Airway anatomy
what are the two types of chin lifts that are used ?
Head tilt chin lift
&
modified jaw thrust = most common for trauma patients or suspected spinal injury
what is the minimum o2 setting for all airway devices?
Nasal cannula 2-6
nrb 12-15
BVM 15
What are the two types of blades that can be use to intubate and the size range?
mac (curved) & miller (straight ) 0-4
What do you do for someone whos choking?
abd thrusts
if unconscious use magic force pts with laryngoscope
How to you ventilate and who do you ventilate?
Used to provide assisted ventilations to patients who are breathing spontaneously or not at all.
Signs of changing mental status, cyanosis w/shallow breathing also indicated need to ventilation
Breathing slower then 8 BPM = assisted ventilation’s
O2 SHOULD BE SET TO 15 LPM WHEN VENTALATING
To ventilate use “E” “C” TECHQUIUQE and cover the patients nose and mouth with mask, give a breath every 5-6 seconds
Pediatric 7-8 seconds < 35 kg
*IF VENTALATIONS ARE TO FORECFULL IT CAN FORCE AIR INTO THE STOMACH = Gastric distension*
How can you tell if your tube has gone to far & what does this mean?
tube has rightmainstemed ( deflate ballon & pull tube back slightly) l/s only heard on right side
tube is in the stomach ( l/s heard over stomach)
What is the dosage for sucs & roc?
Succinylcholine= 1.5mg/kg rapid iv push
- Dosed on the total body weight
- May round to the nearest 50mg for adults (max 200mg)
Rocuronium = 1mg/kg
-dosed on total body weight
-may round to the nearest 20mg for adults (max 100mg)
what are the structures of the upper airway?
• Mouth- Nose – nasal cavity- pharynx(nasopharynx, oropharynx, Laryngopharynx) – larynx, epiglottis, vallecula, glottic opening
• Vallecula = Anatomic space or “pocket”
NPA/OPA ( MEASURING,INSERTION,SIZING)
OPA= measure from the tip of the earlobe to the corner of the mouth
- once measured , may be placed if the patient done’s not have a gag reflex. to insert have the opa open pts mouth have curved part facing the roof of the mouth then rotate once in to conform to the patients tongue
NPA= merasure from the nose to the earlobe, then place a water soluble lubricant on the tube next insert into the right nostril w/ the bevel facing the septum
Where does the mac & Miller blade sit once inside the patient ?
mac- Beneath the epiglottis & lifts it up
miller- tip goes into the vallecula , indirectly lifts epiglottis and exposes vocal cords
What is tidal volume & minuet volume ?
tidal volume is volume of gas inhaled or exhaled during one breath during a normal respiration
minuete volume= total volume of ai Inhaled and exhaled from the lungs in one minuete
How do you ventilate a patient with a stoma ?
-If no tracheostomy is in place, use mouth to stoma or BVM
- Use infant or child size mask and create a seal over the stoma
- Seal pts mouth and nose with one hand and release when giving a breath
Indication for intubation / contraindications
- Airway control needed
- Ventilatory support before impending respiratory failure
- Prolonged ventilatory support
- Absence of gag reflex
- Unresponsiveness
- TBI
- Impending airway compromise
Contraindications:
- Intact gag reflex
Inability to open mouth because of trauma, dislocation of the jaw or a patho condition
- inability to see the glottic opening
- copious secretion’s ,vomit or blood in airway
What is etomidate (class), dosage, effects ?
Sedative hypotonic drug
Can cause resp depression , has little effect on HR,BP.
fast acting, short lasting
0.3 mg/kg rapid IV push
dosed on the total body weightMay round etomidate (Amidate) dose to the nearest 10 mg for adults (Max 40 mg)
Which anatomical structure separates the upper airway from the lower airway?
the glottis opening
What are some lower airway sounds ?
wheezing,crackles,rhonchi,pleural rub
What is the landmark you should look for when intubating ?
vocal cords , epiglottis
What is a biots pattern?
non pattern format of slow,fast and apenic breathing
Hyper ventilation vs hypo ventilation & effects on co2 and how do we vent there patients properly?
Hyperventilation= co level is hirer then 40 (pt is alkalik) slow down breathing
hypoventilation = co levels lower then 30 (acidotic pt) ventilate faster
What is a sedative hypnotic ?
induce sleep, decrease anxiety (benzodiazepine’s) Ativan, versed( midazolam) , valuim (diazepam)
what is a neuromuscular blockade medication ?
which medications are considered this class?
Affect every skeletal muscle
Within about 1 minute, patient is paralyze
Must be able to secure the airway
No effect on LOC.
ex: succ & roc
What is peep?
What are some upper airway sounds that can be heard?
stridor
grunting
What is nasaltracheal intubation& how is it preformed?
• Preoxygenate
• Select correct tube size
• Insert the bevel towards the septum (when patient is inhaling advance the tube)
• Aim tip of the tube straight back toward the ear
• As tube is advanced you will begin to hear air rushing in and out of the tube as the patients breaths
• GOAL= POSTION THE TUBE JUST ABVOVE THE GLOTTIC OPENING
What are adventitious breath sounds ?
irregular breath sounds heared in the lungs during auscultation
What is the process of McGill forceps and who are they used for ?
• Place pts head in the sniffing position, open the airway and insert appropriate sized laryngoscope blade
• Visualize the obstruction and retrieve the object with the Magill forceps’
Remove object
Attempt to ventilate the patients
used for unconscious patients
What is the acronym LEMON mean & 3-3-1 method ?
LEMON
L- look externally
E- evaluate 3-3-2
M- Mallampati ( 1-4 “open mouth say ahhh) 1- see uvula ,2- see top and not bottom of uvula, 3- can barely see uvula ,4 – terrible airway, cannot see anything
O- obstruction - is there a obstruction?
N- neck mobility - can there neck move ?
OR
3- MOUTH WIDTH OF MORE THAN 3 FINGERS (SEE IF YOU CAN GET 3 FINGERS IN MOUTH, IF SO GOOD AIRWAY)
3- MANDIBLE LENGTH OF 3 FINGERS
2- DISTANCE FROM HYIOD BONE TO THYRIOD NOTCH OF 2 FINGERS WIDE IS BEST
* Every time blade enters the mouth= tube attempt *
· * If you cannot get in a decent amount of time take blade out and ventilate patient to prevent hypoxia*
What is a non depolarizing RSI medication?
• blocks ACH receptors, does not cause depolarization of the muscle fiber
- Prevent fasciculations before a depolarizing paralytic
EX; vuercoruim and rocuronium
contraindication’s :
• known hypersensitivity to drug
• 30-40 min half life’s
Which structure is at the end of the trachea?
the carina
what is the difference between respiratory distress and respiratory failure w/signs?
resp distress = pt is still breathing, however there is inadequate gas exchange
- they can not speak in full sentences
accessory muscle use, RR & HR increase , nasal flaring
Respiratory faliure= resp rate slows, oxygenation/ventilation's can’t support body’s demands of patients body
* NEEDS VENTILATORY SUPPORT*
ams, airway not patent, RR decreases, hr decreases
- slow sluggish respirations
What is the procedure for intubating a patient?
1.) pre oxygenate ( use BVM ) (hyperventilate pt) , place a bls airway
- If no visualization of anatomical landmarks, take out blade and give breath
2.) Prepare all necessary equipment ( bugie, ET – tube w/sytlet, suction,10cc syringe)
3.) Place patient in “sniffing position” ( may put a towel under the head)
4.) Open mouth ( mac goes in right side (providers right side) and moves to the left until the tip is in vallecula then pull up)
- Right to left sweeping mechanism
5.) Insert blade technique
6.) Exert gentle traction at a 45° angle to lift the PATIENTS JAW
7.) Continue to lift to bring glottis into view
8.) Gently pass the tube trough the glottis
- As soon as black line or ballon passes your visual field = in deep enough
9.) Remove laryngoscope and turn it off
10.) Hold the tube and pull out stylet or bougie then inflate the ballon (take off synrige)
11.) Ventilate the patient with bvm and auscultate lung sounds / epigastric sounds
( if epigastric sounds are heard then tube may be in the stomach = pull tube )
12.) Apply capnography & also look for return mist condensation in the tube
( apply capno between bvm and the tube) *LOOK FOR WAVEFORM)
13.) APPLY tube holder which has a built in bite block
14.) *NOTE NUMBER OF TUBE AT THE LIP *
Best way to conform tube is in is to visualize tube passing vocal cords
what is SAO2 & SPO2?
sao2 is the % of hemoglobin in the artieral blood that is carrying oxygen
spo2 percentage of hemoglobin molecules that bind to oxygen molecules in the blood
needle circ process & landarks
Uses a canula to ventilate below the glottic opening= temporary
• LANDMARK= cricothyroid membrane ( between thyroid and cricoid membrane)
• Gather the materials 12 or 14 gauge catheter 10/20cc syringe w/needle
• Find the cricothyroid membrane, clean site
• Insert the needle at a 90 degree angle then move it towards a 45 degree angle once in towards the carina ( look for air in the syringe)
• Advance catheter remove needle
• Secure the catcher and provide ventilations
What is the 7 P‘s of rsi?
- Preparation
- Pre oxygenation ( Nc 15lpm and nrb 15 if breathing on their own = nitrogen wash) this allows pt to stay hypoxic or apneic for longer
- Pre-intubation optimization (positioning from beginning)
- Paralysis w/ induction (Give sedative then put into position that you want the patient in to be intubated)
(should not take longer then 60 seconds, when pt is out then push the paralytic)
(once fasciculation stops muscles are paralyzed)
- Positioning
- Placement w/ proof-( capno, l/s, epigastric sounds)
- Post- intubation management
• ( continue to sedate depending on transport time to prevent patient from waking up, evaluate every 5 mins )
What is depolarizing RSI meds?
Depolarizing
Competitively binds with ACh receptor sites
- Fasciculations can be observed during its administration until muscles are paralyzed
Ex; Succlynolcholine
Contraindication’s:
• pt with auto immune
Disorders can not get this
• Creates hyperkalemia