HA oral: Induction (rest), CXR, EKG Flashcards
How do you prevent recall?
Keep in mind the DOA of your induction agent in relation to the onset of your NMB
Induction dose of propofol will have a clinical effect/DOA = 10 minutes
May need additional induction drug available and administer as needed
Use inhalational/Volatile agent during ventilation
BIS monitoring
Recall is V-BAD
V.BAD
Volatile, Bis, Additional induction druv, DOA of agent in relation to NMB
RSI Definition
Rapid sequence intubation/induction (RSI) is an airway management technique that induces immediate unresponsiveness and muscular relaxation and is the fastest and most effective means of controlling the emergency airway.
Used in situations of full stomachs-at risk for aspiration
Adds the Sellick’s Maneuver and removes ventilation from the standard induction sequence
List standard induction steps
- MSMAIDS
- Position pt supine in sniffing position
- turn on oxygen flow & pre-oxygenate
- pre-induction medication
- lidocaine (+/-) induction agent
- wait until effect time. Check responsiveness & lash reflex
- Test ventilation (close APL valve, make sure can ventilate)
- check PNS
- paralytic drugs
- continue to ventilate until drug takes effect (recheck TOF)
- tape eyes
- scissor technique, laryngoscopy & intubate (inflate ETT, confirm placement, secure tube)
- continue ventilation by bag or switch to vent
- begin maintenance (overpressure va)
- check vent setting, observe expired VA and titrate down. give maintenance agent and abx
Rapid Sequence Induction (RSI):
Identify patient in need of RSI Pre-operative prophylaxis for aspiration Bicitra/Reglan/Omeprazole/Pepcid or Zantac Anxiolytic Narcotic (avoid loss of consciousness to early) Monitors on Suction on and at head of bed Supine-sniffing position Pre-oxygenate (spontaneously breathing) Sellick’s maneuver= cricoid pressure –gradually increase pressure as patient falls asleep Induction agent NO TEST VENTILATION
Extubation Criteria
Extubation Criteria – Respiratory Criteria for either fully awake or deeply anesthetized
TV >6mls/kg
VC >10 mls/kg
RR <30 breaths/min (Typically ~10 breaths/min. Make sure vent is turned off, pt must be spontaneously breathing!)
SaO2 >90%
EtCO2 <50 mmHg (COPD & asthmatics will naturally be higher, maybe 55 or 60 EtCO2 appropriate)
Sustained tetanic contraction with PNS
Nearly awake extubation
Muscle relaxant fully reversed and confirmed with PNS (if applicable)
All respiratory extubation criteria have been met
Anesthetic medications including volatile agents and infusions turned off
100% FiO2
Oropharynx suctioned
Patient is responsive to commands/purposeful movement
Sustained (5 second) head lift indicates clinically adequate reversal of NMB
Patient can maintain and protect own airway
ETT removed while positive pressure breath is given
deep extubation
Muscle relaxant fully reversed and confirmed with PNS (if applicable)
All respiratory extubation criteria have been met
Oropharynx suctioned
100% FiO2
Oral or nasal airway may be inserted
ETT removed while positive pressure breath is given
Volatile agents or infusions turned off
Mask airway maintained while patient spontaneously ventilating
Remain vigilant until patient is responsive and maintaining own airway
Cause & s/s of laryngospasm
Prolonged intense glottic closure
May present with high pitched squeak to total absence of sound (ominous sign)
Suprasternal and supraclavicular in-drawing,
increased diaphragmatic excursions
flailing of the lower ribs resembling a “rocking horse”
What muscles are involved in a laryngospasm
lateral cricoarytenoids
thyroarytenoids
cricothyroid
from stimulation of the vagus nerve
Most often seen during induction and emergence
laryngospasm triggers
Secretions (vomitus, blood, saliva) Foreign body Pain Pelvic or abdominal visceral stimulation Stimulating glottis in a light plane of anesthesia Reactive airway disease Loud noises (pediatrics)
S, F, P, V, L, R
Floppy Vocal Lips Shut Please Respond
Fuck! Vocal Lips Shut, Please Respond
laryngospasm prevention
Deep plane of anesthesia reached prior to surgical stimulation
Either fully awake or deeply anesthetized with extubation- not in-between (Avoid stage Two)
Suction oropharynx prior to extubation
Remove ETT with positive pressure breath
Prevent Sudden Airway Death
Positive P, Suction, Avoid st 2, Deepen
Laryngospasm treatment
Recognize the event!
Immediate removal of the offending stimulus
Larson maneuver
Retromandibular notch/ laryngospasm notch
condylar process of the mandibular ramus anteriorly, the mastoid process posteriorly, and the external auditory canal superiorly
Pressure for 3-5 seconds and released for 5-10 seconds
Administration OXYGEN (100% FiO2)
continuous positive pressure
Deepen anesthetic (propofol)
Small dose of short acting muscle relaxant: Succinylcholine 20-40 m
Pray LORRD Savior
Positive pressure continuous, Larsons, Oxygen 100%, Recognize, Remove, Deepen, Succs
justifications for CXR
pneumonia (confirmation) immunosuppressed pt COPD w/acute exacerbation foreign body CHF aspiration pneumonia blunt trauma lung tumor chest pain suspected pneumothorax SOB (severe) hemoptysis pulmonary HTN PE interstitial lung ds ICU pt (adm, inv lines, ETT
basic tissue densities**
Black = Air
Dark gray = Subcutaneous tissue, Fat
Light gray = Soft tissue (muscles, heart, blood vessels, pus, etc.)
Off white = Bone
Bright white = Metal (pacemakers, surgical clips, bullets, etc.)
What does CXR position affect?
Magnification
Organ position
Blood flow
Gravitational pull*
Position Makes Bad Organs Good
causes of pneumothorax
Causes: Trauma Subclavian venous catheter, Liver biopsy Spontaneous (result of a bleb rupture) Metastatic tumors
EMS - Emergency (trauma, liver puncture), metastatic tumor, Spontaneous bleb & SVC
tension pneumothorax definition
Tension pneumothorax = mediastinal shift occurs or there is depression of the hemidiaphragm with displacement of the heart and trachea to the unaffected side
pneumothorax on CXR
UPRIGHT is the best position
Where is the first place to look for pneumothorax? Right and left upper hemithoraces
Supine: Deep Sulcus Sign
pleural effusion : Definition, Looking for? Causes? Best CXR position
Definition: collection of fluid between the visceral and parietal pleura (~100 mL to detect on upright CXR)
Look for:
- Blunting costophrenic angles
- inc basilar density (whiteness)
- loss of nL lung hemidiaphragm
Causes:
Malignancies
Pancreatitis (LEFT-sided pleural effusion)
Cirrhosis (RIGHT-sided pleural effusion)
CHF (BILATERAL pleural effusion, usually associated w/cardiomegaly)
Pneumonias
[PCCCC- Pancreatitis, CA(malignancies), Cirrhosis, CHF, Consolidation (PNA)]
Best XR position: Upright
mediastinal shift in tension pneumonia, atelectasis, airway obstruction?
-Tension pneumothorax: the mediastinum is shifted toward the unaffected side (PUSHING IT)
-Atelectasis: collapse of entire lung segment might result in severe volume loss.
Mediastinal shift toward the affected side (PULL TOWARDS, like suction)
-Airway obstruction: mediastinal shift toward the unaffected side (can’t get out, builds up, push it)
