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5689881-19803RolesMonitor lifeguardDrug pusherDocumenterAirway assistantC-spine stabilizerIntubator00RolesMonitor lifeguardDrug pusherDocumenterAirway assistantC-spine stabilizerIntubatorINTUBATION CHECKLISTAdapted from Greater Sydney Area-HEMS checklist-18852114907Monitor Lifeguard or Assistant reads00Monitor Lifeguard or Assistant reads3821743115570Intubator checks and responds 00Intubator checks and responds Situation briefedCheckResuscitation maximizedCheckRoles assigned CheckSET-UPP.P.E.CheckPosition optimizedCheckOxygen sufficient, maximized and preoxygenatedCheckO2 Mask at 15 liters, Nasal at 15 litersCheckSuction tested/ Gastric suctioning/ In-line suctioningCheckIV/MONITORS/DRUGSTwo I.V.’s workingCheckMonitors visible: Sat Cardiac BPCheckB.P. cuff cycling, opposite sat/IV armCheck Drugs ready:Induction + Paralytic?CheckFluids + or - Pressors?Check Post analgesia / sedation?CheckEQUIPMENTB.V.M., PEEP, Oxygen, End-tidal CO2CheckO.P.A., N.P.A.CheckLaryngoscope testedCheck Endotracheal tube and SyringeCheckCuff tested and lubedCheckStylet and BougieCheckExtra tube, Tube tieCheckAlternate laryngoscope, Supraglottic airway and Cric kitCheckTEAM BRIEFC-spine assistant briefedCheckRisksdiscussedCheckFail plan briefedCheckE.L.M. & bougie plan briefedCheckDesat trigger and plan briefedCheckAny other questions and concerns?47279999224433Yen Chow @TBayEDguy 2016-04-1400Yen Chow @TBayEDguy 2016-04-14CHECKS COMPLETE – ANESTHETIZING AT _ _ : _ _5466080-17307BRIEFINGSituationWhat’s going onTaskWhat we need to doIntentThe reason isConcernsWatch out forCalibrateOther thoughts/ideas?00BRIEFINGSituationWhat’s going onTaskWhat we need to doIntentThe reason isConcernsWatch out forCalibrateOther thoughts/ideas?Succinylcholine contraindications30955369938PROLONGED DURATIONOrganophosphate toxEaton-Lambert Syndrome*Pseudocholinesterase def, Hypothyroidism00PROLONGED DURATIONOrganophosphate toxEaton-Lambert Syndrome*Pseudocholinesterase def, Hypothyroidism6358890NEVER USE (K+ release+++)Malignant hyperthermiaHyperkalemia, Crush injuryMyopathy, Muscular dystrophyAmyotrophic Lateral Sclerosis, Multiple SclerosisGuillain-Barre, Botulism, TetanusBurns ≥ 2nd? >10% BSA >5 days until healedStroke + hemiparesis, Spinal cord injury >5 days until 6 months post injurySevere intra-abdominal sepsis >5 days until resolution00NEVER USE (K+ release+++)Malignant hyperthermiaHyperkalemia, Crush injuryMyopathy, Muscular dystrophyAmyotrophic Lateral Sclerosis, Multiple SclerosisGuillain-Barre, Botulism, TetanusBurns ≥ 2nd? >10% BSA >5 days until healedStroke + hemiparesis, Spinal cord injury >5 days until 6 months post injurySevere intra-abdominal sepsis >5 days until resolutionMalignant hyperthermiaOrganophosphatesHyperkalemia (known or concern), Crush injuryPseudocholinesterase defMyopathies/Muscular dystrophiesMyasthenia gravis(?)Amyotrophic Lateral Sclerosis, Multiple SclerosisGuillain-Barre, Botulism, Tetanus 3095536137086GIVE MOREMyasthenia Gravis** (lasts long tho)00GIVE MOREMyasthenia Gravis** (lasts long tho)Burns ≥ 2nd degree over 10% BSA >5 days until healedStroke with hemiparesis, Spinal cord injury >5 days until 6 months post injurySevere intra-abdominal sepsis >5 days until resolution3095536124696NO PROBLEMParkinson’s DiseaseEpilepsyAcute CVA or spinal cord injury00NO PROBLEMParkinson’s DiseaseEpilepsyAcute CVA or spinal cord injury-146523184150*Sensitive to BOTH depolarizing and non-depolarizing neuromuscular blockers**Resistant to succinylcholine; BUT avoid non-depolarizing, response unpredictable, use ? dose00*Sensitive to BOTH depolarizing and non-depolarizing neuromuscular blockers**Resistant to succinylcholine; BUT avoid non-depolarizing, response unpredictable, use ? doseIntubation drugs09211310Yen Chow @TBayEDguy 2016-02-0700Yen Chow @TBayEDguy 2016-02-07POST-INTUBATIONReassess ABCD vitalsCheckETT securedCheckTube depth, ETCO2 waveform, Cuff pressureCheckIn-line suction readyCheckAnalgesia/SedationCheckSupplies (oxygen, drugs, power)CheckVentilator settingsCheckHead of Bed raised 30 degreesCheckGastric tube & Foley prnCheckSecure all lines and tubesCheckRescue airway equipment nearbyCheckPost debriefingWhat was planned?List objectives and expected actionsWhat actually happened?Review any actions not standard operating procedureReview any safety concernsWhy did it happen?Reasons for ineffective or unsafe performanceWhat can we do next time?Identify effective and ineffective performanceDetermine how to apply the lessons learned to the next time09319471Yen Chow @TBayEDguy 2016-02-0700Yen Chow @TBayEDguy 2016-02-075045710709580012 (3x4) Step Response to desaturationBVMPEEP 15Mask 15 LPMNasal 15 LPMOAW/NPAJaw thrustTwo person1702435113030Jaw thrustAirways (oral / nasal)Work togetherSlow small squeezefrom Rich Levitan@airwaycam00Jaw thrustAirways (oral / nasal)Work togetherSlow small squeezefrom Rich Levitan@airwaycamMask sealUpright lungs, position head / neckClear FB fluidsCoordinated slow small squeeze underhandPulse ox lag? Shock?Sex (6) Steps to BVM (adapted from Jason N. Cook @cptjcook “#SexyBagging”)OPA/NPA2 thumbs down jaw thrust2 person BVMpositionventilate?carefully with coordinationPEEP333946530642Optimize each airway attempt byManipulations (head neck larynx device)AdjunctsSuctionChange size/typeOxygenation, O2 flow, PEEPaddress Toneadapted from #Vortex @VortexApproachNicholas Chrimes @nicholaschrimes and Peter Fritz @pzfritz 00Optimize each airway attempt byManipulations (head neck larynx device)AdjunctsSuctionChange size/typeOxygenation, O2 flow, PEEPaddress Toneadapted from #Vortex @VortexApproachNicholas Chrimes @nicholaschrimes and Peter Fritz @pzfritz 0154940Airways (OPA NPA)BVM and PEEPCO2 end-tidal and confirm (stethoscope)Suction(s) /Gastric /In-line /Magills /MecAspLaryngoscope and alternatesOxygen (pre re and apOx, switch sources)PositionedEndotracheal tube cuff lubed tested syringedStylet Bougie SGA Surgical airwayMonitors, Meds, IV, BP cuff cycling opp armAssistants and roles assigned, tasks briefedELM BougiePlan, approach, fails, risks00Airways (OPA NPA)BVM and PEEPCO2 end-tidal and confirm (stethoscope)Suction(s) /Gastric /In-line /Magills /MecAspLaryngoscope and alternatesOxygen (pre re and apOx, switch sources)PositionedEndotracheal tube cuff lubed tested syringedStylet Bougie SGA Surgical airwayMonitors, Meds, IV, BP cuff cycling opp armAssistants and roles assigned, tasks briefedELM BougiePlan, approach, fails, risks19053077845Assistants help, add or maintainOxygen line switch (NRB to BVM)Collar opening, c-spine stabilizationCricoid pressure (optional, release if prob)Extra suction, operate vent holeExternal Laryngeal ManipulationBougie prepass and 2 person bougieHead elevationExtra laryngoscope liftJaw thrustMouth opening/ Pull right corner mouth00Assistants help, add or maintainOxygen line switch (NRB to BVM)Collar opening, c-spine stabilizationCricoid pressure (optional, release if prob)Extra suction, operate vent holeExternal Laryngeal ManipulationBougie prepass and 2 person bougieHead elevationExtra laryngoscope liftJaw thrustMouth opening/ Pull right corner mouth-2129491133Teaching Handout Yen Chow @TBayEDguy 2016-06-1600Teaching Handout Yen Chow @TBayEDguy 2016-06-163339465123714230s drilled response encountered/anticipated difficulty1) Release/relax cricoid2) Extra head elevation (towels folded)3) ELM bimanual laryngoscopy (assisted prn)4) Extra laryngoscope lift (lock elbow in)5) Use Mac as Miller (esp if Mac4)6) Bougie (get grade 3a view)Also Breathe Relax Expose then Sight Deliver, +/-…1) More jaw thrust/mouth opening2) Check position patient/intubator3) More/better suction4) Change Blade/ Device size/type Technique (e.g. right paraglossal straight blade)5) Change intubator (best experienced)6) Address patient tone, cooperation, muscle relaxation7) Control tongue, ID/control epigl, see notch8) Use right corner of mouth/right cheek pull9) Straight to cuff styletting10) Pass styletted tubes/bougies below line of sight11) Left turn at Laryngeal inLet on railroading ETT over bougie12) Right turn tube tip hitting tracheal RingsEach next attempt MUST Address difficulty encountered and Change something0030s drilled response encountered/anticipated difficulty1) Release/relax cricoid2) Extra head elevation (towels folded)3) ELM bimanual laryngoscopy (assisted prn)4) Extra laryngoscope lift (lock elbow in)5) Use Mac as Miller (esp if Mac4)6) Bougie (get grade 3a view)Also Breathe Relax Expose then Sight Deliver, +/-…1) More jaw thrust/mouth opening2) Check position patient/intubator3) More/better suction4) Change Blade/ Device size/type Technique (e.g. right paraglossal straight blade)5) Change intubator (best experienced)6) Address patient tone, cooperation, muscle relaxation7) Control tongue, ID/control epigl, see notch8) Use right corner of mouth/right cheek pull9) Straight to cuff styletting10) Pass styletted tubes/bougies below line of sight11) Left turn at Laryngeal inLet on railroading ETT over bougie12) Right turn tube tip hitting tracheal RingsEach next attempt MUST Address difficulty encountered and Change something ................
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