MDSO - ADULT - AIRWAY

Question 1

DEFINE RSI VS CRASH VS FACILITATED INTUBATION - BY MEDS USED

Answer 1

RSI: PARALYTIC AND INDUCTION AGENT

CRASH: NO PRETREATMENT - IN MORIBOUND PATIENT

FACILITATED: TOPICAL ANESTHETIC AND SEDATIVE / DISSOCIATIVE AGENT

Question 2

MINIMUM KG FOR A SGA

Answer 2

> 2 KG

Question 3

CONTRAINDICATIONS FOR SGA

Answer 3

INTACT GAG REFLEX
ACTIVE VOMITING
CAUSTIC INGESTION

Question 4

30 second drills from Universal Airway Algorhythm

Answer 4

Head Up
ELM
Mac as Miller
Extra (2 hand Laryngoscope Lift)
Bougie if not already used

(Also another version that has scoop ?)

Question 5

PRE INTUBATION / INTUBATION MEDS - list

Answer 5

Lidocaine - for Facilitated
Ketamine or Midazolam or Etomidate or Propofol for Sedation
Fentanyl for Analgesia
ROC or SUX for Paralysis
Phenylephrine for Sedation related hypotension

Question 6

What’s the dose for Lidocaine when used in SFI (sedation facilitated intubation) ?

Answer 6

5 mg/ kg, to max 400 mg. Each Spray has 10mg.

Question 7

90 kg - Dose for Lidocaine?

Answer 7

5MG/kg (max 400mg) - 90 x 5 = 450 mg, so Max 400 mg…10 mg / spray = 40 sprays

Or 1/2 spray per kg to max 40 sprays. 1/2 x 90 = 45 , so max 40

Question 8

Induction dose for Ketamine?

Answer 8

0.5 to 2 mg/kg > 30 s

Question 9

What are the risks of Ketamine if high doses pushed too fast ?

Answer 9

Secretions / Salivations, Hypertension/Tachycardia , sometimes Hypotension/Brady

Question 10

Precautions for Ketamine ?

Answer 10

Seizure disorders, ICP, HTN, CHF, CVA, Thyrotoxicosis (all want to avoid increased BP)

Question 11

Onset of Ketamine ? Peak ? Duration ?

Answer 11

30 s, 5-10 min, 5-10 min

Question 12

What is the infusion for Ketamine after induction ? Patch ?

Answer 12

0.3 to 2 mg/kg/hr. (Or if IVP 0.5 mg/kg q 20)

No Patch to continue, unless MAP < 60

Question 13

What is the induction dose for Midazolam ? MAP ? Patch?

Answer 13

0.1 mg/kg (max 8mg)
MAP > 80
MP

Question 14

What is the induction dose for Propofol ? MAP? Patch ?

Answer 14

1.0 to 1.5 mg/kg
MAP > 100
MP

Question 15

Induction dose FENTANYL? MAP ? Patch ?

Answer 15

1-2 mcg/kg
MAP > 80
MP

Question 16

Induction ROC Dose ? MAP ? Patch ?

Answer 16

1.2 mg/kg
MAP - n/a
MP

Question 17

Induction Dose of SUX ? MAP ? Patch ?

Answer 17

1.5 mg/kg
MAP - n/a
MP

Question 18

Contraindications of SUX ?

Answer 18

Malignant Hyperthermia
Hyperkalemia
Myopathies/Muscular Dystrophies, ALS, MS
Guillaume Barre
2nd degree Burns > 10 %
Stroke with hemiparesis, Spinal Cord Injury (> 72 hr until 6 months)
Severe abdominal sepsis

Question 19

Dose for PHENYLEPHRINE per Sedation-Hypotension? MAP ? Patch

Answer 19

100 mcg q 3 min x 3 (max 300)
MAP <65 , or < 80 if ICP, ischemic stroke or spinal cord injury

Question 20

Classification of SUX ?

Answer 20

Depolarizing NMB

Question 21

Antidote for Malignant Hyperhermia (sometimes caused by SUX)?

Answer 21

Dantrolene

Question 22

Onset , Duration of SUX ?

Answer 22

30-60 sec, 4-8 min

Question 23

Onset, Duration of ROC ?

Answer 23

1-2 min , 45 min +

Question 24

Indications for Emergency Tracheostomy Tube Reinsertion ? Contraindications ?

Answer 24

Inner and/or Outer Cannula(s) have been removed
AND
Resp Distress
AND
Inability to adequately ventilate

Contra : inability to landmark / visualize

Question 25

If unable to replace Tracheostomy Tube Reinsertion after 2 attempts, then what do you do ?

Answer 25

Initiate BVM from above. Requires occlusion of stoma (hand, tagederm) - - - PCP

Cuffed ETT 6.0 or smaller through stoma site, confirm with ETCO2 , clinical assessment - - - >= ACP

Question 26

When is the highest risk of tube reinsertion into tracheostomy ?

Answer 26

< 7 days - high risk for “false passage” - - > subcutaneous emphysema ; fatal hypoxia

Question 27

Tracy tube in place for < 7 days, no airway obstruction / or Hx of difficult airway —- How do you manage ?

Answer 27

Lower Risk, attempt BVM / intubation from above first; if fails, consider reinsertion with Tracy tube

Question 28

Trach tube < 7 days, w Hx of airway obstruction / difficult airway or laryngectomy - - How do you manage ?

Answer 28

HIGH Risk - - - MANDATORY discussion with TMP + Sending MD - - - trach tube must be inserted and sutured in place by sending, possible deferral of transfer

Question 29

Trach in place over 7 days, no Hx of AW obstruction or difficult airway - how do you manage ?

Answer 29

Lower Risk - attempt trach tube reinsertion first, then bougie/ETT 6.0 cuffed……if this fails manage from above - BVM (occlude stoma), intubate from above…

Question 30

Trach in place > 7 days, Hx of Airway Obstruction , Difficult Airway, or laryngectomy tube ? How do you manage ?

Answer 30

Medium Risk - Confirm that at least 1 trach tube change post initiation has taken place without issues. Attempt reinsertion with trach first, then bougie with ETT (cuffed 6 or smaller)……if this fails manage from above (unless laryngectomy tube)