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Life support Test #3
Intubation
| Question | Answer |
|---|---|
| 6 structures of the upper airway | nasopharynx, nasal passages, pharynx, mouth, oropharynx, epiglottis |
| 5 structures of the lower airway | larynx, trachea, alveoli, bronchi, and bronchioles |
| This structure is considered the end of the upper airway | epiglottis |
| This structure is considered the beginning of the lower airway | larynx |
| The structures of the upper airway are responsible for doing what? | warm, filter, humidify air and protect lower airway |
| This upper airway structure is located behind the nasal cavities to the soft palate, functions in respiration, and is extremely delicate and vascular | Nasopharynx |
| This UA structure is visible via the mouth and includes the teeth, tongue, palate and uvula | oropharynx |
| What is the pendulous structure that hangs suspended from the soft palate? | uvula |
| What 2 structures form the roof of the mouth? | soft and hard palate |
| What structure lies in the space between the tongue and epiglottis and means "little valley"? | vellecula |
| This UA structure lies inferior to the tip of the epiglottis to the epiglottis and functions in respiration and digestion? | Laryngopharynx |
| This LA structure connects the pharynx to the trachea at the level of 4-6 Cervical vertebra | larynx |
| The larynx is composed of ____, ____, and _____. It is innervated with branches of what nerve? | cartilage, ligament, and muscle; vagal |
| What is the function of the larynx? | conduct air between the pharynx and lungs and prevent aspiration |
| This cartilage of the larynx is the largest and most superior, shaped like a shield with the glottic opening located posteriorly. AKA "adams apple" | thyroid cartilage |
| This cartilage is attached to the base of the thyroid cartilage and is the first tracheal ring | Cricoid |
| Located between the thyroid and cricoid cartilage, this structure is used for emergency tracheotomy | cricothyroid membrane |
| Located in the Larynx, What are formed by the upper free edge of the cricothyroid membrane? | vocal cords |
| What do the false vocal cords do? | help open the glottis |
| Laryngeal obstructions d/t loss of muscle tone can be caused by these 4 things? | unconsciousness, sedation, anesthesia, cardiac arrest |
| 2 Causes of laryngeal obstruction not d/t loss of muscle tone | laryngospasm, secretions |
| What is the most common cause of obstruction in an unconscious person | tongue |
| 3 signs of airway obstruction | stridor, snoring respirations, and respiratory effort not resulting in chest rise |
| Name 2 manual airway maneuvers | head tilt, chin life and jaw thrust |
| Indications for head tilt chin lift | no cervical injury, patients must have the ability to protect their own airway to prevent aspiration |
| Contraindications for head tilt chin lift | awake patients and spinal injuries |
| Describe how to perform head tilt chin lift | pt in supine position, Place one hand on the pt forehead and apply downward pressure with palm, place the tips of your fingers on the other head under the chin and gently lift while using the same hand to open the mouth by pulling lip down with thumb |
| indications for modified jaw thrust | unresponsive pt with possible c-spine injury |
| Contraindications for modified jaw thrust | awake patient |
| indications for a nasopharyngeal airway | when oral airway contraindicated or impossible, biting, maxillofacial trauma, responsive pt, frequent sx |
| Contraindication for nasopharyngeal airway | pt intolerance, basilar skull fracture |
| Technique for inserting nasopharyngeal airway | lubricate, open airway with head tilt chin lift or jaw thrust, hold at flange like a pencil, slowly insert with bevel pointing toward septum, advance until flange is flush with nostril |
| Indications for Oropharyngeal airway | maintain open airway of unresponsive pt, aide in ventilation with BVM, used as a bite block after ETT insertion |
| Contraindications for oropharyngeal airway | responsive/awake pt |
| How do you know correct sizing of oropharyngeal airway | corner of mouth to angle of jaw |
| 4 Essential components of a BVM | self refilling bag, mask, oxygen reservoir, and supplemental O2 source |
| 3 advantages of BVM ventilation? | can convey a sense of compliance, immediate ventilatory support, spontaneous or apneic patients |
| 2 disadvantages | difficult to maintain leak proof seal and gastric distention |
| What technique can you use to clamp the esophagus while bagging so air doesn't go into the stomach? | apply cricoid pressure |
| 5 things to do if chest does not rise while using BVM | reposition airway, check for airway obstruction, lift the jaw, suction, and intubate if necessary |
| What could make it hard to achieve an adequate seal with BVM? | obese, facial hair, no teeth (lack of support to form mouth), pt with poor compliance (CHF, bronchospasm, pneumothorax) |
| Reasons for intubation | Respiratory depression d/t drugs, support for gas exchange, increase lung volume, maintain an obstructed airway, foreign body, bleeding, edema, trauma, altered LOC, potential aspiration, elective(surgery) |
| Criteria for intubation | NIF<-20cwp, VC<10cc/kg/ibw, VT<5cc/kg/ibw, RR<10 or >20, low pH, High CO2, low PaO2, VE A-aDO2 |
| What is visible in Mallampati Class I | soft palate, uvula. fauces, tonsillar pillars |
| What is visible in Mallampati Class II | soft palate, uvula, and fauces |
| What is visible in Mallampati Class III | soft palate, base of uvula |
| What is visible in Mallampati Class IV | only the hard palate |
| The distance from the mentum of the chin to the hyoid bone should be how many finger breadths in the adult? | 3 |
| 11 pieces of equipment needed for intubation | oral airway, BVM, Flow meter, Sx, Laryngoscope handle and blades, ETT tubes, 10cc Syringe, Stylet, Tape, Stethoscope, ETCO2 or colormetric |
| Laryngoscope blade sizes for infants | 0-1 |
| Laryngoscope blade sizes for adults | 3-4 |
| The laryngoscope blade should reach between what 2 things? | pt's lips and larynx |
| This type of laryngoscope blade directly lifts the epiglottis upward | Miller/straight |
| This type of laryngoscope blade indirectly lifts the epiglottis | Mac/ curved |
| ETT sizes for Male | 7.5-9.0 |
| ETT sizes for Female | 7.0-8.5 |
| 6 ways to confirm ETT placement | visualize as it passes through vocal cords, auscultate stomach then lungs, condensation in tube, bilateral chest rise, CO2 colormetric turns yellow (after 6 breaths), CXR |
| Common errors in techiniquq include | positioning errors, poor head placement, change bed height, dont hunch over, dont push on teeth, too deep/pull scope back |
| Estimated depths for ETT placement for males and female | 22cm Male, 21cm Females |
| Indications for nasal intubation | more comfortable for awake patients, long term intubation, less tube movement, surgical access to mouth needed, c-spine injury, facial fx, avoid risk of hypotension |
| 4 Contraindications for nasal intubation | nasal fx, basilar skull fx, nose bleeds, sinusitis |
| 5 complications of nasal intubation | nose bleed, submucosal dissection, inflammation, edema, stimulation of gag reflex |
| The patient's vocal cords are most open during _____, so that it when you should slowly advance the ETT for nasal intubation | inspiration |
| When placing a nasal airway make sure to monitor what 6 things? | RR, HR, BP, SpO2, LOC, ETCO2 |
| 4 ways to Provide supplemental O2 to the patient while performing Nasotracheal intubation | NC placed in other nare, face mask over mouth, O2 tubing near pt mouth, nasal airway in other nare hooked to O2 |
| Things to try if passage of NT tube into trachea is difficult | turn head to the side, change degree of flexion or extension, cricoid pressure, push larynx toward opposite side of nares, have pt stick out tongue, use laryngoscope and magill forceps, fiberoptic bronch |
| 3 ways to achieve patient comfort for intubation | relief of anxiety, pain and promote rest/sleep |
| When should you avoid sedation? | in shock, airway obstruction or respiratory failure |
| Sedate ______ when high risk of aspiration | lightly |
| Under-sedation of patient can cause what 3 things | poor cooperation resulting in trauma and aspiration, difficulty performing intubation, and hypertension |
| Over-sedation of patient is life threatening and can cause these 4 things | hypoventilation, apnea, cardiac arrest, and decrease or loss of protective airway reflexes |
| 10 factors influencing drug effect | drug potency, dosage, route, speed of admin, hx of drug exposure, pre-existing sedation, age, pre-existing disease, emotional state and pain |
| What are the 2 types of drugs used in sedation and what do they do? | Narcotic analgesics to relieve pain and Sedative Hypnotics to decrease anxiety and induce sleep |
| 3 benefits of Narcotic analgesics | potent analgesics, moderate sedative properties, and no anxiolytic or amnesic properties |
| 5 adverse effects of Narcotic Analgesics | nausea, vomiting, constipation, confusion, respiratory depression |
| 3 narcotic analgesics are | Morphine, Fentanyl, and Demerol(Penthidine) |
| What receptors does morphine act on and how is it metabolized? | opiate receptors in the brain, hepatically metabolized |
| Renal failure can cause elimination half life of Morphine to ______, and not work as well. | increase to many days |
| What is the onset and duration of Morphine? | Onset: 10-15 mins, Duration: 3-6 hours |
| Why does Fentanyl have a rapid onset and shorter duration? | higher lipid solubility enabling rapid penetration and shorter duration d/t redistribution rather than hepatic metabolism |
| Fentanyl onset and Duration? | onset 30 seconds, duration 30-60 minutes |
| What is the reversal agent for Fentanyl called? | Narcan |
| Demerol onset and duration | Onset 10-45 mins, duration 2-4 hours |
| What are sedative hypnotics and what do they do?(example) | Sedatives with anxiolytic, anticonvulsant and amnesic properties to decrease anxiety and promote sleep (Benzodiazepines) |
| This is the most common sedative hypnotic | Versed(Midazolam) |
| Versed onset and duration | Onset 1-3 mins, duration 20-45 mins |
| Reversal agent for Versed | Romazicon |
| Versed is __ times stronger than Valium | 6 |
| What is the onset and duration of the sedative hypnotic Valium(Diazepam)? | onset 1-3 mins, duration 30 mins-2 hours |
| What is the onset and duration of the sedative hypnotic Ativan? | Onset 30 mins, Duration 10-20 hours(if its a drip) |
| This drug is a sedative and moderate anxiolytic with rapid onset and lipid emulsion | Propofol(Diprivan) |
| Duration of action of Propofol | 2-8 mins |
| This produces a temporary loss of sensation or feeling in a confined area of the body | local anesthesia |
| What do inhaled anesthetic agents do? | aerosolized medication into the oropharynx and lungs to inhibit sensory nerves that carry painful stimuli to the CNS. |
| Inhaled anesthetic agents deposit medications (Lidocaine) onto what? | mucus membranes and larger airways |
| What 2 types of drugs are used for Rapid Sequence induction of Anesthesia | Sedatives and paralytics |
| For RSI, sedatives induce ______ and NMBA induce paralysis for ______ | unconsciousness; rapid placement of ET tube |
| Why must sedatives be used with paralytics? | the pt could be awake but d/t paralytics may appear asleep and without pain |
| 4 benefits of Rapid induction | easier to perform intubation, relief of side effects associated with awake intubations, minimal change in vital signs, and avoid trauma associated with struggle |
| 4 side effects associated with awake intubations | hypertension, tachycardia, increased ICP in head injury, airway stimulation worsening bronchospasm |
| 3 adverse effects of Rapid Induction | Myocardial depression, Hypotension, worsening of airway obstruction due to loss of laryngeal muscle tone |
| Preparation of the pt for Rapid Induction includes monitoring what? | HR and rhythm, RR and depth, SpO2 and skin color, BP, LOC and airway |
| The patient should awaken how soon after Rapid Induction? | 10-15 mins |
| How do you prepare the airway for Rapid induction | preoxygenate with 100% FiO2 |
| What 4 things must you keep immediately available during rapid induction? | suction and yankauer, BVM and crash cart |
| What are the 2 types of NMBA and what do they produce? | depolarizing and non-depolarizing to produce temporary paralysis of all the patient's muscles |
| Depolarizing NMBA combine with what receptors at the NMJ? | ACH |
| Name a depolarizing NMBA and how its given | Succinylcholine(SUCS) given IVP |
| What happens to the muscles when given SUCS? | initially all muscles contract simultaneously(fasciculations) then become flaccid. They then remain paralyzed for many minutes until the Pseudocholinterase breaks down the drug |
| What do Non-Depolarizing NMBA block and what happens to the muscles | block the ACH receptors at the NMJ but does not fire them and causes flaccid paralysis from onset |
| How are Non-Depolarozong NMBA's given? | IV drip |
| What can reverse the effects of Non-Depolarizing NMBA's | Cholinesterase inhibitor |
| Name 2 short acting Non-Depolarizing NMBA's | Vecuronium and Atracurium |
| Name 2 long acting Non-Depolarizing NMBA's | Pancuronium(Pavulon) and D-tubocurarine |
| This short acting Non-depolarizing NMBA is commonly used in babies | Vecuronium |
| What 5 drugs can go down the tube | Atropine, Lidocaine, O2, Narcan, Epi |
| How do you monitor sedation? | peripheral nerve stimulator and tests for reversal |
| 2 things that test for reversal are | heal or head lift for 5 seconds and the BIS monitor |
| What foes BIS stand for? | Bispectral index monitor |
| Where can the electrodes for the BIS monitor be placed? | back of wrist, inner ankle, in front of ear |
| Criteria for extubation | adequate respiratory mechanics, stable VS, Normal electrolytes, Hgb, Hct, adequate UO, no acute processes, Adequate LOC, CXR stable, recovery from airway reflexes, recovery from anesthesia |
| Why is Stridor most likely heard when a patient self extubates? | d/t cuff being pulled out inflated |
| Treatment for mild stridor | Cool mist, racemic EPI, Steroids |
| Treatment for moderate to severe stridor | intubation |
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Dabi2
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