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410908566630553:3:2: mouth opening / thyro-mental / thyro-hyoidMallampati: 1: pillars, uvula, soft palate 2: uvula, soft palate 3: soft palate 4: none of aboveCormack-Lehane: 1: vocal cords 2: post commissure 3: arytenoids 4: epiglottis003:3:2: mouth opening / thyro-mental / thyro-hyoidMallampati: 1: pillars, uvula, soft palate 2: uvula, soft palate 3: soft palate 4: none of aboveCormack-Lehane: 1: vocal cords 2: post commissure 3: arytenoids 4: epiglottis1466215666305515252702586355MacIntosh: size 3 normal, size 4 largeMiller: straight Robertshaw: gently curved McCoy: hinged blade tip (difficult intubation)Video: improved glottic visualisation in 20% in inexperienced hands; none better than standard laryngoscopy in ED use; expensive, fogging, secretions, slow setup; can supervise intubator, Airtraq (cheap), Video-Mac, C-Mac, GlidescopeETT: use uncuffed if <8yrs; insert 20-23cm in adults; inflate pilot balloon until air leak stops (keep pressure <25 to prevent mucosal ischaemia)Indications for ETT: airway protection, GCS <8, ventilatory assistance, hyperventilation required (eg, coning, TCA OD), high inspiratory O2 delivery, selective lung ventilation (eg. Massive haemoptysis, bronchopleural fistula), hydrocarbon ingestion, hyperthermia (for muscle relaxation), drug deliveryCricoid: risk of oesophageal rupture if actively vomiting; may make view more difficult; may occlude airway; may ?lower oesophageal sphincter tone and ?reflux; makes LMA more difficult; can do BURPChecking tube placement: ETCO2 (may be low in cardiac arrest, small amounts may be detected in oesophagus); oesophageal detector device (most useful in arrest when ETCO2 low; may get false positive if TOF); misting; direct inspection of tube passing though cords; auscultation of lungs (less accurate than ETCO2) and stomach; normal airway pressures; no abdominal distension; CXR (@ level of aortic knuckle); palpation of ETT cuff at neckETT complications: dental / oropharyngeal trauma, aspiration 1:7000; death 1:100,000; oesophageal perforation; gastric distension; ? BP (drugs, autoPEEP), ?BP (inadequate sedation), pneumothorax, atelectasis, arrhythmia, ? intracranial pressure, hypoxaemia, side effects of drugs, bradycardia common in children so consider atropine Laryngospasm: from incomplete paralysis, touching cords, irritation, aspiration, foreign body, hypocalcaemia, post-extubation, failed intubation attempt give repeat small dose propofol / thio sustained positive airway pressure to break spasm if needed, half dose sux and re-intubate00MacIntosh: size 3 normal, size 4 largeMiller: straight Robertshaw: gently curved McCoy: hinged blade tip (difficult intubation)Video: improved glottic visualisation in 20% in inexperienced hands; none better than standard laryngoscopy in ED use; expensive, fogging, secretions, slow setup; can supervise intubator, Airtraq (cheap), Video-Mac, C-Mac, GlidescopeETT: use uncuffed if <8yrs; insert 20-23cm in adults; inflate pilot balloon until air leak stops (keep pressure <25 to prevent mucosal ischaemia)Indications for ETT: airway protection, GCS <8, ventilatory assistance, hyperventilation required (eg, coning, TCA OD), high inspiratory O2 delivery, selective lung ventilation (eg. Massive haemoptysis, bronchopleural fistula), hydrocarbon ingestion, hyperthermia (for muscle relaxation), drug deliveryCricoid: risk of oesophageal rupture if actively vomiting; may make view more difficult; may occlude airway; may ?lower oesophageal sphincter tone and ?reflux; makes LMA more difficult; can do BURPChecking tube placement: ETCO2 (may be low in cardiac arrest, small amounts may be detected in oesophagus); oesophageal detector device (most useful in arrest when ETCO2 low; may get false positive if TOF); misting; direct inspection of tube passing though cords; auscultation of lungs (less accurate than ETCO2) and stomach; normal airway pressures; no abdominal distension; CXR (@ level of aortic knuckle); palpation of ETT cuff at neckETT complications: dental / oropharyngeal trauma, aspiration 1:7000; death 1:100,000; oesophageal perforation; gastric distension; ? BP (drugs, autoPEEP), ?BP (inadequate sedation), pneumothorax, atelectasis, arrhythmia, ? intracranial pressure, hypoxaemia, side effects of drugs, bradycardia common in children so consider atropine Laryngospasm: from incomplete paralysis, touching cords, irritation, aspiration, foreign body, hypocalcaemia, post-extubation, failed intubation attempt give repeat small dose propofol / thio sustained positive airway pressure to break spasm if needed, half dose sux and re-intubate2374902586355Intubation00Intubation1532255965835Gag reflex absent in 15%; hypoxia develops more quickly in children, pregnant, obese; if ETT, pre- oxygenate on 100% O2 for 3 mins, or 8 quick breathsGuedel airway: size from central incisors to angle of jawNPA: female size 6, male size 7, tall male size 8Face mask: 60ml dead spaceBVM: bag 1500ml (500ml in paediatrics, 240ml in prem); reservoir bag 2600ml (600ml in paediatrics and prem)Self inflating bag: dead space too large for children <25kg; no reliant on fresh gas flow for bag reinflation; aim to deliver 500ml (1/4 reservoir bag volume); keep airway pressure <20 to prevent stomach inflation00Gag reflex absent in 15%; hypoxia develops more quickly in children, pregnant, obese; if ETT, pre- oxygenate on 100% O2 for 3 mins, or 8 quick breathsGuedel airway: size from central incisors to angle of jawNPA: female size 6, male size 7, tall male size 8Face mask: 60ml dead spaceBVM: bag 1500ml (500ml in paediatrics, 240ml in prem); reservoir bag 2600ml (600ml in paediatrics and prem)Self inflating bag: dead space too large for children <25kg; no reliant on fresh gas flow for bag reinflation; aim to deliver 500ml (1/4 reservoir bag volume); keep airway pressure <20 to prevent stomach inflation244475965835Adjuncts00Adjuncts246380330200Rapid Sequence Intubation00Rapid Sequence Intubation2374906663690Difficult Intubation00Difficult Intubation15322558883650Epidemiology: in 1-3% ED tubes; impossible in 0.5%; predictable in 90%Congenital: Pierre Robin, achondroplasia, Marfans etc…Anatomical: fat, neck + neck movement / instability, teeth, palate, long alveolar-mental, short thyro- mental, ? jaw movement, ?distance between occiput and SP C1, ?posterior depth of mandible, previous surgery / masses, traumaFailed airway: 3 unsuccessful attempts or 1 min by experienced operator / failure to maintain sats; don’t persist with laryngoscopy >1min; use best person available00Epidemiology: in 1-3% ED tubes; impossible in 0.5%; predictable in 90%Congenital: Pierre Robin, achondroplasia, Marfans etc…Anatomical: fat, neck + neck movement / instability, teeth, palate, long alveolar-mental, short thyro- mental, ? jaw movement, ?distance between occiput and SP C1, ?posterior depth of mandible, previous surgery / masses, traumaFailed airway: 3 unsuccessful attempts or 1 min by experienced operator / failure to maintain sats; don’t persist with laryngoscopy >1min; use best person available42037051676302273305052060Surgical Airway00Surgical Airway3627755501332500222250464185Difficult Intubation (cntd) 00Difficult Intubation (cntd) 14992353315335LMA: Pros: better than BVM for protecting airway, convenient, easier than ETT, good pre-hospital, good if difficult BVM, can be used in paediatrics Cons: less protection against aspiration; seal leak if airway pressure >15; small proportion of patients can’t be ventilated; may get laryngospasm from bronchial secretions Contraindications: inability to open mouth, pharyngeal pathology, airway obstruction @/below larynx; ? pulmonary compliance; ? airway resistance6. Fibreoptic if breathing spontaneously7. Or BVM and allow to wake up8. Surgical (<10yrs – tracheostomy; >10yrs – cricothyroidotomy)If unable to ventilate at any time, immediately proceed to LMA, then surgical if that fails00LMA: Pros: better than BVM for protecting airway, convenient, easier than ETT, good pre-hospital, good if difficult BVM, can be used in paediatrics Cons: less protection against aspiration; seal leak if airway pressure >15; small proportion of patients can’t be ventilated; may get laryngospasm from bronchial secretions Contraindications: inability to open mouth, pharyngeal pathology, airway obstruction @/below larynx; ? pulmonary compliance; ? airway resistance6. Fibreoptic if breathing spontaneously7. Or BVM and allow to wake up8. Surgical (<10yrs – tracheostomy; >10yrs – cricothyroidotomy)If unable to ventilate at any time, immediately proceed to LMA, then surgical if that fails42037058547052095405264151. HELP! Get difficult airway trolley2. STOP and BVM with 100% O23. Make change: position of head, adequate relaxation; IV line still working; Miller blade if immobile anterior tissues; McCoy blade if poor neck mobility; reconsider indication for tube; BURP4. Stylet/bougie (in oesophagus if can insertion 45cm without resistance)5. LMA: possibily intubating LMA (6mm tube) or railroad bougie (15-20% failure rate); optimal cuff pressure 60001. HELP! Get difficult airway trolley2. STOP and BVM with 100% O23. Make change: position of head, adequate relaxation; IV line still working; Miller blade if immobile anterior tissues; McCoy blade if poor neck mobility; reconsider indication for tube; BURP4. Stylet/bougie (in oesophagus if can insertion 45cm without resistance)5. LMA: possibily intubating LMA (6mm tube) or railroad bougie (15-20% failure rate); optimal cuff pressure 601499870464820498983088188801561465501332563798455167630156146572739250052978056965950Indication: inability to establish ETT in patient who cannot be ventilated / oxygenated adequately by other methodsContra-indications: neck mass, no neck, bleeding diathesis; open cricothyroidotomy contraindicated in <10yrs (as is narrowest part of airway and only circumferential support of upper airway) – use needle cricothyroidotomy or tracheostomyComplications: haematoma / bleeding (thyroid IMA artery), pre-tracheal pkacement, pneumothorax, subcutaneous emphysema, tracheal tear, oesophageal damage, recurrent laryngeal nerve damage00Indication: inability to establish ETT in patient who cannot be ventilated / oxygenated adequately by other methodsContra-indications: neck mass, no neck, bleeding diathesis; open cricothyroidotomy contraindicated in <10yrs (as is narrowest part of airway and only circumferential support of upper airway) – use needle cricothyroidotomy or tracheostomyComplications: haematoma / bleeding (thyroid IMA artery), pre-tracheal pkacement, pneumothorax, subcutaneous emphysema, tracheal tear, oesophageal damage, recurrent laryngeal nerve damage2184407825105RSI in Head Injury00RSI in Head Injury14979657825739Indications: GCS <9, agitation, elective hypocapnia, hypoxaemia Goals: avoid low O2, avoid low / high BP, avoid cough / gag (? intracranial pressure)Difficulties: C spine immobilisation, ETOH, full stomachTechnique: inline stabilisation while remove collar Lignocaine 1mg/kg (not useful) / fentanyl 1mcg/kg / 0.3mg/kg vec to blunt ?ICP Use thio (2.5-5mg/kg; or fentanyl) or propofol sux (1 – 1.5mg/kg) Have atropine ready incase bradycardia Elevate head 20-30° (aids venous drainage); avoid compression of neck Afterward, maintain good sedation with 1-5mg/kg/hr thio + vec 4mg / panc 8mg Avoid hypotension (if ?BP, give IVF / metaraminol), hypertension (if ?BP, give 20-100mg thio or morphine to 30mg) and raises in ICP (eg. Unnecessary suctionning) Maintain euvolaemia and eunatraemia (not fluid restriction; ?2/3 maintenance); steroids if tumour oedema; ulcer prophylaxis Aim PCO2 35-40, paO2 100, MAP >80 (use vasopressors if needed), CVP 0-2, BSL <8 (treat with insulin if >10) Can consider fibrescopic if C spine injury and airway hard00Indications: GCS <9, agitation, elective hypocapnia, hypoxaemia Goals: avoid low O2, avoid low / high BP, avoid cough / gag (? intracranial pressure)Difficulties: C spine immobilisation, ETOH, full stomachTechnique: inline stabilisation while remove collar Lignocaine 1mg/kg (not useful) / fentanyl 1mcg/kg / 0.3mg/kg vec to blunt ?ICP Use thio (2.5-5mg/kg; or fentanyl) or propofol sux (1 – 1.5mg/kg) Have atropine ready incase bradycardia Elevate head 20-30° (aids venous drainage); avoid compression of neck Afterward, maintain good sedation with 1-5mg/kg/hr thio + vec 4mg / panc 8mg Avoid hypotension (if ?BP, give IVF / metaraminol), hypertension (if ?BP, give 20-100mg thio or morphine to 30mg) and raises in ICP (eg. Unnecessary suctionning) Maintain euvolaemia and eunatraemia (not fluid restriction; ?2/3 maintenance); steroids if tumour oedema; ulcer prophylaxis Aim PCO2 35-40, paO2 100, MAP >80 (use vasopressors if needed), CVP 0-2, BSL <8 (treat with insulin if >10) Can consider fibrescopic if C spine injury and airway hard2184401896745Ventilation 00Ventilation 14979651896745Pressure limited: decelerating waveform optimises distribution of ventilation; changes in compliance change volume deliveredVolume limitedDual control: uses both of aboveAssist/control: patients trigger (usually 1-2cm H20) to receive assisted breath; least WOB; good in respiratory distress; may cause respiratory alkalosis, more reduction in VR, higher mean airway pressure, autoPEEP and hyperexpansionIPPV: no triggering; most reliable TV and MVSIMV: specified number of volume present breaths/min, can breathe between mandatory breaths; +/- PS (without this, spontaneous breaths cause ? WOB, 5-10cm H20 needed to offset resistance of tubing)IFR: high less uniform distribution, ?inspiratory time, ?mean airway pressure and cardiovascular complications, not well tolerated; low even distribution, ?VRPEEP: improves oxygenation (may take 1hr to see difference), distributes air favourably, recruits collapsed alveoli, prevents collapse of alveoli, helps restore FRC, improves alveolar fluid distribution ? distance between capillary and alveolar space Indications: paO2 <60 despite FiO2 >50%; diffuse acute pulmonary disease; non-compliant lungs Not helpful: only 1 lung/zone affected; emphysema; cardiovascular compromiseCommon settings: TV 600ml (6-8ml/kg), RR 12-14, I:E 1:2, PAP 40mmHg; PEEP 5; FiO2 100% 40%, IFR 60L/minGoals: PaO2 60-90, PaCO2 40, pH 7.35-7.45, FiO2 40-60%, IPP <35Complications: cardiac output usually fine in normovolaemic patients with good myocardial reserve; hypotension (incr intrathroacic p decr VR): if occurs, maintain euvolaemia and ?PEEP, may need inotropes / vasopressors; ?CVP, PCWP; ? ICP, ? renal blood flow, hepatic congestion; ? CO ?systemic O2 delivery; ? O2 admixture of blood; ? non-capillary shunt flow; causes high VQ units ? physiological dead space may cause CO2 retention; may ? WOB if not PS; lung hyperventilation (gas trapping, auto-PEEP); barotrauma (incidence related to peak static airway p, minimised if PAP <50); bronchospasm; mucosal drying and cilial paralysisLow system pressure: check circuit connections, check seal with patientsHigh system pressure: check neck position, check for obstructionLow airway pressure: cuff leak, pilot balloon rupture, check connectionsHigh airway pressure: check patency of ETT, suction ETT, check for kinking or jaw clamping, check for cuff prolapse, spontaneous respiration, epigastric distension, bilateral BS’s, wheeze (?asthma, anaphylaxis, LVF, aspiration, pneumothorax)00Pressure limited: decelerating waveform optimises distribution of ventilation; changes in compliance change volume deliveredVolume limitedDual control: uses both of aboveAssist/control: patients trigger (usually 1-2cm H20) to receive assisted breath; least WOB; good in respiratory distress; may cause respiratory alkalosis, more reduction in VR, higher mean airway pressure, autoPEEP and hyperexpansionIPPV: no triggering; most reliable TV and MVSIMV: specified number of volume present breaths/min, can breathe between mandatory breaths; +/- PS (without this, spontaneous breaths cause ? WOB, 5-10cm H20 needed to offset resistance of tubing)IFR: high less uniform distribution, ?inspiratory time, ?mean airway pressure and cardiovascular complications, not well tolerated; low even distribution, ?VRPEEP: improves oxygenation (may take 1hr to see difference), distributes air favourably, recruits collapsed alveoli, prevents collapse of alveoli, helps restore FRC, improves alveolar fluid distribution ? distance between capillary and alveolar space Indications: paO2 <60 despite FiO2 >50%; diffuse acute pulmonary disease; non-compliant lungs Not helpful: only 1 lung/zone affected; emphysema; cardiovascular compromiseCommon settings: TV 600ml (6-8ml/kg), RR 12-14, I:E 1:2, PAP 40mmHg; PEEP 5; FiO2 100% 40%, IFR 60L/minGoals: PaO2 60-90, PaCO2 40, pH 7.35-7.45, FiO2 40-60%, IPP <35Complications: cardiac output usually fine in normovolaemic patients with good myocardial reserve; hypotension (incr intrathroacic p decr VR): if occurs, maintain euvolaemia and ?PEEP, may need inotropes / vasopressors; ?CVP, PCWP; ? ICP, ? renal blood flow, hepatic congestion; ? CO ?systemic O2 delivery; ? O2 admixture of blood; ? non-capillary shunt flow; causes high VQ units ? physiological dead space may cause CO2 retention; may ? WOB if not PS; lung hyperventilation (gas trapping, auto-PEEP); barotrauma (incidence related to peak static airway p, minimised if PAP <50); bronchospasm; mucosal drying and cilial paralysisLow system pressure: check circuit connections, check seal with patientsHigh system pressure: check neck position, check for obstructionLow airway pressure: cuff leak, pilot balloon rupture, check connectionsHigh airway pressure: check patency of ETT, suction ETT, check for kinking or jaw clamping, check for cuff prolapse, spontaneous respiration, epigastric distension, bilateral BS’s, wheeze (?asthma, anaphylaxis, LVF, aspiration, pneumothorax)205105461010Surgical Airway (cntd)00Surgical Airway (cntd)1484630461644Anatomy: cricoid is 1st rigid structure above sternal notch; cricothyroid membrane is 1/3 distance from manubrium to chinOpen cricothyroidotomy: vertical incision skin horizontal incision cricothyroid membrane open with arterial forceps hold with tracheal hook; use 6mm tube (never >7mm)Needle cricothyroidotomy: 14G IVL insert at 90° when aspirate air angle 45° and go caudally connect to 3mm ETT / 2ml syringe then 7.5-8mm ETT; allows short term oxygenation (ie. 45mins) but not ventilation (CO2 levels will rise) with 15L O2 via Y connector; occlude 1: release 4; airway is not protected00Anatomy: cricoid is 1st rigid structure above sternal notch; cricothyroid membrane is 1/3 distance from manubrium to chinOpen cricothyroidotomy: vertical incision skin horizontal incision cricothyroid membrane open with arterial forceps hold with tracheal hook; use 6mm tube (never >7mm)Needle cricothyroidotomy: 14G IVL insert at 90° when aspirate air angle 45° and go caudally connect to 3mm ETT / 2ml syringe then 7.5-8mm ETT; allows short term oxygenation (ie. 45mins) but not ventilation (CO2 levels will rise) with 15L O2 via Y connector; occlude 1: release 4; airway is not protected2565407048500Others00Others15360657047865Pregnancy: Elevate R hip 10-12cm; elevate head and shoulders on pillows; use standard doses; preoxygenate wellARDS: TV 4-6ml/kg, ? RR to maintain MV (RR 16-20), aim PaO2 55-80 and SaO2 88-95%; this associated with ? mortality and ? duration of mechanical ventilationEpiglottitis: do in OT or at least with anaesthetists, have surgical airway kit ready; sevoflurane / halothane induction (rapid, some bronchodilation, non-irritating) slowly anaesthetise over 5- 10mins (small, minimally reactive pupils = ready to go) aim where bubbles coming from, use 0.5mm smaller tubeCroup: <5% admitted need ETT; most common <1yrs; always use adrenaline NEB first; use uncuffed tube 1mm smallerMaxfax trauma: hypoxia, bleeding, obstruct when sedated; get skilled help, ensure good suction, have OT and surgical airway ready, have 3x good laryngoscopes; fibreoptic may be safestBurns: anticipate need for ETT early as oedema; nasotracheal may be suggested00Pregnancy: Elevate R hip 10-12cm; elevate head and shoulders on pillows; use standard doses; preoxygenate wellARDS: TV 4-6ml/kg, ? RR to maintain MV (RR 16-20), aim PaO2 55-80 and SaO2 88-95%; this associated with ? mortality and ? duration of mechanical ventilationEpiglottitis: do in OT or at least with anaesthetists, have surgical airway kit ready; sevoflurane / halothane induction (rapid, some bronchodilation, non-irritating) slowly anaesthetise over 5- 10mins (small, minimally reactive pupils = ready to go) aim where bubbles coming from, use 0.5mm smaller tubeCroup: <5% admitted need ETT; most common <1yrs; always use adrenaline NEB first; use uncuffed tube 1mm smallerMaxfax trauma: hypoxia, bleeding, obstruct when sedated; get skilled help, ensure good suction, have OT and surgical airway ready, have 3x good laryngoscopes; fibreoptic may be safestBurns: anticipate need for ETT early as oedema; nasotracheal may be suggested2578105046980RSI in Obesity00RSI in Obesity15373355046345Physiology: resting hypoxaemia and hypercarbia, VQ mismatch, less O2 reserve with pre- oxygenation; 50% shorter time to desat; inefficient respiratory muscles; hiatus hernia and GORD; may need ? drug doses (if lipophilic drug); SaO2 inaccurate ? TLC, VC, chest wall compliance, ERV, basilar ventilation, FRC, gastric pH ?airway resistance, abdo cavity contents, O2 consumption, CO2 production, neck circumference (best predictor of difficult)Technique: position well with head and shoulders above chest (external auditory canal level with sternal notch); don’t use sniffing position; pre-oxygenate sitting up (do 10mins) perhaps with CPAP 10; use laryngoscope with wider angle; use PEEP Total body weight: propofol, suxamethonium, fentanyl, etomidate, atracurium Ideal body weight: ketamine, rocuronium, vecuronium, benzos, tidal volume00Physiology: resting hypoxaemia and hypercarbia, VQ mismatch, less O2 reserve with pre- oxygenation; 50% shorter time to desat; inefficient respiratory muscles; hiatus hernia and GORD; may need ? drug doses (if lipophilic drug); SaO2 inaccurate ? TLC, VC, chest wall compliance, ERV, basilar ventilation, FRC, gastric pH ?airway resistance, abdo cavity contents, O2 consumption, CO2 production, neck circumference (best predictor of difficult)Technique: position well with head and shoulders above chest (external auditory canal level with sternal notch); don’t use sniffing position; pre-oxygenate sitting up (do 10mins) perhaps with CPAP 10; use laryngoscope with wider angle; use PEEP Total body weight: propofol, suxamethonium, fentanyl, etomidate, atracurium Ideal body weight: ketamine, rocuronium, vecuronium, benzos, tidal volume15360652285365Indications: only intubate if life threatening and max therapy failed (eg. Progressive hyperCO2 and acidosis, decr O2, fatigue, confusion, pre-arrest)Aims: limit PAP, avoid gas trapping; permissive hypercarbia to help this (contraindicated if ? intracranial pressure / severely impaired myocardial function; risk of cerebral oedema, ? myocardial contractility, vasodilation, pulmonary vasoconstriction; can give NaHCO3 if pH <7.2 and don’t want to change ventilator settings)Technique: use ketamine 2mg/kg IV 20-60mcg/kg/min INF (or fentanyl / midaz) + sux; isoflurane is Bronchodilatory; start sitting up and lie down only when spontaneous respirations stopped hand ventilate place on volume cycled ventilator once airway pressure and tidal volume acceptable (TV 8ml/kg, RR 4-10, IFR 100L/min, MV 8-10ml/min, PAP <30, PEEP <5, FiO2 1.0) titrate RR to lowest tolerable pH titrate inspiratory time to airway pressure <55 low I:E – 1:5 or more (not possible on Oxylog 3000) titrate FiO2 to O2 goals; permissive hypercarbia Chest expiratory pressure; heliox ? resp distress, ?WOB, ? GE); continuous nebs (? dose 2-4x as ETT is barrier to delivery)00Indications: only intubate if life threatening and max therapy failed (eg. Progressive hyperCO2 and acidosis, decr O2, fatigue, confusion, pre-arrest)Aims: limit PAP, avoid gas trapping; permissive hypercarbia to help this (contraindicated if ? intracranial pressure / severely impaired myocardial function; risk of cerebral oedema, ? myocardial contractility, vasodilation, pulmonary vasoconstriction; can give NaHCO3 if pH <7.2 and don’t want to change ventilator settings)Technique: use ketamine 2mg/kg IV 20-60mcg/kg/min INF (or fentanyl / midaz) + sux; isoflurane is Bronchodilatory; start sitting up and lie down only when spontaneous respirations stopped hand ventilate place on volume cycled ventilator once airway pressure and tidal volume acceptable (TV 8ml/kg, RR 4-10, IFR 100L/min, MV 8-10ml/min, PAP <30, PEEP <5, FiO2 1.0) titrate RR to lowest tolerable pH titrate inspiratory time to airway pressure <55 low I:E – 1:5 or more (not possible on Oxylog 3000) titrate FiO2 to O2 goals; permissive hypercarbia Chest expiratory pressure; heliox ? resp distress, ?WOB, ? GE); continuous nebs (? dose 2-4x as ETT is barrier to delivery)2565402285365RSI in Asthma00RSI in Asthma2578101574165RSI in Hypovolaemia00RSI in Hypovolaemia15373351574165Use ketamine 1.5-2mg/kg or fentanyl 3mcg/kg or etomidate 0.3mg/kg or thio 1.5mg/kg or propofol 1mg/kg; avoid PEEP initially unless critically hypoxic; use midazolam / fentanyl for ongoing sedation00Use ketamine 1.5-2mg/kg or fentanyl 3mcg/kg or etomidate 0.3mg/kg or thio 1.5mg/kg or propofol 1mg/kg; avoid PEEP initially unless critically hypoxic; use midazolam / fentanyl for ongoing sedation1537335476885Try to avoid cerebral reperfusion injury (due to free radicals, ?ATP/ADP/AMP/NADP, anaerobic metabolism lipid peroxidation and membrane damage, enzyme dysfunction etc…; initial ? cerebral blood flow with ROSC cerebral vasospasm after 1hr ? cerebral blood flow 60-90% and incomplete ischaemia mismatch of cerebral O2 demand and delivery for 12-24hrs; generalised endothelial damage DIC / ARDS00Try to avoid cerebral reperfusion injury (due to free radicals, ?ATP/ADP/AMP/NADP, anaerobic metabolism lipid peroxidation and membrane damage, enzyme dysfunction etc…; initial ? cerebral blood flow with ROSC cerebral vasospasm after 1hr ? cerebral blood flow 60-90% and incomplete ischaemia mismatch of cerebral O2 demand and delivery for 12-24hrs; generalised endothelial damage DIC / ARDS257810476886RSI Post-Cardiac Arrest00RSI Post-Cardiac Arrest ................
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