Mod 4: Intubation Flashcards
Why do you intubate (need airway management)?
Protect airways
partially obstructed airways
complete airway obstruction
Apnea
Respiratory distress
Hypoxemia, hypercarbia, acidemia
What is the RR before someone fatigues and fails to breathe on their own?
35
Drooling and strider are indicators of what?
intubation, usually they’re a sign of some sort of inflammation that is partially blocking the airway
Clinical signs for intubation? (7)
Decreased LOC (GCS < 8)
Ventilation irregular or ineffective
Color: cyanosis
Adventitious sounds
excessive secretions/inability to clear secretions
increased WOB (such as retractions)
What is a good indicator that intubation was placed correctly or in?
End tidal CO2
Crash vs Rapid sequence intubation (RSI) intubation
Edit
What does the acronym “Lemon” indicate?
Predictors of possible difficult laryngoscope
- Look at the patient
- Evaluate the 3-3-2
- Mallampati to classification
- Obstruction
- Neck mobility
What is the Mallampati classification?
What are 3 points of the 3-3-2 rule?
Edit
Burp vs Sellick maneuver? what do they both ultimately do?
Edit
Improve the grade of view for the mouth by 1
Method
Gently applied pressure to cricoid.
Assisting a laryngoscopy or intubation is always done on which side?
on the right side
Colorimeter is normally purple, what does it indicate when it turns yellow?
CO2
What are the indications of intubation
hint A-E?
Inability to manage airway through other means
A: Airway: Airway obstruction
B: breathing
C: Circulation
D: Disability
E: Expected course
Airway indications for intubation
Airway obstruction present or potential aspiration occurred/potential
Breathing indications for intubation
Oxygenation failure
Ventilation failure
Circulation indications for intubation
Shock
Disability indications for intubation
Alter LOC (GCS > 8)
Expected course indications for intubation
Expected decoration of A,B, C, or D
Intubation needed for intervention (surgery, cath lab)
Long transports
Indicators for airway management
Protect airways
partially obstructed airway (or complete)
Apnea
Respiratory distress
hypoxemia, hypercarbia, acidemia
Need for airway management;
Signs that demonstrate a lack of response to protect airways?
Coma
lack of gag
inability to cough
respiratory distress
Examples of respiratory distress?
increased RR
High/low Vt
signs of a partially obstructed airways?
strider, paradoxical respiration, accessory muscle use
Emergency indications for Intubation?
hypoxemic respiratory failure
hypercapnic respiratory failure
upper airway obstruction/injury
shock/hemodynamics instability
clinal conditions associated with risk for airway compromises
Clinical signs for intubation?
Decreased LOC
ventilation irregular or ineffective
cyanosis (colour)
Adventitious sounds O/A: strider, diminished or absent
excessive secretions or can’t clear
increased WOB: i.e nasal flaring, retractions etc.
How do you confirm EDT placement?
Auscultation
-both sides
-epigastric
-chest expansion
Monitors:
-SpO2
-HR
-EtCO2
Normal capnogram or Normal EtCO2 value/range?
35-45mmHg
Esophageal detection device (blue bulb) what does it indicate?
attach with bulb compressed:
If it does not inflate = esophagus
if inflates = trachea (intubated)
how do you secure the ETT?
twill ties
tapes
device
Post intubation magement
confirm placement at the teeth, gums, or lips
record on patient chart
monitor patient prior to leaving bedside
RSI Notes:
complications with intubation?
-failure to establish patient airway
-vocal chord paralysis
-upper airwa trauma, laryngeal, esophageal damage
-Aspiration
-cervical spine trauma
-laryngo/bronchospasm
-bleeding or dental incidents
Problems w/endotracheal tube
-cuff perforation
-cuff her inaction
-pilot tube valve incompetence
-nosocomial infection
Nasal complications (nasal intubation specific)
-Nasal damage including epistaxis
-Tube kinking in pharynx
Nasal complications not local to nasal
-sinusitis and otisis media
-tracheal damage including tracheoesophageal fistula, tracheal i nominate fistula, tracheal stenosis and tracheomalacia
-pneumonia
-laryngeal damage with consequent laryngeal stenosis, laryngeal ulcer, granuloma, polyps
What equipment do you want to Prep for intubation
suction and BVM
laryngoscope handle and blades (mac/miller 3 or 4)
stylet
ETT appropriate size and 1 down.
Magill forceps
xlocaine spray
10cc syringe
OPA
ETT tape or holder
spare batteries
What things should you consider when assisting w/intubation?
suction
safety check equipment
manual ventilation
monitor patient
air pause (2 attempts, 30s)
ETT size?
women: 7 or 7.5
men: 8 or 8,5
what should be done before deciding to intubate?
maneuver position to create a patient airway and to ventilate with O2
factors that could make intubation difficult?
short neck
protruding maxillary incisors
receding mandible
reduced mobility of neck
how do you measure Ç-spine mobility?
measuring distance from lower border of mandible to beyond to thyroid notch at full neck extension (sniffing position)
should be greater than 4 finger breaths
7 P’s for RSI
preparation
preoxygenation
pre-treatment
paralysis and induction
placement and confirmation
post-intubation management
preparation for RSI
assess degree of difficulty (airway, IV access, monitoring)
gather equipment
ensure adequate team is present
identify back up plan
pre-oxygenate patient for RSI
100% O2, usually done with a manual resuscitator or NRB (3-5 mins, obtain highest SpO2 possible)
Allows several minutes before desaturation to 90%
provides patients w/reserve during intubation
Time frame for desaturation during intubation?
8 mins for a healthy 70kg adult
Desaturation from 90 to 0 occurs in less than 120 seconds
varies for pregnant and obese patients
pre-treatment for RSI
anxiolytics, benzodiazepines, or opiodes could be given prior to intubation drugs
Sedatives -> paralytic
RSI: paralysis with induction
combo of a sedative with a neuromuscular blocking agent
renders patient unconscious and induces paralysis
-sedatives also have a amnesia affect
What are common intubation drugs
Propfol, ketamine, etomidate
-commonly have a short onset of action and half life.
What are induction agents and why are they given with intubation drugs?
sedatives to provide amnesia, blunt sympathetic responses, and improve intubation conditions
what are paralytic drugs? why are they given during intubation?
Neuromuscular blocking agents (NMBA)
cause skeletal muscle paralysis
-must be used with an induction agent.
Examples of paralytic drugs?
succinylcholine
rocuronium
what is the Sellick Maneuver?
Considered to help with aspiration.
look this one up.
what is a biannual laryngoscopy?
pressure applied on the neck opposite of the lift of the laryngoscope
laryngeal grades?
what is the purpose of B.U.R.P?
Burp improves laryngeal position
-brings glottis down into view by 1 full grade
Backwards
upwards
rightwards
pressure
Depth of insertion
visually, when the black line on the ETT goes through vocal chords
Women: (average) 19-21
Men: 21-23
when Inflating ETT Cuff, what pressure do you want?
25-30 cmH2O
Confirmation of ETT placement
Detection of CO2 exhaled gas - EtCO2
Chest x-ray (depth inserted by carina)
Endoscopic visual
Auscultation can suggest, but is not full proof.
-i.e bilateral symmetrical breath sounds.
condensation suggests but not full proof.
colorimeter changes color to what?
CO2, purpose -> yellow
What is the Sellick maneuver?
helps with aspiration (anterior cricoid pressure)
-doesn’t do much tho apparently
When would you use “BURP”? (backward pressure)
Grade 3 or 4 view.
Helps bring the glottis down and improve view by 1 full grade
What could cause aspiration when giving oxygenation w/BVM?
full stomach or pregnancy (things could come back up)
Why do you want to avoid BVM once RSI drugs are given?
avoid gastric insufflation and regurgitation
What are indicators that patient can’t protect their airway
Lack of gag
Inability to gag
resp. distress
signs of a partially obstructed airway
Stridor
Paradoxical resp
accessory muscle use
Signs of resp. distress
Increased RR
High/Low Vt
Signs of increased WOB?
Accessory muscle use:
-Retractions
-Nasal flaring
-High RR
Indications for intubation:
ABCDE
-Inability to manage airway through other means
-prolonged need for vent. assistance
What is ABCDE protocol?
Identifies intubation via
[A]irway: obstruction or potential aspiration
[B]reathing: oxygenation/ventilation failure
[C]irculation: shock
[D]elirum: altered LOC aka GCS < 8
[E]xpected course: impending failure of above
4 cardinal signs of airway obstruction
Muffled (hot potato voice)
Can’t clear secretions
stridor
sensation of dyspnea
Before intubation, what steps should you take to clear/create the pt’s airway for optimal oxygenation and ventilation?
Correct pt position (sniffing position)
Preoxygenate to 100% (if possible)
Ready necessary equipment
sometimes drugs
How long should you preoxygenate a patient
3-5 mins to obtain highest possible SpO2 (oxygen reservoir)
How long does it generally take for a patient to desaturate from 100% to 90%
8 minutes
but can easily be 120 seconds if depending on the pt size
What is the typical drug order given to a patient for intubation?
An induction agent is given first, followed by a paralytic.
1.[Protocol or ketamine] —>
2. [succinylcholine or rocuronium]
Why do you avoid BVM after preoxygenating and RSI drugs are given to a patient?
Avoid regurgitation and aspirations
Indications for intubation: specific cases
Hypoxemic resp. failure
Hypercapnic resp. failure
upper airway obstruction or injury
shock/hemodynamic instability
clinical conditions associated w/risk of airway compromise
What are some examples of clinical conditions associated w/risk of airway compromise?
Stroke
Drug overdose
Coma
Why would Hypoxemic resp. failure lead to intubation?
Despite 100% FiO2 or non-invasive PPV support, the patient condition may not be improving.
What Indicators are usually associated w/hypercapnic resp. failure and why are they important to pay attention to?
Resp. acidosis and increased WOB
They’re indicative of impending resp. failure.
