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