can deliver a little less than 100% FIO2 (liter flow needs to be at least 10)
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5
Q

Nasopharyngeal Airways (NPA)

  1. Usually better with what?
  2. Can be used when there is what? (cant with an oral airway)
  3. Ensure what before placement? 2
  4. Can lead to?
A
  1. Usually better tolerated in conscious patients vs. the oropharyngeal airways
  2. Can usually be used even with intact gag reflex

3.

  • Ensure it is not too long or too big
  • Lube with lidocaine jelly
    4. Can lead to epistaxis
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6
Q

Nasopharyngeal airway placement

  1. OUter diameter of the NPA should be what size?
  2. Length should not be longer than what?
  3. Lubricate and place how?
A
  1. Outer diameter of the NPA should not be larger than the inner diameter of the nares
  2. Length should not be longer than from the tip of the patient’s nose to the earlobe
  3. Lubricate with water-soluble lube and insert in a plane perpendicular to the face
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7
Q

Oropharyngeal Airways (OPA)

  1. For who?
  2. Will ogten lead to emesis if what?
  3. Needs to be inserted carefully because?
  4. Impossible to insert on who?
  5. Not as adequate in?
A
  1. For unconscious patients
  2. Will often lead to emesis if gag is intact
  3. Needs to be inserted carefully so that tongue is not pushed back therefore blocking the airway
  4. Difficult or impossible to insert with seizing patient
  5. Not as adequate in edentulous patients
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8
Q

Proper size OPA stretches from where to where?

A

the mouth to the angle of the mandible

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9
Q

Laryngeal Mask Airway (LMA) Indications

5

A
  1. Rescue device after failed intubation
  2. Can be attempted quickly while another person is preparing for a cricothyroidotomy
  3. Prehospital setting
  4. Plan for short term intubation
  5. Good alternative to continued bag-mask ventilation
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10
Q

LMA can decrease aspiration risk (for which pts?)

A

can’t be intubated but can be ventilated)

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11
Q

Laryngeal Mask Airway

  1. Allows isolation of what?
  2. It is designed to sit where in the patient?
  3. Used in what settings? 3
  4. Advanatges?
  5. Success rate?
A
  1. Allows relative isolation of the trachea
  2. It is designed to sit in the patient’s hypopharynx and cover the supraglottic structures
  3. Used in many settings
    - operating room,
    - the emergency department, and
    - out-of-hospital care
  4. Easy to use and quick to place, even for the inexperienced provider
  5. A success rate for placement of a LMA of nearly 100% occurs in the operating room
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12
Q

LMA Contraindications? 2

A
  1. Cannot open mouth
  2. Complete upper airway obstruction
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13
Q

LMA Insertion

7 steps

A

1) Select the proper size

Size 4 for females

Size 5 for males

2) Inflate then deflate the cuff
3) Lubricate the back of the mask
4) Patient placed in sniffing position

May need to use sedation like Versed or Propofol

5) Slide the mask down the posterior pharyngeal wall until resistance is felt
6) Inflate the mask with the recommended amount of air
7) Confirm tube position

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14
Q

LMA Complications

3

A
  1. Any airway device with a cuff can cause necrosis if the cuff is overinflated
  2. Mask tip can fold and can cause obstruction by pushing down on the epiglottis
  3. Mask tip can fold back on itself
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15
Q

When could the LMA mask tip fold back on itself?

3

A
  1. If mask is not pushed up against the hard palate
  2. If not adequately lubricated
  3. If cuff is not adequately deflated
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16
Q

Combitube

  1. Functions when placed in either the what? 2
  2. Does insertion require neck movement?
  3. Insert how?
  4. Check what for esophageal intubation?
  5. Ventilate through the what?
A
  1. esophagus or trachea
  2. Insertion does not require neck movement
  3. blindly
  4. white port
  5. blue port
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17
Q

Intubation “Rules”

4

A
  1. Oxygenate before and after you intubate
  2. Intubate early
  3. Intubate as soon as you think about it
  4. Make sure the patient is not a DNI/DNR prior to intubation
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18
Q

Rapid Sequence Intubation (RSI)

  1. What drugs are given initially? 2
  2. Incorporates medications and techniques to minimize risk of what?
A

1.

  • Rapidly acting sedative (ie, induction) agent and a
  • neuromuscular blocking (ie, paralytic) agent
    2. aspiration of stomach contents
19
Q

Rapid Sequence Intubation (RSI)

  1. Indications?
  2. Contraindications?
A
  1. Indications

Standard of care for intubations not anticipated to be difficult

  1. Contraindications

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

20
Q

RSI – 7 P’s (Key steps)

A
  1. Preparation
  2. Preoxygenation
  3. Pretreatment
  4. Paralysis with induction
  5. Protection and positioning
  6. Placement with proof
  7. Postintubation management
21
Q

RSI Step 1: Preparation

Mnemonic for preparation: STOP MAID

A
22
Q

RSI: Step 2: Preoxygenation

6

A
  1. Administration of high flow oxygen
  2. Have patient take 8 vital capacity breaths with O2 if able
  3. Manual ventilation if needed but slow and easy so as to avoid excessive inflation of the lungs or distention of the stomach
  4. Maintain patency of upper airway with NPA/OPA or positioning maneuvers
  5. Consider head up position in obese patients
  6. 5L of O2 per nasal cannula during apneic period
23
Q

RSI Step 3: Pretreatment

  1. Atropine for who and what?
  2. Which patients specifically? 3
  3. Dose?
A
  1. Atropine for peds to prevent vagal response (severe bradycardia)

2.

  • All children less than one year old
  • All children less than 5 yrs receiving succinylcholine
  • Children older than 5 receiving a second dose of succinylcholine
    3. Dose 0.02 mg/kg IV, min dose 0.1 mg
24
Q

RSI Step 3: Pretreatment

  1. Lidocaine for what? 2
  2. Opiods for what and why?
  3. Do not use when?
A
  1. Lidocaine
    - asthma
    - head injury)
  2. 5mg/kg IV
  3. Opioids (Fentanyl) may decrease the sympathetic response to intubation in adults (3 mcg/kg IV)
  4. do not use in pt’s with low BP (hemodynamic compromise)
25
Q

RSI Step 4: Paralysis with Induction

Name the ideal patient and the dose for the following drugs:

A
26
Q

Neuromuscular blocking agents (paralytics) options? 3

A
  1. Succinylcholine 1.5mg/kg IV FIRST LINE
  2. Vecuronium priming dose of 0.01 mg/kg 3 min prior to intubating dose of .15 mg/kg IV OR
  3. rocuronium 1mg/kg IV
27
Q

Neuromuscular blocking agents (paralytics)

Succinylcholine 1.5mg/kg IV

  1. Onset of action? Duration?
  2. CI? 6
A
  1. Onset of action is 45-60 sec, duration 6-10 min
  2. Contraindications
    - Hyperkalemia,
    - neuromuscular disease,
    - ocular trauma,
    - malignant hyperthermia,
    - rhabdomyolysis,
    - stroke or burn > 72h old
28
Q

RSI Step 5: Protection and positioning

Cricoid pressure

  1. Why would we do this?
  2. May help with what? 2
  3. BURP means what?
A

Cricoid pressure

  1. To collapse the esophagus between the cricoid cartilage and the spine to prevent regurgitation of gastric contents

2.

  • May help facilitate visualization of the vocal cords
  • May help the intubator as you may be able to tell them you feel the tube
    3. BURP

Backwards, upwards, rightward (pt’s right) pressure may bring the larynx into view (esp on kids)

29
Q

RSI Step 6: Placement with Proof

4

A
  1. Place ETT with direct laryngoscopy (visualize the cords)
  2. Can release cricoid pressure after tube is placed
  3. Inflate cuff
  4. Confirm placement of the tube in the proper position
30
Q

RSI Step 6: Placement with Proof

Confirm placement of the tube in the proper position by? 4

A
  1. End tidal CO2 monitor
  2. Auscultation of breath sounds
  3. Esophageal intubation detection device
  4. CXR often cannot distinguish if in the trachea or esophagus but can tell how far in the tube is
31
Q

End Tidal CO2 Monitor

  1. Use when?
  2. Color on inhalation?
  3. Color on exhalation?
  4. How many methods do you need to confirm tube placement?
A
  1. Use to confirm tube placement
  2. Purple on inhalation
  3. Yellow on exhalation
  4. Confirm tube position using 2 methods
32
Q

RSI Step 7: Postintubation management

  1. Secure the what?
  2. CXR to evaluate for what?
  3. Support what?
  4. __________ ventilation?
  5. Determine need for what?
A
  1. endotracheal tube
  2. depth of ETT and assess for barotrauma
  3. blood pressure
  4. Mechanical
  5. ongoing sedation or paralysis
33
Q

RSI: Pearls

  1. Giving a paralytic without sedation is bad. Why?
  2. If properly preoxygenated the patient may tolerate up to how long of apnea with minimal decrease in saturation?
  3. Can sedate and take a quick look for the what prior to starting the RSI?

This takes practice. If someone offers to set you up with anesthesia to learn intubation on a rotation go for it!

Always have a back up plan in place.

A
  1. Patient is paralyzed and awake.
  2. 4 minutes
  3. vocal cords
34
Q

What is this?

A

Endotracheal tube inducer or “bougie”

35
Q

What is this?

A

Fiberoptic stylets

36
Q

What is this?

A

Fastrach

37
Q

Cricothyroidotomy

  1. When would we do this?
  2. Relatively contraindicated in who? Due to?
  3. What is the preferred surgical airway in young children?
A
  1. When patient has failed to be oxygenated adequately (SpO2<90) by all other possible methods and intubation has failed
  2. Relatively contraindicated in young children due to the shape of the airway, may lead to subglottic stenosis
  3. Preferred surgical airway in young children is transtracheal ventilation using a 14 g needle
38
Q

Cricothyroidotomy

Several techniques? 3

A
  1. Standard technique
  2. Rapid four step technique
  3. Seldinger technique
39
Q

Cricothyroidotomy

Rapid 4 step technique: Steps? 7

A
  1. Identify the cricothryroid membrane by palpation
  2. Make a horizontal stab incision through both the skin and cricothyroid membrane with the scalpel (20 blade):
  3. Incision 1-2 cm
  4. Prior to removal of the scalpel, the hook is placed and directed inferiorly.
  5. Caudal traction is used to stabilize the larynx.
  6. Hold the hook in the nondominant hand.
  7. Insert the tracheostomy tube into the trachea.

Or can insert a tracheal tube introducer and then slide a tracheal tube over the introducer.

40
Q

What is this?

A

Percutaneous transtracheal jet ventilation

41
Q

Cardiovascular collapse

  1. Cardiac output =?
  2. As cardiac output decreases the heart rate will?
  3. Hypotension causes what? 2
  4. Decreased coronary perfusion? 2
A
  1. Cardiac output (CO) = Stroke volume (SV) X HR
  2. As cardiac output decreases the heart rate will increase
  3. Hypotension causes an
    - increase in systemic vascular resistance
    - decreased tissue perfusion
  4. Decreased coronary perfusion =
    - increased cardiac ischemia and
    - further LV systolic dysfunction (decreased stroke volume) and further downward spiral
42
Q

Pathophysiology of cardiogenic shock

A
43
Q

Cardiovascular collapse

  1. The cause of EVERY (that’s correct – EVERY) death is what?

Remember : As long as blood goes round and round and air goes in and out the patient lives.

Your mission is to properly identify the underlying cause of this “soon-to-be” cardiac arrest and PREVENT IT!

A
  1. cardiac arrest

Emergency Medicine (26 decks)

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