Airway Basics

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    Airway Basics

    Airway

     

    For Patients in Cardiac Arrest use LMA until there is ROSC and situation under control

     

    Induction Agents

    Etomidate: 0.3mg/kg IV dose, “cardiac Stable,” unclear effect if dose decreased, may not be ideal for patients in shock

    Propofol: 2mg/kg IV dose, shortest half-live, ideal in scenarios where neurologic exams may be required, sedation for EtOH withdrawal, bronchodilator in Asthma/COPD, most likely to cause hypotension

    Ketamine: 1-2mg/kg IV dose, sympathomimetic effect may be ideal in patients who are already hypotensive, new evidence showing ok to use in patients w/ head trauma/ICH and may actually be agent of choice, ideal agent in bronchospasm (asthma/COPD)

    Note: for patients w/ shock, all agents should be reduced up to 1/10 normal dose depending on scenario, I recommend Ketamine

     

    Preparation:

    – Suction x2

    – Pre-oxygenation (and peri-intubation O2 via NC)

    – Bougie

    – Have second and third failed airway plans ready (e.g. Glideoscope and Cric tray)

     

    For Patients on BiPAP

     

    – Ventilator Setting: NIV

    – Mode: Spontaneous

    – Mandatory Setting: Pressure Control (PC)

     

    For Patients w/ CHF increasing PEEP directly increases alveolar pressure and helps extract fluid, the excess PEEP also reduces preload and thereby decreases congestion by allowing for increased EF

    For Patients w/ Asthma/COPD you essentially want CPAP, these patients have an obstructive etiology for their respiratory distress and are “auto-peeping.”  Therefore, in a pure Asthma/COPD exacerbation PEEP should be zero.  If the patient has unclear history or is presenting w/ a pure CHF exacerbation in this setting it is ok to use PEEP up to 5

     

    For Intubated Patients

     

    – Ventilator Setting: Invasive

    – Mode: Assist Control (AC)

    – Mandatory Setting: Volume Control for Sepsis/ARDS, consider Pressure Control for CHF/MI

     

    Tidal Volume = Protection, 6cc/kg of Ideal Body Weight in ARDS type picture

    Respiratory Rate = Ventilation, use to correct for changes in PCO2

    Flow Rate = Comfort, in patients w/ Asthma/COPD ideally want ration > 1/4

    O2%/PEEP = oxygenation (use table and increase both accordingly)

     

    Once intubation is done and patient is on ventilator do not forget:

    – Head Elevation (or Reverse Trendelenburg when appropriate e.g. C-spine precautions)

    – Blood Gas

    – NG or OG tube

    – CXR

    – Sedation/Patient Comfort***

    – Titrating O2

     

     

    For more information please see attachments below from Dr. Weingart and his Airway Videos/Podcasts

    Vent-handout

    Emcrit-airway-checklist-2013-02-05

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