Chapter Test July25

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thom.mccusker@gmail.com
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Chapter Test July25
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2011-07-25 13:17:12
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airway documentation rsi capnography
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airway documentation rsi capnography
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  1. Airway Triage Steps
    • 1. basic manuevers
    • 2. basic adjuncts
    • 3. intubation
    • 4. bailouts
    • 5. surgical
    • 6. dead pt
  2. 1. basic manuevers
    2. basic adjuncts
    3. intubation
    4. bailouts
    5. surgical
    6. dead pt
    Airway Triage Steps
  3. RSI definition
    admin of potent induction agent followed immediately by a rapid acting neuomuscular blocker (nmb) to render unconsciousness & motor paralysis for tracheal intubation.
  4. admin of potent induction agent followed immediately by a rapid acting neuomuscular blocker (nmb) to render unconsciousness & motor paralysis for tracheal intubation.
    RSI definition
  5. RSI assumptions
    • 1. intubation is indicated
    • 2. stomach is full
    • 3. intubation is anticipated to be successful
    • 4. if intubation fails, vetilation is expected to be successful
  6. 1. intubation is indicated
    2. stomach is full
    3. intubation is anticipated to be successful
    4. if intubation fails, vetilation is expected to be successful
    RSI assumptions
  7. RSI Goals
    • 1. optimize intubation conditions
    • 2. minimize aspiration risk by avoiding positive pressure ventilation after intubation is accomplished
  8. 1. optimize intubation conditions
    2. minimize aspiration risk by avoiding positive pressure ventilation after intubation is accomplished
    RSI Goals
  9. Indications for Tracheal Intubation
    • 1. inability to maintain an airway
    • 2. inability to maintain adequayte oxygenation & ventilation
    • 3. anticipated airway obstruction / special situations
  10. 1. inability to maintain an airway
    2. inability to maintain adequayte oxygenation & ventilation
    3. anticipated airway obstruction / special situations
    Indications for Tracheal Intubation
  11. RSI Goals
    • 1. optimize intubation conditions
    • 2. minimize aspiration risk by avoiding positive pressure ventilation until after intubation is accomplished
  12. 1. optimize intubation conditions
    2. minimize aspiration risk by avoiding positive pressure ventilation until after intubation is accomplished
    RSI Goals
  13. RSI Contraindications
    • 1. tracheal / laryngeal injury / disruption
    • 2. S/P laryngectomy
    • 3. massive facial trauma
    • 4. anticipated difficult airway
  14. 1. tracheal / laryngeal injury / disruption
    2. S/P laryngectomy
    3. massive facial trauma
    4. anticipated difficult airway
    RSI Contraindications
  15. RSI Alternatives
    • 1. awake oral intubation with local anesthesia and sedation
    • 2. blind nasotracheal intubation (BNTI)
  16. 1. awake oral intubation with local anesthesia and sedation
    2. blind nasotracheal intubation (BNTI)
    RSI Alternatives
  17. RSI - 7 Ps
    • 1. Preparation
    • 2. Preoxygenation
    • 3. Pretreatment
    • 4. Paralysis with induction
    • 5. Protection with proof
    • 6. Placement with proof
    • 7. Post-intubation management
  18. 1. Preparation
    2. Preoxygenation
    3. Pretreatment
    4. Paralysis with induction
    5. Protection with proof
    6. Placement with proof
    7. Post-intubation management
    RSI - 7 Ps
  19. RSI Timeline
    • 00:00 - 10:00 preparation
    • 00:00 - 05:00 preoxygenation
    • 00:00 - 03:00 pretreatment
    • 00:00 00:00 paralysis with induction
    • 00:00 - 00:20-30 protection with positioning
    • 00:00 - 00:45-60 placement with proof
    • 00:00 - 00:60-90 post-intubation management
  20. 00:00 - 10:00 preparation
    00:00 - 05:00 preoxygenation
    00:00 - 03:00 pretreatment
    00:00 00:00 paralysis with induction
    00:00 - 00:20-30 protection with positioning
    00:00 - 00:45-60 placement with proof
    00:00 - 00:60-90 post-intubation management
    RSI Timeline
  21. Preparation
    • Patient:
    • 1. discussion, airway assessment, IV access
    • 2. positioning
    • Equipment
    • 1. airway, monitoring, failed airway
    • 2. blade type and size, ETT size
    • 3. OPA airway, placement confirmation device
    • 4. cuff integrity and stylet, laryngoscope fxn
    • Personnel
  22. Patient:
    1. discussion, airway assessment, IV access
    2. positioning
    Equipment
    1. airway, monitoring, failed airway
    2. blade type and size, ETT size
    3. OPA airway, placement confirmation device
    4. cuff integrity and stylet, laryngoscope fxn
    Personnel
    Preparation
  23. Airway Assessment (LEMON)
    • 1. look externally
    • 2. evaluate 3-3-2
    • 3. mallampati
    • 4. obstruction
    • 5. neck
    • 6. (pediatrics)
  24. 1. look externally
    2. evaluate 3-3-2
    3. mallampati
    4. obstruction
    5. neck
    6. (pediatrics)
    Airway Assessment (LEMON)
  25. Look Externally
    • 1. difficult BVM ventilation
    • 2. difficult laryngoscopy / intubation
    • 3. difficult surgical airway
  26. 1. difficult BVM ventilation
    2. difficult laryngoscopy / intubation
    3. difficult surgical airway
    Look Externally
  27. Difficult BVM Ventilation (BONES)
    • 1. beard
    • 2. obesity
    • 3. no teeth
    • 4. elderly
    • 5. snores
    • 6. severe facial burns / angloedema / trauma (unstable midface and or mandible)
  28. 1. beard
    2. obesity
    3. no teeth
    4. elderly
    5. snores
    6. severe facial burns / angloedema / trauma (unstable midface and or mandible)
    Difficult BVM Ventilation (BONES)
  29. Difficult Laryngoscopy Intubation
    • 1. (severe facial burns / angiodema / trauma)
    • 2. buck teeth
    • 3. jay leno
    • 4. micronathia
    • 5. down's syndrome
  30. 1. (severe facial burns / angiodema / trauma)
    2. buck teeth
    3. jay leno
    4. micronathia
    5. down's syndrome
    Difficult Laryngoscopy Intubation
  31. Difficult Surgical Airway (SHORT)
    • 1. surgery
    • 2. hemotoma or infection
    • 3. obesity
    • 4. radiation
    • 5. tumor (including goiter)
    • (anatomic variability, females)
  32. 1. surgery
    2. hemotoma or infection
    3. obesity
    4. radiation
    5. tumor (including goiter)
    (anatomic variability, females)
    Difficult Surgical Airway (SHORT)
  33. Mallampati Classification
    • 1. tonsillar pillars and fauces visible
    • 2. upper portion of pillars and uvula visable
    • 3. base of uvula / soft palate visible
    • 4. only tongue and hard palate visible
  34. 1. tonsillar pillars and fauces visible
    2. upper portion of pillars and uvula visable
    3. base of uvula / soft palate visible
    4. only tongue and hard palate visible
    Mallampati Classification
  35. Laryngoscopic Classification
    • Grade 1 - entire glottis visible
    • Grade 2 - arytenoid cartilage and posterior glottis visible
    • Grade 3 - epiglottis only visible
    • Grade 4 - tongue or soft palate visible
    • (grade 3 & 4 are considered difficult intubations [about 5% of OR cases])
  36. Grade 1 - entire glottis visible
    Grade 2 - arytenoid cartilage and posterior glottis visible
    Grade 3 - epiglottis only visible
    Grade 4 - tongue or soft palate visible
    (grade 3 & 4 are considered difficult intubations [about 5% of OR cases])
    Laryngoscopic Classification
  37. Obstruction
    • 1. Angiodema
    • 2. Epiglottis
    • 3. Abscess
    • 4. Burn
    • 5. Trauma
    • 6. Tumor
  38. 1. Angiodema
    2. Epiglottis
    3. Abscess
    4. Burn
    5. Trauma
    6. Tumor
    Obstruction
  39. Neck
    • 1. possible curvature of the spine
    • 2. pheumatoid arthritis
    • 3. ankylosing spondylitis
  40. 1. possible curvature of the spine
    2. pheumatoid arthritis
    3. ankylosing spondylitis
    Neck
  41. High Risk Patients
    • 1. ASA Class 3 and higher
    • 2. chronic pulmonary or cardiac disease
    • 3. fever, volume depletion, current URI
    • 4. airway assessment suggestive
    • (consider OR, anesthesia consult and/or awake intubation)
  42. 1. ASA Class 3 and higher
    2. chronic pulmonary or cardiac disease
    3. fever, volume depletion, current URI
    4. airway assessment suggestive
    (consider OR, anesthesia consult and/or awake intubation)
    High Risk Patients
  43. ETT Size and Depth
    • Size
    • - females 7.5-8, males 8-8.5
    • - broslow tape, little finger diameter
    • - 4 + age/4
    • depth
    • - females - 21cm, males - 23cm
    • - broslow tape, markings on ETT
    • - ETT size x 3 (cm), age + 10
  44. Size
    - females 7.5-8, males 8-8.5
    - broslow tape, little finger diameter
    - 4 + age/4
    depth
    - females - 21cm, males - 23cm
    - broslow tape, markings on ETT
    - ETT size x 3 (cm), age + 10
    ETT Size and Depth
  45. Preoxygenation
    • Establish an O2 reservoir in the lungs and body
    • 1. essential to "no bagging" principle of RSI
    • 2. function residual capacity is primary reservoir
    • 3. permits several minutes of apnea without desaturation
    • 100% O2 via nonrebreather for 5 minutes or 8 VC breaths with 10% O2 via bag/mask
  46. Establish an O2 reservoir in the lungs and body
    1. essential to "no bagging" principle of RSI
    2. function residual capacity is primary reservoir
    3. permits several minutes of apnea without desaturation
    100% O2 via nonrebreather for 5 minutes or 8 VC breaths with 10% O2 via bag/mask
    Preoxygenation
  47. Pretreatment (LOAD) 1/2
    • mitigate adverse effects of laryngoscopy
    • Lidocaine 1.5 mg/kg
    • - airway bronchospasm / cough reflex
    • - increased ICP
    • Opiates (Fentnyl 3-6 mcg/kg)
    • - increased ICP, aortic dissection, ruptured aortic or IC aneurysm, ischemic heart disease
    • - blunts reflex sympathetic respone to laryngoscopy
    • (not recommended under age 1)
  48. mitigate adverse effects of laryngoscopy
    Lidocaine 1.5 mg/kg
    - airway bronchospasm / cough reflex
    - increased ICP
    Opiates (Fentnyl 3-6 mcg/kg)
    - increased ICP, aortic dissection, ruptured aortic or IC aneurysm, ischemic heart disease
    - blunts reflex sympathetic respone to laryngoscopy
    (not recommended under age 1)
    Pretreatment (LOAD) 1/2
  49. Pretreatment (LOAD) 2/2
    • Atropine 0.01-0.02 mg/kg (0.1 - 0.5 mg)
    • - children <= 10 y/o
    • - blunts vagal response to laryngoscopy
    • Defasiculation (with succinylcholine)
    • - increased ICP
    • - 1/10th dose of a non-depolaring NMB
    • - not indicated under age 5
  50. Atropine 0.01-0.02 mg/kg (0.1 - 0.5 mg)
    - children <= 10 y/o
    - blunts vagal response to laryngoscopy
    Defasiculation (with succinylcholine)
    - increased ICP
    - 1/10th dose of a non-depolaring NMB
    - not indicated under age 5
    Pretreatment (LOAD) 2/2
  51. Paralysis with Induction
    Rapid IV admin of sedation followed immediately by rapid admin of a neuromuscular blocking agent.
  52. Rapid IV admin of sedation followed immediately by rapid admin of a neuromuscular blocking agent.
    Paralysis with Induction
  53. Protection and Positioning
    • Sellick's Maneuver
    • 1. firm pressure (10#)
    • 2. maintain until placement cinfirmation and cuff inflation
    • Positioning
    • 1. keep the pillow to maximize POGO
    • 2. height of bed, height in bed
  54. Sellick's Maneuver
    1. firm pressure (10#)
    2. maintain until placement cinfirmation and cuff inflation
    Positioning
    1. keep the pillow to maximize POGO
    2. height of bed, height in bed
    Protection and Positioning
  55. Placement with Proof - 1/2
    • 1. test jaw for flaccidity
    • 2. gentile controlled technique
    • 3. blade entry on right, sweep tongue to left
    • 4. lift handle up and away
    • 5. suction prn
    • 6. insert into esophagus, then slowly withdraw
    • 7. visualize vocal cords
    • 8. watch ETT pass through vocal cords
    • 9. check ETT depth
    • 10. NEVER LET GO OF THE TUBE!
  56. 1. test jaw for flaccidity
    2. gentile controlled technique
    3. blade entry on right, sweep tongue to left
    4. lift handle up and away
    5. suction prn
    6. insert into esophagus, then slowly withdraw
    7. visualize vocal cords
    8. watch ETT pass through vocal cords
    9. check ETT depth
    10. NEVER LET GO OF THE TUBE!
    Placement with Proof - 1/2
  57. Placement with Proof - 2/2
    • Confirm Tracheal Placement
    • 1. direct visualization plus either ETCO2 or esophageal detector (preferred in cardiopulmonary arrest)
    • Confirm Depth (cords > bronchus)
    • 1. Auscultation
    • 2. CXR
  58. Confirm Tracheal Placement
    1. direct visualization plus either ETCO2 or esophageal detector (preferred in cardiopulmonary arrest)
    Confirm Depth (cords > bronchus)
    1. Auscultation
    2. CXR
    Placement with Proof - 2/2
  59. Post-Intubation Management
    • 1. secure ETT
    • 2. Reassess VS
    • 3. PCXR for depth of placement
    • 4. bradycardia/hyposia -> nontracheal tube placement until proven otherwise (DOPE)
    • 5. hypertension -> inadequate sedation/analgesia
    • 6. hypotension
  60. 1. secure ETT
    2. Reassess VS
    3. PCXR for depth of placement
    4. bradycardia/hyposia -> nontracheal tube placement until proven otherwise (DOPE)
    5. hypertension -> inadequate sedation/analgesia
    6. hypotension
    Post-Intubation Management
  61. Post-Intubation Management (Hypotention) 1/2
    • Tension PTX
    • - high PIP, hard to bag, decreased BS, hypoxia
    • - immediate thoracostome
    • Decreased venous return
    • - high PIPs 2ndary to high intrathoracic presure
    • - fluids, bronchodilators
    • - increased expiratory time, decrease TV
  62. Tension PTX
    - high PIP, hard to bag, decreased BS, hypoxia
    - immediate thoracostome
    Decreased venous return
    - high PIPs 2ndary to high intrathoracic presure
    - fluids, bronchodilators
    - increased expiratory time, decrease TV
    Post-Intubation Management (Hypotention) 1/2
  63. Post-Intubation Management (Hypotention) 2/2
    • induction agent
    • - other causes excluded
    • - fluid bolus, consider reversal agent, expectant
    • cardiogenic
    • - usually a compromised pt
    • - check EKG, exclude other causes
    • - fluid bolus (caution), pressors
  64. induction agent
    - other causes excluded
    - fluid bolus, consider reversal agent, expectant
    cardiogenic
    - usually a compromised pt
    - check EKG, exclude other causes
    - fluid bolus (caution), pressors
    Post-Intubation Management (Hypotention) 2/2
  65. Medications
    • pretreatment drugs (LOAD)
    • 1. lidocaine
    • 2. opiates
    • 3. atropine
    • 4. defasiculation
    • sedation
    • paralysis
  66. pretreatment drugs (LOAD)
    1. lidocaine
    2. opiates
    3. atropine
    4. defasiculation
    sedation
    paralysis
    Medications
  67. Sedation
    • 1. midazolam
    • 2. etomidate
    • 3. methohexital / thiopental
    • 4. ketamine
    • 5. propofol
  68. 1. midazolam
    2. etomidate
    3. methohexital / thiopental
    4. ketamine
    5. propofol
    Sedation
  69. Neuromuscular Blocking Agents
    • noncompetitive depolarizing
    • 1. succinycholine (anectine)
    • compeditive nondepolarizer
    • benzylisoquinolinium group
    • 1. atracurium (tracrium)
    • 2. cisatracurium (nimbex)
    • 3. mivacurium (mivacron)
    • aminosteroid group
    • 1. pancuronium (pavulon)
    • 2. vecuronium (norcuron)
    • 3. rocuronium (zemuron)
  70. noncompetitive depolarizing
    1. succinycholine (anectine)
    compeditive nondepolarizer
    benzylisoquinolinium group
    1. atracurium (tracrium)
    2. cisatracurium (nimbex)
    3. mivacurium (mivacron)
    aminosteroid group
    1. pancuronium (pavulon)
    2. vecuronium (norcuron)
    3. rocuronium (zemuron)Su
    Neuromuscular Blocking Agents
  71. Succinylcholine (SCh) (Anectine)
    S T O P
    • 1. rapid onset (45 seconds) and short duration of action (< 10 minutes)
    • 2.

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