Chapter Test July25

Airway Triage Steps

1. basic manuevers
2. basic adjuncts
3. intubation
4. bailouts
5. surgical
6. dead pt

RSI definition

admin of potent induction agent followed immediately by a rapid acting neuomuscular blocker (nmb) to render unconsciousness & motor paralysis for tracheal intubation.

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

RSI Goals

1. optimize intubation conditions
2. minimize aspiration risk by avoiding positive pressure ventilation after intubation is accomplished

Indications for Tracheal Intubation

1. inability to maintain an airway
2. inability to maintain adequayte oxygenation & ventilation
3. anticipated airway obstruction / special situations

RSI Goals

1. optimize intubation conditions
2. minimize aspiration risk by avoiding positive pressure ventilation until after intubation is accomplished

RSI Contraindications

1. tracheal / laryngeal injury / disruption
2. S/P laryngectomy
3. massive facial trauma
4. anticipated difficult airway

RSI Alternatives

1. awake oral intubation with local anesthesia and sedation
2. blind nasotracheal intubation (BNTI)

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

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

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

Airway Assessment (LEMON)

1. look externally
2. evaluate 3-3-2
3. mallampati
4. obstruction
5. neck
6. (pediatrics)

Look Externally

1. difficult BVM ventilation
2. difficult laryngoscopy / intubation
3. difficult surgical airway

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)

Difficult Laryngoscopy Intubation

1. (severe facial burns / angiodema / trauma)
2. buck teeth
3. jay leno
4. micronathia
5. down's syndrome

Difficult Surgical Airway (SHORT)

1. surgery
2. hemotoma or infection
3. obesity
4. radiation
5. tumor (including goiter)
(anatomic variability, females)

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

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])

Obstruction

1. Angiodema
2. Epiglottis
3. Abscess
4. Burn
5. Trauma
6. Tumor

Neck

1. possible curvature of the spine
2. pheumatoid arthritis
3. ankylosing spondylitis

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)

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

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

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)

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

Paralysis with Induction

Rapid IV admin of sedation followed immediately by rapid admin of a neuromuscular blocking agent.

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

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!

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

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

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

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

Medications

pretreatment drugs (LOAD)
1. lidocaine
2. opiates
3. atropine
4. defasiculation
sedation
paralysis

Sedation

1. midazolam
2. etomidate
3. methohexital / thiopental
4. ketamine
5. propofol

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)Su

Succinylcholine (SCh) (Anectine)
S T O P