Rosens 1 : Airway ( + Tintinalli And Procedures)

Front 1

List three indications for intubation.

Back 1

Failure to maintain or protect the airway
2. Failure of ventilation or oxygenation
3. Patient’s anticipated coarse and likelihood of deterioration

Front 2

How is the patient’s ability to maintain or protect the airway evaluated?

Back 2

- Ability to phonate
- Level of consciousness
- Ability to manage his or her own secretions
- Requirement of a maneuver to establish patent airway
- Tolerance of an oral airway

Front 3

What are the reported failure rates for intubation in the emergency department (from NEAR studies)?

Back 3

Medical intubations: 1%
- Trauma intubations: 3%

Front 4

What is estimated incidence of can’t intubate, can’t ventilate situation (in elective anesthesia cases)?

Back 4

- 1/5000 to 1/200 000

Front 5

The difficulty of what three maneuvers should be assessed preintubation?

Back 5

1. Difficult intubation
2. Difficult BVM
3. Difficult LMA
4. Difficult cricothyrotomy

Front 6

What does the pneumonic “LEMON” stand for in the evaluation of the difficult airway?

Back 6

Look externally, especially for signs of difficult intubation (by gestalt), difficult bag mask ventilation, and difficult cricothyrotomy

Evaluate the ‘3-3-2 rule’

Mallampati

Obstruction

Neck mobility

Front 7

What does the pneumonic “MOANS” stand for in evaluation for difficult BVM?

Back 7

Mask seal

Obesity

Aged

No teeth

Stiffness (resistance to ventilation)

Front 8

List conditions which increases stiffness of resistance to ventilation.

Back 8

- Asthma/ COPD
- Pulmonary edema
- Restrictive lung disease
- Term pregnancy

Front 9

What is the RODS mnemonic for difficult LMA?

Back 9

· Restricted mouth opening, Obstruction, Distorted anatomy, Stiff lungs

Front 10

List predictors of difficult cricothyrotomy. ADD RODS

Back 10

- Disturbance of the ability to locate and access the landmarks of the anterior airway via the neck

o Obesity

0 N
o Edema

o Prior surgery
o Hematoma
o Anatomic disruption
o Tumor

o Abscess
o Scaring (radiation, prior surgery)

o Subcutaneous emphysema

Front 11

Direct laryngoscopy to visualize the glottis requires the alignment of what three axis?

Back 11

1. Oral axis
2. Pharyngeal axis
3. Laryngeal axis

Front 12

What is required anatomically to align the oral, pharyngeal, and laryngeal axis?

Back 12

- Adequate mouth opening
- Adequate submandibular space to accommodate the tongue
- Larynx positioned low enough in the neck to be accessible

Front 13

Describe the 3-3-2 rule for evaluating difficult laryngoscopy?

Back 13

Mouth opening: 3 fingers
- Thyromental distance: 3 fingers
- Thyrohyoid distance: 2 fingers

Front 14

Describe the Mallampati score.

Back 14

Class I:
o Soft palate, uvula, fauces, pillars all visible
§ Predicts no difficulty
- Class II:
o Soft palate, uvula and fauces visible
§ Predicts no difficulty
- Class III:
o Soft palate and base of uvula are visible
§ Predicts moderate difficulty
- Class IV:
o Hard palate only visible
§ Predicts severe difficulty

Front 15

What is the Cormack and Lehane grading scheme for larygoscopic view?

Back 15

Grade 1:
- Entire glottic aperture is seen
Grade 2:
- Portion of glottis is seen
o Grade 2a:
§ Arytenoids and part of vocal cords
o Grade 2b:
§ Arytenoids alone
Grade 3:
- Epiglottis only
Grade 4:
- Not even epiglottis is visible

Front 16

List methods to confirm endotracheal tube placement.

Back 16

Primary:
- End-tidal CO2 via capnography
- End-tidal CO2 via colorimetric detector device
- Aspiration with the esophageal detector device (EDD)

Secondary:
- Physical exam findings, bilat BS
- Oximetry
- CXR
- Condensation on tube

Front 17

What are some causes of false positive and false negative colorimetric ETCO2 devices?

Back 17

· False positive
o Failure to measure before 6 breaths are given
o Carbonated beverages
o Air in stomach – secondary to bagging
o Bicarb administration
o Contact with gastric contents
o Contact with acidic drugs like lidocaine and epi
· False negative
o Failure to measure before 6 breaths are given
o Cardiac arrest
o Device or ETT clogged with secretions
o Severe airway obstruction
o Pulmonary edema
o Severely hypocarbic (must have at least ETCO2 of 2%)

Front 18

Name false positives and false negatives for the EDD (*note a true positive is considered when the tube is in the esophagus)

Back 18

· False positive
o Morbid obesity, late pregnancy, status asthmaticus, copious endotracheal secretions, occlusion of ETT by tracheal wall, tracheal compression, COPD, bronchial intubation
· False negative
o Air leak in the device or ETT (above the esophagus)
o Supraglottic placement of ETT
o Gas from stomach
o Esophageal distension with gas

Front 19

emergency airway algoritm

Back 19

Front 20

crash airway algorithm

Back 20

Front 21

Define failed airway.

Back 21

- Oxygen desaturation below 90% despite good two person BVM
- 3 or more failed intubation attempts (optimal positioning, gear, technique and by a skilled operator)
- Skilled operator ascertainment that intubation would be impossible even after a single attempt (i.e. grade IV larygoscopic view)

Front 22

DIfficult airway algortim

Back 22

Front 23

Failed airway algorithm

Back 23

Front 24

What is “double set-up”?

Back 24

- RSI is performed, but
- All preparations for rescue cricothyrotomy are undertaken prior to drug administration (including surgical preparation of the neck and knife and tray open and ready)

Front 25

What is the desaturation time for fully preoxygenated normal adult, moderately-ill adult, obese adult, and child?

Back 25

- Normal adult: 8 min
- Ill adult: 5 min
- Obese adult: 3.5 min
- Child: 2.5 min

Front 26

What are the six P’s of RSI?

Back 26

1. Preparation

2. Preoxygenation (8 vital capacity breaths or 3 minutes on 100%)

3. Pretreatment

4. Positioning / Protect (Sellick)

5. Paralysis with induction

6. Placement of tube

7.Post-intubation management

Front 27

List risk factors for rapid desaturation during RSI.

Back 27

Obese
- Ill
- Pregnant
- Child
- Comorbid disease

Front 28

How is optimal preoxgenation achieved?

Back 28

- 100% O2 nonrebreather mask for 3 minutes or 8 tidal breath

Front 29

What are the pretreatment agents for RSI?

Back 29

· Reactive airways disease: Lidocaine: 1.5 mg/kg IV, to mitigate bronchospasm. Salbutamol 2.5 mg by nebulizer (if time permits and not already given).

· Cardiovascular disease (AMI+HTN or dissection): Fentanyl: 3 µg/kg to mitigate sympathetic discharge.

· Elevated ICP: Lidocaine: 1.5 mg/kg IV to mitigate ICP increase in response to airway manipulation. Fentanyl 3 µg/kg to mitigate sympathetic discharge and attendant rise in ICP.
· Given 3 minutes before induction and paralysis.

Front 30

RSI protocol

Back 30

0-10 Preparation

0-5 Preoxygenation
100% O2 (3 minutes or 8 tidal breaths)

0-3 Pretreatment

0 Paralysis and Induction
Etomidate 0.3mg/kg
Succinycholine 1.5mg/kg

0 + 45s Placement
Cricoid pressure
Laryngoscopy and intubation
Endtidal CO2 confirmation
Clinical correlation
Secure the tube, ensure cuff is adequately inflated

0+2min Post intibation management
Midazolam 0.1mg/kg
CXR

Front 31

What is the algorithm for laryngospasm?

Back 31

Try each step in successive order if the one before fails:
o PPV
o Deepen sedation
o Paralysis

Front 32

What is the difference between depolarizing and nondepalarizing NMBAs?

Back 32

- Succinylcholine (the depolarizing NMBA) binds noncompetitively with ACh receptors on the motor endplates causing sustained depolarization of the motor endplates

- The competitive or nondepolarizing NMBAs bind competitively to ACh receptos preventing ACh from causing motor activity

Front 33

What is the chemical composition of succinylcholine?

Back 33

- Two molecules of ACh

Front 34

What is responsible for the breakdown of succinylcholine

Back 34

- Plasma pseudocholinesterase (not present at the motor endplate)

Front 35

List conditions and drugs that reduce the activity of pseudocholinesterase and therefore increase the quantity of succinylcholine being effective at the motor endplate?

Back 35

THINK of things that can damage the liver or inhibit it’s pseudocholinesterase production
· Liver disease
· Cancer
· Cytotoxic drugs
· Pregnancy
· Metoclopramide, phenylzine

Front 36

What conditions are associated with hyperkalemia after succinylcholine administration?

Back 36

Burns >10% BSA>5 days until healed

Crush injury>5 days until healed

Denervation (stroke, spinal cord injury)>5 days until 6 mo

Neuromuscular disease (ALS, MS)Indefinitely

Intra-abdominal sepsis>5 days until resolutio

Anesthesia lit says after 24 hrs do not use succ, ron walls says 3 days. Rosen’s is 5 days.
Time to wait until safe again for acquired injuries (ie not neuromusc disease) approx 3 months. EF

Front 37

What is the emergent treatment of malignant hyperthermia?

Back 37

- Stop offending agent and initiate active cooling
- Dantrolene 2mg/kg IV Q 5 min to maximum of 10mg/kg

Front 38

List examples of the two classes of competitive NMBAs.

Back 38

Aminosteroid agents
- Pancuronium
- Vecuronium
- Rocuronium

Benzylisoquinolines
- Tubocurarine
- Atracuriujm
- Cisacurium
- Mivacurium
- Doxacurium
- Metocurine

Front 39

Provide a rapid sequence protocol using etomidate and rocuronium.

Back 39

0-10 Preparation
0-5 Preoxygenation
- 100% O2 for 3 min or 8 tidal breaths
0-3 Pretreatment

0 Paralysis and Induction
- Etomidate 0.3mg/kg
- Rocuronium 1.0mg’kg
0+60s Pass tube
- Cricoid pressure
- Larygoscopy and intubation
- End-tidal and clinical confirmation
0+2 Post intubation management
- Midazolam 0.1mg’kg
- Rocuronium 0.3mg/kg prn

Front 40

How is vecuronium dosed?

Back 40

- 0.3mg/kg IVP, or
- 0.01mg/kg priming dose then after 3 minutes another 0.15mg/kg IVP

Front 41

What medications and doses are good for post intubation maintenance of sedation?

Back 41

- Midazolam 0.1mg/kg
- Fentanyl 3mcg/kg
- Morphine 0.1mg/kg

Front 42

Provide an RSI protocol for status asthmaticus.

Back 42

Prepare
Preoxygenation
- 100% O2 3min or 8 tidals
- Continuous albuterol
Pretreatment
- Lidocaine 1.5mg/kg
Paralysis and Induction
- Ketamine 1.5 mg/kg
- Succinylcholine 1.5mg/kg
Pass tube
- Cricoid pressure
- Laryngoscopy and intubation
- End tidal and clinical confirmation
Post intubation management
- Midazolam 0.1 mg/kg
- Rocuronium 0.3mg/kg
- Albuterol nebulization
- Ketamine prn

Front 43

What medications blunt the sympathetic stimulation to laryngoscopy and intubation?

Back 43

- Fentanyl
- Esmolol

Front 44

Outline an RSI protocol for intubation in a patient with elevated ICP.

Back 44

0-10 Preparation
0-5 Preoxygenation
- 100 O2 3 min or 8 tidals
0-3 Pretreatment
- Lidocaine 1.5mg/kg
- Fentanyl 3 mcg/kg
0 Paralysis and Induction
- Etomidate 0.3mg/kg
- Succinylcholine 1.5mg/kg
0+45 Placement
- Cricoid pressure
- Larygoscopy and intubation
- Endtidal and clinical confirmation
2 Post intubation management
- Fentanyl 3 mcg/kg
- Midazolam 0.1mg/kg
- Rocuronium 0.3mg/kg

Front 45

What is the incidence of cricothyrotomy in ED intubations?

Back 45

- ~1%

Front 46

List relative contraindictions to cricothyrotomy.

Back 46

- Distorted neck anatomy
- Preexisting infection
- Coagulopathy
- Age < 10 years (exceedingly difficult)

Front 47

What are approximate size ETT tubes use for most adult males and females?

Back 47

- Males: 8.0-8.5
- Females: 7.5-8.0

Front 48

What is the name of the second hole at the end of the ETT tube that permits flow if the tip is occluded?

Back 48

- Murphy eye

Front 49

What are the functional differences between the Miller and Macintosh larygoscopes?

Back 49

- Miller (straight) blade:
o Designed to directly lift epiglottis and compress tongue
- Macintosh (curved) blade:
o Designed to be placed in the vallecula above the epiglottis and indirectly lift the epiglottis

Front 50

What does “BURP” stand for?

Back 50

- Backwards, upwards, rightwards pressure

Front 51

Differentiate between BURP and cricoid pressure.

Back 51

- BURP is applied to the trachea and is designed to improve view of the glottis
- Cricoid pressure is applied to the cricoid and is to prevent aspiration of gastric contents

Front 52

What does correct tube position usually correspond to in cm at the lips?

Back 52

- Men: 23cm (corner of mouth)
- Women: 21 cm

Front 53

What cuff pressure range should be maintained within the ETT balloon?

Back 53

- 20-40cm H2O

Front 54

List causes for absent CO2 detection in the properly intubated patient (false negative).

Back 54

- Cardiac arrest with poor chest compressions
- Massive PE
- Massive obesity
- Severe pulmonary edema
- Plugged ETT tube

Front 55

LIST causes of false positive CO2 detection.

Back 55

- Carbonated beverages
- Bicarbonate administration
- Gastric distention from BVM

Front 56

List traumatic complications of endotracheal intubation.

Back 56

- Arytenoids avulsion, displacement
- Intubation of pyriform sinuses
- Paryngeal- esophageal perforation
- Cordal synecheiae
- Commissural stenosis
- Subglottic stenosis

Front 57

How is translaryngeal anesthesia obtained?

Back 57

- Palpate the superior border of the circoid cartilage
- Puncture the midline of the cricoid cartilage with a 22 to 25GA 0.5-1.0 Inch needle
- Needle should be perpendicular to membrane in the midline and level of injection is just superior to cricoid cartilage
- Aspirate air
- Inject 1.5-2.0cc of 4% lidocaine
- Press the site firmly for a few seconds (prevents subcutaneous emphysema)

Front 58

List sedative induction agents, their doses, induction times, durations, benefits and caveats.

Back 58

Front 59

What is “emergence pohenomenon”?

Back 59

- Nightmares, visual hallucinations and dissociative sensations experienced by some patients when recovering from ketamine

Front 60

List complications of succinylcholine.

Back 60

- Bradydysrhythmias
- Masseter spasm
- Increased intragastic, intraocular, and possibly ICP
- Malignant hyperthermia
- Hyperkalemia
- Prolonged apnea (pseudocholinesterase deficiency)
- Fasciculation-induced musculoskeletal trauma
- Histamine release
- Cardiac arrest

Front 61

How much will serum potassium rise during succinylcholine administration?

Back 61

- 0.5 mEq/L

Front 62

How does recent cocaine use potentially prolong paralysis with succinylcholine?

Back 62

- Cocaine is metabolized by plasma pseudocholinesterase reducing available enzyme for hydrolization of succinylcholine

Front 63

How are nondepolarizing NMBAs reversed?

Back 63

- Atropine 0.01mg/kg (prevent muscarinic side effects)
- Edrophonium 0.5-1.0mg/kg
- Neostigmine

Front 64

Over what range of CPP is CBF normally maintained by cerebral autoregulation?

Back 64

- 50mmHg to 150mmHg

Front 65

What is the CPP equation?

Back 65

- CPP=MAP-ICP

Front 66

In traumatic brain injury what should the target MAP be?

Back 66

- >90mmHg

Front 67

What are potential complications of suctioning the ETT tube?

Back 67

- Hypoxia
- Dysrhythmias
- Hypotension
- Pulmonic collapse
- Direct mucosal injury

Front 68

What is reasonable set of initial ventilator settings?

Back 68

- AC
- FiO2 100% then titrated to ABGs
- Volume 10cc/kg (more recently 6-8cc/kg) or
- Rate adjusted to ABGs (allow sufficient exhalation) usually 8-12 bpm
- Peak pressures maintained <35-45mmHg
- PEEP 3-5mmHg
- Peds set pressure control to 20mmHg

Front 69

What is treatment of post extubation larygospasm?

Back 69

- 100% O2 and positive pressure, 1/10th dose of succs
- Nebulized racemic epinephrine 0.5cc of 2.25% epinephrine in 4cc NS

Front 70

Define cricothyrotomy.

Back 70

- Establishment of a surgical opening in the airway through the cricothyroid membrane and placement of a cuffed tracheostomy tube or ETT.

Front 71

List indications for cricothyrotomy.

Back 71

- Primary indication:
o Failure of intubation by the oral or nasal means in the presence of a immediate need for definitive airway management (rescue)
- Secondary indication:
o Primary airway management in patients for whom nasotracheal or orothracheal intubation is contraindicated or felt to be impossible (primary) i.e. severe lower facial trauma

Front 72

List contraindication to cricothrotomy.

Back 72

- Absolute
o Young age (<12 years unless teenage or adult size)

- Relative
o Preexisting laryngeal or tracheal pathology (tumour, infection, abscess)
o Hematoma or other anatomic destruction of landmarks that would render the procedure difficult or impossible
o Coagulopathy
o Lack of operator expertise

Front 73

What equipment is required for cricothyrotomy?

Back 73

- Trousseau dilator
- Tracheal hook
- Scalpel with #11 blade
- Cuffed, nonfenestrated, #4 Shiley tracheostomy tube
- (prep, gauze, hemostats, drapes)

Front 74

What are the basic steps of cricothyrotomy?

Back 74

1. Identify the landmarks
2. Prepare the neck
3. Immobilize the larynx
4. Incise the skin
5. Reidentify the membrane
6. Incise the membrane
7. Insert the tracheal hook
8. Insert the trousseau dilator
9. Insert the tracheostomy tube
10. Inflate the cuff and confirm tube position

Front 75

What are important landmarks to identify when performing cicothyrotomy?

Back 75

- Laryngeal prominence and thyroid cartilage
- Cricoid cartilage
- Cricothyroid space
- (Hyoid bone and thyrohyoid space)

Front 76

How far below the laryngeal prominence is the cricothyroid membrane (approximately)?

Back 76

- One finger width

Front 77

How far above the sternal notch is the cricothyroid membrane (approximately)?

Back 77

- 4 finger widths

Front 78

How is the larynx immobilized during the procedure?

Back 78

- Between the thumb and long (middle) finger of the nondominant hand (L hand), or
- Tracheal hook
- (Maintain immobization the tracheal through out entire procedure)

Front 79

What direction is the initial incision recommended by The Airway Manual?

Back 79

- Vertical (2cm)

Front 80

List tissues cut with the initial vertical incision?

Back 80

- Skin
- Subcutaneous tissue
- Anterior cervical fascia

Front 81

How is the actual membrane incised?

Back 81

- 1cm horizontal stabbing incision (lower half of membrane)

Front 82

How is the Trousseau dilator used?
1. Inserted well though the incision with blades directed longitudinally down the airway, or
2. Minimally into the incision with the blades oriented superiorly and inferiorly (allows incision to be enlarged vertically)

Back 82

1. Inserted well though the incision with blades directed longitudinally down the airway, or
2. Minimally into the incision with the blades oriented superiorly and inferiorly (allows incision to be enlarged vertically)

Front 83

List complications of cricothyrotomy.

Back 83

- Major
o Major hemorrhage
- Minor
o Hemorrhage
o Pneumonmediastinum
o Infection
o Voice change
o Subglottic stenosis
o Laryngeal/tracheal injury
o Other

Front 84

What type and size tube do you want?

Back 84

- #4 Shiley (5mm diameter)

Front 85

Describe the location of the cricoithyroid membrane.

Back 85

- Between the cricoid and thyroid cartilages
- Approximately 1/3 the distance from the manubrium to chin in normal habitus adults
- Closer to manubrium in patient with fat short neck
- Closer to the chin in Patient with long thin neck

Front 86

What vascular structure is at particular risk during cricothyoidotomy?

Back 86

- Thyroid ima artery

Front 87

What are the steps of needle cricothyroidotomy?

Back 87

- Standing above head of patient, locate cricoid ring, cricoithyroid membrane and grasp the thyroid cartilage (left hand)
- Advance 12 or 14-guage catheter attached to the 3cc syringe at 90 degrees into cricothroid membrane, aspirating gently
- When airway is entered adjust angle to 45 degrees and advance catheter over needle
- Withdraw the plunger from the 3cc syringe and attach to catheter
- Place adapter from 7mm ETT tube into end of syringe
- Attach Y connector or BVM
- Supply O2 at 15L/min (40-50PSI) at ratio of 1:4 seconds (although if it is straight from the wall Walls textbook recommends 1:1 at 15L/min because it is only at about 10psi. At 50 psi you use the 1:4 ratio)
- Hold catheter firmly in place

Front 88

What are some important things to know about intubating the 3rd trimester pregnant patient?

Back 88

· Consider the airway a difficult airway and proceed with that algorithm unless you are sure it will be easy
· Positioning – rolled towel between the shoulders to displace breasts from midline, “ramp” towels under neck and occiput like an obese patient
· Anatomy – higher diaphragm due to uterus, more airway tissue edema and friability
· Physiology – decreased FRC so they desat quicker, need to increase minute ventilation by 30-50% on vent
· No differences in induction and paralysis agent choices. Note paralytics do not cross the placenta.

Front 89

What are some important things to know about intubating the morbidly obese patient

Back 89

?
· Consider these patients a difficult airway
· Positioning – prop the patient up on linens or a pillow from the mid-point of the back to the shoulders and head
o *You should be able to draw a horizontal line from the external auditory canal to the angle of Louis*
o the patient is essentially up on a ramp
· If you are paralyzing the patient be aware that the fat laden airway tissues collapse making BVM very difficult so oral and nasal airways should be available and used.
· These patients desat faster
· Lipophilic drugs have increase in their Vd so should be dosed to observed body weight
o Propofol, thiopental, fentanyl,
· Hydrophilic drugs have less of a Vd and should be dosed to ideal/lean body weight
o Rocuronium
· Use doses of sux based on total body weight because, although it is lipophilic, these patients have higher levels of pseudocholinesterase
· Surgical airway: need assistants to retract the tissues
o Most tracheostomy tubes are not long enough for this population so consider a 6.0 ETT

Front 90

What are some important points in an airway foreign body obstruction?

Back 90

· Bag the patient
· Have a look and remove with McGill forceps if possible
· If below the cords, intubate and ventilate
· If obstructed put stylet into ETT and push FB into R or L mainstem bronchus, withdraw tube to normal position and ventilate
· If that doesn’t work then consider bilateral needle thoracostomies as these patients sometimes have a tension pneumothorax because of preceding increased airway pressures