Professional Documents
Culture Documents
Objectives
Recognise signs of threatened airway
Describe techniques of establishing airway
and for mask ventilation
Explain proper applications of airway
adjuncts
Describe preparation for endotracheal
intubation and difficult intubation
Describe alternative methods
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Oxygenation
Respiratory rate and use of accessory muscles
- Is the patient in respiratory distress?
cmount of supplemental oxygen
- What is the patient¶s oxygen demand?
cirway
cnatomy
- Will this patient be difficult to intubate?
Patency
- Is there a reversible anatomical cause of respiratory failure
as opposed to intrinsic lung dysfunction?
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(In order of degree of support)
Nasal Cannula
4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow
= 45%)
Face tent
ct most delivers 40% at 10-15 L flow
Ventimask
Small amount of rebreathing
8 L flow = 40%, 15 L flow = 60%
Nonrebreather mask
cttached reservoir bag allows 100% oxygen to enter mask with
inlet/outlet ports to allow exhalation to escape - does not guarantee
100% delivery.
Respiratory pattern
cccessory muscle use is an indication of distress.
Rate > 30 can indicate need for more support by noninvasive positive
pressure or intubation
Pulse oximetry
O2 saturation less than 92% on 60 - 100% oxygen can suggest the need
for intubation based on whether there is anything immediately reversible
which could improve ventilation.
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With the head fully extended and mouth closed
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cbout one third of diabetics characterized by short stature, joint rigidity, and tight waxy skin
Positive prayer sign with an inability to oppose fingers
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Potential for aspiration requires rapid sequence intubation with
cricoid pressure
Clear liquids < 4 hours
Particulate or solids < 6hours
Organ failure
Renal and hepatic failure will limit medication used.
Potential for preexisting pulmonary edema and airway bleeding from
manipulation
Sodium Thiopental
3 - 5 mg/kg IV
Profound hypotension in patients with hypovolemia, histamine release, arteritis
Dose should be decreased in both renal and hepatic failure.
Propofol
2 - 3 mg/kg IV
Hypotension, especially in patients with systolic heart dysfunction, bradycardia,
and even heart block
Unlikely to have prolonged effect in organ failure
Ketamine
1 - 4 mg/kg IV, 5 - 10 mg/kg IM
Stimulates sympathetic nervous system
Requires atropine due to stimulated salivation and midazolam for potential of
dysphoria
cvoid in patients with loss of autoregulation and closed head injury
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Succinylcholine
1 - 2 mg/kg IV, 4 mg/kg IM
cvoid in patients with malignant hyperthermia, > 24 hours out from burn or
trauma injury, upper motor neuron injury, and preexisting hyperkalemia
Rocuronium
0.6 - 1.2 mg/kg, highest dose required for rapid sequence
Hemodynamically stable, 10% renal elimination
Vecuronium
0.1 mg/kg
Hemodynamically stable, 10% renal elimination
Cisatricurium
0.2 mg/kg
Mild histamine release, Hoffman degradation, not prolonged in renal or
hepatic failure
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Cricoid is circumferential
cartilage
Pressure obstructs
esophagus to prevent
escape of gastric
contents
Maintains airway patency
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clign oral, pharyngeal, and laryngeal axes to
bring epiglottis and vocal cords into view.
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Mask ventilation crucial,
especially in patients who are
difficult to intubate
Sniffing position with tight
mask fit optimal
May require two hands
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Direct visualization
Humidity fogging the endotracheal tube
End tidal CO2 which is maintained after > 5 breaths
Low cardiac output results in decreased delivery of CO2
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Puncture of the
cricothyroid membrane
with retrograde passage of
a wire to the trachea
Endotracheal tube guided
endoscopically over the
wire through the trachea
Catheter through the
cricothyroid can be used
for jet ventilation if
necessary.
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Emergency airway used mostly by
paramedics and emergency
physicians for failed endotracheal
intubation
Ventilation confirmed through blind
blue tube
Combitube is in the esophagus and salem
sump can be placed through white tube
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1. Caplan Rc, et al. Practice guidelines for management of the
difficult airway.
1993;78:597-602.
2. Langeron O, et al. Predictors of difficult mask ventilation
2000;92:1229-36.
3. Frerk CM, et al. Predicting difficult intubation.
1991;46:1005-08.
4. Tse JC, et al. Predicting difficult endotracheal intubation in
surgical patients scheduled for general anesthesia
5
1995;81:254-8.
5. Benumof JL, et al. LMc and the cSc difficult airway
algorithm.
1996;84:686-99.
6. Reynolds S, Heffner J. cirway management of the critically
ill patient. '
2005;127:1397-1412.