Airway lab
ET tube sizing
Adults- 6.5-8 children 4-7 neonates 3-3.5
post sedation medication
Fentanyl gtt 50mcg/hr, titrate to sedation up to 200mcg/hr And Versed gtt 4mg/hr, titrate to sedation up to 20mg/hr OR Propofol gtt 10mcg/kg/min, titrate to sedation or hypotension
more paralytic less sedative ▸Sedatives: reduce dose by 50% ▸Paralytics: full dose to 200% dose ▸Avoid propofol in hypotensive patients ▸Consider Ketamine
How must you ADJUST your induction and paralytic dose in critically ill/hypotensive/ acidotic pts
propofol
Induction agent onset: 15-45 secs duration 5-10mins pros: bronchospasm, seizures cons: lowers BP, caution in head injury, caution in hemodynamically unstable, allergy to egg or soy, pain on injections
etomidate
Induction agent onset: 5-45 secs duration 3-10 mins pros: good for most intubations , cons: myoclonus, adrenal suppression, pain with injection, nausea and vomiting
ketamine
Induction agent onset: 60-90 secs duration 5-15 mins pros: good for hemodynamically unstable, bronchospasm cons: increases secretions, caution in hypertensive pts, nausea and vomiting
signs of a difficult intubation
LEMON score micrognathia (small jaw) facial hair (diff to seal) obstruction (large tongue) obesity neck immobility
sedative
What med is administered first?
avoid Propofol consider ketamine
What sedative should you avoid in hypotensive pts and instead should consider?
End-tidal capnography ▸All of the other methods are useful adjuncts ▸End-tidal CO2 waveform is considered the gold-standard ▸A good wave-form indicates that the tube is either in the tracheal or directly at the outlet of the cords
Which of the following confirmation techniques is considered a "gold standard" for confirming successful intubation? ▸A. Absent epigastric sounds ▸B. Bilateral breath sounds ▸C. End-tidal capnography ▸D. Misting in the tube
A. Etomidate classically causes myoclonic jerking movements Generally not optimal choice for sedation for procedures that require the patient to be still
Which of the following medications is associated with myoclonus? ▸A. Etomidate ▸B. Methohexital ▸C. Midazolam ▸D. Propofol
PLAN
___________ to optimize conditions prior to intubation -preoxygenation -BP control -positioning -back up intubation plan
sniffing position
aligned the oropharynx and trachea in one plane neck is flexed and head it extended B
bimanual laryngoscopy(/BURP)
backwards, upwards, rightward pressure operator uses right hand to optimize view of the airway then has assistant maintain that position while the operator passes the tube take your right hand and make small movements side to side or even posteriorly until the glottis comes into view once you get a view have a helper hold the larynx in that position
nasal canula bipap/cpap
best ways to pre-oxygenated
upward
can see the epiglottis and arytenoid cartilages only -cords are just above and anterior to the arytenoids -aim your ET tube or bougie _________________ -lots of times you can intubate even if you can't se cords -try to use VL to confirm tube going thru cords after placement
Bougie
can use for 1st pass or as back up coude tip should point upwards and help you make the at sometimes anterior turn towards the cords once it passes the cords, the ET tube is threaded over it, while the laryngoscope stay in the airway to facilitate ET tube passage through the cords
indications(to intubate)
cannot ventilate cannot oxygenate cannot protect airway [others include: cardiac arrest, emergent procedure that can compromise airway, facilitation of further work up in combative pt, rapidly deteriorating pt]
calorimetric device
changes from purple to yellow in the presence of acid (CO2) [yay for yellow!!!]
chest xray
confirms depth that the ET tube is down far enough NOT USED TO CONFIRM TRACHEAL PLACEMENT
waveform capnography
considered the gold standard for proof of placement -other techniques may be falsely elevated [colorimetric CO2 detector, auscultation of bilat breath sounds, auscultation over the abdomen for absence of gastric insufflation, misting in the tube, O2 sat rising]
Macintosh blade (procedure)
continue anteriorly until the tip falls into the vallecula slowly advance the blade down the base of the tongue
DNI
contraindications to intubate
L-look externally E- eval with 3-3-2 rule M-mallampati score (1 good, 4 bad) o-obstruction n- neck mobility
describe each component of the LEMON score
OPA (oral airway)
don't use in unconscious pt
ET tube and stylet
dont let stylet go out the tip of the ET tube
hypotensive
during intubation a hemodynamically stable pt will become more ______________
hypercarbic (increase in bicarb- CO2 increase)
during intubation a hypercarbic pt will become more
hypoxic
during intubation an already hypoxic pt will become more
capnography
end tidal CO2 detector connected to monitor. Should be a square waveform with each horizontal plateau representing exhalation
Miller blade (procedure)
ensure that the tip is advanced slightly posteriorly to gently lift the epiglottis slowly advance the blade down the base of the tongue
preparation
equipment, medications AND proper dosages are ready plan A, back up plans B, C and D made AND verbalized pre intubation resuscitation (optimizing conditions for pts]
SUCTION, SUCTION, SUCTION
fluids in the airway emesis, blood, pulmonary edema, secretions ____ solid material using an ET tube or a DuCanto catheter(large bore) use double ________ when lots of fluids are present (one maybe be left in the pharynx)
jaw-thrust maneuver
for those with c-spine immobilization pull the mandible anteriorly by pressing behind the angle of the mandible purpose is to displace the tongue anteriorly to open the airway
Macintosh (Laryngoscope Blade)
goes under the epiglottis and lifts
capnometry devices
helps confirm proper tube placement in the trachea Calorimetric and capnography
BVM (bag valve mask)
if you properly pre oxygenate the pt you do not need to use ______ prior to intubation -use is avoided in the ED because it can distend stomach increasing risk of aspiration - if your pt desaturated during procedure and you need to buy more time, then we use ___________ for pre-oxygenation -consider placing OPA/NPA to improve _____ O2 delivery
sternal notch
in sniffing position what is the ear in line with
patient postion
keep them sitting up for as long as possible after induction meds, drop HOB to 20 degree incline Pt head should be height of provider xiphoid (adjust bed eight as needed)
video laryngoscopy
look at the mouth until the blade passes the tongue THEN look at the screen in general blade doesn't not have to be inserted as deeply as direct laryngoscopy blade to visualize larynx rule of thumb: only fill upper half of the screen with the larynx this way you can still see your tube coming and see if it snags
paralytics
med that is given after induction agent neuromuscular blockers: depolarizing (succinylcholine) or non-depolarizing (rocuronium)
induction agents(sedatives)
med that is given first given at high doses REMEBER in hypotensive pts these doses must be decreased by 50%!!!
Pre-oxygenation
most IMPORTANT step in the rapid sequence intubation--> buys you apneic time -use 100% FiO2 -aim for full denitrogenating of lungs by replacing nitrogen reservoir with O2 -ensure an O2 sat of near 100% before stating
NPA (nasopharyngeal airway)
nasal trumpet~ don't use if facial trauma
suction
one of the tips will likely clog so keep two!
complications
oral/dental injury bleeding perforation right main stem intubation esophagus intubation aspiration obstruction hematoma tracheal laceration
succinylcholine
paralytic agent onset: 45-60 secs duration 6-10 mins pros: shorter duration allow return of neuro exam cons: bradycardia, transient incr in ICP and IOP; aminoglycosides may prolong effects. Contraindiations: HyperK, guillain-bare, malignanry hyperthermia, >3 d post burn or denervation, neruromuscular disorders, digitalis toxicity contraindicated in pts with neuromuscular disorders due to potential for significant hyperkalemia tx for this include CA, soium bicarb, insulin and albuterol
Rocuronium
paralytic agent onset: 60-120 secs duration 15-85 mins pros: good for most intubations cons: longer duration may delay return of neuro exam, can be revered by sugammadex
apneic oxygenation
pre oxygenation technique during intubation place pt on NC and increased flow rates >15L/min --------------->allows for passive gas exchange and prolonging time to desaturation high flow rates of NC may also provide some minimal degree of PEEP NC flow rate is only turned up to high (>15L/m) AFTER the pt is unconscious
cardiac arrest
preintubation resuscitation critically ill pts are prone to _____________________ during intubation MUST optimize their hemodynamics prior to intubation at least 2 IVs fill the tank oxygenation expect their blood pressure to DROP during and immediately after post intubation Be prepared to manage pre/post intubation hypotension IVF infusing to help mitigate hypotension push dose vasopressors ready (vasopressors inc BP) pressers primed on pump and ready to start infusion if need Must ADJUST your induction and paralytic dose in critically ill/hypotensive/ acidotic pts
P's of rapid sequence intubation
preparation positioning pre-oxygenation paralysis with intubation placement with proof post- intubation management
cannot see the folds?
problem is likely mechanics your view: 1. did you slowly insert the laryngoscope identifying anatomy as you go? 2. identify what you are looking at often fixed by head lift or bimanual laryngoscopy something pink and soft? -maybe the blade went too deep- are you in the esophagus? - slowly back out - don't insert the blade so forcefully and deeply often times you're seeing the aryepiglottic folds which means you are lateral---> angle to the sides or try bimanual laryngoscopy to bring the larynx into view
tips for success for placemnt
proper bed height proper pt head position adequate sedation/ paralytics have suction ready have bougie on hand have back up plan ready and make sure nursing knows plan
8
pts with nml physiology, full preoxygenation can provide as much as ______ minutes of apnea time before desaturation in sick pts, esp with pulmonary disease, apnea time is markedly reduced: -may be less than a minute this is also true in children, obese and pregnant pts
Miller (Laryngoscope Blade)
pulls epiglottis forward
post intubation
sedation and analgesia are critical (should be prepped and ready prior to intubation) chest xray is standard to assess tube depth (NOT USED TO CONFIRM TRACHEAL PLACEMENT) soft restraints are critical to prevent inadvertently self- extubation ventilator settings arterial blood gas OG tube placement (oral gastric tube)
head lift (placement)
some pts need additional lift of the head to optimize view if no c-spine precautions, take your right hand and slide underneath the occiput and lift up once you get a view have a helper hold the head in that position
laryngeal inlet
sometimes you can see the cords and the tube is right there but is getting sucks at the _______________________ -rotate the tube 90 degrees to the left (counterclockwise) -this moves the bevel from the left side to the bottom -less likely for the point of the tube to snag on the aryepiglottic folds which scoop upwards
non-rebreather mask
technique used for preoxygenation a flow rate of 15L/min acheives an FiO2 of 60-70% if you turn up the dial past the max marking it can go uo to flow rates of 30-60L/min which may acheve an FiO2 >90% add NC underneath for additional O2 {another technique that can be used is CPAP}
cricoid(pressure)
thought to push the esophagus closed by downward displacement of __________ may worsen view no longer recc
tracheal rings
tube is snagging on anterior ____________________ -rotate tube 90 degree to the right (clockwise) -this moves the bevel from the left side to the top so it can slide more easily down past _________
sugammadex
what can rocuronium be reversed by? expensive and not widely available
three or more laryngoscopic attempts to place the ETT into the trachea or A situation where the attempts last for more than 10 minutes using conventional laryngoscopy
what does ASA define as a difficult intubation (2) Patients who were difficult to intubate had a 51% incidence of life threatening complications defined by death, cardiac arrest, cardiovascular collapse, shock, or hypoxic injury Increases the incidence of esophageal intubation, aspiration, pneumothorax, dental injury, and death in those requiring emergent intubation
LEFT
what hand should the laryngoscope with held with?
E-C maneuver
what maneuver should be used when using a BVM (bag valve mask) this method makes a seal
21-24 cm
what should be the lip line reading
bougie
what to do when good view but cannot pass tube - use a ___________ - downsizing the tube
Mallampati classification
▸I - complete visualization of the soft palate ▸II - complete visualization of the uvula ▸III - partial visualization of the uvula ▸IV - soft palate cannot be visualized
equipment
▸Oxygen: NC + NRB ▸OPA/NPA ▸BVM (bag valve mask) ▸Laryngoscope/Blade ▸Endotracheal Tube ▸Stylet ▸10ml Syringe ▸Lube ▸CO2 Detector (to confirm placement) ▸Tape/Tube holder ▸Bougie (back up plan) ▸Suction (hooked up and turned on) ▸PLAN B
Placement procedure (2)
-LIFT UP, NOT BACK to expose the pts vocal cords - your arm should remain straight, DO NOT BEND AT THE WRIST - visualization of some portion of the cords--- sometimes its only the corniculate cartilage - insert the ET tube at the RIGHT CORNER OF THE MOUTH and advance through the cords -must visualize the cuff of the ET tube passing through the vocal cords
Placement procedure (1)
-NC on with >15L/min once medications are given -hold the laryngoscope in your LEFT hand -head tilt/chin lift or jaw thrust -scissor method to open the mouth -enter the mouth with the tip of your laryngoscope at the right labial corner and sweep towards midline (pushes the tongue outta the way) -advance the blade along the curve of the tongue until epiglottis is visualized NEXT IS DEPT ON MAC OR MILLER BLADE
Placement procedure (3)
-after tube and cuff have passed through the cords, while holding the ET tube in place, retract your laryngoscope -remove the stylet -inflate the ET tube cuff with <10ml of air -DO NOT RELEASE THE ET TUBE -confirm proper placement with capnography /end tidal CO2 AND auscultation before securing ET tube
Pearls
-communication with team -check your equipment -position the patient -get things ready in order -stay calm -wait the full 60 seconds after the paralytic is administrated -tip of the blade can get into the aryepiglottic folds, which can look like the esophagus--------- less likely to happen if the blade is introduced slowly along the base of then tongue and epiglottis is identified first -if the pt begins to desat STOP the procedure and start BVM (bag valve mask)---------- continued efforts to pass the tube without ventilation are dangerous --> subsequent attempts are unlikely to yield success if nothing is adjusted or changed
proof of placement
-end tidal CO2 detector PLUS -visualization of equal chest rise PLUS -auscultation for lack of gastric sounds PLUS -auscultation of bilateral breath sounds PLUS -waveform capnography AND -chest xray Need to preform all for ____________________________
maneuvers to improve visualization
-head lift -bimanual laryngoscopy (BURP- backward, upward, rightward placement) -cricoid pressure (not recc)
emergency cricothyroidotomy
-surgical incision into the cricothyroid membrane to establish an advanced airway -longitudinal incision over the site, incise membrane and spread with a hemostat at 90 - insert cuffed ET tube or tracheostomy tube -items needed- finger, scalpel, bougie, ET tube
paralytic and sedative
2 drug types used for intubation -increase the chances of success - decrease risk of aspiration
usu plan
A -video laryngoscopy B- VL with different blade size or VL + Bougie or Direct Laryngoscopy C- VL/DL + Bougie or LMA D- Surgical airway
B. Calcium ▸Succinylcholine is contraindicated in patients with neuromuscular disorders due to the potential for significant hyperkalemia. ▸In this patient who suddenly went into ventricular fibrillation following succinylcholine administration, most appropriate initial treatment would be with IV calcium (gluconate or chloride) to lower serum potassium. ▸Other treatments include sodium bicarbonate, insulin with/without dextrose, and albuterol to shift potassium intracellularly
A 65-year old male with amyotrophic lateral sclerosis is brought in by EMS in respiratory distress. The patient is diagnosed with pneumonia and the decision is made to intubate. The patient is given etomidate and succinylcholine and is intubated successfully, but shortly thereafter suffers a ventricular fibrillation arrest. In addition to cardiopulmonary resuscitation and support, which of the following medications should be administered? ▸A. Bromocriptine ▸B. Calcium ▸C. Dantrolene ▸D. Sugammadex
A. 10 mg etomidate, 120 mg succinylcholine ▸Dosage for succinylcholine is 1 - 1.5 mg/ kg ▸Dosage for Etomidate is 0.3 mg/kg ▸When intubating patients with hypotension, must adjust medication dosages ▸Sedatives contribute further to hypotension ▸Adjust the dose down (e.g. half dose) ▸Paralytics are less effective ▸Adjust the dose up (e.g. double dose)
A 70-year old female is brought in by EMS for cough, shortness of breath and fever. Vital signs are HR 150, BP 70/palpation, RR 40, O2 saturation 86% on a non-rebreather mask, T 102.2o F (39o C). Physical exam reveals an ill-appearing female in respiratory distress with accessory muscle use and diffuse wheezing. The decision is made to intubate the patient with etomidate and succinylcholine. She weighs 60 kg. Which of the following dosages is most appropriate given the patient's hypotension? A. 10 mg etomidate, 120 mg succinylcholine B. 20 mg etomidate, 60 mg succinylcholine C. 20 mg etomidate, 120 mg succinylcholine D. 60 mg etomidate, 120 mg succinylcholine
3-3-2 rule
A method used to predict difficult intubation. A mouth opening of less than three fingers wide, a mandible length of less than three fingers wide, and a distance from hyoid bone to thyroid notch of less than two fingers wide indicate a possibly difficult airway.
Relative Contraindications(for intubation)
C-spine injury facial trauma suspected difficult intubation or ventilation( short neck, big tongue, obsese)
ET tube sizing (neonates)
Remember 0 1 2 3 ▸Blade 0 ▸For 1-2kg baby ▸Size 3.0 uncuffed ET tube Remember 7 8 9 ▸7cm @ lips for 1kg baby ▸8cm @ lips for 2kg baby ▸9cm @ lips for 3kg baby
