RSI Flashcards

Question

Succinylcholine

Answer 1

* Depolarizing muscle relaxant * Rapid relaxation * Absolutely CI in malignant hypothermia * Identify pts with Hyperkalemia concerns * 1mg/kg (4mg/kg IM) * Dose based on total body weight * Intubating conditions in 45 seconds It is best to overestimate and get a good blockade than to risk the airway from under dosing. The safety margin of SCh is 6 mg/kg. For children the TBW dosing is 2mg/kg.

Answer 2

* Non-depolarizing neuro-muscular blocker * Longer onset * Prolonged muscle relaxation if failed intubation occurs * 0.1 mg/kg * 90 sec to intubating conditions * 2.4 min to full muscular blockade * Some experts reccomend priming method for RSI dosing * Best "automatic margin of safety" of all NMBA's Priming method - 0.01mg/kg given 3 minutes prior to induction. Then induction agent and remaining relaxant given. This can shorten time to intubating conditions to 75 seconds in some patients.

Answer 3

* Best alternative to SCh * Non-depolarizing NMBA * Intubating conditions in 60 sec * Painful on injection * 1 mg/kg induction dosing for RSI * Unpredictible duration of action * Acceptible side effect profile, slight histamine release in large doses Rocuronium is actually less potent than vecuronium, however due to the large dose needed to achieve intubating conditions, it has a faster onset. The slight histamine release seen in some patients may cause brief hypotension, therefore vecuronium is considered the most CV-safe of all muscle relaxants.

Answer 4

* Sedative, amnestic qualities * **Crosses placenta** * Half life of 1-4 hours * Can decrease BP ⇒ compensatory increase in HR * Offers cerebral protection (seizures, head injury) * 3-5 mg IV/IO depending on clinical situation Although Midazolam alone does not decrease cardiac output, in conjunction with narcotics in has an additive effect on myocardial depression. Use with caution in your cardiac patients that you need to medicate for pain and also sedate after intubation.

Answer 5

* Greater amnestic qualities than Versed * Longer Acting * Dosing 0.5-2.0 mg * decrease dose with advanced liver disease

Answer 6

* Functional residual capacity * Create an oxygen reservoir * 100% o2 for 3 minutes * healthy adult \> 90 % SpO2 for 8 minutes * obese adult \> 90 % SpO2 for 3 minutes * child \> 90 % SpO2 for 4 minutes * Compromised obese/pregnant patient decompensate more rapidly Preoxygenation is the second most important thing you can do. It buys you time to allow your medications to take effect and perform laryngoscopy in a controlled and unrushed fashion. If you have not taken the steps to properly assess and prepare, you will lose valuable time you gained through preoxygenation and a calm controlled intubation can become hurried and suboptimal resulting in a failed attempt.

Answer 7

* A non-rebreather mask only provides 65-75% oxygen. * A bag-mask device with a good seal is the only way to deliver 100% oxygen. * It should be your goal that once you have prepared your intubation equipment and you begin to preoxygenate, to not allow the patient to draw in any ambient air. You want their FRC to be 100% oxygen. * 3 minutes of normal tidal breathing is routinely considered adequate to replace the FRC with 100% oxygen. Recent studies have shown that 8 vital capacity breaths is equally effective. However in EMS situations it is unlikely that patients will be able to accomplish this.

Answer 8

* Fentanyl * Aortic Disscetion * Intercranial hemorrhage / Head injury * Ischemic Heart Disease * Lidocaine * Reactive airway disease * Increased ICP (can increase risk of seizures) Lidocaine IV can be given to reduce tracheal irritation and worsening of asthma or bronchospasm. Fentanyl is generally used cardiac patients to reduce CNS stimulation of cardiac reflexes that can induce tachycardia and hypertension resulting in increased myocardial demand. Fentanyl is also used in suspected aortic dissection or intracranial hemorrhage. Lidocaine and Fentanyl are used in tandem in head injured patients to blunt stimulation from laryngoscopy resulting in increases in ICP, tachycardia and blood pressure.

Answer 9

* Rapid IV push of induction agent * Immediate IV push of paralytic agent * Medications should eb selected based on desire for rapid LOC followed by rapid neuro muscular blockade * There will be an period of apnea *without assisted ventillation* befor intubation Recall that when we discussed drugs used in RSI that we talked about two muscle relaxants—succinylcholine and vecuronium. One key difference is the time of onset. Succinylcholine will have an onset of approximately 45 seconds. Vecuronium on the other hand takes approximately 75-90 seconds to achieve intubation level relaxation. The drawback of vecuronium and even rocuronium, is a longer duration of muscle relaxation. It is imperative to have the ability to ventilate when using vecuronium or rocuronium.

Answer 10

* C-Collars * prevent good mouth opening * do not maintain immobilization during laryngoscopy * Manual Immobilization is best * Allows for good mouth opening * Requires additional personnel

Answer 11

* The tounge is your ENEMY * The epiglottis is your FRIEND * SIZE DOSE MATTER * First attempt should be your best attempt * Every laryngoscopist should be proficent with a bougie * Intubation skill does not substitute for expertise in BVM

Answer 12

* Gives best intubating conditions * Easier to sweep tounge * Tip of blade goes in valeculla * not always best golottic view * avoid blindly inserting MAC blade * Use "look as you go" technique * Use MAC 4 blade for 90% of the population

Answer 13

* Two techniques * look as you go * blind insertion * You have to move that tounge * Better glottic view * Diminished area to manuver for intubation * Partners finger in cheek pulling out will give you more room

Answer 14

Cormack and Lehane developed a glottic view grading scale. In many instances a view can be improved a grade by instituting the BURP maneuver. If you are using a MAC blade and find you have a grade 4 view that is not improved by the BURP maneuver, switch to a MILLER. In many instances you will be able to intubate, always have your bougie at the ready, because if you are using SCh you may only have one shot at getting the tube in while they are fully relaxed if it takes some maneuvering to get a good view.

Answer 15

***CHANGE SOMETHING*** ## Footnote A laryngoscopy attempt is defined as insertion of a laryngoscopy blade until it’s removal. If you need to change tube sizes, institute the BURP maneuver or use a bougie, have your equipment ready and don’t take your eye off the ‘ball’. If these attempts fail, remove the laryngoscope, bag the patient with cricoid pressure if they are compromised and determine what can be changed to improve the next attempt and do it. Did you have a great view, but the tube was too big? Was the patients head extended too far or too little? Was the blade too short, or is the patient anterior and you need to switch from a MAC to a MILLER? Are you comfortable enough to say to your partner ‘You know I’m not sure what I can do to improve my view….you have more experience do you want to attempt the intubation?” There is no room for ego in airway management and knowing our own limitations and working to improve them makes us professionals

Answer 16

* CUFF UP, STYLET OUT * Confirm Bi-lateral breath sounds * Auscultate the stomach * Observe etCO2 * Secure the tube * Secure the patient (sedatives, muscle relaxant)

Answer 17

* Positive gastric sounds, remove tube and prepare to re-attempt intubation * Positive BBS, negative gastric sounds, but no et CO2? * Check pulses and BP * Does pt have reactive airway disease? * Is ET cuff adequately inflated? * Is device connected, no kinks, device turned on?

Answer 18

**ET Troublshooting Pneumonic** ## Footnote **D**islodged **O**bstructed **P**neumothorax **E**sophageal

Answer 19

www.capnography.com/find.htm

Answer 20

You will also see the same waveform as hypoventilation with patients who are in hypermetabolic states, or after return of spontaneous circulation after cardiac arrest (washout of built up CO2 in peripheral tissues) The hyperventilation waveform can also be seen in PE, decreasing cardiac output and impending cardiac arrest.

RSI Flashcards

(48 cards)