AIR METHODS CRITICAL CARE
REVIEW AIRWAY ANESTHESIA AND
ANALGESICS
You are transporting a traumatic patient who has been in the Trauma ICU with
significant injuries for 1 week. He has not developed sepsis with the following VS:
BP: 88/55
P: 120 Sinus tach without ectopy
RR: 10
SpO2: 100%
Temperature: 102.1F
ABGs
pH: 7.1
PaCO2: 50mmHg
PaO2: 340 mmHg
HCO3: 30mEq/L
What would you expect with this patient's O2 Hemoglobin dissociation curve? -
Answer- The curve will be shifted right
You are intubating a 54 year old female who is 5'2" and weighs 235lbs. While
preforming a mallampati assessment, you notice her soft palate and major part of
uvula present. You could classify her as a class: - Answer- II
Structures seen with Class I Mallampati assessment - Answer- Soft palete, uvula,
fauces, pillars visible
Structures seen with Class II Mallampati assessment - Answer- Soft Palate, major
part of uvula, fauces visible
Structures seen with Class III Mallampati assessment - Answer- Soft palate, base of
uvula visible
Structures seen with Class IV Mallampati assessment - Answer- Only hard palate
visible
What can cause a left shift in the oxyhemoglobin dissociation curve?
ARDS
A pt. who received mass transfusion
Respiratory Acidosis
Sepsis - Answer- A patient who received mass transfusion
Would shift left due to increased oxygen carrying. ARDS, Respiratory acidosis, and
sepsis all are associated with acidosis, lower pH, higher levels of CO2, which would
cause a right shift
,When it comes to making ATP during aerobic respiration, why is oxygen necessary?
- Answer- Oxygen is the final electron acceptor in the electron transport chain
High-energy electrons go through the electron transport chain in a series of
exe3rgonic redox reactions. Ultimately used to produce ATP.
Which of the following methods is the least effective way to confirm endotracheal
tube placement?
End Tidal CO2 capnometry
Fogging in the tube
Direct visualization between the vocal cords
Bilateral equal lung sounds - Answer- Fogging in the tube
What is the gold-standard to confirm ETT placement? - Answer- End Tidal CO2
capnometry
What is Graham's law? - Answer- Gas will diffuse from high pressure to low pressure
Higher O2 concentration in alveoli will diffuse to capillaries, which has lower
concentrations of O2
Acronym to consider for surgical cric considerations - Answer- SMART
Surgery of Neck
Mass
Access to the neck - obesity, Limited ROM
Radiation
Tumor
Acronym to consider when predicting a difficult airway - Answer- HEAVEN
Hypoxemia
Extremes of size - obese pt, petite pt.
Anatomic disruption/obstruction
Vomit/blood/fluid
Exsanguination- bled out so much they can't keep SpO2 up
Neck mobility/neuro injury
Mallampati score vs Cormack-Lenane score - Answer- Mallampati is direct
visualization of the oral cavity and oropharynx
Cormack-Lenane score is direct visualization of the pharynx and glottis with
laryngoscope
How do non-depolarizing paralytic agents, like rocuronium, work? - Answer- They
compete with acetylcholine, blocking nicotinic receptors
Non-depolarizing neuromuscular blocking drugs do not depolarize receptions. They
compete with Ach for binding sites on nicotinic alpha subunits, causing skeletal
relaxation
, You prepare to intubate a pediatric patient experiencing severe bronchospasm.
Which induction agent will you utilize? - Answer- Ketamine
Ketamine is the induction agent of choice for reactive airway disease due to its
sympathomimetic and bronchodilatory effects.
Which is the shortest acting paralytic? - Answer- Succinylcholine
On a scene call with a 63 year old male patient, you elect to intubate him after a
failed trial of BPAP for fluid overload and respiratory failure. Your patient has a hx of
hypertension, diabetes, end stage renal disease and missed his last 3 dialysis
appointments. What paralytic would be contraindicated for this patient? - Answer-
Succinylcholine
Which neuromuscular blocking agent is classified as depolarizing? - Answer-
Succinylcholine
How is Ketamine unique compared to other induction agents? - Answer- It provides
both amnesia and analgesia
You elect to intubate your elderly female patient that presented febrile, tachycardic
and has an elevated lactate level after a recent minor outpatient surgery. You
suspect the patient to be septic. Which induction agent would be contraindicated?
Ketamine
Etomidate
Propofol - Answer- Etomidate
Contraindicated in patients with sepsis due to inhibiting cortisol production
Propofol is a direct myocardial depressant that can blunt compensatory tachycardia
An asthmatic patient was intubated in the ER 45 minutes ago. You are ready to
transport the patient who begins to move, ventilator asynchrony and high pressure
alarms are noted. What sedative would be the most appropriate? - Answer-
Ketamine
Etomidate is a barbiturate like medication with rapid onset, quick recovery and is not
a good choice for long term sedation
Ketamine has beneficial effects with reactive airway disease
While intubating a patient with airway compromise using direct laryngoscopy, what is
the correct placement of the tip of a Macintosh laryngoscope blade? - Answer- Into
the vallecula
The curved tip of the Macintosh blade is inserted into the vallecula, the space
between the base of the tongue and the pharyngeal surface of the epiglottis
Which of these is NOT a contraindication of King airway placement
Esophageal injury
Ingestion of caustic substances
Awake, semi-obtunded patients
REVIEW AIRWAY ANESTHESIA AND
ANALGESICS
You are transporting a traumatic patient who has been in the Trauma ICU with
significant injuries for 1 week. He has not developed sepsis with the following VS:
BP: 88/55
P: 120 Sinus tach without ectopy
RR: 10
SpO2: 100%
Temperature: 102.1F
ABGs
pH: 7.1
PaCO2: 50mmHg
PaO2: 340 mmHg
HCO3: 30mEq/L
What would you expect with this patient's O2 Hemoglobin dissociation curve? -
Answer- The curve will be shifted right
You are intubating a 54 year old female who is 5'2" and weighs 235lbs. While
preforming a mallampati assessment, you notice her soft palate and major part of
uvula present. You could classify her as a class: - Answer- II
Structures seen with Class I Mallampati assessment - Answer- Soft palete, uvula,
fauces, pillars visible
Structures seen with Class II Mallampati assessment - Answer- Soft Palate, major
part of uvula, fauces visible
Structures seen with Class III Mallampati assessment - Answer- Soft palate, base of
uvula visible
Structures seen with Class IV Mallampati assessment - Answer- Only hard palate
visible
What can cause a left shift in the oxyhemoglobin dissociation curve?
ARDS
A pt. who received mass transfusion
Respiratory Acidosis
Sepsis - Answer- A patient who received mass transfusion
Would shift left due to increased oxygen carrying. ARDS, Respiratory acidosis, and
sepsis all are associated with acidosis, lower pH, higher levels of CO2, which would
cause a right shift
,When it comes to making ATP during aerobic respiration, why is oxygen necessary?
- Answer- Oxygen is the final electron acceptor in the electron transport chain
High-energy electrons go through the electron transport chain in a series of
exe3rgonic redox reactions. Ultimately used to produce ATP.
Which of the following methods is the least effective way to confirm endotracheal
tube placement?
End Tidal CO2 capnometry
Fogging in the tube
Direct visualization between the vocal cords
Bilateral equal lung sounds - Answer- Fogging in the tube
What is the gold-standard to confirm ETT placement? - Answer- End Tidal CO2
capnometry
What is Graham's law? - Answer- Gas will diffuse from high pressure to low pressure
Higher O2 concentration in alveoli will diffuse to capillaries, which has lower
concentrations of O2
Acronym to consider for surgical cric considerations - Answer- SMART
Surgery of Neck
Mass
Access to the neck - obesity, Limited ROM
Radiation
Tumor
Acronym to consider when predicting a difficult airway - Answer- HEAVEN
Hypoxemia
Extremes of size - obese pt, petite pt.
Anatomic disruption/obstruction
Vomit/blood/fluid
Exsanguination- bled out so much they can't keep SpO2 up
Neck mobility/neuro injury
Mallampati score vs Cormack-Lenane score - Answer- Mallampati is direct
visualization of the oral cavity and oropharynx
Cormack-Lenane score is direct visualization of the pharynx and glottis with
laryngoscope
How do non-depolarizing paralytic agents, like rocuronium, work? - Answer- They
compete with acetylcholine, blocking nicotinic receptors
Non-depolarizing neuromuscular blocking drugs do not depolarize receptions. They
compete with Ach for binding sites on nicotinic alpha subunits, causing skeletal
relaxation
, You prepare to intubate a pediatric patient experiencing severe bronchospasm.
Which induction agent will you utilize? - Answer- Ketamine
Ketamine is the induction agent of choice for reactive airway disease due to its
sympathomimetic and bronchodilatory effects.
Which is the shortest acting paralytic? - Answer- Succinylcholine
On a scene call with a 63 year old male patient, you elect to intubate him after a
failed trial of BPAP for fluid overload and respiratory failure. Your patient has a hx of
hypertension, diabetes, end stage renal disease and missed his last 3 dialysis
appointments. What paralytic would be contraindicated for this patient? - Answer-
Succinylcholine
Which neuromuscular blocking agent is classified as depolarizing? - Answer-
Succinylcholine
How is Ketamine unique compared to other induction agents? - Answer- It provides
both amnesia and analgesia
You elect to intubate your elderly female patient that presented febrile, tachycardic
and has an elevated lactate level after a recent minor outpatient surgery. You
suspect the patient to be septic. Which induction agent would be contraindicated?
Ketamine
Etomidate
Propofol - Answer- Etomidate
Contraindicated in patients with sepsis due to inhibiting cortisol production
Propofol is a direct myocardial depressant that can blunt compensatory tachycardia
An asthmatic patient was intubated in the ER 45 minutes ago. You are ready to
transport the patient who begins to move, ventilator asynchrony and high pressure
alarms are noted. What sedative would be the most appropriate? - Answer-
Ketamine
Etomidate is a barbiturate like medication with rapid onset, quick recovery and is not
a good choice for long term sedation
Ketamine has beneficial effects with reactive airway disease
While intubating a patient with airway compromise using direct laryngoscopy, what is
the correct placement of the tip of a Macintosh laryngoscope blade? - Answer- Into
the vallecula
The curved tip of the Macintosh blade is inserted into the vallecula, the space
between the base of the tongue and the pharyngeal surface of the epiglottis
Which of these is NOT a contraindication of King airway placement
Esophageal injury
Ingestion of caustic substances
Awake, semi-obtunded patients
