CRASH NOTES

AIRWAY MANAGEMENT
 Gag reflex is NOT indicative of the ability to protect one’s own airway, rather
if the patient has the ability to swallow = patent airway
 Failure to oxygenate, failure to ventilate (remove Co2) refractory to medical
management NIPV is an indication for intubation
 Elective intubation is far more successful than emergent intubation – so
clinical course of illness is an indication for intubation
 Universal Airway Algorithm – Unconscious, unreactive, near death? = crash
airway y/n? – failed airway - Difficult airway? y/n? failed airway - RSI? y/n?
failed airway
 RSI – no crash and no difficult airway concerns, pulse ox MUST be
maintained above 90% otherwise = failed airway, allowed 3 times total
otherwise failed airway – one attempt is the insertion and removal of the
laryngoscope.
 Crash Airway – bag, attempt y/n? no, bag again success y/n? yes, 2.0mg/kg
succinocholine, attempt y/n? no, 2 more attempts for total of 3 attempts with
succinocholine before failed airway
 Difficult Airway – assistance/bag >90% y/n? no, = failed. Can I bag? y/n?
Can I intubate y/n? yes to both = RSI!!! If not = awake technique (sedation
without paralysis), if not able to intubate with laryngoscope, but able to keep
spo2 >90% then use glydescope, blind nasal, King LT
 RSI is better than RSS except if a difficult airway, then RSS is documented as
being more successful
 Failed Airway – spo2 <90% or no success in 3 attempts. Can we keep spo2
>90% y/n? yes, then use rescue airway. If NO, then CRIC (and you may
attempt rescue while setting up cric).

 Preparation – LEMON Look, Evaluate (3/3/2), Mallenpatti, Obstruction,

Neck Mobility (assessment if RSI is feasible)
 3/3/2 3 fingers in the mouth, 3 from chin to hyoid bone, 2 from hyoid bone
to thyroid
 Cormack and lehane grade 1= full cords, grade 2 = half cords, grade 3 = no
cords, only arytnod notch, grade 4 = no glottis opening
 Mallanpatti class one = all uvula and tonsilas pillars, class two = loss of
tonisial pillars, class 3 = only see base of uvula, no throat class four – you just
see hard palate
 SODA – Suction, Oxygen, Drugs, Airways
 MOANS – Mask seal, Obese, Age >55, No teeth, Stiff Lungs = do we have the
ability to bag when RSI’d
 SHORT – Surgery, Hemothorax, Obese, Radiation, Tumor = will we have
difficulty in performing a cricothyrotymy
Preoxygenation – 3-5min of 100% BVM/NRB/CANNULA
 Obese patients d-sat very very quickly
 Pretreatment LOAD Lidocaine (Tight head/tight lungs) 1.5mg/kg, Opiates
for everyone Fentynyl 3mcg/kg Atropine for kids <10 0.02mg/kg
Defasiculaing does 10% normal dose for that agent
 Needs at least 3min before laryngosopy
 Smooth and rapid push, sedative then paralytic
 RSI inductive agents:
Drug does onset duration good/negs
Etomidate 0.3mg/kg 30-60sec 3-5min trismus/vomit/adrenal
supression
Fentanyl 15-30 mcg/kg 60sec 30-60 anagelsic/quick
onset/hemodynamically stable
Ketamine 1-2 mg/kg 30-60 sec 15min symp drug/bad trips
(PCP) – give benzo within 10min to limit emergence reactions
Midazolam 0.2-0.3mg/kg 1-2min 1-2 hr hemo unstable
Thiopental 3-6mg/kg 20-40sec 5-10min big drop in
B/P/decreases cerebral metabolic rate - protective
Propofol 1-3mg/kg 10-50sec 3-10min hypotension

 RSI Neuromuscular Agents

Med Dose Onset Duration
Succs 1-2 mg/kg 1-2min 4-6min
Rocuronium 0.5-1.0mg/kg 1-2min 20-40min

 Contraindications to Succs include anyone with of suspected hyper kalemia,

(rhabdomylyosis, burns greater than 24 hrs, renal failure, labwork) d/t the
increase in K release resulting from the fasiculations diagnoised of family
history of malignant hypothermia, any eye thing (injury, glaucoma ect.)
 Protection
 Positioning - C-spine issues, Kyphosis, Bull neck, Selleck’s manuver
 Placement – place and secure21/23 cm at the teeth women/men or 3 x
diameter of the tube for peds
 Proof – primary and secondary (most definitive is waveform capnography)
 Post-intubation management commercial device, BVM, continued sedation
and possible continued paralysis, monitor ecg/sao2/etco2/NIBP/Temp
 Paralysis increase potential pneumonias and increased ventilator time and
difficulty to wean off. Except ARDS, heat stroke, or traumatic brain injuries
Sedative Drips
Med Dose Class
Midazolam 0.04-0.2 mg/kg/hr Benzo
Lorazopam 0.01-0.1 mg/kg/hr Benzo
MS 0.1 – 0.2 mg/kg/hr Narcotic
Fentanyl 1-3 mg/kg/hr Nacotic
Ketamine 0.5 -4.5 mcg/kg/hr Gen. Anestetic
Propofol 10 – 150 mcg/kg/hr Gen Anesthetic