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Typical indications in a rural emergency room for intubation?
- Head trauma
- Drug overdose
- Respiratory failure
What equipment do you want for intubation?
- ET tubes
- Ambu bag (with reservoir)
- IV access
- Taping for tube
- Monitoring system - ECG, pulse oximetry, end tidal O2 monitor
- Syringe (to inflate the cuff)
- Lubricant and Xylo spray
- Rescue airways (LMA, etc)
- Oral airway and nasal airway
- Glide scope
- Kit available for cricothyroidotomy
Physical features difficult intubation?
- Short, thick muscular neck
- Fracture, receding or immobile mandible
- Prominent incisor teeth
- Rigid cervical spine
- Neck trauma
- Mallampati III or IV
What does each class of Mallampati mean?
- Structures that can be seen with mouth open, seated
- I: soft palate, uvula, fauces and pillars visible
- II: soft palate, uvula, fauces visible but not pillars
- III: soft palate only visible
- IV: hard palate only
What is another score for predicting laryngoscopic view?
- Hussain Khan (Upper Lip bite) class
- I - lower incisors can hide mucosa of upper lip
- II - lower incisors partially hide mucosa of upper lip
- III - unable to touch mucosa of upper lip
Dose of succhinylcholine for induction?
- 1 - 1.5 mg/kg
- 100mg in 70kg man
What kind of drug is Succinylcholine (SCH)?
Depolarizing muscle relaxant - made up of 2 ACh molecules bound together
Onset and duration of succinylcholine?
- Onset 30-45s (fastest)
- Duraiton - 4-5 min
Contraindications of SCH (succinylcholine)?
- burns, crush injuries
- pseudocholinesterase deficiency
- malignant hyperthermia
- open eye injuries
Dose of Thiopental (Pentothal) for induction?
Thiopental 2.5-4 mg/kg IV = 200mg in 70kg man
What is the class of Thiopental?
Properties of sodium thiopental?
- barbiturate - for induction/sedation
- direct myocardial depressant
- peripheral vasodilation --> lowers MAP
- Reflex tachycardia
Speed of onset and duration of thiopental?
- Onset 10-20s
- Duration 10 minutes
What is Rocuronium?
A non-depolarizing muscle relaxant
Dose of Rocuronium for induction?
- 0.6 - 0.8 mg/kg as intubating dose for short-acting (30 min duration) (2-3 min onset)
- 1.2mg/kg for longer acting (60 min) with quicker onset (1 min)
- Typical dose in 70kg man:
- 50 mg intubation dose, 80mg for longer action
Properties of Etomidate?
- Imidazole derivative - for induction/sedation
- Acts on GABA Rc
- Hemodynamic stability
- mild decrease in MAP
- s/e - adrenal suppression, pain on injection, n/v
Properties of propofol?
- Substituted phenol - for induction/sedation
- myocardial depression, peripheral vasodilation - drop in MAP
- (moreso than STP/thiopental)
- Minimal effect on HR
Propofol onset and duration?
Contraindications to propofol?
Properties of Ketamine?
- Phencyclidine derivative - induction/sedation
- Sympathomimetic - increased CO, MAP and HR
1 - 2.5 mg/kg IV
Onset of Ketamine and duration?
Contraindications to ketamine?
- head trauma (relative)
- ischemic heart disease
- 0.02 mg/kg (sedation range)
- 0.3 mg/kg (induction range)
Contraindications to Midazolam?
- Disadvantage is its unpredictability
Properties of midazolam?
- Benzodiazepine - induction/sedation
- anxiolysis, sedation, amnesia
- No effect on MAP or CO.
Properties of opioids?
- For induction/sedation
- vagolytic effect - bradycardia
- (except meperidine - tachy)
- decreased MAP
Contraindications of thiopental (STP)?
- sulfa allergy - contains sulfa
- porphyria - induces porphyrin synthesis - abdo pain, weakness, autonomic dysfxn
- caution in hypovolemia or poor systolic fxn
- advance age, hepatic dysfxn, obesity (prolonged effects)