Common anesthetic pitfalls in ER

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  • 1. Common anesthetic pitfall in ER Associate professor TharnthipPranootnarabhal 2/9/2007
  • 2. Objectives
    • Airway management in ER
    • Sedation/ opioids for minor procedures
    • Local anesthetics used
    • IV access
  • 3. Airway management
    • Role of ED physicians in airway management
    • 25 yrs ago :
    • Blind nasotracheal intubation by ED doctors
    • Anesthesiologists used paralytic agents
    • 1977 Institution survey
    • Intubation by ED physician: 45%
    • by anesthesia personnel 32%
    • Both 19%
    Anesth Analg1997;85:62-8
  • 4. Airway management
    • Use of NMB&RSI by ED physician
    • Complications of emergency intubation without NMB
    • aspiration 15%
    • airway trauma 28%
    • dead 3%
    • No complication in RSI groups
    • AmJEmergMed1999;17:141-3
  • 5. Difficult Airway
    • Difficult ventilation : cannot ventilate, SpO 2  90%
    • Difficult intubation : cannot intubate > 3attempts
    • duration > 10 minutes
  • 6.  
  • 7.  
  • 8.  
  • 9. Rapid Sequence Intubation
    • Be prepared to perform surgical airway in the event that airwaycontrol is lost
    • Preoxygenation the patient with 100% oxygen
    • Apply pressure over the cricoid cartilage
    • Administer 1-2 mg/kg succinyl choline IV
    • After the pateint relaxes,intubate the patieint orotracheally
    • Inflate the cuff and confirm tube placement
    • Release cricoid pressure
    • Ventilate the patient
  • 10. Evaluation of Difficult AW
    • Anatomy
    • Malampati classificati
    • Mouth opening  3 cm.
    • Movement at atlanto-occipital  35 º
    • Thyromental distance  7 cm
    • Large incisor length
    • Short thick neck
    • Narrow palate
  • 11. Drugs for RSI
    • Preinduction drugs: Fentanyl, Lidocaine, Esmolol
    • Induction drugs:
    • Etomidate, Propofol, Thiopental, Ketamine
    • Muscle relaxant :
    • Succinyl choline, Rocuronium,
  • 12. 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 reactivity
    • Be careful in traumatic hypovolemia
  • 13. 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
  • 14. 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/kg
    • difficult AW
    • allergy to aminosteroid NMB
    • ,
  • 15.  
  • 16.  
  • 17.  
  • 18. 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
  • 19. Airway equipment
    • Airway :
    • Oropharyngeal airway
    • Nasopharyngeal airway
    • LMA
    • Surgical Airway
    • Cricothroidotomy
    • Tracheostomy
    • Face mask
  • 20.  
  • 21. Airway equipment
    • Endotracheal tube
    • Orotracheal tube
    • Nasotracheal tube
    • Combitube
    • Laryngoscope
    • Bullard
    • McCoy
    • Light wand
    • FOB
  • 22.  
  • 23.  
  • 24.
    • Airway burn patient
    • Maxillofacial trauma : Lefort II, III
    Caution!
  • 25.  
  • 26.  
  • 27.  
  • 28.  
  • 29. Sedation in ER
    • Minimum Sedation
    • Moderate Sedation
    • Deep Sedation
  • 30. Preparation for sedation
    • S uction
    • O xygen
    • A irway
    • Pharmacy ที่จำเป็นต้องใช้ : adrenalin, atropine, ephedrine, amiodarone, lidocaine, flumazenil ( ต้านฤทธิ์กลุ่ม benzodiazepine) naloxone
    • M onitor
    • E quipment เช่น อุปกรณ์การช่วยชีวิต
  • 31. ยาที่ใช้ sedatio n
    • Propofol 100-200  g/kg/min IV หรือ Etomidate
    • Midazolam 0.5-0.75 mg/kg IV
    • Chloral hydrate 25-100 mg/kg รับประทานในเด็กไม่ เกิน 2 gm.
    • Ketamine 1-1.5 mg/kg IV, 4-5 mg/kg IM
    • Fentamyl 1.0  g/kg
  • 32. ยาต้านฤทธิ์
    • Naloxone 0.1 mg/kg IM ทุก 2 นาที
    • ไม่เกิน 2 mg
    • Flumazenil 0.02 mg/kg IV. ทุก 1 นาที
    • ไม่เกิน 1 mg. ต่อครั้ง
  • 33. Selection of patient
    • Painless procedures
    • Painful procedures
    • Be careful of AWO, ↑ ICP, Change of consciousness, intestinal obstruction, CHF, allergy, not cooperate
    • Pediatric patient : Ketamine + Topical
    • Midazolam + Ketamine
  • 34. Local anesthetics
    • Lidocaine
    • Dose 5 mg/kg (plain)
    • 7 mg/kg (with epinephrine)
    • Bupivacaine
    • Dose ต่อครั้ง 175mg (plain)
    • 250mg (with epinephrine)
  • 35. IV access
    • External jugular vein , Internal jugular vein
    • Femoral vein
    • Evaluation of circulating volume
  • 36. Thank you