Airway management
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![Page 1: Airway management](https://reader036.fdocuments.in/reader036/viewer/2022062513/55625c72d8b42ae87d8b474f/html5/thumbnails/1.jpg)
Airway ManagementAirway Management
Emergency Medicine Emergency Medicine
Seminar SeriesSeminar Series
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Michael HaMichael HaSection of Emergency Medicine
4th year Resident
John SokalJohn SokalHealth Sciences Centre
12 years
Bob SweetlandBob SweetlandHealth Sciences Centre
15 years
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May 2, 2002
BRANDON
KILLARNEY
PORTAGE
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eMEDiUMeMEDiUM
Emergency Medicine Emergency Medicine in the U of Min the U of M
emergency.mb.caemergency.mb.ca
Back
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CAEP CAEP ACEP ACEP
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CME ObjectivesCME Objectives
To discuss:
• the indications for intubation
• the approach to RSI
• capnometry
• bougies
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Intubate?
RSI vs. Awake
Preparing for patient
Difficult BVM
Difficult Intubation
Capnography
Laryngoscopy Tips
Bougies
Lightwand - LMA
Preoxygenation
Pretreatment
O2 Delivery
Thiopental
Ketamine
Propofol
Succinylcholine
Rocuronium
Finish
Master
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Intubation Indications
Is there a failure of
airway maintenance or protection?
Is there a failure of
ventilation or oxygenation?
What is the
anticipated clinical course?
Back
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45 female
alcoholic beverages empty pill bottles
HR 125
BP 98/40
RR 20 GCS 8
O2Sats 100% (PRB)
no injuries
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
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Cases60 VF
44 MVA
25 asthma
15 fall
28 bull
16pencil
40fire
22 TCA
54CRF
67HTN
51melena
45 overdose
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AMI VF - defibrillated 3x
60 male IHD
HR 110
BP 68 / 40
RR 10
O2Sats 90% (BVM)
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
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MVA MVA 100 kph kph
44 female
HR 130
BP 100 / 70
RR 28
O2Sats 99% (BVM)
GCS 6
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
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SOB 2 days severe distress
HR 145
BP 98 / 42
RR 30
O2Sats 80% (PRB)
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
25 female asthma
cases
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fell from treefell from tree
HR 110
BP 100 / 50
RR 20
O2Sats 99% (BVM)
GCS 8
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
15 15 female
cases
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playing with bull blunt trauma
HR 130
BP 80 / 60
RR 28
O2Sats 99% (PRB)
abdomen rigid
pelvic fracture
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
28 male
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pencil oropharynx 'buddy' pulled it out
HR 80
BP 115 / 60
RR 16
O2Sats 99% (room)
voice change
hematoma visible
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
16 male
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house fire prolonged exposure
HR 115
BP 130 / 60
RR 28
O2Sats 96% (PRB)
singed facial hair
soot in mouth
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
40 female
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ingestion amitryptyline quantity unknown
HR 145
BP 100 / 42
RR 14
O2Sats 99% (PRB)
GCS 8
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
22 22 female
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on dialysis holiday respiratory distress
HR 115
BP 200 / 120
RR 36
O2Sats 88% (NRB)
peaked T's
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
54 male CRF DM
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on ACE inhibitor oral angioedema
HR 85
BP 150 / 80
RR 20
O2Sats 99% (room)
slight stridor
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
67 female HTN
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melena 2 days hematemesis
HR 165
BP 50 palpation
RR 28
O2Sats 92% (NRB)
vomiting red blood
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
51 male cirrhosis
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HR 125
BP 180 / 100
RR 32
O2Sats 86% (NRB)
SOB over 3 days SOB over 3 days worsened overnightworsened overnight
Questions?
Indication?
Awake vs RSI?
LOAD?
Induction agent?
Paralytic agent?
cases
68 male CHF
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45 female
alcoholic beverages empty pill bottles
Intubate?Intubate?
HR 125 BP 98/40
RR 20 GCS 8
O2Sats 100% (PRB)
no injuries
Indication?
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Intubation Indications
Is there a failure of
airway maintenance or protection?
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50 yo male
SOB over 2 days worsened overnight
HR 135 BP 150/90
RR 10
O2Sats 86% (NRB)
'tight'
wheezes bilaterally
Intubate?Intubate?
Indication?
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Intubation Indications
Is there a failure of
ventilation or oxygenation?
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HR 100 BP 105/60
RR 20 GCS 10
O2Sats 100% (PRB)
multiple injuries
transfering to HSC
Indication?
34 yo male
MVA ejected from car
Intubate?Intubate?
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Intubation Indications
What is the
anticipated clinical course?
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Intubation Indications
Is there a failure of
airway maintenance or protection?
Is there a failure of
ventilation or oxygenation?
What is the
anticipated clinical course?
Back
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Rapid Sequence IntubationRapid Sequence Intubationa potent induction agent
followed immediately by
the patient has not fasted• at risk of aspiration
a rapidly-acting NMB
to induce unconsciousness and motor paralysis for intubation.
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Rapid Sequence IntubationRapid Sequence Intubation
take nothing that you cannot return or replace
approach every airway as a potential difficult airway
be prepared
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The 7 P’sThe 7 P’s1. Preparation
2. Preoxygenation
3. Pretreatment
4. Paralysis with induction
5. Positioning with protection
6. Placement with proof
7. Postintubation management
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Awake IntubationsAwake Intubations
“Awake” means that patient can:
• follow simple instructions
• provide feedback
• can respond to events
• sedation – versed, fentanyl• topical lidocaine• oral, nasotracheal, fiberoptic
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Paralysis contraindications
Choices… paralyze?Choices… paralyze?
prediction of difficulty
difficult BVM
difficult intubation
lack of equipment
unnecessary
inexperience
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STOP IC BARS
S staff, suction
T tube
O oxygen
P pharmacology (meds)
PreparationPreparation
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PreparationPreparation
I intravenous lines
C connect to monitors
B blades, bougies
A alternate (lightwand)
R rescue (LMA, combitube)
S surgical (cricothyroidotomy)
STOP IC BARS
Back
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Difficult Mask VentilationDifficult Mask Ventilation
B eard
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Difficult Mask VentilationDifficult Mask Ventilation
O bese
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Difficult Mask VentilationDifficult Mask Ventilation
O lderT oothless
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Difficult Mask VentilationDifficult Mask Ventilation
S nores
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PreparationPreparationAssessment for Difficult Mask Ventilation
BOOTS
B beard
O obese
O older
T toothless
S snores
Back
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Difficult Mask VentilationDifficult Mask Ventilation
repositionOP / NP airway2 person change mask? obstruction
Back
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RepositioningRepositioningOral – Pharyngeal - Laryngeal Axes
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RepositioningRepositioningHead extended on neck
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RepositioningRepositioning“Sniffing” position
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RepositioningRepositioning“Sniffing” with extension
Back
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PreparationPreparation
Assessment for a difficult intubation
Lemon Law
L look E evaluate (3-3-1 rule)M MallampatiO obstructionN neck mobility
Back
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3-3-1 Rule3-3-1 Rule
3
3 fingersmouth
opening
1 fingeranterior jaw subluxation
31
3 fingershyomentaldistance
(room for tongue)
Back
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MallampatiMallampati
Back
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PreoxygenationPreoxygenationis the establishment of an is the establishment of an oxygen reservoir.oxygen reservoir.
• “ “no baggingno bagging” principle of RSI” principle of RSI
• “ “apnea timeapnea time” concept” concept
• 100% O100% O22 for 5 minutes for 5 minutes
• effect of body size & metabolic demandseffect of body size & metabolic demands
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Back
ApneaTime
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PretreatmentPretreatmentis the administration of drugs is the administration of drugs to mitigate the adverse effects to mitigate the adverse effects associated with intubation.associated with intubation.
L L idocaineidocaineO O piodespiodesA A tropinetropineD D efasciculationefasciculation
Back
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Paralysis after inductionParalysis after induction
thiopentalthiopentalketamineketaminepropofolpropofoletomidateetomidateversedversed
succinylcholinesuccinylcholinerocuroniumrocuronium
skip drug section
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Contraindication: porphyria
ThiopentalThiopentalINDUCTIONINDUCTION
cerebroprotective
potent vasodilator myocardial depressant
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ThiopentalThiopentalINDUCTIONINDUCTION
Onset: 15 - 30 seconds
Dose: 3 - 5 mg / kg (euvolemic)
1 - 3 mg / kg (hypovolemic)
Duration: 5 - 10 minutes
Back
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analgesia - amnesia
KetamineKetamineINDUCTIONINDUCTION
bronchodilation
catecholamine release
hypovolemic - hypotensive agent of choice
ICP (significance ?)(cerebroprotective ??)
stimulating effects: laryngeal reflexessecretions
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KetamineKetamineINDUCTIONINDUCTION
Onset: 15 - 30 seconds
Dose: 1 - 2 mg / kg
Duration: 15 - 30 minutes
lower dose if profound shock:maximal sympathetic stimulation already -ketamine has intrinsic CV depression
Back
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PropofolPropofolINDUCTIONINDUCTION
dose-dependant sedation - amnesia
no analgesic properties
airway reflexes: dose-dependant depression
potent vasodilator, myocardial depressant(effect may exceed that of thiopental)
cardiac & respiratory depression related to rate of administration as well as dose
cerebroprotective ICPICP CPP
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Contraindication:Contraindication: egg, soybean allergiesegg, soybean allergies
PropofolPropofolINDUCTIONINDUCTION
Onset:Onset: 30 - 4030 - 40 secondsseconds
1 - 31 - 3 mg / kg mg / kg (induction)(induction)Dose:Dose:
Duration:Duration: 5 - 105 - 10 minutesminutes
Combo: Combo: ketamine 50 mgketamine 50 mgpropofol propofol 50 mg50 mg
Back
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EtomidateEtomidateINDUCTIONINDUCTION
most hemodynamically stablemost hemodynamically stable
minimal cardiac & respiratory depressionminimal cardiac & respiratory depression
cortisol suppression (cortisol suppression (nono ED cases) ED cases)
myoclonus / hiccupsmyoclonus / hiccups
cerebroprotectivecerebroprotective ICPICP
30% - 40% nausea / vomiting30% - 40% nausea / vomiting
does not block BP response to intubation does not block BP response to intubation
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Onset:Onset: 20 - 3020 - 30 seconds seconds
Dose:Dose: 0.2 - 0.30.2 - 0.3 mg / kg mg / kg
EtomidateEtomidateINDUCTIONINDUCTION
Duration:Duration: 5 - 155 - 15 minutes minutes
Back
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Paralysis contraindications
Choices… paralyze?Choices… paralyze?
prediction of difficulty
difficult BVM
difficult intubation
lack of equipment
unnecessary
inexperience
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SUX contraindications
Choices… SUX or ROC?Choices… SUX or ROC?
difficult BVM or intubation neuromuscular disorders hyperkalemia 24 hours post-burns 7 days post-crush 7 days post-denervation malignant hyperthermia
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SuccinylcholineSuccinylcholinePARALYSISPARALYSIS
• duration of action is dependant on:• rapid hydrolysis - pseudocholinesterase• diffusion away from motor end plate (no
pseudocholinesterase at end plate)
• only a fraction of dose ever reaches end plate give large doses no harm giving too much problem when incompletely paralyzed give extra 20% (2 mg / kg)
• depolarizing NMB fasciculations
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Onset: 10 - 15 seconds (fasciculations)
45 - 60 seconds (paralysis)
Dose: 1 - 2 mg / kg (adults) 2 mg / kg (children) 3 mg / kg (newborns)
SuccinylcholineSuccinylcholine
Duration: 3 - 5 minutes (some resps)
8 - 10 minutes (adequate)
PARALYSISPARALYSIS
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SuccinylcholineSuccinylcholine
Side- Effects
• fasciculations
• hyperkalemia
• bradycardia
• malignant hyperthermia
• prolonged blockade
• trismus - masseter muscle spasm
PARALYSISPARALYSIS
Back
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SuccinylcholineSuccinylcholine
Fasciculations
• nicotinic receptor stimulation
• inhibiting fasciculations - little evidence
• occurs same time as ICP
PARALYSISPARALYSIS
side-effects
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SuccinylcholineSuccinylcholine
SUX-induced Hyperkalemia
• under normal situations, increase of:
0.50.5 mEq/L KmEq/L K++
• small risk of dysrythmia: CRF severe acidosis rhabdomyolysis
Preexistent K+
PARALYSISPARALYSIS
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• increased extrajunctional receptors:
5 - 105 - 10 mEq/L KmEq/L K+ +
prolonged depolarization
refractory to non-depolarizing NMB, may require large doses
SuccinylcholineSuccinylcholine
Exaggerated release of KExaggerated release of K++
PARALYSISPARALYSIS
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SuccinylcholineSuccinylcholine
Exaggerated release of K+
• functional denervation of muscle: stroke spinal cord injury
• extensive burns
• massive crush injuries
• neuromuscular disorders
PARALYSISPARALYSIS
side-effects
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SuccinylcholineSuccinylcholinePARALYSISPARALYSIS
Receptor Recruitment & Sensitization
Onset: 7 daysDuration: 2 - 3 months
Crush:
Onset: 7 daysDuration: 6 months
Denervation:
Onset: 24 hoursDuration: 2 years
Burns:
(% burn does not determine response)
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Neuromuscular disorders:
SuccinylcholineSuccinylcholinePARALYSISPARALYSIS
Receptor Recruitment & Sensitization
SUX contraindicated
If give SUX: intractable cardiac arrest may
occur (even if recognize and treat K+)
side-effects
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SuccinylcholineSuccinylcholine
Bradycardia
• cardiac muscarinic receptor stimulation
• succinylmonocholine (a metabolite) sensitizessinus node receptors to repeat doses
consider atropine if: age < 10repeating dose
• children have vagal tone
PARALYSISPARALYSIS
side-effects
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SuccinylcholineSuccinylcholine
Prolonged Neuromuscular BlockadeProlonged Neuromuscular Blockade
• congenital absence of pseudocholinesterase
• presence of an atypical form
may last hours
PARALYSISPARALYSIS
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• acquired absence:• cocaine• metoclopramide (Maxeran)• CRF• severe liver disease• hypothyroidism• malnutrition• pregnancy• cytotoxic drugs• organophosphates
SuccinylcholineSuccinylcholine
Prolonged Neuromuscular Blockade
PARALYSISPARALYSIS
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• acquired absence:
• even worst of acquired not reportedto last > 25 minutes
SUX not contraindicated
SuccinylcholineSuccinylcholine
Prolonged Neuromuscular Blockade
PARALYSISPARALYSIS
side-effects
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• mortality 60%
• onset can be acute or delayed for hours
SuccinylcholineSuccinylcholine
Malignant Hyperthermia
• genetic skeletal muscle abnormality
• can be triggered by: SUX stress vigorous exercise halothane
PARALYSISPARALYSIS
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• muscle rigidity• autonomic instability• hypotension• hypoxia• severe lactic acidosis• myoglobinemia• DIC• fever - late manifestation
SuccinylcholineSuccinylcholine
Malignant Hyperthermia
PARALYSISPARALYSIS
side-effects
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• prevents Ca++ release from sarcoplasmic reticulum of skeletal muscle
SuccinylcholineSuccinylcholine
Dantrolene for MH
• essential to resuscitation
• give as soon as Dx suspected
• free of serious side-effects
Dose: 2.5 mg/kg IV q5min until muscle relaxation, or max 4
doses
PARALYSISPARALYSIS
side-effects
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SuccinylcholineSuccinylcholine
Trismus - Masseter Muscle Spasm
• rise in jaw muscle tension is normal should not affect laryngoscopy
• pretreatment will not prevent
• if severe, or progresses to other muscles: consider malignant hyperthermia spasm is not pathonomonic for MH
• if occurs - administer non-depolarizing NMB (Rocuronium)
PARALYSISPARALYSIS
side-effects
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RocuroniumRocuronium
• Nondepolarizing, does not stimulate receptor
no fasciculations
PARALYSISPARALYSIS
• minimal hemodynamic effects
• do not need priming dose
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Dose: 0.6 - 1.2 mg / kg
RocuroniumRocuroniumPARALYSISPARALYSIS
Onset: 60 - 90 seconds
Duration: 30 - 60 minutes
Defasiculating: 0.05 mg / kg
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Comparing NMBComparing NMBPARALYSISPARALYSIS
SUX ROCONSET 30 - 60 60 - 90 sec
DURATION 3 - 10 20 - 60 min
rapid rapidno primingCVS stability
advantages
precautions K+
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Comparing NMBComparing NMBPARALYSISPARALYSIS
sec
min
VEC
150 - 180
25 - 30
no histaminerelease
PAN
120 - 180
60 - 90
histaminerelease
ATRA
120 - 150
20 - 35
histaminerelease
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Positioning with protectionPositioning with protection
You are asked to apply:
cricoid pressure
(Sellick’s maneuver)
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BURPBURP
B ackwards
U pwards
R ightward
P ressure
• distinct from Sellick’s maneuver• second assistant• first assistant’s other hand
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ManeuversManeuvers
Back
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LaryngoscopyLaryngoscopy
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LaryngoscopyLaryngoscopy
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LaryngoscopyLaryngoscopy
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LaryngoscopyLaryngoscopy
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LaryngoscopyLaryngoscopy
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Placement with proofPlacement with proof
methods of confirmation
chest riseair entryfogging of ETT60 cc syringe
* capnometer
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Colorimetric CapnometryColorimetric Capnometry
exhaled CO2
simple color change from
purple to yellow
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Colorimetric CapnometryColorimetric Capnometry
NEGATIVE POSITIVE
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Colorimetric CapnometryColorimetric Capnometry
ETCOETCO2 2 < 4 mm Hg< 4 mm Hg
ETT ETT not innot in trachea trachea
inadequate perfusioninadequate perfusion (ineffective CPR)(ineffective CPR)
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Colorimetric CapnometryColorimetric Capnometry
ETCOETCO2 2 15 - 38 mm Hg15 - 38 mm Hg
ETT ETT inin trachea trachea
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Colorimetric CapnometryColorimetric Capnometry
ETCOETCO2 2 4 to < 15 mm Hg4 to < 15 mm Hg
retained COretained CO22 in esophagus in esophagus
low perfusionlow perfusion
deliver deliver 66 more breaths more breaths
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Colorimetric CapnometryColorimetric Capnometry
Standard of CareStandard of Care
Limitations:
Back
• decreased cardiac output
• low metabolic CO2 productionex. hypothermia
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BougieBougie
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Epiglottis
![Page 102: Airway management](https://reader036.fdocuments.in/reader036/viewer/2022062513/55625c72d8b42ae87d8b474f/html5/thumbnails/102.jpg)
Laryngoscopy GradesLaryngoscopy Grades
CormackLehane
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Bougie
![Page 104: Airway management](https://reader036.fdocuments.in/reader036/viewer/2022062513/55625c72d8b42ae87d8b474f/html5/thumbnails/104.jpg)
LightwandLightwand
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LightwandLightwand
Source: Laerdal
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LightwandLightwand
Source: Laerdal
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Laryngeal Mask AirwayLaryngeal Mask Airway
Source: LMA North Americaskip insertion technique
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Laryngeal Mask AirwayLaryngeal Mask Airway
Source: LMA North America
• deflate the cuff deflate the cuff • apply water-soluble lubricant to the apply water-soluble lubricant to the
posterior surfaceposterior surface• place index finger at the junction of the cuffplace index finger at the junction of the cuff
skip insertion technique
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Laryngeal Mask AirwayLaryngeal Mask Airway
Source: LMA North America
• press the tip of the cuff upward against the hard press the tip of the cuff upward against the hard palate and flatten the cuff against itpalate and flatten the cuff against it
skip insertion technique
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Laryngeal Mask AirwayLaryngeal Mask Airway
Source: LMA North America
• use the index finger to guide the LMA, use the index finger to guide the LMA, press backward toward the other hand, which press backward toward the other hand, which exerts counter-pressure (do not use force)exerts counter-pressure (do not use force)
skip insertion technique
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Laryngeal Mask AirwayLaryngeal Mask Airway
Source: LMA North America
• advance the LMA into the hypopharynx until a advance the LMA into the hypopharynx until a definite resistance is felt.definite resistance is felt.
• inflate the cuffinflate the cuff
skip insertion technique
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O2 Delivery Systems
Nasal cannulae
Double rate - add to room air FiO2
ex. 3 L / min + 21 % FiO2
= 27 %
Limitations:rates > 3 L / min uncomfortablemouth breathing
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O2 Delivery Systems
Simple Face Mask
6 – 10 L / min flow
35 – 55 % FiO2
• entrainment of room air through exhalation ports
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O2 Delivery Systems
PartialRebreathingFace Mask
reservoir bag
• first ~ 1/3 of exhaled gas is directed into bag
(that which was in patient’s upper airway)
• up to 60 % FiO2
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O2 Delivery Systems
Non-Rebreathing Face Mask
• reservoir bag• one-way valves
• up to 80 % FiO2
(realistically)
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O2 Delivery Systems
Bag Valve Mask
(BVM)
• up to 100 % FiO2
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Airway ManagementAirway Management
?? ??
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eMEDiUMeMEDiUM
Emergency Medicine Emergency Medicine in the U of Min the U of M
emergency.mb.caemergency.mb.ca
Back
![Page 119: Airway management](https://reader036.fdocuments.in/reader036/viewer/2022062513/55625c72d8b42ae87d8b474f/html5/thumbnails/119.jpg)
HSC ED HSC ED
Maryann Cromwell
phone: 787-2934fax: 787-2231
Department of Emergency MedicineHealth Sciences CentreGF 201-800 Sherbrook StreetWinnipeg, MBR3A 1R9
Back
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CAEP CAEP ACEP ACEP