ANAESTHETICS AND AIRWAY
ANAESTHETICS - GENERAL KNOWLEDGE
PromptIndications for intubation
ResponseFailure to ventilate
Failure to oxygenate
Failure to protect airway
Projected clinical course
Basically if you think about these 4 things you can answer most questions of “when would you intubate” questions.
Failure to oxygenate
Failure to protect airway
Projected clinical course
Basically if you think about these 4 things you can answer most questions of “when would you intubate” questions.
PromptDifficult BVM
ResponseMOANS
Mask seal - Facial hair, trauma
Obese
Advanced age
No teeth
Stiff neck
Mask seal - Facial hair, trauma
Obese
Advanced age
No teeth
Stiff neck
PromptTechniques to improve BVM if difficult
ResponseOptomise positioning - Elevate occiput with pillow - indication: hyperextension/flexion leading to possible upper airway obstruction
Two person technique - indication - inadequate seal/leak with one person BVM technique
Oropharyngeal/Nasopharyngeal adjuncts - Suspected upper airway obstruction from oedematous/large soft tissue
Sedation (propofol) - Laryngospasm
Paralysis and ETT - failure to respond to above
Two person technique - indication - inadequate seal/leak with one person BVM technique
Oropharyngeal/Nasopharyngeal adjuncts - Suspected upper airway obstruction from oedematous/large soft tissue
Sedation (propofol) - Laryngospasm
Paralysis and ETT - failure to respond to above
PromptDifficult Laryngoscopy/ETT
ResponseLEMONS
Look externally (Facial trauma, incisors, beard, large tongue)
Evaluate 3-3-2 (incisor distance 3 finger breadths, Hyoid mental 3FB, Thyro-hyoid distance 2 fingers)
Mallampati >=3
Obstruction
Neck
Situation
Look externally (Facial trauma, incisors, beard, large tongue)
Evaluate 3-3-2 (incisor distance 3 finger breadths, Hyoid mental 3FB, Thyro-hyoid distance 2 fingers)
Mallampati >=3
Obstruction
Neck
Situation
PromptMallimpatti score
ResponsePUSH
1 - Pillars
2 - Uvula
3 - Soft
4 - Hard
1 - Pillars
2 - Uvula
3 - Soft
4 - Hard
PromptEquipment required for intubation
ResponseDR SOAP ME
Drugs
Rescue plan/drugs
Suction
Oxygen
Adjuncts
Positioning
Monitoring
ETCO2
Drugs
Rescue plan/drugs
Suction
Oxygen
Adjuncts
Positioning
Monitoring
ETCO2
PromptHow to confirm ETT placement
ResponseVisualisation (Direct vs videolaryngoscopy)
Auscultate for breath sounds bilaterally
CO2 Capnography trace
Fogging/misting of tube
CXR 3cm above carina
Auscultate for breath sounds bilaterally
CO2 Capnography trace
Fogging/misting of tube
CXR 3cm above carina
PromptCauses of post intubation hypotension
ResponseAAHH SHITE
Acidosis
Anaphylaxis
Heart (tamponade)
Heart (pulmonary hypertension)
Stacked breaths
Hypovolaemia
Induction agent
Tension pneumothorax
Electrolytes
Acidosis
Anaphylaxis
Heart (tamponade)
Heart (pulmonary hypertension)
Stacked breaths
Hypovolaemia
Induction agent
Tension pneumothorax
Electrolytes
PromptDifficult cricothyroidotomy
ResponseSHORT
Surgery
Haematoma
Obesity
Radiation
Trauma
Surgery
Haematoma
Obesity
Radiation
Trauma
PromptOPA size
Response“Hard to Hard” - Center of the mouth between the first incisors to the angle of the mandible in an adult
PromptNPA size
Response“Soft to soft” - tip of the patient’s nose to the earlobe (Ie: Tip to Tragus)
PromptAirway intervention complications
ResponseMucosal trauma
Tongue displacement
Failed procedure
Gastric aspiration
Pneumothorax
Tongue displacement
Failed procedure
Gastric aspiration
Pneumothorax
PromptGeneric Airway plan for sick patient in extremis
ResponseGet help - at least 1 more senior MO + 2 nursing staff
Resus area, full monitoring (ECG, NIBP Q2min, ETCO2, Sats)
Optomise oxygenation - upright with BVM 10 cm.H2O PEEP or NIV, FiO2 1.0
Optomise BP - N/S 250+250 aim SBP >90
Vasoppressors - Aramine or adrenaline 10 mic boluses/infusion
Equipment
(? needs defib pads on if cardiac)
Resus area, full monitoring (ECG, NIBP Q2min, ETCO2, Sats)
Optomise oxygenation - upright with BVM 10 cm.H2O PEEP or NIV, FiO2 1.0
Optomise BP - N/S 250+250 aim SBP >90
Vasoppressors - Aramine or adrenaline 10 mic boluses/infusion
Equipment
- Video/direct laryngoscope, bougie, ETT 7.0+8.0, suction
- Ketamine 0.5-1mg/kg or Fent + midaz (Prop bad if hypotensive)
- Rocuronium 1.5-2mg/kg
(? needs defib pads on if cardiac)
PromptVideo Laryngoscope pro/con
ResponsePros:
Better view if C spine protection required
Others can see and help
Less risk of oesophageal intubation
Less haemodynamic response to intubation
Con
More expensive
Equipment may fail
Slower to set up
Better view if C spine protection required
Others can see and help
Less risk of oesophageal intubation
Less haemodynamic response to intubation
Con
More expensive
Equipment may fail
Slower to set up
PromptD (Dorges) hyperangulated blade Pro/con
ResponsePro
Good view if larynx anterior
Can get D blades with video capabilities
Con
Can make normal intubation very difficult (especially if operator not familiar with blade)
Good view if larynx anterior
Can get D blades with video capabilities
Con
Can make normal intubation very difficult (especially if operator not familiar with blade)
PromptDirect laryngoscopy pro/con
ResponsePro
Portible
Inexpensive
Easily accessible in any ED
Performance similar to videolaryngoscope in experienced user
Camera lens can’t obstruct with secretions/blood
Con
Failure rate higher than videolaryngoscope
Portible
Inexpensive
Easily accessible in any ED
Performance similar to videolaryngoscope in experienced user
Camera lens can’t obstruct with secretions/blood
Con
Failure rate higher than videolaryngoscope
PromptMcCoy Blade (adjustable hinged tip) Pros/cons
ResponseBetter direct visualisation of the cords
Can cause trauma to epiglottis
May be difficult if operator not experienced with this type of blade
Can cause trauma to epiglottis
May be difficult if operator not experienced with this type of blade
PromptThings that make induction and intubation more difficult (Non airway stuff)
ResponseHaemodynamic instability
Drug/Etoh use - non compliance with interventions/preoxygenation
Drug EtOH use - Potential for vomiting with decreased LOC
Trauma
Drug/Etoh use - non compliance with interventions/preoxygenation
Drug EtOH use - Potential for vomiting with decreased LOC
Trauma
- C spine precautions
- Facial trauma
PromptProblems during peri-intubation period
ResponseHypotension
Hypoxia
Difficulty intubating
Difficulty ventilating
Difficult BVM
There was a lot on management of these problems and it was all common sense
Hypoxia
Difficulty intubating
Difficulty ventilating
Difficult BVM
There was a lot on management of these problems and it was all common sense
PromptDescribe your preferred ventilator setting
ResponseARDSNet Ventilation = protective lung ventilation
TV 6 mL/kg (on ideal body weight) - up to 8 mL/kg with severe dyspnoea
Set RR to maintain optimal minute ventilation (RR<35)
Aim for sats 88-95%, or PaO2 55-80
Invrease PEEP (5-24 cm.H2O) with increasing FiO2 on sliding scale
Aim for plateau pressure <30
TV 6 mL/kg (on ideal body weight) - up to 8 mL/kg with severe dyspnoea
Set RR to maintain optimal minute ventilation (RR<35)
Aim for sats 88-95%, or PaO2 55-80
Invrease PEEP (5-24 cm.H2O) with increasing FiO2 on sliding scale
Aim for plateau pressure <30