Induction & Emergencies

Question 1

Induction Part A: Arrival=>LOC (5 steps)

Answer 1

1. Position correctly (sniffing position)
2. Place on monitors and get pre-induction vitals
3. Begin Pre-oxygentation
4. Administer drugs (Versed/ Fentny/Lidocaine)
5. Induction agent (Propofol/Ketamine/Etomidate)

Question 2

Induction Part B: LOC=>NMB (5 Steps)

Answer 2

1. Confirm LOC (eyelash test)
2. Test ventilate; use APL; reposition
3. Apply PNS and check baseline
4. Make sure Plan B airway available
5. Administer NMB (Succ/Roc/Vec)

Question 3

Induction Part C: NMB=>Gasses (5 Steps)

Answer 3

1. Ventilate while NBM takes effect
2. Tape eyes
3. Confirm loss of twitches
4. Intubate
5. Confirm (watch pass cords, auscultate L=> R; 3 ETCo2; chest rise)

Question 4

Sellick’s Maneuver

Answer 4

Upward cricoid pressure; increase pressure as patient falls asleep; decreases risk of aspiration in RSI

Question 5

Extubation must take place when patient is…

Answer 5

Fully awake or deeply anesthestized; in between called Phase 2 extubation and raises risk of laryngospasm

Question 6

Basic Extubation Criteria (6 items)

Answer 6

1. TV > 6ml/kg
2. VC > 10ml/kg
3. RR greater than 5, less than 30 (>30 usually pain)
4. ETCO2 <50 mmHg
5. Sustained contraction with PNS

Question 7

Awake Extubation Criteria (3 items)

Answer 7

1. Basic criteria met
2. Patient responsive, follows commands, can protect
   airway
3. Can lift head >5 sec (NMB fully reversed)

• Always suction then remove ETT on positive pressure breath*
• Always make sure any gasses/drips turned completely off*

Question 8

Deep Extubation Criteria (4 items)

Answer 8

1. Basic criteria met
2. Muscles relaxant fully reversed (sustained PNS)
3. Able to maintain airway with mask while patient
   awakens (no secretions, difficult airway)
4. Ability to remain vigilant while patient awakens

• Always suction then remove ETT on positive pressure breath*
• Always make sure any gasses/drips turned completely off*

Question 9

Laryngospasm:

1. Definition
2. Signs
3. Cause
4. When seen

Answer 9

1. Prolonged intense glottic closure
2. May be high-pitched squek or absent of sound (ominous); may see rocking horse breahting (flailing of lower ribs and suprasternal in-drawing)
3. Contraction of lateral cricoarytenoids, thyroarytenoids, and cricothyroid muscle from stimulation of CN X (Vagus)
4. Induction and more commonly emergence

Question 10

Laryngospasm Triggers (6 items)

Answer 10

1. Secretions
2. Foreign Body
3. Pain
4. Abdominal stimulation
5. Glottis stimulation on light anesthesia
6. Reactive airway disease

Question 11

Laryngospasm Prevention (4 items)

Answer 11

1. Deep plane of anesthesia (for induction laryngospasm)
2. No Phase 2 extubation (either awake or deep)
3. Suction prior to extubation
4. Remove ETT with positive pressure breath

Question 12

Laryngospasm Treatment (6 steps)

Answer 12

1. Recognize event
2. Remove offending stimulus
3. Larson Maneuver
4. 100% FiO2 w/ PPV
5. Deepen anesthetic (Prop push)
6. Small dose of NMB (Succ 20-40mg)

Question 13

Larson Maneuver

Answer 13

Retromandibular notch; apply painful pressure for 3-5 seconds

Question 14

Rapid Sequence Intubation:

1. Indications
2. Differences between standard induction

Answer 14

1. Used in situations when aspiration risk high and emergent airway needed
2. Cricoid pressure, keep on till AFTER confirmation of placement; watch the clock after NMB (60 seconds); removes test ventilations