Induction Flashcards
Discuss paralysis maintenance
0.6mg/kg of roc at 20 minutes and than 0.3mg/kg every 30 minutes after that
List SpeedBomb check list
S: - Suction P- positioing E-equipment (2x laryngoscope + bougie +ETT) E - ETco2 D- drugus B- backup airway (LMA, BVM) O- oxygen M- Monitoring minimum B- Briefing (roles, Plan a,b,c)
Post
S- Secure ETT
P- Position ETT - equal air entry not length at lips
E- etco2
e- Elevate head
D- Drugs for analgesia/sedation/paralysis
B - BVM handy
O- O2 adequiate
M- monitor ventilator setting and platue pressure
B- bloods gas
Describe optimisation of intubation in prehospital setting
360 degree access to head
Open space is best – QAS stretcher or vacmat with sheet on top
Nominate roles usually M1 Tubing , p1 assisting, Ambo 1 drugs, ambo 2 c-spine
BVM only if spo2 <93%
If needing to replace due to torn cuff railroad over the top
Describe what is in the Kit
Intubation
1) Speedbomb checklist
2) RSI drugs
- fentanyl (10ml syringe)
- Ketamine (20ml syringe)
- Rocuronium (10ml red syringe)
- metaraminol (predrawn)
2) BVM
3) Video and 4 blade
4) Video and X blade
5) Spare lary and mac blade
6) bougie
7) stylet
8) 2x appropriate ETT
9) 10ml syringe
10) tube tie
11) magills
12) cap
13) 2x o2 source
14) spare suction
Rescue Airway
1) Guedells
2) 2 NPA
3) lma
4) Surgical airway kit
Ventilation
1) vent circuit
2) perform vent pre-op checks
3) etco2 line
4) filter
5) liquorice stick
6) manometer
Describe how to draw up post intubation sedation and rates
M&M - 3x10mg of morph + 2x15mg of midaz dilute into 30mls = 1mg/1mg/ml of morph and midaz run at 5-15ml/hr
Fentanyl and midaz 3x100mcg of fentanyl + 2x15mg of midaz dilute into 30 ml 10mcg/1mg /ml run at 5-15ml/hr
Describe dilution of adrenaline for push dose
1mg/ml dilute into 10 mls and lable 100mic/ml
Dilute again into 10 mls and labile 10mc/ml m
Bolus dose 10-50mic (1-5ml)
Describe rough guide for ideal body weight
Men = Height - 100cm Women = Height - 105cm
List induction drug dose of ideal or actual body weight
Ketamine - LBW Fentanyl - ABW Midaz -- bolus -ABW --INfusion - IBW Prop - IBW ROC - IBW but actually in flight use ABW
Describe DSI in flight
1) set up Hamilton T1 ventilator to provide NIV initially with a Peep of 5 and a pressure support of 5
2) give 1-2mg/kg of ketamine (if HD unstable half or less if the patient is HD compromised)
3) OPTION 1 once dissociated and will tolerate a NRB at 15lmin if maintaining spo2 >95% allow spont breath for 3 minute to denitrogenate – all equipment for intubations should be available if any problems ie vomiting or laryngospasm proceed to paralytic and intubate
4) OPTION 2 if not maintaining spo2 >95% on NRB swithc to hamilton as set up above - airway support as needed – 3minutes if tolerating and then proceed with paralytics
Describe recruitment manoeuvres
1) Baseline vent setting
- PCV aiming at tidal volumes of 6ml/kg
- fio2 >94%
- RR 10-15
- Peep 10-20
- I:E ratio 1/1
2) Increase Peep level to 20cm for oxylog and as tolerated for hamilton
3) Recruitment – increase Pinsp by 2-4cmh20 to obtain P insp of 35-40
4) when you noticed a marked increase in TV for a change in Pinsp this is the opening pressure
5) decrease Pinsp to TV of 6ml/kg
6) gradually lower Peep by 1cm increment until you notice a significant drop in TV this is the closing pressure set Peep 2-3cm above this
7) icnrease Pinsp for a few cycle to opening pressure
Discuss indications and contraindiations for recruitment maneuver
Indications
- Suspected or verified ARDS
- T1RF
- Post suctioning of vented patients
- mechanically venitlated bariatric patients
Contraindications
- HD unstable
- Head trauma with suspected ICP
- Suspected pneumo
- Bullous emphyesema
Abort
- Significant HD instability or arrhythmia
- significant drop in spo2 <85%
Discuss preparation for RM
1) invasive BP monitoing is adivsed
2) correct hypovolaemia first
3) Ensure syncrony (adequate analgesia and paralysis)
4) adjust alarm limits
Discuss simple suggest PEEP for Fio2 requirment
fio2 .3 — Peep 5-10
Fio2 .4 – 10-18
Fio2 .5 - 18-20
Fio2 .6-1 –Peep 20-24
Discuss assessment of head injured patient
Assess for
1) GCS
2) Pupils
3) lateralising signs
Important above is performed prior to paralysis
Describe neuroprotective measures
1) Appropriate CCP – target a MAP >80 or systolic between 110-150
2) minimise cvp
- head up 30 degrees
- avoidance of jugular venous outflow (careful of collar and tube tie)
3) minimise intracranial pressure
- Adequate sedation analgesia and neuromuscular blockade
- Avoid sympathetic reflex to laryngscopy with fentnayl pre treatment
- avoid hypotension
- maintian low normal Co2
4) optimise physiology
- prevent hypoxia (spo2 >90%)
- maintain normoglycamiea
- maintain normothermia
5) Seizure
- prophylaxis is not recommeneded
- if seizure occurs treat with benzo and keppra
- suspect seizure if increasing etco2, hr or BP
Discuss indication and approach to osmotherapy
Indications
1) Severe TBI with
- abnromal pupil response
- extensor posturing or nil response
- GCS decrease >2 from the initial GCS <9
Caution – do not infuse in same line as RBC as can cause lysis
Dosage 2-5ml/kg of 3% – usually 250mls in an adult
Discuss fluid resus in the setting of traumatic arrest
In general initial fluid resus in TCA should be crystalloid with blood if ROSC is achieved.
If loss of output while running blood it is reasonable to continue
Discuss an approach to blunt traumatic cardiac arrest in the retrieval setting
1) when was the arrest
- >10 minutes stop and declare dead
- <10 minutes step 2
2)
- paramedic secures airway cold – low pressure low frequency and ZEEP
3)
- bilateral finger thoracostomy
4) site cannula and start crystalloid resus
5) manage major external haemorrhage - pelvic binder, reduce long bones
6) if ROSC formally secure airway, further resus should be along lines of severe trauma with fluid resus with products
Thorcotomy only if arrest in front of you and 1) above is unsuccessful 2) tamponade on ultrasound 3) no evidence of major head injury
Discuss blood products in children
RBC - 10mls/kg - 40mls/kg is considered a massive transfusion trigger TXA 15mg/kg over 10 minutes After 40ml/kg of RBC given give -40ml/kg ffp -20ml/kg platelets -10-20ml/kg cryo
Be aware of hypocalcaeia with transfusion and treat with 0.3ml/kg of gluconate
Discuss benefits of Prothrombinex over FFP for reversal of Warfarin and indications for warfarin reversal
Prothombinex contains only four factors 2,7,9 and 10
Smaller volume and faster infusion
fast onset of action (15 minutes)
no requirement to check patient blood group
minimal risk of viral transmission and reduced risk of TRALI
IN life threatening bleeding with any INR > 1.5
50units/kg of promthombinex
10mg of IV vit K
2 units of FFP
Discuss reversal of heparin and DOACs
Heparin
-LMWH - 1unit of protamine for eveyr unit of clexane
Unfractionated - 1 unit for every 100
Rivaroxaban
- Prothrombinex 50 units/kg
- consider TXA
- consider platelets if under 70
Dabigatrin
- Idaruzicamab - 5gram
Discuss use of slishman and ct6 with concurrent pelvic trauma
The slishman and ct 6 apply force across the femoral neck rather then the ischial tuberosity - and can be safely used in the prehospital setting with concurrent pelvic trauma
pelvic binder should be placed first
Describe insertion of rapid rhino
use 7.5cm rhino
soak in water for 30 seconds prior
use mckeeson dental prop to brace the hard palate
inflate with water
Describe cric in the prehospital setting
Always have double set up
appropriate pre-oxygenation
Equiptment
- scalple
- size 6 ETT or trachy tube
- 10 ml syringe for balloon
- small artery forceps
Technique
- IF palpable anatomy horizontal incision through over the cric caritlage - if difficult anatomy vertical incision and blunt dissection
- pass mosquitoe forceps through the cricoid membrane before removing scaple to maintain tract
- pass boujie bent end towards the feet may feel clicks of thyroid ring
- railroad over boujie
- blow up cough prior to removal of boujie
