1
Q
Two main reasons to intubate
A
- oxygenation
- ventilation
(also protect airway)
2
Q
In what situations should you intubate early
A
Dynamic airways
- neck trauma from bullets
- anaphylaxis/angioedema
- thermal/caustic airway injuries
3
Q
What is visible when you have a great view (the money shot)
A
epiglottis
vocal folds
4
Q
Purpose of airway maneuvers
A
- improves airflow
VERY important, get this right, everything else should be more smooth
5
Q
Patient positioning prior to and when starting intubation
A
- keep patient sitting up as long as possible, easier to breath unless medical reason they aren’t able (LOC, trauma, etc.)
- supine: tongue falls posterior, soft tissue of upper airway relaxes, reduced lung capacity
- wait until last minute to recline patient
- want ear to sternal notch to be aligned, use padding to lift head
6
Q
Airway maneuvers
A
- Head-tilt, chin-lift (no c-spine concern). More for alignment, doesn’t change airway much
- Jaw thrust (ok with c-spine concern). opens airway much more
7
Q
How to deal with potential c-spine injury
A
- airway manipulation = easy to move c-spine
- stabilize!!!
- manual in-line stabilization is preference
8
Q
Airway adjuncts
A
- OPA: no gag reflex, measure from corner of mouth to angle of mandible, insert upside down with 180 rotation into place
- NPA: better tolerated than OPA, coat with ky, insert along floor of nares, rotate if resistance
9
Q
Bag-valve-Mask ventilation
A
- bag gives time to prepare for definitive airway management
- 3 elements for success
1. Patent airway
2. Mask seal
3. Proper ventilation (volume, rate, cadence)
10
Q
BVM
- proper fit
A
over the bridge of the nose and the ridge of th chin
- if no teeth, stick bottom part in mouth
- if beard, use tegaderm or pacer pad over beard for better seal
11
Q
BVM
- methods to secure mask
A
- C-E technique if only on person
- Two hand, two person: preferred (two thumbs down technique)
* in either case, pull face into mask, don’t mash mask onto face
12
Q
BVM
- what does ventilation depend on
A
- volume: 400-500 mL per squeeze (bag volume 1,000 to 1,500 mL)
- rate: <10-12 breaths/min, aim for EtCO2 35-45 mmHg
- Cadence: constant and smooth
13
Q
BVM
- what tool can optimize
A
- PEEP valve
- always use
- recruits and stents the lungs
14
Q
BiPAP, CPAP
- indications
A
- COPD exacerbations with hypercapnic acidosis
- Cardiogenic pulmonary edema
- Great way to avoid intubation
- Might need very mild sedative if person is confused, they may fight it
15
Q
List the different airway options
A
- BVM
- Laryngeal mask airway (LMA)
- Direct laryngoscopy
- Video assisted direct laryngoscopy
- Surgical airway - cricothyrotomy
16
Q
LMA
- overview
A
- provides oxygenation and ventilation without entering trachea
- does NOT protect the airway from obstruction or aspiration
- can become dislodged
17
Q
LMA
- contraindications
A
- gag reflex (vomiting and aspiration risk)
- trauma/disease of oropharynx
- foreign body obstruction
18
Q
LMA
- common indications
A
- elective sx
- cardiac arrest
- failed intubation attempt, at least you can oxygenate even if can’t intubate
19
Q
iLMA
A
intubating LMA
- special opening to allow ET tube through
20
Q
Direct laryngoscopy and endotracheal intubation
- definition
A
- direct visualization of the airway to place ET tube in trachea
- protects airway
- conduit for oxygenation and ventilation
21
Q
Direct laryngoscopy and endotracheal intubation
- two types of blade
A
Mac: curved
- curve approximates tongue curve
- tip fits the vallecula, recess at the back of the tongue, elevates the epiglottis
Miller: straight
- more narrow, sharp curved tip
- tip lifts the epiglottis
- use: deep, long, anterior airways, floppy epiglottis
22
Q
Direct laryngoscopy and endotracheal intubation
- how to determine kid size
A
- (age +16) / 4
- size of pinkie is good approximation
23
Q
Laryngoscopy technique
A
- pt in sniffing position
- align EAM with sternal notch
- ramp up bed height
- might need to still elevate pt head/flex lower neck
- open mouth with scissor technique
- sweep tongue to left side (hold blade in left hand)
- advance blade, press up and away
- If can’t find epiglottis, find the tongue and use as reference mark
- If can’t see well, perform external laryngeal manipulation (BURP: backward, upward, rightward pressure)
- DO NOT rotate risk or push against teeth!!
24
Q
Laryngoscopy technique
- tube placement
A
- pass tube through cords
- should be approx 22 cm at teeth
- Co2 detector: yellow is golden :)
- do not rely on misting of tube or auscultation
- CXR to determine depth, should be 4cm above carina and below clavicle heads
25
Laryngoscopy technique
| - helpful tools
1. Stylet: shapeable, have assistant remove it once past cords
2. Bougie/hockey stick: can be placed blind. Place with tip anterior and place under epiglottis (clicking of trachea) then place ET tube over and remove stick
26
How to know if placed correctly
- end tidal flow on monitor
| - Sats on monitor - O2 and CO2
27
Post intubation care
- secure tube, don't let go until secure
- elevate head 30-45 degrees
- adequate sedation/analgesia
- in-line suction
- gastric tube
- balloon pressure: 20 mmHg
28
Video laryngoscopy
- go to option today
29
RSI
- admin of induction agent and neuroMSK blocking agent to create optimal intubation conditions: max success rate and min risk of aspiration
- used in critically ill pts
- consider alt option if anticipate rapid desaturation, severe hypotension, anatomic challenge
30
7 Ps of RSI
```
Preparation
Preoxygenation
Pre-intubation optimization
Paralysis with induction
Protection
Placement (intubation)
Post-intubation management
```
31
RSI
| - Preparation
- assess airway for potential difficulty
- develop plan A and B
- Assemble people, equipment, medications
32
How to assess airway for potential difficulty
LEMON
- Look externally
- Evaluate 332
- Mallampati: score based on open mouth view
- Obstruction/obesity
- Neck mobility
33
Mnemonic for preparation
STOP MAID
- suction
- Tools
- O2 for preoxygenation and ongoing ventilation
- Positioning
- Monitors
- Assistant, Ambu, Airway devices
- IV access
- Drugs
34
Preoxygenation
- high possible concentration of O2 for min 3 minutes prior to intubation
- create O2 reservoir, delay desaturation. "safe apnea"
- Nasal is best delivery
35
Preintubation optimization
- optimize physiology (give blood, decompress pneumothorax, etc.)
- Tx hypotension: IVF, blood products, vasopressor
36
Paralysis with induction
- precalculated dose of induction agent and paralytic
- goal: 45-60 seconds desired level of sedation and paralysis
- Ketamine is best induction option
- Succinylcholine best paralytic
37
Placement with proof
- relaxation: laxity of jaw = can begin laryngoscopy
38
Post intubation management
- secure tube
- CXR
- check for complications
- vent setup
- long-term sedation
ER 2
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