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323 Cards in this Set

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What are the three essential criteria upon which to base your decision to intubate?
-can the patient maintain and protect his airway
-can the patient ventilate and oxygenate
-what is the patient's anticipated course and likelihood of deterioration
What are reasons to intubate?
A - airway obstruction
A - compromised airway reflexes(decreased GCS)
B - inadequate oxygenation
C - severe systemic hypoperfusion (sepsis)
D - need for profound sedation (seizures, psychiatric)
E - expected deterioration (burn, penetrating neck trauma), movement to less monitored area (transport)
Discuss the use of the gag reflex to test a patient's ability to protect their airway
-Traditionally been used
-Gag is absent in 12-25% of people
-there is no evidence that its presence or absence corresponds to airway protective reflexes
Outline the recommended approach to evaluating a patient's ability to protect their airway
-evaluate the patient's ability to phonate
-assess level of conciousness
-assess the patient's ability to handle his or her secretions (pooling of secretions in the oropharynx, ability to swallow spontaneously or on command)
What are the value of ABG results in the decision to intubate
ABG results are rarely helpful, may cause delay in the deteriorating patient and may be misleading
List conditions where there is a moderate to high likelihood of predictable deterioration requiring airway intervention
-TCA OD
-significant multiple trauma (anticipated deterioration, loss of ability to protect airway, need for invasive and painful procedures, need for studies outside the ED)
-penetrating neck trauma (with any evidence of vascular or direct airway injury)
What are 4 crucial domains to evaluate pre-intubation
Difficult intubation
Difficult BMV
Difficult ventilation using extraglottic device (EGD)
Difficult cricothyroidotomy
How do you assess for difficult direct laryngoscopy?
LEMON
Look Externally
Evaluate (3-3-2)
Mallampati
Obstruction/Obesity
Neck Mobility
How do you evaluate a patient for difficult BMV?
MOANS
Mask Seal
Obstruction/Obesity
Aged (>55 increases risk)
No teeth
Stiffness (to ventilation) (asthma, COPD, pulmonary edema, term pregnancy)
How do you evaluated a patient for placement of an extraglottic device?
RODS
R- restricted mouth opening
O - Obstruction or obesity
D - Distorted Anatomy
S - Stiffness (resistance to ventilation)
What are features that predict difficult cricothyrotomy
SHORT
S-surgery
H-hematoma
O-obesity
R - radiation
T - tumore
Describe the Cormack and Lehane grading system.
It is a system that grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen.

Grade I - the entire glottic aperture is seen
Grade 2 = only a portion of the glottis is seen (arytenoid cartilages alone or arytenoid plus a portion of the glottis
Grade 3 - laryngoscopy visualizes only the epiglottis
Grade 4 - not even the epiglottis is visualized
What are traditional methods for ensuring correct placement of an ETT?
Chest auscultation
Gastric auscultation
Bag resistance
Exhaled volume
Condensation within the ETT
Chest Radiography
How many ventilations are required to assess end-tidal Co2? and why?
-six manual ventilations
-avoids false positives as it allows for the washout of CO2 related to BMV before intubation or ingestion of carbonated beverages
Describe the pitfall of colourimetric ETCO2
Caution is required for patients in cardiopulmonary arrest. Insufficient gas exchange may hamper CO2 detection in the exhaled air, even when the tube is correctly placed within the trachea. This situation may arise in 25-40% of intubated cardiac arrest patients.
What defines a 'crash airway'?
A patient in cardiopulmonary arrest or a state near to arrest and is predicted to be unresponsive to direct laryngoscopy.
What is the 'crash airway' technique?
immediate intubation without use of drugs, supplemented with a single dose of succinylcholine if the attempt to intubate fails and the patient is felt not to be sufficiently relaxed
Under what circumstances should the difficult airway algorithm be used?
If the patient represents a difficult intubation as determined by the LEMON, MOANS and RODS evaluation.
What is the definition of a failed airway?
If the clinician cannot maintain oxygen saturation with BMV, despite optimal use of a two-person, two-handed technique with an oral airway in place.
OR
If three attempts at direct laryngoscopy have been unsuccessful (defined as attempts by an experienced clinician, using best possible patient positioning and technique. OR
If a clinician ascertains after even a single attempt at laryngoscopy that intubation is impossible.
What are the criteria for administering neuromuscular blockade to a patient?
the clinician should believe that
-intubation is likely to be successful (or a double setup is in place to handle the can't intubate can't ventilate)
--oxygenation via BMV or EGD is likely to be successful if a first intubation attempt does not succeed.
If adequate oxygenation cannot be maintained in the failed airway what is the rescue technique?
Cricothyrotomy
Define RSI
Virtually simultaneous administration of a potent sedative (induction) agent and an NMBA (neuromuscular blocking agent) usually succinylcholine for the purpose of endotracheal intubation.
What are the 7 P's of RSI
Preparation
Preoxygenation - 3minutes of 100% O2 gives 8 minutes of apnea in healthy adults before SaO2 <90% / or 8 vital capacity breaths
Pretreatment
Paralysis with induction - assess paralysis by moving mandible
Positioning
Placement of the tube
Postintubation management
What are the complications of blind nasotracheal intubation?
epistaxis
delayed/incorrect tube placement
long term complications (sinusitis, turbinate destruction, laryngeal perforation)
What are the 4 methods of intubation
Rapid Sequence Intubation
Blind Nasotracheal Intubation
Awake Oral Intubation
Oral Intubation without pharmacologc agents
Define awake oral intubation
a technique in which sedative and topical anesthesia agents are administered to permit management of a difficult airway. AFter the patients is sedated and anesthetized gentle direct, video or fiberoptic laryngoscopy is performed to determine whether the glottis is visible and intubation possible. The patient may be intubated at this time or may show that RSI is possible and safe.
What are the problems with succinylcholine?
-cardiovascular (in particular bradycardia)
-fasciculations
-hyperkalemia
(burns >10%BSA, crush, denervation (stroke, spinal cord), neuromuscular disease, intraabdominal sepsis)
(only >5days after the inciting injury)
-increased IOP (not proven)
-masseter spasm
-malignant hyperthermia (hyperthermia and rhabdo)
-requires refrigeration
What 3 questions must be answered once the need for ventilatory support has been identified?
1) what will constitute a breath (delivered tidal volume or delivered airway pressure) (cycle)
2) to what extent will the patient be allowed to participate in breathing (mode)
3) how will the support be delivered (method)
What are the commonly available modes of positive-pressure ventilation?
1) controlled mechanical ventilation
2) assist/control ventilation
3) synchronized intermittent mandatory ventilation
Describe CMV
the ventilator delivers breaths at a preset rate, regardless of any ventilatory effort made by the patient. Only appropriate for the apneic, pharmacologically paralyzed patient
Describe Assist Control
This mode continuously monitors the ventilator circuit for either negative pressure or air flow deflections and responds with a full breath, in the absence of any such patient effort the device automatically cycles at a preset minimum
What are disadvantages of A/C ventilation
-poor tolerance in awake patients
-worsening of intrathoracic air trapping in patients with COPD
Describe SIMV
delivery of a mandatory breath is synchronized as much as possible with a patient's spontaneous respirations.
What is the difference between PEEP and CPAP?
PEEP refers to pressure applied during invasive mechanical ventilation whereas CPAP is the application of positive pressure during spontaneous breathing. The terms are occasionally used interchageably.
What is the purpose of PEEP or CPAP
increase functional residual capacity (FRC) by maintaining patency of injured or flooded alveoli that would otherwise collapse at the end of exhilation.
What is a potential adverse effect of PEEP?
decreased cardiac output
What is the purpose of pressure support ventilation (PSV)
It decreases the work of breathing
Describe CPAP and BiPAP
CPAP provides constant pressure throughout the respiratory cycle.

BiPap alternates between higher pressure during inspiration (IPAP) and lower pressure during expiration (EPAP)
Which patients in the ED are more likely to respond to NPPV.
Patients with readily reversible causes where fatigue is a significant factor
(COPD and cardiogenic pulmonary edema)
What predicts the success of NPPV in COPD?
Younger age
unimpaired conciousness
less severe acidemia
prompt response (in less than 2 hours)
What are contraindications to NPPV? (9)
Severely impaired level of conciousness
cardiac arrest
acute MI
inability to protect airway
apnea
copious secretions
uncontrolled vomiting
upper airway obstruction
facial trauma
What are the recommended initial settings for BiPAP ventilators
IPAP - 8cm
EPAP - 3 cm
3-5L/min supplemental O2
Spontaneous mode
What parameters in BiPAP should be changed in the event of hypoxemia? hypercapnia
hypoxemia - increase EPAP in 2-cm increments (IPAP maintained a a fixed interval higher)
hypercapnia - increase IPAP in 2 cm increments with EPAP being increased in 1:2.5cm ratio to IPAP
What are reasonable initial ventilator settings in the ED?
A/C - for a breathing patient with inadequate ventilatory effort
TV - 6-8mL/kg, RR 12-14 breaths/min, FiO2 1.0 (to be titrated to maintain oxygen saturation of 90%)
Also consider PEEP of 2.5-5cm H20

(pressure-cycled ventilator - usually 25-40 cmH20)
What are 2 important ventilator readouts and why?
PIP - peak inspiratory pressure
reflects lung compliance and airway resistance
Expiratory volume - allows estimation of the effectiveness of spontaneous respiratory efforts, and effectiveness of ventilation
What are potential adverse effects of Positive-pressure ventilation?
Increased intrathoracic pressure
-decreased venous return
-increased ventilation/perfusion ratio
-air trapping and iPEEP
-barotrauma

Nosocomial infections (lungs and sinuses)
Respiratory alkalosis
Agitation and increased respiratory distress
Increased work of breathing (asynchrony or improperly set triggers)
How do you approach acute difficulty with oxygenation/ventilation or high airway pressures?
Check tube placement
Check tube patency
R/o pulmonary edema, pneumothorax and bronchospasm
r/o PE
-ensure no abdominal distention and pass NG tube
Ensure no dynamic hyperinflation or ventilator malfunction

DOPE
Displaced tube
Obstructed tube (kink mucus plug)
Tension pneumothorax
Equipment Failure
What is intrinsic PEEP and how do you manage it
Often occurs in patients with obstructive lung disease where expiratory flow rate is slowe than usual. Often respiratory rate is set too high and breath stacking results. Patients improve by being taken off the ventilator, when replaced on the ventilator decrease the respiratory rate or modify the inspiratory/expiratory ratio to allow the patient more time to exhale
What fine tuning adjustments are required for mechanical ventilation in COPD patients?
-correct acidosis gradually and allow target values to reflect patient's baseline function rather than normal values
-low rate
-increased I/E ratio to 1:3 or 1:4
-keep TV low
-allow high inspiratory flow rates
-employ the use of PEEP
What fine tuning adjustments are required for mechanical ventilation in patients with status asthmaticus?
-small TV (5-8mL/kg)
-low resp rate (8-10 breaths/min)
-permissive hypercapnia
-occasional external chest compression to assist in exhalation
What fine tuning adjustments are required for mechanical ventilation in acute lung injury patients?
-keep PEEP (strategically lower FiO2 with PEEP) and FiO2 as low as possible
-small TV (6-8cc/kg ideal body weight) and fast rates (20-25 breaths/min)
-plateau pressures <30cm H20
What fine tuning adjustments are required for mechanical ventilation with pulmonary edema and cardiogenic shock patients?
Cardiogenic shock limits the use of PEEP which is ordinarily a primary mode of therapy for pulmonary edema.
-use only sufficient PEEP to allow titration of the inspired oxygen concentration
What fine tuning adjustments are required for mechanical ventilation in hypovolemic shock patients?
PPV may exacebate hypotension in hypovolemic shock. Ventilate with 100% oxygen with near TV and rate to produce near physiologic PaCO2 and avoid PEEP until circulating volume is restored.
What are the advantages of NPPV over ETT?
preservation of speech, swallowing and physiologic airway defence
reduced risk of airway injury
reduced risk of nosocomial infection
decreased length of stay in ICU
reduced need for admission to ICU
What parameters are required in order to extubate a patient in the ED?
-adequate ventilatory drive and oxygen must be confirmed
-resp rate less than 30breaths/min
-PEEP <5cm H20
-PaO2 >60mmHg
-FiO2 <60%
Discuss the use of paralytics in myasthenia gravis
Myasthenia gravis increases the sensitivity to non-depolarizing agents therefore a smaller dose may be considered. (0.5mg/kg rocuronium)

Succinylcholine is not contraindicated in MG because there is no upregulation of receptors (which cause the increased potassium response). In fact MG patients are more resistant to sux and need to get 2.0mg/kg - a prolonged paralysis may occur.
Myasthenia gravis decreases the sensitivity to depolorizing agents therefore a larger dose should be used.
What is the purpose of RSI?
-optimum intubating conditions
-minimizing risk of aspiration
-counteracting the physiologic responses to intubation
What are maneuvers that facilitate effective BVM ventilation?
-use a larger mask (should approximate the bridge of the nose, the two malar eminences and the mandibular alveolar ridge
-add or remove air from the mask seal
-effect jaw thrust
-use oral airway and two nasal airways
-detach the bag and apply the mask from the nose down to chin
-use webspace at 45 degrees to push mask down (one-person)
-use two person technique with four fingers down position
-do not impinge soft tissues of the neck
-apply gel to beard
-place unfolded 4x4s inside mouth on buccal pouches
-gather cheeks , hold inside mask body
Summarize the main Walls airway management algorithm?
-if unresponsive/near death ->crash airway
-if difficult airway predicted -> difficult airway
-otherwise RSI
*if unsuccessful, BVM
*if can not BVM ->failed airway
*repeat twice, making modifications in technique
*if unsuccessful after three attemps ->failed airway
What are intubation failure rate in the ED for medical and trauma cases?
-medical 1%
-trauma 3%
What is the rate of failure to intubate and failure of BMV in elective anesthesia practice
1 in 5000 to 1 in 20,000
What is the crash airway algorithm?
BVM, then attempt oral intubation without RSI
If unsuccessful, paralyze and repeat
If at any point BVM not possible ->failed airway
If 3 attempts unsuccessful ->failed airway
What is the failed airway algorithm?
-call for assistance
if failure to maintain oxygenation->cricothyrotomy
if no failure to maintain oxygentation can choose other method -> fiberoptic, video, extraglottic device, lighted stylet, cric

A difficult airway is predicted, and the goal is cuffed ETT in trachea. A failed airway is unpredicted and the goal is adequate ventilation and oxygenation.
Summarize the difficult airway algorithm
-call for assistance
if failure to maintain oxygenation ->failed airway
awake direct laryngoscopy, fiberoptic laryngoscopy, or video laryngoscopy ->if unsuccessful then intubating LMA, FO, VL, BNTI, Cric, lighted stylet.
What are preliminary airway opening measures?
-repositioning
-chin lift
-jaw thrust
-oral/nasal airway
Describe RSI pretreatment options (drugs,dosages and indications)
lidocaine (1.5kmg/kg IV) - mitigate bronchospasm or ICP increase in response to airway manipulation
Albuterol - 2.5mg nebulizer to mitigate bronchospasm
Fentanyl - 3micrograms/kg to mitigate sympathetic discharge in cardiovascular disease or rise in ICP

Should be given 3 minutes before induction and patalysis.
What are 2 important differences in RSI of children?
-excessive bradycardia may be seen with Sux in children younger than 1 year old - some choose to give atropine 0.02mg/kg during pretreatment but it is unknown if this prevents any adverse outcome
-the dose of sux is 2mg/kg
What is the primary indication for transtracheal ventilation in the ED
Initiation of emergency oxygenation for a pediatric patient who is apneic and in whom intubation and BMV are impossible
What are the indications for cricothyrotomy?
Oral or nasal intubation is impossible or fails and when BMV cannot maintain adequate oxygen saturation
What are contraindications for cricothyrotomy
distorted neck anatomy
preexisting infection
coagulopathy
(these are 'relative' contraindications as the establishment of an airway takes precendent
Describe the technique to establish transtracheal jet ventilation
Immobilize larynx
Place 12-16 gauge angiocath through membrane
Advance catheter
Connect to jet ventilation (30-50psi in adults)
Connect to adaptor on 3.0 ETT and bag, esp if <5years of age
What are the limitations of cuff-type noninvasive BP monitoring?
-obese arms
-uncooperative, moving patients
-patients with very high and very low BP

Even with these limitations, automatic devices are more accurate and reliable than manual auscultation in patients with very high or very low BP.
What is the most accurate method of measuring BP
Intraarterial catheter transduced to an electronic display
List situations in which invasive BP monitoring may be required (5)
1. exceedingly high (>250mmHg) or low pressures (<80mmHg)
2. Patients requiring continuous BP monitoring (ie sodium nitroprusside etc.)
3. Impending shock states (best chance to insert catheter is in the ED while the pulse is still palpable)
4. patients with anatomic abnormalities (no suitable limb, morbidly obese)
5. Conditions where frequent arterial sampling is required.
In which situations can the pulse oximetry reading be limited?
-alterations in perfusion and severe vasoconstriction (shock, hypothermia)
-excessive movement
-interference with transfer through the nail bed (synthetic nails or nail polish)
-alterations in hemoglobin
How does a pulse oximeter work?
Through transmission oximetry which is based on differences in the optical transmission absorption of oxygenated and deoxygenated hemoglobin at red and infrared spectrums of light.
How does carboxyhemoglobin affect pulse oximetry readings?
The pulse oximeter senses COHb as through it were mostly oxyhemoglobin and provides a falsely high reading.
How does methemoglobin affect pulse oximetry readings?
MetHab produces a large pulsatile absorbance signal at red and IR wavelengths forcing the ratio towards unity and showing a SpO2 of 85% (which may be higher or lower than the true level)
What is the difference between capnography and capnometry?
Capnography is the graphic record represented as a waveform.

Capnometry is the quantitative measurement of ETCO2, displated as a number.
What are the 3 levels of response of the colorimetric CO2 detectors?
purple (<4mmHg Co2)
tan (4-15mmHg Co2)
yellow (>20mmHg Co2)
What is the difference between a mainstream and sidestream CO2 detectors?
Mainstream devices measure Co2 directly from the airway with the sensor attached directly to the ETT.

Sidestream devices aspirate a sample of gas through tubing into a sensor locate inside the monitor - they can be used for intubated and nonintubated patients.
What are uses of capnographys in the ED? (11)
-confirmation of ETT placement
-continuous monitoring of tube position in trachea during transport
-qualitative and quantitative assessment of cardiac output
-gauge effectiveness of CPR during cardiac arrest
-determine prognosis in CPR and trauma
-maintain appropriate ETCo2 levels in patients with increased ICP
-estimate alveolar CO2 in patients with normal lung function
-aid in the detection and diagnosis of PE
-assess response to treatment in patients with ARDS
-determine adequacy of ventilation in patients with altered mental status
-assess ventilatory status of an actively seizing patient
-help detect metabolic acidosis
What is the prognostic value of ETCO2 in CPR
-No patient with a mean ETCO2 less than 10mmHg after 20minutes of CPR survived

-ROSC (return of spontaneous circulation) is heralded by an almost immediate increase in ETCO2 from baseline
What is the utility of capnography in actively seizing patients?
It can differentiate between actively seizing patients with
1)apnea (flatline waveform, no ETCO2 reading)
2) ineffective ventilation (small capnograms, low ETCO2)
3) effective ventilation (normal capnogram, normal ETCO2
What is the ACOG recommendation for monitoring of pregnant patients with trauma?
Pregnant patients with a viable fetus should undergo fetal monitoring for 2-6 hours after an injury characterized with any degree of abdominal jarring.
Which findings on fetal monitoring require urgent obstetrical consultation?
-persistent fetal tachycardia
-bradycardia
-loss of baseline variability
-decelerations following contractions
-uterine hyperactivity
What is the Bispectral index
It is a monitor that analyses and processes a patient's electroencephalogram during sedation to produce a single number - the bispectral index

Ranges form 0-100 (0 is EEG silence and 100 is a fully awake adult)
What are 4 broad categories of shock?
Hematologic
Neurologic
Vasogenic
Cardiogenic
What is the definition of base deficit?
The amount of strong base that would have to be added to a litre of blood to normalize the pH

A normal base deficit is more positive than -2mEq/L
Why will gram positive sepsis continue to increase in prevalence?
-indwelling catheters serve as excellent portals of entry into the vascular space for staph aureus and coag-negative staph
-the frequency of community acquired infections caused by antiobiotic resistant gram positive organisms has greatly increased in recent years.
Define sepsis
2 or more SIRS criteria
suspected infection
What are the SIRS criteria
-Temperature >38 or <36 degrees Celsius
-HR >90bpm
-RR>20breaths/min or PaCO2<32mmHg
-white blood cell count >12000/mm3, <4000/mm3 or >10%band neutrophilia
What is severe sepsis?
SIRS with suspected or confirmed infection and organ dysfunction or hypotension
What is septic shock?
SIRS with suspected or confirmed infection with hypotension despite adequate fluid resuscitation
What is hemorrhagic shock?
Systemic hypoperfusion that manifests as lactic acidosis with organ dysfunction
What is cardiogenic shock?
Cardiac failure that cuases systemic hypoperfusion that manifests as lactic acidosis with organ dysfunction
How can lactate clearance be used to monitor resuscitation?
It involves measuring the blood lactate concentration at two or more times. If the lactate concentration has not decreased by 10% two hours after resuscitation has begun then additional steps should be taken.
What is the mixed venous oxygen saturation (SvO2)
It is the oxygen saturation of blood in the pulmonary artery after the venous effluent has been mixed thoroughly in the RV. It is measured by withdrawing a sample of blood from the distal port of the unwedged PAC.
What is central venous oxygen saturation (ScVO2)?
It is the oxygen saturation in the vena cava. It is measured through a central venous catheter and has been shown to closely parallel the Svo2
What is red cell apheresis?
When red cells are separated from the blood at the time of collection
What changes occur in stored blood?
-lower pH
-less 2,3 diphsphoglycerate
-rbcs more spherical and right (increased resistance to capillary flow)
-leakage of K+
What is a 'type and screen'?
When a blood specimen from the patient is sent for ABO grouping, Rh typing and an antibody screen for unexpected (non-ABO/Rh) antibodies
What happens when ABO incompatible blood is administered to a patient?
Acute hemolysis
What is involved in ABO grouping?
1. Test a patient's red cells with serum containing anti-A and anti-B antibodies
2. Test a patient's serum agains A and B red cells
How is Rh typing done?
Add anti-D reagent to the recipients red cells.
How is the antibody screen done?
Take rbc reagents (which are red cells with clinically significant antigens) and mix them with the patient's serum.
What is a crossmatch?
When you mix the recipient's serum with donor rbcs.
What is the universal type of blood? type of serum?
O-
AB (serum from AB individuals has neither anti-A or anti-B antibodies)
What is the definition of massive transfusion?
Transfusion equivalent to the patient's blood volume with stored rbis within a 24 hour period
What are problems with prbc transfusion that are not related to storage?
-Hypothermia
-Transiently decreased patient levels of ionized calcium
What are the signs of hypocalcemia?
-circumoral tingling
-skeletal muscle tremors
-QT prolongation
What did the TRICC trial demonstrate?
In the critical care setting a transfusion threshold of 7g/dL was as safe as a threshold of 10g/dL
What are the current practice guidelines for the administration of FFP?
Administer if INR >1.5-2.0 and actively bleeding (or requires and invasive procedure)
At what level should platelets be transfused?
<10,000/mL
What level of platelets is sufficient to perform a procedure?
40,000-50,000/mL
What is the usual dosage of FFP?
10-15mL/kg
(may use 5-8mL/kg in those that are warfarin anti coagulated)
Is a crossmatch needed for platelet transfusion?
No, but platelets should be Rh compatible
What are the doses for prcbs/FFP and platelets in children?
10cc/kg
15cc/kg
-1U/10Kg of body weight
What are immune-mediated adverse effects of rbc transfusion?
1. Acute
-Intravascular hemolytic transfusion reaction
-febrile transfusion reaction
-allergic reaction
-transfusion-related acute lung injury

2.Delayed
-extravascular hemolytic transfusion reaction
-transfusion associated graft-versus host disease
What are signs and symptoms of a intravascular hemolytic transfusion reaction?
-immediate onset
-fever
-chills
-HA
-N and V
-Chest restriction
-Joint and back pain
-burning at the infusion site
What are the clinical effects of an Intravascular Hemolytic Reaction?
Hypotension
DIC
ATN
How do you confirm an Intravascular Hemolytic Transfusion Reaction?
Detect free Hgb in the blood and urine and a positive Coombs test on the post-transfusion test (but not pre-transfusion)
What is the definition of a febrile transfusion reaction?
A 1 degree celsius increase in temperature associated with transfusion that has no medical explanation.
What is the medical explanation for a febrile transfusion reaction?
It is the result of anti leukocyte antibodies (therefore it should not occur in a first time transfusion)
Which patient's are more prone to anaphylactic transfusion reactions?
IgA deficient patients, the anaphylaxis is due to the presence of anti-IgA in IgA deficient patients
What precautions should be taken for IgA deficient patients to try and prevent transfusion related anaphylaxis?
Give then washed prbcs and plasma from IgA deficient individuals.
What blood products can cause TRALI
prbcs
FFP
platelets
cryoprecipitate
What is the clinical presentation of TRALI?
A non-cardiogenic pulmonary edema picture with dyspnea, hypoxemia and bilateral infiltrates
What strategy has been suggested to decrease the incidence of TRALI?
Use only male donors for plasma in order to avoid allotypic leukocyte antibodies which can occur in females.
Can you continue any blood product transfusions after TRALI?
It is safe to continue transfusions of products from a different donor.
What is an extravascular hemolytic transfusion reaction?
It is a non-ABO mediated immune reaction often due to an anamnestic response in a patient previously sensitized to red cell antigens (from pregnancy, transfusion or transplant)
What is transfusion associated GvHD?
It occurs when transfused lymphocytes proliferate and attack the recipient
What are Risk Factors for TA GvHD
-Cell mediated immunodeficiency
-Identical HLA type between donor and recipient

This diagnosis should be considered in anemic leukaemia and lymphoma patients
What are non-immune mediated AE associated with Transfusion?
-Circulatory overload (infuse over 4hrs)
-bacterial contamination
-Hypocalcemia, hyperkalemia, hypothermia, acidosis, microemboli, coagulopathy (consequences of multiunit transfusions)
-risk of transmission of virus' (HIV/Hep C - 1:2 million, Hep B 1: 200,000-500,000 and others CMV, West Nile)
What is the most common bacterial contaminant of blood products and why?
Yersinia enterocolitica
(it grows well in cool. iron-rich environments and more commonly occur in platelets and rbcs because of the temperature at which they are stored)
What are the determinants of oxygen delivery to the brain?
Cerebral perfusion pressure
Cerebrovascular resistance
Blood oxygen saturation
What is the efficacy of closed chest compression generating adequate cerebral perfusion?
Traditionally it has been estimated that closed chest compressions can generate 20-30% of normal cardiac output, however recent studies have led to estimates ranging from 1-60% of traditional CBF.
Discuss PaCO2 and CBF
CO2 is a potent vasoactive agent therefore decreasing CO2 through hyperventilation results in rapid reduction of CBF through increase in Cerebrovascular resistance however when ICP is not elevated, increases in CVR can cause dangerous decreases in cerebral blood flow.
What PaCO2 should you maintain in patients post cardiac arrest?
PaCO2 35-40mmHg
What PaO2 should be maintained post cardiac arrest?
PaO2 80-100mmHg
What is the NNT for therapeutic hypothermia post cardiac arrest
NNT: 7
What was the therapeutic hypothermia protocol in the landmark trials?
Achieve 33 +/-1 degree within 2-8 hours and maintain for 12-24 hours.
What physical examination findings are considered the best predictors of a poor neurologic outcome post cardiac arrest?
-absence of pupillary and corneal reflexes at 24 hours
-absence of motor responses at 72 hours
What is the typical presentation of cardiac arrest from a primary cardiac origin?
-Ventricular fibrillation
(less commonly pulseless ventricular tachycardia)
What is the most common metabolic cause of cardiac arrest?
Hyperkalemia
By what mechanism does electrocution cause cardiac arrest?
Dysrhythmia or apnea
100mA - 1A ->VF
>10A -> ventricular asystole
ligntening -> asystole or prolonged apnea
What is the usual dysrhyhmia in drowning?
bradyasystolic arrest
What is the definition of cardiopulmonary arrest?
-triad of unconsciousness, apnea and pulselessness
What is the sequence of physiological events in a primary respiratory arrest?
-transient tachycardia and hypertension
-LOC
-bradycardia + pulselessness usually within 5 min
Discuss the use of a palpable pulse to monitor CPR adequacy?
The lack of a palpable pure may indicate inadequate forward flow, however the degree of forward flow cannot be estimated accurately in the presence of a palpable pulse because pressures generated are transmitted equally to the venous and arterial vasculature
What may cause a false positive ETCO2 during CPR?
-Administration of NaHCO3
What parameters determine ETCO2?
-CO2 production
-alveolar ventilation
-pulmonary blood flow (cardiac output)
What are typical ScVo2 values in cardiac arrest?
(The normal ranges from 60-80%)
-During cardiac arrest with CPR 25-35%. Failure to reach an SCVO2 of 40% has as 100% NPV for ROSC
What is the difference between monophasic and biphasic defibrillators?
In biphasic defibrillators the energy required for successful defibrillation (the defibrillation threshold) is less, but their superiority in achieving ROSC or survival to hospital discharge has not been proven
What is EMD?
Coordinated electrical activity of the heart with no myocardial contraction
What is pseudo-EMD?
Coordinated electrical activity of the heart with myocardial contractions (but no palpable pulse)
What is the typical true EMD rhythm
bradycardia with wide QRS (abnormal automaticity)
What is the typical initial rhythm of pseudo-EMD?
Narrow complex tachycardia which can progress to bradycardia with conduction abnormalities and QRS widening
What should you do if systole is seen on the monitor
Check another lead (VF may appear as systole in a single lead if the rhythm vector is completely perpendicular to the lead vector)
What were the parameters/conditions of the RCTs that showed improved survival and functional outcomes for therapeutic hypothermia?
-witnessed arrest with initial VF
-target temp 32-34
-time to target temp <2hrs to 16hour (median 8)
-duration of hypothermia 12-24 hours
-gradual rewarming for 12 hours
What are 3 CPR monitoring techniques?
-ETCO2
-Coronary perfusion pressure
-Central venous oxygen saturation
What is systemic shunting?
A situation where there is impaired tissue oxygen extraction
-SCVO2 is abnormally high in the face of inadequate delivery of O2
-continually elevated lactate levels
therapy involves decreasing vasopressors, volume loading with careful vasodilator therapy
List post cardiac arrest treatment goals?
-MAP 70-90
-CVP 10-15mmHg
-Hgb >10g/dL
-lactate <2.0 mmol
SaO2 94-98%
ScVo2 65-75%
List the order of interventions to achieve goals
-1st volume load to achieve CVP 10-15 mmHg
-If MAP is still low, administer dobutamine
-if Scvo2 inadequate ensure Hgb >10g/dL
-IF still low consider revascularization or mechanical assistance (IABP or ECMO)
What is the overall survival to discharge of paediatric in hospital cardiac arrest?
-25%
What are the 3 common pathways to cardiac arrests and their frequencies in paediatric patients?
1) asphyxial (67%)
2) ischemic (61%)
3) arrhythmogenic (10%)
(many are asphyxial and ischemic)
What is the effect of the child's compliant chest wall on CPR?
Cardiac output is greater (than in adults)
What are the 4 phases of cardiac arrest?
-prearrest (the phase in which CA is prevented)
-no flow phase (untreated CA)
-low flow phase
-post-resuscitation
Which should be used in paediatrics: circumferential vs focal sternal compressions?
Two thumb circumferential technique results in higher systolic and diastolic blood pressures and a higher pulse pressure than traditional two-finger compression
When are myocardial and cerebral blood flow generated during CPR?
-cerebral blood flow is generated during the compression phase
-myocardial blood flow is generated during the relaxation phase (by increasing DBP)
When should PCI be performed on a post-arrest patient?
-patients with ST segment elevation MI or new LBBB (can be performed during therapeutic hypothermia)
-angioplasty of acute coronary lesions regardless of history or initial post arrest ECG has been shown to be an independent predictor of survival after cardiac arrest
What are relative exclusion criteria unique to the post arrest period?
-CPR duration greater than 10minutes
-evidence of significant CPR trauma
What is the role of epi/vasopressin during CPR?
to vasoconstrict and preferentially direct cardiac output during CPR to the coronary and cerebral circulations
What are the one-rescuer and two-rescuer compression to ventilation ratios in paediatric CPR?
-30:2 and 15:2 respectively
What is the compression to ventilation ratio for the newly born?
3:1
What is "leaning"?
Incomplete decompression of the chest during the relaxation phase of chest compressions
What are goals for aortic pressures during CPR
-aortic diastolic pressure 20-30 mmHg
-aortic systolic pressure >50mmHg - newborn
70-80mmHg - child
80-90 mmHg - adolescent
Why is hands-only CPR for children not recommended?
-respiratory arrest and asphyxia generally precede paediatric cardiac arrest.
Define apnea?
Cessation of airflow
-May be central, diaphragmatic, obstructive or mixed)
-<15 seconds of central apnea can be normal at all ages
Define pathologic apnea?
An abnormal respiratory pause
-prolonged (>20s)
-associated with cyanosis
-marked pallor
-hypotonia
-bradycardia
Define periodic breathing?
Breathing pattern with 3 or more respiratory pauses of >3 seconds duration with < 20s respiration in between (may be a normal event)
Define ALTE (apparent life threatening event)
-Frightening to the observer
some combination of
-apnea
-color change
-marked change in muscle tone
-choking
-gagging

-often the observer fears that the infant has died
Define SIDS
-Sudden death of an infant
-<1 year
-remains unexplained after full investigation incl autopsy, examination of death scene, clinical hx.
What are RF assc with SIDS
-maternal smoking during pregnancy
-preterm or low birth weight
-male gender
-prone sleeping
-overheating
(soft sleep surface, loose bedding, bed sharing)
Recommendations to decrease risks of SIDS
-place infant supine
-do not place on waterbed, sofa, soft surface
-no soft materials in infants sleeping environment
-discourage smoking in pregnancy
-avoid bed sharing
-avoid overheating
-avoid commecial SIDS prevention devices
-home monitoring has no effect
-place infant prone when awake
What is the pathophysiology of SIDS?
Multifactorial
-genetic
-maturation
-environmental
What is the epidemiology of an ALTE?
Children are generally <1year of age
-between 2-3 months
-predominantly male
What are the aetiologies of ALTE?
Cardiac
Child Abuse
GI
Infectious
Neuro
Metabolic
Respiratory
Other (breath holding, vasovagal, drug/toxin exposure)
What are the most common causes of ALTE?
GERD
seizures
lower respiratory tract infections
Which patients with ALTE are safe for discharge
Many criteria have been suggested though none have been validated.
84% of cases of ALTE are admitted for evaluation and monitoring
What are indications and paediatric dosages of the following meds: adenosine, alprostadil, amiodarone, atropine
Adenosine: SVT
-0.1mg/kg IV push (max 6mg)
-0.2mg/kg IV push (max 12mg)

Albuterol - asthma/anaphylaxis/hyperkalemia
-MDI 4-8puffs INH q 20min
2.5mg/dose (<20kg)/ 5mg/dose (>20kg)
continuous 0.5mg/kg/hr (max 20mg/hr)

Alprostadil - ductal dependant congenital heart disease
0.05-0.1ug/kg/min
then 0.01-0.05ug/kg/min

Amiodarone:
SVT and VT with pulse
5mg/kg IV load (over 20-60min)
repeat to a daily max 15mg/kg

Pulseless VT
5mg/kg IV bolus, repeat to a daily max 15 mg/kg

Atropine - bradycardia
0.02mg/kg (min dose 0.1mg, max child 0.5mg, adolescent 1mg)
0.04-0.06 mg/kg ETT

atropine - toxins
0.02-0.05mg/kg (<12yrs) or 0.05 mg/kg (>12 yrs)
What are the indications and paediatric dosages of the following medications: calcium chloride, diphenhydramine, dobutamine, dopamine)
Calcium chloride 10% - hypocalcemia, hyperkalemia, hypermagnesemia, CCB OD
20 mg/kg (0.2mL/kg) slow push

Dextrose - hypoglycemia
0.5-1 g/kg
2-4 mL/Kg D25W
5-10mL/kg D10W

Diphenhydramine - anaphylactic shock
1-2mg/kg

dobutamine - CHF - cardiogenic shock
2-20ug/kg/min

dopamine - cardiogenic shock, distributive shock
2-20ug/kg/min
What are the indications and paediatric dosages of epinephrine?
Pulseless arrest/bradycardia - 0.01mg/kg IV
Hypotensive shock 0.1-1ug/kg/min IV
Anaphylaxis 0.01mg/kg 1:1000 IM
Asthma 0.01mg/kg 1:1000 SC
Croup 0.25-0.5mL racemic solution (2.25%) mixed in 3mL NS INH or 3mL 1:1000 INH
What are the indications and paediatric dosages of furosemide/hydrocortisone/ipratropium bromide
furosemide - pulmonary edema - 1mg/kg (max 20mg)
hydrocortisone - adrenal insufficiency - 2mg/kg (100mg)
ipratropium bromide - asthma - 250ug-500ug INH q 20min x 3
What percentage of newborns require resuscitative assistance at birth? Extensive resuscitation measures?
10% require resuscitative assistance
1% require extensive resuscitative measures
How does neonatal resuscitation differ from paediatric and adult resuscitation?
-newborns have rapidly changing cardiopulmonary physiology, their own range of VS and unique responses to stress
-the approach focuses entirely on respiratory and not cardiac management
-because of their small size, infants require special equipment
What are 2 major cardiorespiratory changes required for successful transition from the fetal to the extrauterine environment?
-removal of fluid from unexpanded alveoli
-redistribution of cardiac output to provide lung perfusion
In fetal circulation, what % of RV output goes to the lung? Where does the remainder of the RV CO go?
-40%
-the remainder is shunted from the PA through the ductus arterioles to the descending aorta
How long after birth does the sound/DA close?
15 hours
What is persistent fetal circulation?
The re-institution of fetal circulation with its attendant shunting
What is primary apnea?
The cessation of respiration and decreasing heart rate the follows initial hypoxia in the newborn which and infant gasping rapidly
What is secondary apnea?
The apnea that follows ongoing asphyxia resulting in final deep gasping respirations
What is a major indicator of hypoxia in the newborn?
Bradycardia
Why can a newborn not maintain body temperature?
-Cannot generate heat by shivering
-cannot retain heat because of low fat stores
-relatively large surface to volume area
What is the definition of hypoglycaemia in a newborn?
<2.2 mmol/L if >2.5kg
<1.6 mmol/L if <2.5kg
What does the presence of meconium in the amniotic fluid at delivery indicate?
That the infant has been stressed before delivery
What is the first step in resuscitation of a non-vigorous infant where there was meconium in the amniotic fluid?
-suctioning of the trachea
In which neonates is resuscitation not recommended?
-gestational age <23weeks
-BW <400g
-confirmed anencephaly, trisomy 13 or 18
When should resuscitation efforts be terminated?
-After 10 min of continuous and adequate resuscitative efforts
Should intrapartum suctioning (suctioning after delivery of the head but prior to delivery of the shoulders) be done
This is not currently recommended
Which infants are candidates for tracheal suctioning?
Meconium stained fluid and
1) absent/depressed respirations
2) poor muscle tone
3) HR <100bpm
How should meconium be suctioned?
Attach a meconium aspirator to the ETT connected to wall suction at 100mmHg
What should be done expeditiously if there is a diagnosis of diaphragmatic hernia?
-intubation (because ventilations distend the stomach)
What is the management of newborns with meningomyelocele or gastroschisis/omphalocele?
Cover the defect with gauze pads soaked in warm sterile saline and cover with a plastic covering
What are the anatomic anomalies in Pierre-Robin sequence and what is a good rescue airway?
-small jaw and large tongue
-LMA
What are the 5 components of the APGAR score?
Heart Rate
Respirations
Muscle Tone
Reflex irritability
Color
What defines the APGAR 0,1 and 2 for HR?
0 - absent
1 - HR<100bpm
2 - HR >100bpm
What defines the APGAR 0,1 and 2 for Respirations?
0 - absent/limp
1 - some, irregular
2 - good, crying
What defines the APGAR 0, 1 and 2 for Muscle tone?
0 - limp
1 - some flexion
2 - active good flexion
What defines the APGAR 0, 1 and 2 for reflex irritability?
0 - no response
1 - grimace
2 - cough, sneeze
What defines APGAR 0, 1 and 2 for colour?
0 - blue, pale
1 - pink body,blue hands/feet
2 - pink
What 4 questions should be asked immediately following birth?
-term gestation?
-amniotic fluid clear?
-breathing or crying?
-good muscle tone?
What are the first steps in neonatal resuscitation?
-dry/warm
-position/suction
-stimulate
How is the appropriate airway position for a neonate achieved?
With slight flexion
rolled diaper or small towel under the shoulders
What is the order of suctioning?
Mouth before nose (M before N)
How should an infant be stimulated?
-Flicking the soles of the feet
-rubbing the back
What is the roll of APGAR in neonatal resuscitation? Is it useful in resuscitation management
-it is a newborn prognostic indicator
-no, it is not useful in resusciation
What are the most important indicators of hypoxia in a newborn?
-HR
-repiratory effort
-color
What are indications that more resuscitation is needed?
-insufficient resp effort
-HR <100bpm
-central cyanosis is present
What is the ventilation rate for a newborn?
40-60 breaths/min
When is endotracheal intubation indicated in neonatal resuscitation?
-tracheal suctioning for meconium
-ineffective/ prolonged BVM
-when chest compressions are performed
-extreme low birth weight infants
-infants with anatomic anomalies (diaphragmatic hernia)
What is the DOPE mnemonic?
Post intubation
D - dislodgement
O - obstruction
P - pneumothorax
E - equipment
Can an LMA be used to ventilate infants?
-It has been shown to be useful in full term infants
-limited data preterm
When should chest compressions be provided in a newborn?
HR <60bpm for >30sec
What is the compression/ventilation ratio in newborns
3:1
(90/min:30/min)
What is the depth of compressions in a newborn?
1/3 AP diameter
What is the preferred vascular access in the neonate?
The umbilical vein
What is the dose of dpi in neonatal resuscitation and what are the indications?
0.01-0.03 mg/kg (0.1-0.3mL/kg of 1:10,000)

Indications: asystole or HR <60bpm despite effective ventilations and chest compressions
What is the treatment for hypoglycaemia in the neonate?
D10W 2-4mL/kg IV (do not give D25W because it is hyperosmolar)
What are options for volume expansion in neonatal resuscitation?
NS
RL
blood
(10cc/kg over 5-10min)
in what situations is VA not the first thing that you do with an eye complaint?
-caustic exposure
-sudden unilateral loss of vision -> in this case do fundoscopy to look for signs consistent with CRAO
Is subconjunctival hemorrhage painful?
No
What are the components of a complete eye exam?
VVEEPPs
Visual acuity
Visual Fields
EOM
External exam
Pupillary examination
Pressure
Slit lamp/fundoscopy
At what distance is a SNellen chart test done?
20 ft (6m)
What can be done instead of a Snellen chart?
Rosenbaum chart at 14 inches
What chart is used for VA assessment in children who do not know letters and numbers?
Allen chart
What can be done if the patient does not have their prescription lenses for an eye exam?
Use a pin hole eye cover which negates most refractive error
If a patient cannot read a Snellen chart, how is VA recorded?
-qualitatively (can read a paper at 3ft for example)
-fingers
-hand motions
-light perception
What does detection of a scotoma imply?
-a retinal problem
-glaucoma
What does hemi or quadra anopsia imply?
a problem of the neural pathways to the brain
What should be done if exophthalmos is detected?
tonometry
What is the most common cause of enophthalmos?
pseudoenophthalmos (when the other globe is prophetic)
What is the differential for diplopia in the extremes of gaze?
-EOM entrapment
-edema or hemorrhage related to injury
What are causes of RAPD?
-vitreous hemorrhage
-loss of retinal surface (secondary to schema or detachment)
-lesions affecting the pre-chiasmal optic nerve such as optic neuritis
What are causes of elevated IOP?
-glaucoma
-suprachoroidal hemorrhage
-space occupying retrobulbar pathology
What are indirect indicators of globe penetration?
-hyphema
-irregular shaped pupil
-absence of red reflex
What are the steps to emergently decrease IOP?
-place the HOB at 30 degrees
-instill 2 drops of timolol 0.5%
-instill dorzolamide (or give 500 mg acetazolamide PO or IV)
-in SCD substitute dorzolamide with methazolamide
What are the most common causes of bacterial conjunctivitis?
non-typable Haemophilus influenza
strep pneumo
staph aureus
What should you use to trade the neonatal red eye?
ceftriaxone IV (to cover n gonorrhea)
azithromycin PO (to cover chlamydia)
What is the definition of hemoptysis?
Expectoration of blood from the respiratory tract which originates below the vocal cords
What is considered massive blood loss in hemoptysis?
-100-600cc in 24 hours
What are possible causes of hemoptysis?
TB
bronchiectasis
CF
Cancer
AVM
post procedural complication
What vessels does massive hemoptysis typically involve?
bronchial arteries (high pressure system)
pulmonary arteries (low pressure systems)
What is the definition of bronchiectasis?
a chronic necrotizing infection of the lungs resulting in bronchial wall inflammation and dilatation
What is the most lethal sequelae of hemoptysis?
hypoxia from ventilation perfusion mismatch
What should be done in massive hemoptysis where the side of bleeding is known?
"lung down" position (place the bleeding lung down)
What size of ETT should be used in patients with massive hemoptysis?
8-0
What is the next intervention in a patient with massive hemoptysis, filled bronchi and unstable for the OR?
interventional angiography
What is the differential diagnosis of hemoptysis?
-airway disease
-parenchymal disease
-vascular disease
-hematologic disease
-cardiac disease
-miscellaneous (cocaine, post procedural, tracheo-aarterial fistula)
What is the diagnostic test of choice in stable patients with hemoptysis?
CT chest
What should you think of in an adult patient with acute sore throat and severe symptoms?
epiglottitis
Is the presence of a gag reflex a reliable indicator of the ability to protect the airway?
No. a gag reflex is absent in 12-25% of normal adults. There is no evidence that it's presence or absence corresponds to airway protective reflexes or the need for intubation
In what proportion of cases of failure of intubation is BMV difficult?
1/3
By how much is the likelihood of difficult intubation and impossible intubation increased by difficult BMV?
4x greater for difficult intubation
12x greater for impossible intubation
When should neuromuscular paralysis be avoided?
Patients for whom a high degree of intubation difficulty is predicted
Explain the 3-3-2 rule
3 - patient places 3 fingers between the open incisors
3 - patient paces 3 fingers along the floor of the mandible beginning at the mentum
2 - patient places 2 finger form the laryngeal prominence to the floor of the mandible
Explain the Malampati scale?
Class I and II -> predict adequate oral access for intubation
Class III -> predicts moderate difficulty with laryngoscopy
Class IV -> predicts a high decree of difficulty with laryngoscopy

A recent meta-analysis confirmed that the Mallampati score performs well as a predictor of difficult laryngoscopy (and less so difficult intubation) but that the Mallampati score alone is not a sufficient assessment tool
What is a Mallampati class I?
Soft palate, uvula, fauces, pillars visible
What is a Mallampati class II?
Soft palate, uvula, fauces visible
What is a Mallapati class III?
Soft palate, base of the uvula visible
What is a Mallampati class IV?
Only hard palate visible
Name conditions that are associated with upper airway obstruction and potentially difficult intubations?
Infections: epiglottitis, croup, bacterial tracheitis, abscess (RPA, PTA), Ludwig's angina
Allergic: anaphylaxis, angioedema
Neoplastic: laryngeal and hypopharyngeal carcinomas
Traumatic: blunt and penetrating neck and upper airway trauma
Physical/chemical agents: FB, thermal injuries, caustic injuries, inhaled toxins
How is neck mobility assessed?
By having the patient flex and extend the head and neck through a full range of motion
List conditions associated with limited neck mobility and potentially difficult laryngoscopy?
Rheumatoid arthritis
Ankylosing spondylitis
C-spine injury or immobilization
Why is obesity associated with difficult BVM and intubation?
Difficult BMV:
Redundant upper airway tissues
Chest wall weight
Resistance of abdominal mass
More rapid oxyhemoglobin desaturation

Difficult intubation:
Chest wall volume interfering with laryngoscopy
More rapid oxyhemoglobin desaturation
List maneuvers that facilitate effective BMV?
-leave dentures in place
-use mask of appropriate size (not too large, not too small)
-place the mask on the patients' face detached from the bag
-apply the nasal part of the mask on the bridge of the nose first, then apply body of the mask downwards towards the chin
-Use optimal single hand technique
-Do not obstruct the soft tissues of the neck when applying the jaw thrust
-add or remove air from the mask
-put gel on beard
-use two-person technique with two hand mask hold
-use an oral airway and two nasal airways
What conditions are associated with resistance to ventilation?
COPD
Asthma
Restrictive lung disease
Pulmonary edema
Term pregnancy
What is the most serious complication of endotracheal intubation?
Unrecognized esophageal intubation with resultant hypoxic brain injury
What results in false positive ETCO2?
Esophageal intubation with BVMV prior to intubation
Esophageal intubation after recent ingestion of carbonated beverages
Esophageal intubation after recent ingestion of antacids
Esophageal intubation with recent (5-10min) injection of bicarbonate
Supraglottic placement of ETT
What results in false negative ETCO2?
Tracheal intubation in the following situations
-cardiac arrest
-complete obstruction of the trachea or both mainstem bronchi
-contamination of the ETCO2 with acidic substances like gastric acid, lidocaine or epinephrine
-clogging of the ETCO2 detector with secretions
-broken ETCO2 detector
-post epi (transient decrease in pulmonary blood flow)
What is persistent obvious leak despite positive ETCO2 suggestive of?
Cuff malfunction or supraglottic placement of ETT
When should laryngoscopy be aborted and BVMV resumed?
O2 sat <90%
Describe how you would perform an awake intubation?
Glycopyrollate 0.2mg IVP
Wait 10 minutes
Suction mouth and dry with 4x4 gauze
nebulized 5cc 4% lidocaine at 5L/min
have patient gargle viscous lidocaine
suction again
Place laryngoscope
3 cc 4% lidocaine and atomize into the posterior pharynx and cords
Ketofol sedation
pass the bougie through the cords
pass ETT
confirm position
Why is intubation with sedation alone considered inappropriate for ETI?
Intubating conditions achieved with deep anesthesia are significantly inferior to those achieved when neuromuscular blocade is used
Explain the physiology of muscle contraction.
Action potential conducted down innervating axon
release of ACh neurotransmitters from the terminal axon
ACh reversibly binds to the receptors on the motor endplate
Opens channels on the myocyte membrane
Depolarization of the motor endplate
Massive intracellular release of Ca++ from the sarcoplasmic reticulum
Contraction of myofibrils
What are intubating doses of succinylcholine?
Adults 1.5mg/kg IV or 4mg/kg IM
children <10 2mg/kg IV but length based dosing is recommended
What is the management of masseter spasm?
Administration of a competitive NMBA terminates the spasm

if severe persistent spasm -> suspect malignant hyperthermia
What is malignant hyperthermia?
Extremely rare myopathy characterized by rapid temperature rise and rhabdomyolysis that occurs in genetically predisposed individuals who receive such or certain volatile anesthetics
What is the treatment of malignant hyperthermia?
dantrolene 2mg/kg IV q 5min
reduce body temperature
What are contraindications to rocuronium?
Patients with myasthenia gravis may experience greater more prolonged paralysis at any given dose
Explain the 2 reflexes triggered by intubation?
RSRL - reflex sympathetic response to laryngoscopy. Modest increase in BP and HR, clinically significant only in patients with increased ICP and patients with cardiovascular disease (AAA, aortic dissection, ACS, CAD) this is blunted by pretreatment with fentanyl 3mcg/kg

Other separate reflex that increases ICP - this is blunted by pretreatment with lidocaine 1.5mg/kg
What are the particularities of intubation in cases of increased ICP?
Maintain MAP >/= 100mmHg so that CPP is maintained
Pretreatment with fentanyl and lidocaine to blunt the 2 reflexes triggered by laryngoscopy and intubation
How do you perform RSI in a patient with a suspected c-spine injury?
RSI with in-line stabilization because provides maximum control of the patient and conditions for intubation
When should you immobilize the c-spine in penetrating trauma?
If there was a secondary mechanism of injury (fall) or if there are neuro deficits suggesting spinal involvement
What are alternatives to intubation by direct laryngoscopy?
extraglotting devices
video laryngoscopy
fiberoptic laryngoscopy
lighted stylet
rigid optical stylet
retrograde intubation
How are extraglottic devices classified?
Supraglottic: sits above and surrounds the glottis
Retroglottic: enters the upper esophagus
How does the intubative LMA differ from the LMA?
Rigid, stainless steel ventilation tube bent almost to a right angle attached to mask. There is a distal epiglottis elevator at the distal end of the mask
What are the indications for using the LMA and Combitube in the ED?
Rescue emergency airway
-rescue device in the "can't intubate can oxygenate situation"
-single attempt in the "can't intubate, can't oxygenate" situation simultaneously with preparation for cricothyrotomy
When is the LMA contraindicated?
When the cause of unsuccessful BVMV or intubation is laryngeal pathology
What are the complications associated with LMA insertion?
PArtial insertion block when the distal collar tip rolls up during insertion (hinder optimal placement)
Pharyngeal abrasion and bleeding during insertion
Difficulty achieving sufficient seal -> difficult ventilation
What are contraindications to using the retroglottic devices?
-responsive patients with intact airway protective reflexes
-Patients with known esophageal reflexes
-caustic ingestions
-upper airway obstruction due to laryngeal foreign bodies or pathology
What are the complications associated with the insertion of the combitube?
-upper airway hematoma
-pyriform perforation
-perforation of the esophagus
Why are the LMA and combitube used as a temporizing measure only?
They do not prevent aspiration of gastric contents
What is the only absolute contradindication to using the glidescope?
Mouth opening <16mm because that is the width of the widest portion of the blade
What are the advantages of the glidescope?
Distal angulation of the device allows better visualization of the anterior larynx when laryngoscopy is unsuccessful
Does not require direct visualization of the larynx through the mouth -> less neck movement -> useful when cervical mobility or mouth opening is limited
Performs well in the presence of secretions, blood and vomitus
Explain the technique of retrograde intubation?
A flexible wire is passed in retrograde fashion through the cricothyroid membrane puncture. The wire is retrieved through the mouth, then used to facilitate intubation serving as a guide over which the ETT is passed
Why is cricothyrotomy preferred over tracheotomy?
Faster more straightforward and more likely to be successful than tracheotomy. Less soft tissue, less thyroid, less vascularity
What are 7 complications of surgical airway management?
-hemorrhage
-laryngeal/tracheal injury
-voice change
-barotrauma
-pneumomediastinum
-infection
-subglottic stenosis
What kit has all the necessary equipment for either a Seldinger percutaneous cricothyrotomy or an open cricothyrotomy?
Melker universal kit
What are 3 cardinal signs of acute upper airway obstruction?
Hot potato voice
Difficulty in swallowing secretions because of pain or obstruction with patient typically sitting up, leaning forward and spitting or drooling secretions
stridor
Which sign suggests total upper airway obstruction is imminent?
stridor -> implies the patient has already lost at least 50% of the airway caliber -> intervention is required -> in children with croup, medical treatment may be sufficient, in adults and older children surgical airway or at lease a double set up
How do you approach partial airway FB obstruction?
Ideally move to OR for removal under double set up
If not possible, attempt extraction using awake technique with caution not to push the FB further down -> risk of converting the partial obstruction into a complete one
How do you approach complete airway FB obstruction?
Heimlich until unconscious
Once unconscious
-look into the mouth for FB
-laryngoscoty, remove FB if possible
-if unremovable supraglottic FB then cric
-if no FB seen -> intubate and assess ventilation
if able to ventilate arrrage for definitive removal by bronchoscopy
if unable to ventilate-> deflate cuff and push ETT down in an attempt to force down the maindtem bronchus

After FB removal-> r/o residual FB with bronchoscopy
Monitor patient for 12-24 hours post procedure