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30 Cards in this Set
- Front
- Back
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What are the indications for endotracheal intubation? |
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What is the definition of respiratory failure? |
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Describe the steps involved in a rapid sequence intubation (RSI). |
Remember the “seven Ps”
1) Preparation (of equipment and medication) 2) Preoxygenation 3) Pretreatment (supplementary and nonessential, e.g. lidocaine, fentanyl) 4) Paralysis with induction (administration is virtually simultaneous in RSI) 5) Protection and positioning 6) Placement with proof 7) Postintubation management |
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Step 1) Preparation
Describe the equipment that should be prepared for endotracheal intubation. |
Suction catheter Endotracheal tube: The size of the tube refers to its diameter and ranges from 5-10 mm in cuffed tubes. Typical size is 7.5 in females and 8 in males. Have the size 0.5 mm above and below on hand just in case. Stylet Laryngoscope (with functioning light) and several blades 10mL syringe for cuff inflation Tape Water-soluble lubricant Exhaled CO2 detector Alternative airways (oral airway, LMA) |
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Step 2) Preoxygenation
Describe the rationale, technique, and duration of preoxygenation for endotracheal intubation. |
Rationale: Preoxygenation creates an oxygen reservoir in the lungs, blood, and tissues that enables patients to tolerate a longer period of apnea without oxygen desaturation. The oxygen saturation of adults with severe illness or obesity falls below 90 percent in less than three minutes.
Technique: In a spontaneously-breathing patient, provide high-flow oxygen through a non-rebreather mask for an unspecified period of time. Avoid positive pressure ventilation in the spontaneously-breathing patient as it carries a risk for regurgitation and aspiration. |
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Step 3) Pretreatment
Describe what is meant by pretreatment in rapid sequence intubation. |
Administration of drugs PRIOR to the induction phase of RSI for the purpose of mitigating adverse effects associated with intubation (e.g. lidocaine, fentanyl) |
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Step 4) Paralysis with induction
Name four potential agents for induction in RSI.
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1) Ketamine 2) Propofol 3) Etomidate 4) Midazolam |
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Describe a strategy for choosing an induction agent in RSI.
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1) Hypotension - ketamine 2) Hypertension without concern of raised ICP - propofol 3) Need to maintain hemodynamic neutrality - etomidate |
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What are the advantages of ketamine as an induction agent? |
Respiratory function is preserved, and there is a theoretical bonus of bronchodilation secondary to catecholamine release. Blood pressure and cardiac function are preserved, though blood pressure may transiently rise (ideal in shock)
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What are the contraindications to ketamine?
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Contraindications: The use of ketamine is controversial in patients with both raised ICP and hypertension. Avoid in patients with suspected intracranial hypertension with elevated systemic blood pressure. Adverse events: Laryngospasm (rare) Tachyarrhythmia (rare) Emergence reactions (common) |
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What is the induction dose of ketamine? What are the relevant kinetics of ketamine |
1-2 mg/kg IV Sample dose: 70 mg KINETICS: Onset <1m Duration approximately 10m |
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What are the risks with propofol as an induction agent? |
Propofol causes dose-dependant hypotension.
A decrease in MAP caused by propofol can reduce cerebral perfusion pressure, thereby exacerbating a neurologic injury. |
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What are the contraindications to propofol? What are the serious adverse effects associated with propofol? |
CONTRAINDICATIONS: Known or suspected raised ICP Hypotension Hypersensitivity to eggs or soy products ADVERSE EFFECTS: Injections site pain Hypertriglyceridemia and pancreatic injury |
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What is the induction dose of propofol?
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1.5-3 mg/kg IV
KINETICS: Onset <1m Duration approx. 10m |
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What are the advantages of etomidate as an induction agent? |
Etomidate is the most cardiovascularly neutral induction agent. |
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What are the risks with etomidate as an induction agent? |
Risk of adrenal suppression |
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What is the induction dose of etomidate?
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0.3 mg/kg IV Sample dose: 21mg Kinetics: onset <1m, duration approx. 10m |
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What are the options for paralytic agents in RSI? |
Broadly, the choice is between depolarizing and non-depolarizing neuromuscular blocking agents.
Depolarizing NMBA: succinylcholine (SCh)
Non-depolarizing NMBA: rocuronium |
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Describe a strategy for choosing a NMBA for RSI. |
In the absence of contraindications, SCh is the NMBA of choice.
The main advantage of SCh over the nondepolarizing rocuronium is its short duration of action. |
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What is the mechanism of action of SCh? |
SCh is the classic depolarizing agent.
It is an acetylcholine analogue that stimulates all cholinergic receptors throughout the parsympathetic and sympathetic nervous systems.
SCh binds directly to the postsynaptic ACh receptors of the motor endplate causing continuous stimulation of these receptors.
This leads to transient fasciulations followed by muscular paralysis. |
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What is the onset and duration of action of SCh?
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Intubation-level sedation is achieved withing 1 minute and duratio of action is approx. 10 minutes. |
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What are the contraindications to SCh? |
Personal or family history of malignant hyperthermia
Patients deemed to be at high ris of developing severe hyperkalemia (rhabdomyolysis, suggestive EKG changes
There are more here... having to do with up-regulation of receptors and susceptibility to hyperkalemia |
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What is the dose of SCh for RSI? |
1.5 mg/kg IV |
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What is the dose of rocuronium for RSI? |
I mg/kg IV |
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Step 5) Protection positioning
What does "protection" refer to in this step? |
1) Avoidance of bag-mask ventilation
Not necessary if the patient has been successfully preoxygenated
May increase the risk of aspiration
2) If bag-mask ventilation is needed, apply cricoid pressure (Sellick's maneuver)
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Describe the correct patient positioning for intubation. |
Sniffing position (expand this) |
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6) Placement with proof
Describe the technique for endotracheal tube placement. |
Perform direct laryngoscopy: with the laryngoscope in your left hand, place the laryngoscope into the vallecula and visualize the glottis.
Place the tube between the vocal cords.
Inflate the cuff.
Withdraw the stylette. |
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What should the centimetre markings on the tube show if it is sufficiently placed? |
Usually between 19 and 23 cm |
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Describe five methods of confirming correct placement of an endotracheal tube. |
Misting of the tube with ventilation
Rising of the chest wall with ventilation
Auscultation of bilateral breath sounds in both axillae
End-tidal CO2 determination (either colorimetric or quantitative)
Chest radiograph (can only confirm appropriate depth, cannot exclude esophageal intubation) |
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7) Post-intubation management
Describe the key elements of postintubation management. |
Secure the tube
Initiate mechanical ventilation
Obtain a post-procedural chest radiograph to confirm the depth of tube replacement and to exclude significant barotrauma from positive pressure ventilation |
