AIRAWAY Notes with Complete
Solutions Rated A+
Airway assessment -(teaching/approach to question)
(intubation scenario & procedural sedation )
Aim is to asses for & Establish ASA class to determine safety of sedation in ED
Involves Hx ,Physical exam.
Hx-Issues with previous intubations/Documented difficulty in previous attempts
Radiation therapy, Tumor,
-Problems with mouth opening - e.g. trauma, soft tissue disorders, arthridities
- Problems with neck mobility - e.g. cervical spine disruption, rheumatoid arthritis,
cervical fusion (e.g. operative, ankylosing spondylitis, scleroderma)
AMPLE HX
-Cardio respiratory status (COPD,CCF,Exercise tolerance)
1) Difficult intubation
L-look externally for signs of difficulty eg facial trauma
E- Evaluate 332 rule - inter incisor distance <3 finger breadths, hyoid to mental distance
<3finger breadths, thyroid to hyoid distance <2 finger breadths
M- Mallampati score
O- Obstruction
N- Neck mobility limited
S-sats>93%
2) - ANSWER-Difficult intubation scenarios
-
Difficult RSI scenarios ( Check OSCE Resus, SAQ Airway )
-Asthma
-Acidosis-DKA
-Hypotension
-Obese
,-Pregnant
-Tox
-ELderly
-Soiled airway-(Airway Haemorrage- Haematemesis, Hemoptysis, Epistaxis, Post
tonsillectomy)
-Trauma
-Head injury/ICH/Seizure( Neuroprotective)
- Face, chest .
- Airway trauma - blunt or penetrating
- Airway obstruction
-Airway Burns
Dynamic Airways:
- Recent intubation (swelling, trauma)
- Angioedema/Anaphylaxis
-Craniofacial syndromes
An 80 year old woman with a history of heart failure and diabetes presents with a
dislocation of her left hip prosthesis. You plan to reduce the dislocation under
procedural sedation.
a) Describe your pre-procedural sedation assessment (70%)
b) During the procedure, she becomes apnoeic and desaturates. Describe your
treatment of this complication. (30%) - ANSWER-Features of successful answers
Competence/consent considered.
-Consider implications of assessment for choice and amount of agent.
-Comment on hydration state, fasting state and record weight for dose calculation.
-State that emergency department sedation not appropriate if high level of CVS
impairment.
-Comment on features of the assessment that would alter the sedation process or
increase the likelihood of complications.
Consider reversal agents.
Prolonged post recovery observations.
-Departmental/staffing issues.
Key issues:
History (from patient, others, old notes)
1. Functional assessment of premorbid health, including exercise tolerance/
cardiorespiratory function (or similar).
, 2. Medications and allergies, previous anaesthetics and problems. PMH including
dementia.
3. Fasting status
4. Pt's weight for drug doses
Examination:
1. Vital signs
2. Full cardiorespiratory examination
3. Sensible assessment of airway
4. Mental state exam for capacity/consent
Investigations:
ECG and BSL (others CXR, U&Es, CXR, ECHO report if available)
Response to Apnoea
1. Realized that likely to be brief and respond to simple measures
2. Optimize airway position, Jaw thrust, chin lift, stimulate patient etc.
3. Supplemental O2, bag mask, deliver breaths if significant respiratory depression,
consider simple adjuvants OPA, NPA
4. Proceed to more invasive airway strategies if respiratory depression prolonged
Features of unsuccessful answers
-Inadequate assessment of functional status, and/or omission of vital signs, appropriate
cardiorespiratory assessment.
-Airway assessment too brief.
-Rapid progression to RSI/CPR.
-Failure to respond if patients had an advanced directive.
Burn Airway Issues
Difficult airway - potential airway burns and oedema
Possible difficult to ventilate
Low respiratory reserve, with toxic inhalation
Low cardiac reserve, with tissue hypoxia and other potential injuries - high risk of
hypotension with induction
? C spine injury - may need - ANSWER-
DC considerations post sedation
Key Elements :
-Recovery from sedation ( Able to walk, No vomiting)
-Analgesia
-Joint mobility (joint stability, ROM)
-Follow up & rehab (ortho & Physip)
Solutions Rated A+
Airway assessment -(teaching/approach to question)
(intubation scenario & procedural sedation )
Aim is to asses for & Establish ASA class to determine safety of sedation in ED
Involves Hx ,Physical exam.
Hx-Issues with previous intubations/Documented difficulty in previous attempts
Radiation therapy, Tumor,
-Problems with mouth opening - e.g. trauma, soft tissue disorders, arthridities
- Problems with neck mobility - e.g. cervical spine disruption, rheumatoid arthritis,
cervical fusion (e.g. operative, ankylosing spondylitis, scleroderma)
AMPLE HX
-Cardio respiratory status (COPD,CCF,Exercise tolerance)
1) Difficult intubation
L-look externally for signs of difficulty eg facial trauma
E- Evaluate 332 rule - inter incisor distance <3 finger breadths, hyoid to mental distance
<3finger breadths, thyroid to hyoid distance <2 finger breadths
M- Mallampati score
O- Obstruction
N- Neck mobility limited
S-sats>93%
2) - ANSWER-Difficult intubation scenarios
-
Difficult RSI scenarios ( Check OSCE Resus, SAQ Airway )
-Asthma
-Acidosis-DKA
-Hypotension
-Obese
,-Pregnant
-Tox
-ELderly
-Soiled airway-(Airway Haemorrage- Haematemesis, Hemoptysis, Epistaxis, Post
tonsillectomy)
-Trauma
-Head injury/ICH/Seizure( Neuroprotective)
- Face, chest .
- Airway trauma - blunt or penetrating
- Airway obstruction
-Airway Burns
Dynamic Airways:
- Recent intubation (swelling, trauma)
- Angioedema/Anaphylaxis
-Craniofacial syndromes
An 80 year old woman with a history of heart failure and diabetes presents with a
dislocation of her left hip prosthesis. You plan to reduce the dislocation under
procedural sedation.
a) Describe your pre-procedural sedation assessment (70%)
b) During the procedure, she becomes apnoeic and desaturates. Describe your
treatment of this complication. (30%) - ANSWER-Features of successful answers
Competence/consent considered.
-Consider implications of assessment for choice and amount of agent.
-Comment on hydration state, fasting state and record weight for dose calculation.
-State that emergency department sedation not appropriate if high level of CVS
impairment.
-Comment on features of the assessment that would alter the sedation process or
increase the likelihood of complications.
Consider reversal agents.
Prolonged post recovery observations.
-Departmental/staffing issues.
Key issues:
History (from patient, others, old notes)
1. Functional assessment of premorbid health, including exercise tolerance/
cardiorespiratory function (or similar).
, 2. Medications and allergies, previous anaesthetics and problems. PMH including
dementia.
3. Fasting status
4. Pt's weight for drug doses
Examination:
1. Vital signs
2. Full cardiorespiratory examination
3. Sensible assessment of airway
4. Mental state exam for capacity/consent
Investigations:
ECG and BSL (others CXR, U&Es, CXR, ECHO report if available)
Response to Apnoea
1. Realized that likely to be brief and respond to simple measures
2. Optimize airway position, Jaw thrust, chin lift, stimulate patient etc.
3. Supplemental O2, bag mask, deliver breaths if significant respiratory depression,
consider simple adjuvants OPA, NPA
4. Proceed to more invasive airway strategies if respiratory depression prolonged
Features of unsuccessful answers
-Inadequate assessment of functional status, and/or omission of vital signs, appropriate
cardiorespiratory assessment.
-Airway assessment too brief.
-Rapid progression to RSI/CPR.
-Failure to respond if patients had an advanced directive.
Burn Airway Issues
Difficult airway - potential airway burns and oedema
Possible difficult to ventilate
Low respiratory reserve, with toxic inhalation
Low cardiac reserve, with tissue hypoxia and other potential injuries - high risk of
hypotension with induction
? C spine injury - may need - ANSWER-
DC considerations post sedation
Key Elements :
-Recovery from sedation ( Able to walk, No vomiting)
-Analgesia
-Joint mobility (joint stability, ROM)
-Follow up & rehab (ortho & Physip)
