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Common anesthetic pitfall in ER
Associate professor TharnthipPranootnarabhal
2/9/2007
Objectives
Airway management in ER Sedation/ opioids for minor procedures Local anesthetics used IV access
Airway management Role of ED physicians in airway management
25 yrs ago :Blind nasotracheal intubation by ED doctorsAnesthesiologists used paralytic agents
1977 Institution surveyIntubation by ED physician: 45%
by anesthesia personnel 32% Both 19%
Anesth Analg1997;85:62-8
Airway management Use of NMB&RSI by ED physician Complications of emergency intubation
without NMBaspiration 15%airway trauma 28%dead 3%
No complication in RSI groups
AmJEmergMed1999;17:141-3
Difficult Airway Difficult ventilation : cannot ventilate,
SpO2 90%
Difficult intubation : cannot intubate > 3attempts
duration > 10 minutes
Rapid Sequence Intubation
1. Be prepared to perform surgical airway in the event that airwaycontrol is lost
2. Preoxygenation the patient with 100% oxygen3. Apply pressure over the cricoid cartilage4. Administer 1-2 mg/kg succinyl choline IV5. After the pateint relaxes,intubate the pati\eint
orotracheally6. Inflate the cuff and confirm tube placement7. Release cricoid pressure8. Ventilate the patient
Evaluation of Difficult AW
Anatomy Malampati classificati Mouth opening 3 cm. Movement at atlanto-occipital 35º Thyromental distance 7 cm Large incisor length Short thick neck Narrow palate
Drugs for RSI Preinduction drugs:
Fentanyl, Lidocaine, Esmolol
Induction drugs:Etomidate, Propofol, Thiopental,
Ketamine
Muscle relaxant :Succinyl choline, Rocuronium,
Preinduction drugs Fentanyl 2-3 µg/kg IV:
↓ pain masseter muscle,chest wall rigidity
bradycardia Lidocaine 1.5mg/kg IV :
↓ hypertensive response ↓ airway reactivity prevent ↑ICP ↓dysrhythmia from intubation hypotension
Esmolol 2mg/kg :
↓tachycardia, hypertention
airway reactivityBe careful in traumatic hypovolemia
Induction drugs
Etomidate 0.15-0.3mg IV
stable CVS
Inhibit cortisol synthesis
↓ Threshold of focal seizure Propofol 0.5-2 mg/kg IV :
BP ↓ , allergy Thiopental 1.5-3 mg/kg
bradycardia, BP ↓ Ketamine 2mgkg : in asthma, COPD
Muscle relaxant
Succinyl choline 1.5mgkg :MH, Diff.AW, K+↑ myopathy,chronic nephropathy, burn >24hrs.CRF, crush inj. >3d,sepsis >7d
Rocuronium high dose 1mg/kgdifficult AWallergy to aminosteroid NMB
,
Preparation for Intubation Mnemonic
Mnemonic Description Y Yankauer suction B Bag-valve mask A Access vein G Get your team, get help if predict a difficult
airway P Position patient (sniffing, position if no
contraindications) and place on monitor
E Endotracheal tubes and check cuff with syringe O Oxygen, oropharyngeal airway available P Pharnacy: draw up adjunctive medications,
induction agent, and neunomuscular blocker
L Laryngoscope and blades: ensure a variety and that they are working
E Evaluate for difficult airway: look for
obstruction, assess theyromental distance < 3 finger breadth,
interincisor distance < 2 finger breadths, neck immobilization
Airway equipment
Airway :
Oropharyngeal airway
Nasopharyngeal airway
LMA
Surgical Airway
Cricothroidotomy
Tracheostomy
Face mask
Airway equipmentEndotracheal tube
Orotracheal tube
Nasotracheal tube
Combitube
Laryngoscope
Bullard
McCoy
Light wand
FOB
Airway burn patient
Maxillofacial trauma : Lefort II, III
Caution!
Sedation in ER
Minimum Sedation
Moderate Sedation
Deep Sedation
Preparation for sedation S uction O xygen A irway Pharmacy ที่��จำ��เป็นต้�องใช้� : adrenalin,
atropine, ephedrine, amiodarone, lidocaine, flumazenil (ต้��นฤที่ธิ์��กลุ่��ม benzodiazepine) naloxone
M onitor E quipment เช้�น อ�ป็กรณ์�ก�รช้�วยช้�ว�ต้
ย�ที่��ใช้� sedation
Propofol 100-200g/kg/min IV หร!อ Etomidate
Midazolam 0.5-0.75 mg/kg IV Chloral hydrate 25-100 mg/kg ร"บป็ระที่�นในเด็&กไม�
เก�น 2 gm. Ketamine 1-1.5 mg/kg IV, 4-5 mg/kg IM Fentamyl 1.0g/kg
ย�ต้��นฤที่ธิ์��
Naloxone 0.1 mg/kg IM ที่�ก 2 น�ที่�ไม�เก�น 2 mg
Flumazenil 0.02 mg/kg IV. ที่�ก 1 น�ที่�
ไม�เก�น 1 mg.ต้�อคร")ง
Selection of patient
1. Painless procedures
2. Painful procedures
3. Be careful of AWO, ↑ ICP, Change of consciousness, intestinal obstruction, CHF, allergy, not cooperate
4. Pediatric patient : Ketamine + Topical
Midazolam + Ketamine
Local anesthetics
Lidocaine
Dose 5 mg/kg (plain)
7 mg/kg (with epinephrine)
Bupivacaine
Dose ต้�อคร")ง 175mg (plain)
250mg (with epinephrine)
IV access
External jugular vein , Internal jugular vein
Femoral vein
Evaluation of circulating volume
Thank you