Respiratory/Cardiology Flashcards
Intubation Indications
- Unable to Swallow
- Patient can’t ventilate/oxygenate
- GCS < 8
- Inhalation burns / circumferential neck/chest burns
- Anaphylaxis
- Respiratory Failure = pH < 7.2, CO2 > 55, PaO2 < 60
(only ONE value needs to be off for need to intubate to exist)
LEMON
LEMON =
Look
Evaluate 3-3-2
Mallampati (I-IV)
Obstructions
Neck Mobility
Mallampati Grading
Mallampati I - soft palate, uvula, anterior/posterior tonsillar pillars visible
(tall thin neck - no difficulty
Mallampati II - Tonsillar pillars hidden by tongue
(no difficulty)
Mallampati III - Only base of the uvula can be seen
(moderate difficulty)
Mallampati IV - Uvula cannot be seen
(short, fat or muscular neck / severe difficulty)
Visualization Aids
Sellick’s Maneuver: Direct downward pressure on the thyroid cartilage, occludes the esophagus and prevents aspiration during intubation.
DO NOT RELEASE UNTIL INTUBATION IS COMPLETE!!
BURP: Backward, Upward, Rightward, Pressure
DO NOT RELEASE UNTIL INTUBATION IS COMPLETE!!
Failed Airway Algorithm
ETT Placement Confirmation
Chest XR - GOLD STANDARD
Distal tip of ETT should be 2-3cm above the carina or;
1’ above the cirina
Level of the T2 or T3 vertebrae
NEXT most reliable confirmation method = visualization of the tube passing through the vocal cords.
**Inflation of the distal ETT cuff should be between 20-30mmHg to prevent mucosal tissue damage (only use the amount required to make good seal)
“7 P’s”
Preparation (make sure equipment is serviceable)
Preoxygenate (3-5 minutes, 10-15 LPM if possible)
Pretreatment (load - lidocaine, opiates, atropine, defasiculating dose)
Paralysis with induction (NMB, induction agent, and pain control)
Protect and position (sniffing position, towel under shoulders)
Placement with proof ETT passing through the vocal cords, CXR, ETCO2)
Post intubation management (maintain sedation, oxygenation)
Rapid Sequence Induction/Intubation Medications
Succinycholine (Anectine)
Depolarizing Neuromuscular Blocking Agent (NMB)
Dose 1-2 mg/kg
1-2 minute onset, 4-6 minute duration
Causes fasiculations
Can cause hyperkalemia (antidote calcium gluconate)
Contraindications- crush injuries, eye injuries, narrow angle glaucoma, hx of malignant hyperthermia, burns > 24hrs, HYPERKALEMIA, any nervous system disorder (Guillain-Barre, Myasthenia gravis)
Malignant Hyperthermia
Caused by a defect in the skeletal muscle sarcoplasmic reticulum
Signs/Symptoms: lockjaw, sustained tetanic msucle spasms, rapid increase in temp (can be as high as 110), increased ETCO2, tachycardia/hypertension
Treat with Dantrolene Sodium (Dantrium)
Dose: 3.0 mg/kg
DO NOT GIVE CCB’s (MH is due to a problem with calcium removal from the cells)
RSI Medication Vecuronium
Non-Depolarizing Neuromuscular Agent
Does NOT cause fasiculations
Used after succinycholine to keep the patient paralyzed
(slow onset, long acting)
Defasiculating dose of a non-depolarizing agent reduces increase in ICP during intubation
Slower onset (4-6 min), longer duration of action (30-45min)
Dosing: 0.04 - 0.06 mg/kg if following succinylcholine, PLUS maintenance: 0.01 - 0.015 mg/kg IVP 20-45 min post initial PRN.
RSI Medication Rocuronium
Non-Depolarizing Neuromuscular Blocking Agent
Does not cause fasiculations
Defasiculating doses of a non-depolarizing agent reduces increase in ICP during intubation
Maintenance: 0.1 - 0.2 mg/kg IV q20-30 min
Requires refrigeration - “Rocuronium Refrigerate”
RSI Sedation - Etomidate
Induction agent preferred for awake sedation
(fast onset, short half-life)
30-60 second onset, 3-12 min duration
Dose: 0.3 mg/kg
Has NO ANALGESIC PROPERTIES
Contraindications: adrenal suppression
(DO NOT use in septic shock or Addison’s disease)
Analgesics - Ketamine
Hypnotic analgesic
Dose: 1-2 mg/kg IV / 2 mg/kg IM
45-60 sec onset, 11-17 min duration
Used to stop pain impulses
Potent BRONCHODILATOR, USE IN ASTHMA PT’s
Ketamine can cause hypersalivation (use Atropine 0.01 mg/kg)
Analgesics - Morphine
Opiod Analgesic
Dose based on intended use
IV preferred route
Causes hypotension, nausea and flushing
Antidote: Narcan 0.4 - 2 mg
Analgesic Fentanyl
Opiod Analgesic
(100 x more powerful than morphine)
Avoid in patients with increased ICP, hypoventilations (can cause chest wall rigidity), hypotension and bradycardia
Antidote: Narcan 0.4 - 2 mg
Respiratory Patterns - Apneustic
Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release.
Associated with Decerebrate Posturing
Respiratory Patterns - Ataxic
Complete irregularity of breathing, with irregular pauses and increaseing periods of apnea.
Caused by damage to the medulla secondary to trauma or stroke
Very poor prognosis
Respitory Patterns - Biots
groups of quick, shallow inspirations followed by regular or irregular periods of apnea.
Caused by damage to the medulla by stroke or trauma, or pressure on the medulla secondary to brainstem herniation
Respiratory Patterns - Cheyne-Stokes
Progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary apnea
Associated with decorticate posturing (cushing’s brainstem herniation)
Respiratory Patterns - Kussmaul’s
Respirations gradually become deep, labored and gasping
Associated with DKA
Asthma
“The problem is breathing out”
Exhalation problems fatigue the quickest!
Asthma exacerbation treatment:
Increase I:E ratio to 1:4
High flow O2 (high FiO2)
Bronchodilators
IV fluids
USE KETAMINE FOR SEDATION IN RSI DURRING ASTHMA ATTACK
KETAMINE IS A BRONCHODILATOR
CAPNOGRAPHY = “SHARK FIN”
