What percent of airways are "difficult airways"?
5%
How much intubation time do you have if you pre-oxygenate by bag valve mask or high flow
5 minutes
What happens if you don't get the pt intubated in 5 mintues?
Re-oxygenate
How often should you monitor the O2 sats?
ALWAYS
What nerves are part of the afferent pathway?
glossopharyngeal and vagus
What nerve mediates the parasympathetic system?
vagus nerve, stimulation can cause sinus arrest and bradycardia
What happens when the sympathetic nervous system is stimulated?
tachycardia
hypertension
increased PAOP
What happens with hypoxemia and hypercapnea
peripheral vasoconstriction
bradycardia
sympathetic outflow
acidosis with severe hypercapnea (bradycardia, hypotension, decreased CO)
What are the indications for Intubation?
Airway protection
relief of obstruction
provision of mechanical ventilation and oxygen therapy
respiratory failure
shock
hyperventilation for intracranial hypertension
reduce the work of breathing
facilitation of suctioning/pulmonary toilet
What are the legalities of intubation?
not malpractice to not get a pt intubated
is malpractice not to try
have a back up method or technique
What is the gold standard of ensuring you are intubated and in the right position?
chest xray
What are the hazards of intubation?
Hemodynamic
Comorbid conditions: cervical spine, trauma issues (CNS, open eye, oral/facial)
agitation
full stomach(recent ingestion, trauma, esophageal/abdominal pathology, pregnancy, obesity)
What is the thyromental distance?
mandible to thyroid cartilage should be 3 finger widths or 6.5cm, if it isn't, it may indicate anterior airway structures
What are the characteristics of Mallampati Class I?
faucial pillar, soft palate and uvula can be visulized
What are the characteristics of Mallampati Class II?
faucial pillar, and soft palate can be visualized
Uvula masked by the base of the tongue
What are the characteristics of Mallampati Class III?
only the base of the uvula can be visualized
What are the characteristics of Mallampati Class IV?
none of the structures can be visualized
What is the Cormack-Lehane Grading System?
system that uses direct laryngoscopic visualization of the glottis opening.
Grades I-IV
What is the difference between partial and total airway obstruction?
partial: decreased tidal volume, chst retractions, snoring, stridor
total: no air movement
How do you treat airway obstruction?
Soft tissue-mandible lift, neck extension
positive pressure
oral/nasal airway
racemic epinephrine
helium/oxygen
What are some traumatic airway problems?
laryngeal fracture
soft tissue injury
cervical spine injury
basilar skull fracture
What are some non-traumatic airway pathologies?
epiglottitis
abscess
laryngeal edema
neoplasm of the airway
ankylosing spondylitis
TMJ
What are ways the body protect the airway?
Glottic closure reflex
coughing
What can diminish the body's protective reflexes for the airway?
neurologic problems
neuromuscular problems
muscular problems
What is the triple airway maneuver?
extend the neck (if no neck injury)
elevate the mandible with fingers from both hands
open mouth with thumb an forefingers
What is an LMA?
Laryngeal Mask Airway
Can you use an LMA in children?
Yes, both children and adults
What is the major drawback when using an LMA?
it does NOT protect against aspiration
Can you intubate through an LMA?
Yes, the LMA size for a normal adult is 4-5 and it allows an ETT size of 6.0-7.0
What are some complications of laryngoscopy intubation?
Damage to the teeth, and or soft tissue
coughing, laryngospasm, increased ICP, IOP, spinal cord.
hypoxemia, hypercapnea, aspiration
HTN, tachycardia, dysrhythmia
Broncospasm
How do you treat HTN, tachycardia, or dysrhythmia associated with intubation?
esmolol, lidocaine, fentanyl
How do you treat bronchospasm associated with intubation?
steroids, beta agonists, lidocaine
What are some complications of ET intubation?
esophageal intubation
mechanical damage
endobronchial placement
nasopharyngeal damage with nasal intubation
What of some complications of EXtubation?
airway obstruction
laryngospasm
aspiration
laryngeal edema
vocal cord paralysis
What are some treatments that can help when a pt has laryngeal edema?
use warmed, humidified O2
nebulized racemic epinephrine
steroids
helium/oxygen
reintubation
What are some reasons you would NOT be able to ventilate the pt once intubated?
obstructed ETT(pass a suction catheter)
balloon herniation
carinal placement w/bronchospasm
mainstem placement
pulmonary pathology
tension pneumothorax
What are some general things to consider prior to intubating a pt?
1. PreOxygenate!!
2. have a free running IV
3. use a stylet
4. be careful w/sedation
5. insert appropriate sized tube(think bronchoscopy)
6. know your limitations, if it is a bad airway, need an experienced intubator
7. oxygenate between attempts
8. if th
In Rapid Sequence Intubation (RSI), when do you give the neuromuscular blocking agent?
AFTER you do the Selnick maneuver
What kind of narcotics can you give for intubation?
morphine and fentanyl
How do narcotics help in intubation?
they attenuate the hyperdynamic response to laryngoscopy and intubation
can be used with sedatives (benzodiazepines)
What is a major plus for using etomidate?
rapid onset, short action of duration
What is the dosing for etomidate?
0.15-.30mg/kg
Does etomidate have analgesic properties?
No, can combine w/fentanyl
What is a potential problem using etomidate?
HTN and tachycardia, however, most pts are cardiovascularly stable
What are the properties of Propofol in relation to intubation?
fast/short acting
no analgesic properties
can cause hypotension and tachycardia
What agent for intubation is both an analgesic as well as a hypnotic?
Ketamine
What is the action of Ketamine?
directly stimulates the CNS and increases sympathetic outflow: Increased HR, BP, CO and contractility
What is a drawback of using Ketamine?
Pt may have emergence delirium
What are some properties of Barbituates in relation to intubation?
rapid distribution
decreased ICP
negative inotropic effects: increased venous capacitance, hypotension
NON-analgesic
What are 2 types of paralytics?
Depolarizing (succinylcholine)
Non-Depolarizing (rocuronium, vecuronium, pancuronium)
What kind of paralytics are best for intubation?
Short acting
What is the normal ETT size and placement for a normal sized adult male?
8-8.5cm and 23 at the lip
What is the normal ETT size and placement for a normal sized adult female?
7.5-8.0cm and 21 at the lip
Where should the ET tube rest when intubated properly?
1-2cm above the carina
What is Selnick Maneuver?
cricoid pressure
What hand is the scope held in, regardless of hand dominance?
Left hand
What side of the mouth do you intubate from?
Right side of the mouth until at the base of the tongue
What do you do with the tongue during intubation?
sweep the tongue to the left when you reach the base of the tongue.
What action when intubating may cause damage to the teeth, gingiva or lips?
using a rocking motion with the scope
What laryngoscope has a straight blade and what is the normal size blade?
Miller
2-3 blade, 2 is the most common
When is it useful to use the Miller laryngoscope
useful with people who have large incisors. it physically and directly lifts the epiglottis
What laryngoscope has a curved blade?
Macintosh, normal sized blade is 3-4 with 3 being most common
When is it useful to use the macintosh?
in obese pts and those with a large tongue
Where is the macintosh placed?
in the vallecula, above the epiglottis and is used to indirectly lift the epiglottis off the larynx by traction on the frenulum
Once the macintosh is in place, how do you lift the blade?
lift upward with the handle to about 90 degrees
Does the miller elevate the epiglottis anteriorly or posteriorly?
anteriorly
When should you go for it and insert the tube?
Once you visualize the cords and glottis opening, you can barely see them
What are some things to remember when inserting the laryngoscope?
It is NOT a pry bar
Proper positioning is key
Watch the teeth
What does BURP mean in intubation
have an assistant grab the thyroid cartilage between the thumb and index finger and move it
Backward , towards the anterior spine, then
Upward pressure to lift the larynx superiorly
Rightward Pressure to shift the thyroid cartilage no more than 2 cm
How do you intubate if you suspect a C-spine injury?
Do NOT tip the head
digital intubation
retrograde intubation
cricothyrotomy
trach
What are some considerations for fiberoptic intubation?
Preparation is important
nasal vs oral
experience is needed
there may be airway bleeding
Where should the stylet end when inserted into the et tube?
2-3 cm before the end of the tube
How much oxygen should be used when intubating?
whatever it takes to maintain an SpO2 as close to 100% as possible
What are properties of lidocaine when considering this for pre-medication for intubation?
it decreases ICP, vagal stimulation, ventricular ectopy, catecholamine release associated w/htn during the procedure
it reduces bronchospasm/cough
it administered as a single IV bolus of 1-2mg/kg, depending on pre-existing rhythm 3 minutes prior to intuba
When is atropine used as a premedication for intubation?
Usually with pediatric pts
When should you NOT use atropine?
if the pt is tachycardic to begin with
What are properties of atropine in relation to intubation?
it is an anticholinergic,
decreases the effect of vagal stimulation and bradycardia,
decreases salivation and GI secretions
What is the onset of action and how long does etomidate last?
onset is <30 seconds
unconsciousness lasts 5 minutes w/full recovery in 7-14 minutes
What are some considerations when using Midazolam for intubation?
Provides sedation, relaxation and AMNESIA
Onset begins in 30-60 seconds, w/peak effect in 3-5 minutes
The therapeutic effect can last 2-6 hours, but generally need redosing every hour
Can result in hypotension and hypoventilation
What are some properties of Fentanyl for intubation?
Opioid analgesic
Provides relaxation, sedation, analgesia and has a mild amnesic effect
Onset is 1-2 minutes, peak is 3-5 minutes, duration is 30-60 minutes
Dose is 50-150mcg/kg IV w/maintenance doses of 2-50mcg/kg
What is the onset of succinylcholine?
30 seconds, peak effect 1-2minutes
What is the dosing of succinylcholine?
1.5mg/kg IV,
3mg/kg IM if no IV access available
Why is it better to overdose when using succs, than to underdose?
prevents complications such as fasiculations and vomiting
When is succs contraindicated?
pt w/hyperkalemia
MH(pt or family hx of)
progressive neuromuscular disease
>24 hours post burn or 7 days post crush/denervation injury
What is the onset and duration of Rocuronium?
onset 1-2minutes
duration 20-30 minutes
What is the dosing of roc
0.6mg/kg
m/c dosing is 1 mg/kg which results in paralysis within 1 minute, but extends duration to 30-45 minutes
What is the onset and duration for the non-polarizing agent vecuronium?
onset 2-3 minutes
duration: 30-45 minutes
higher dosing can speed up onset, however it extends duration of action
What is the dose of vecuronium?
0.1mg/kg
What is the onset, duration, and dose for pancuronium?
onset 2-3 minutes
duration-very long-60-90 minutes or longer...very unpredictable
0.1 mg/kg IV