This is a lecture by Michele Nypaver, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
The questions asked in the Anaesthesiology viva examination are presented in this presentation which will be useful for the post-graduates appearing for the M.D-Anaesthesia examination.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
The questions asked in the Anaesthesiology viva examination are presented in this presentation which will be useful for the post-graduates appearing for the M.D-Anaesthesia examination.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
Slideshow is from the University of Michigan Medical School's M1 Cardiovascular / Respiratory sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M1Cardio
RSI is a method of intubating patients who have a gag reflex who would otherwise be difficult to intubate. Intubation is accomplished by sedating and paralyzing the patient, allowing for easier intubation.
Dr. Akira Nishisaki (Children's Hospital of Philadelphia) talks about A Just-in-Time Training study on pediatric advanced airway skills at the CHOP PICU.
GEMC: “Taming the Wild Child” - Pearls, Pitfalls and Controversies in Pediatr...Open.Michigan
This is a lecture by Dr. Jeff Holmes from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: Evaluation and Management of Epistaxis: Resident TrainingOpen.Michigan
This is a lecture by Dr. Patrick Carter from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: ENT Case Files: Resident Training Open.Michigan
This is a lecture by Dr. Matt Dawson and Dr. Zach Sturges from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Ryan LaFollette, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Slideshow is from the University of Michigan Medical School's M2 Respiratory sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M2Resp
Learn about AORN's recommended practices for surgical attire in the perioperative setting. This presentation is from a webinar on August 8, 2012. Listen to the webinar for free to learn more, and you can also earn 1.0 contact hour: www.aorn.org/PreviouslyRecordedWebinars
GEMC - Nursing Assessment and ResuscitationOpen.Michigan
This is a lecture by Antoinette Bradshaw from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Ghana Grab Bag Pediatric Quiz- Resident TrainingOpen.Michigan
This is a lecture by Hannah Smith, MD and Ruth S. Hwu, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC - Measles, Mumps, Rubella - for NursesOpen.Michigan
This is a lecture by Katherine A Perry from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Acute Sinusitis - Resident Training Open.Michigan
This is a lecture by Dr. Jim Holliman from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Peter Moyer from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Peter Moyer from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Stuart Bradin from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Jeff Holmes from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Oral and Facial Infections- Resident TrainingOpen.Michigan
This is a lecture by Dr. Shannon Langston from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
05.26.09(b): Development of the Respiratory System and DiaphragmOpen.Michigan
Slideshow is from the University of Michigan Medical
School's M1 Embryology sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M1Embryology
Similar to GEMC- Rapid Sequence Intubation & Emergency Airway Support in the Pediatric Emergency Department- Resident Training (20)
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Jim Holliman, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Alterations in Body Temperature: The Adult Patient with a Fever- Reside...Open.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Disorders of the Pleura, Mediastinum, and Chest Wall- Resident TrainingOpen.Michigan
This is a lecture by Andrew Barnosky, DO from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Dental Emergencies and Common Dental Blocks- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Arthritis and Arthrocentesis- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Bursitis, Tendonitis, Fibromyalgia, and RSD- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Right Upper Quadrant Ultrasound- Resident TrainingOpen.Michigan
This is a lecture by Jeff Holmes from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: Nursing Process and Linkage between Theory and PracticeOpen.Michigan
This is a lecture by Jeremy Lapham from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
2014 gemc-nursing-lapham-general survey and patient care managementOpen.Michigan
This is a lecture by Dr. Jeremy Lapham from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Jessica Holly from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: The Role of Radiography in the Initial Evaluation of C-Spine TraumaOpen.Michigan
This is a lecture by Dr. Stephen Hartsell from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Jim Holliman from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Sickle Cell Disease: Special Considerations in Pediatrics- Resident Tra...Open.Michigan
This is a lecture by Hannah Smith, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Ruth S. Hwu, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
How to Create Map Views in the Odoo 17 ERPCeline George
The map views are useful for providing a geographical representation of data. They allow users to visualize and analyze the data in a more intuitive manner.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
GEMC- Rapid Sequence Intubation & Emergency Airway Support in the Pediatric Emergency Department- Resident Training
1. Project: Ghana Emergency Medicine Collaborative
Document Title: Rapid Sequence Intubation & Emergency Airway Support
in the Pediatric Emergency Department
Author(s): Michele Nypaver (University of Michigan), MD, 2009
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or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please
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Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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2
3. Rapid Sequence Intubation & Emergency Airway Support in the Pediatric Emergency Dept.
Michele M. Nypaver, MD
UMHS Pediatric Emergency Medicine Fellowship Lecture Series
July 2009
3
4. Objectives
Basics Review
The 7 P’s of RSI
RSI Pharmacology
Procedure
Indications/Complications of RSI
Advanced Airway options
Resources for skill maintenance and help
A is for airway!
4
5. Definitions
Rapid Sequence Intubation:
• Describes a sequential process of preparation, sedation, and paralysis to facilitate safe, emergent tracheal intubation.
• Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal intubation.
• At the same time, careful preparation (including pre- oxygenation) and the use of specific techniques (such as applying cricoid pressure and avoiding positive pressure ventilation) minimize the risks of hypoxia and aspiration.
• Assuming a patient with full stomach.
5
6. The Evidence for RSI
“NEAR” data: n=156 pediatric intubations Success Rates for intubation
Sagarin et. al., 2002
METHOD
FREQ.
(%)
FIRST ATTEMPT (%) *
FIRST PERSON (%)
OVERALL SUCCESS
(%)
COMPLIC-ATION (%)
RSI
81
78
85
99
1
NO MEDS
13
47
75
97
5
SED, NO NMBA
6
44
89
97
0
* May be due to size and age
6
7. Basic Pediatric Anatomy: Size
Take home point: Small changes in pediatric airways cause large incremental increases in airway resistance
4 mm
8 mm
2 mm
6 mm
NORMAL
EDEMA 1mm
RESISTANCE (R proportional to 1/(radius^4)
X-SECT AREA
INFANT
ADULT
Increase 16x
Increase 3x
Decrease 75%
Decrease 44%
7
8. 23) In this picture taken during DL, the arrow is pointing to which of the following anatomic structure(s)? a) Arytenoid cartilages b) Epiglottis c) Vallecula d) Vocal cords e) Aryepiglottic fold
PEM BOARD QUESTION!
True Vocal Cords
Pearson Scott Foresman, Wikimedia Commons
8
9. Physical Assessment to identify signs of a real/potential difficult airway in children
Prominent or misshapen occiput
short neck
poor neck mobility
Facial trauma (including burns)
Facial anomalies:
Small mouth
Small mandible/recessed chin
Abnormal palate
Large tongue
Loose teeth
Signs of upper airway obstruction
hoarseness, stridor, drooling, upright position of comfort
9
10. Airway Assessment: Malampati & ASA Classification
Malampati Score
UMHS / CES requires documentation of these on all procedural sedation consents
10
Hard palate
Pillar
Uvula
Soft palate
Jmarchn, Wikimedia Commons
Source Undetermined
11. The Lemon
Pneumonic
TheCulinaryGeek, Flick
11
Mouth opening > 3 cm
Chin to neck distance > 3 finger breadths
http://archive.ispub.com/journal/the-internet-journal-of-anesthesiology/
volume-10-number-1/the-dilemma-of-airway-assessment-
and-evaluation.html#sthash.TmMgasnc.dpbs
12. RSI Procedures
The 7 “P”s of RSI
Preparation Pre-oxygenation/Positioning Pre-treatment Protection (Pressure) Pharmacology Placement of the tube Post intubation management
12
13. RSI Timeline/Protocol
Preparation: Zero-10 Min
Monitors, Patient position, Assess for difficulty
Equipment and Meds
Pre oxygenate: Zero-5 Min
Pre treat: Zero-3 Min
Time Zero: Inject Paralytic with induction
Protection: Zero-30 seconds
Placement: Zero-45 seconds
Post intubation management: Zero-90 seconds
13
18. Which is the most appropriate equipment and position for the provided patient age? a) 1 mo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 8 Fr NG tube b) 1 mo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 8 Fr NG tube c) 3 yo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 12 Fr NG tube d) 3 yo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 12 Fr NG tube e) 7 yo: Miller 2 blade, 5.5 uncuffed tube inserted to 16 cm, 12 Fr NG tube
PEM BOARD QUESTION!
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19. Which is the most appropriate equipment and position for the provided patient age? a) 1 mo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 8 Fr NG tube b) 1 mo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 8 Fr NG tube c) 3 yo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 12 Fr NG tube d) 3 yo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 12 Fr NG tube e) 7 yo: Miller 2 blade, 5.5 uncuffed tube inserted to 16 cm, 12 Fr NG tube
PEM BOARD QUESTION!
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20. 14) Which of the following is true regarding laryngoscope blades?
a) Miller blades are designed to sit in the vallecula
b) Miller blades are available in sizes from neonates to large adults
c) Macintosh blades are used more commonly in infants/children than in adults
d) Macintosh blades provide a better laryngoscopic view
e) Macintosh blades should not be used to lift the epiglottis because of increased risk of epiglottic trauma
PEM Board Question!
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21. 14) Which of the following is true regarding laryngoscope blades? a) Miller blades are designed to sit in the vallecula b) Miller blades are available in sizes from neonates to large adults c) Macintosh blades are used more commonly in infants/children than in adults d) Macintosh blades provide a better laryngoscopic view e) Macintosh blades should not be used to lift the epiglottis because of increased risk of epiglottic trauma
PEM Board Question!
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22. RSI: Pre-oxygenation
A critical step
Reservoir of oxygen for apnea time
Time varies by patient/condition
Begin pre-oxygenation immediately
Administer 100% oxygen
If spontaneously breathing:
•Non Rebreather Face mask FIO2 100% X 5 min
Avoid bagging sponteously breathing pt
If need to bag: Selick maneuver
If assisted ventilation or BVM req’d: 8 effective VC
breaths provides best pre oxygenation.
Goal: O2 sat > 90% duration of procedure
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23. Time to desaturation during RSI
Children have a short interval to desaturation after paralyzation
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Source Undetermined
24. RSI Pharmacology: The perfect pharmacologic recipe?
Medical Trauma (ICP?) Special Cases (Asthma)
Mkhmarketing, flickr
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25. RSI Pre-treatment: Prevent adverse effects of laryngoscopy and /or succinylcholine
Lidocaine
Atropine
Defasciculation dose of Non depolarizing ?
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26. RSI Pretreatment: Lidocaine
Local anesthetic
Use in RSI
Theory: Blunt rise in ICP (unknown exact mech)
No studies available measuring efficacy of lidocaine on neurologic
•Outcome after trauma
Current recommendations 1-2mg/kg IV 2-5 min before intubation
Adverse Effects:
Seizure
Hypotension
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27. RSI Pre-treatment: Atropine
Mechanism of Action:
Anti cholinergic, Blocks muscarinic ACH receptors
Original Science:
Milk introduced in lamb = laryngeal reflex:
Apnea, hypoxia and bradycardia
Reflex particularly strong in newborn animals and infants
•Wennergren G, Milerad J, Hertzberg T. Laryngeal reflex.
•Acta Paediatr Suppl. 1993;389:53–56.
Limited data to answer question:
Does atropine prevent bradycardia in children undergoing RSI?
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28. Fastle RK Roback MG. Pediatric rapid sequence intubation: incidence of reflex
bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care.
2004 Oct;20(10):651-5
Does Atropine prevent bradycardia
during RSI?
Retrospective cohort study
comparing atropine RSI vs
no atropine RSI children
(0-19y/o)
Rates of bradycardia
4% each group.
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29. RSI: Atropine?
Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation
Bethany Fleming, BA, BS; Maureen McCollough, MD; Sean O. Henderson, MD CJEM. 2005 Mar;7(2):114-7
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30. Atropine: What can we say?
Who:
All children < 1 year, Children < 5 y/o SCh, AND
Prior to repeat dose SCh (in adolescent/adult)
Dose
Current recommendations: AAP ACEP AHA PALS
“Cannot recommend uniform guidelines based on lack of evidence”
•0.01-0.02mg/kg (min 0.1, max 1.0mg) 1-2 min
•Prior to intubation
Adverse effects Increase HR, Increase IOP
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31. RSI: Pharmacology/Paralytic with Induction
Agents determined by condition/scenario
Induction options
Etomidate
Midazolam
Ketamine
Propofol (Currently NOT available in UMHS ED)
Barbiturates
Pentothal
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32. RSI Pharmacology Etomidate
Non narcotic, non barbiturate hypnotic induction
Sedative, not analgesic
Lowers ICP
Pro:
Min CV effects so safe in pts with unstable hemodyn
Dose: 0.3mg/kg IV, onset 2-30 seconds
May cause
pain on injection
myoclonic jerks
hiccups
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33. RSI Pharmacology Etomidate….but
Adverse Effects
Inhibits mitochondrial hydroxylase activity
Even after single dose
Effects seen in PICU population
•Implications in septic patients
Risk of infection may be increased
No randomized clinical trials assess outcome
Bottom line: Using judiciously
Arcadian, Wikimedia Commons
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34. RSI Pharmacology: BDZ’s Midazolam, Lorazepam, Diazepam
Sedative, anxiolytic, amnestic NOT analgesic
Resp depressants
Reversible with Flumazenil
Several choices
Midazolam: Dose 0.1-0.3mg/kg (induction)
More potent than diazepam
Rapid onset < 1 min
Caution when used with narcotics, esp in younger children/infants
“Near “data suggest many underdose Midazolam!
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35. RSI Pharmacology: Ketamine
Dissociative agent; amnestic and analgesia
Release of catecholamine
Increased HR and BP
Adverse Effects
Increased secretions
Emergence reactions
Laryngospasm
May increase ICP (relative contraindication)
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36. RSI Pharmacology: Ketamine
Bronchodilator: intubation of asthmatics
Induction dose: 1-2 mg/kg
Onset 10-15 sec
Duration 10-15 min
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37. A 12 yo boy with severe asthma is being treated in the ED. So far he has received 2 hours of continuous nebulized albuterol and ipratropium bromide, methylprednisolone and IV magnesium. He is still in severe respiratory distress. A bedside ABG reveals a pH of 7.12, pCO2 80 torr, and pO2 45 torr on 100% supplemental oxygen. You are getting ready to perform rapid sequence intubation (RSI) and preoxygenate with 100% oxygen with a bag/mask system. During induction with ketamine, he develops stridor with suprasternal retractions. Which of the following would be most appropriate?
A) Administer nebulized racemic epinephrine B) Administer IV fentanyl C) Administer IV succinylcholine D) Administer IV flumazenil E) Perform jaw thrust until ketamine wears off
PEM Board Question!
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38. A 12 yo boy with severe asthma is being treated in the ED. So far he has received 2 hours of continuous nebulized albuterol and ipratropium bromide, methylprednisolone and IV magnesium. He is still in severe respiratory distress. A bedside ABG reveals a pH of 7.12, pCO2 80 torr, and pO2 45 torr on 100% supplemental oxygen. You are getting ready to perform rapid sequence intubation (RSI) and preoxygenate with 100% oxygen with a bag/mask system. During induction with ketamine, he develops stridor with suprasternal retractions. Which of the following would be most appropriate?
A) Administer nebulized racemic epinephrine B) Administer IV fentanyl C) Administer IV succinylcholine D) Administer IV flumazenil E) Perform jaw thrust until ketamine wears off
PEM Board Question!
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39. RSI Pharmacology: Propofol
Alkphenol
Sedative hypnotic
Attenuates ICP rise
Dec CPP
Induction dose 0.5-1.2mg/kg IV
Adverse problems: BP
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40. RSI Pharmacology: Thiopental
Barbiturate
GABA receptor
Rapid onset sedation (15 sec)
Decrease ICP
Cardiac depressant, venodilator: Lower BP
Dose: Euvolemic child 5-8mg/kg IV
Hypovolemic child 1-5 mg/kg IV
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41. RSI: Neuromuscular Blocking Agents (NMB’s)
NMB issues to consider
Documentation of neuro exam
Make sure to sedate too
Dosing must be adequate
Anticipate complications
•Failed intubation
•Adverse effects
•Prep for surg airway
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43. RSI: Neuromuscular Blocking Agents (NMB’s)
Depolarizing Agent (Succ)
Simulate Ach receptors
Reliable paralysis with long track record of use
Non depolarizing agents
Competitively block Ach receptors without
Stimulating them
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44. RSI: Neuromuscular Blocking Agents (NMB’s): Succinylcholine
Dose: Infants/Young 2mg/kg IVP Dose: Older children 1-1.5mg/kg IVP Contraindications: Personal/Fam with Malignant Hyperthermia Burn >10% BSA > 24 hr old (not problem in acute) Crush injury > 1 week old Denervation > 1 week old Progressing/ongoing neuromuscular dz; watch for children with suspected myopathies Side Effects Bradycardia (esp after >1 dose); reduced with pre tx with Atropine Hyperkalemia: Pk 5 min, resolves 15 min, rarely sig Fasciculations Myotonic syndromes MH
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45. RSI Pretreatment: Defasciculation?
Prior Recommendations for defasc dose
Non depolarizing NMB before Succ
Enhance effect of succ and reduce side effect
Not routine in peds RSI but some evidence
Of succ induced hyperkalemia.
Theroux MC, Rose JB, Iyengar S, et al. Succinylcholine pretreatment using gallamine or mivacuronium during rapid sequence intubation in children: a randomized controlled study. J Clin Anesth 2001; 13:287-292
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46. In which of the following patients could succinylcholine be used safely for RSI? a) 2 yo with 2nd and 3rd degree burns covering 20-30% of the body surface area b) 4 yo in a cervical spine (c-spine) collar with concern for a c- spine injury c) 12 yo s/p CVA 2 months ago with residual left hemiparesis d) 1 yo with Type 1 spinal muscle atrophy e) 17 yo with renal failure on hemodialysis with known electrolyte abnormalities
PEM BOARD QUESTION!
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47. In which of the following patients could succinylcholine be used safely for RSI? a) 2 yo with 2nd and 3rd degree burns covering 20-30% of the body surface area b) 4 yo in a cervical spine (c-spine) collar with concern for a c- spine injury c) 12 yo s/p CVA 2 months ago with residual left hemiparesis d) 1 yo with Type 1 spinal muscle atrophy e) 17 yo with renal failure on hemodialysis with known electrolyte abnormalities
PEM BOARD QUESTION!
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48. Answer: b. Succinylcholine may be used for RSI given its rapid onset and short duration of action. When succinylcholine binds to acetylcholine receptors, potassium is released, increasing serum potassium concentrations. Therefore, it is contraindicated in patients with known/suspected hyperkalemia, including patients with severe burns and those in renal failure (unless potassium is already known to be within normal limits). In patients with neurological denervation, such as would occur s/p CVA, and those with known or suspected myopathies or neuromuscular disease, acetylcholine receptors are upregulated at motor endplates. Therefore with succinylcholine use, massive amounts of potassium can be released precipitating hyperkalemic arrest even in patients with baseline normal potassium levels.
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49. RSI: Neuromuscular Blocking Agents (NMB’s): Non depolarizing Agents
Competitively block Ach receptor
Does not stimulate receptor
Eventually diffuses out of synapse
Useful for pts who cannot use Succ
Longer duration of action
Onset of action may be a little longer than Succ
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50. RSI: Neuromuscular Blocking Agents (NMB’s): Non depolarizing Agents
Vecuronium
Dose 0.1-0.2mg/kg/IV
Max paralysis: 1-2 min
Duration of apnea: 25-45 min
Less vagolytic than pancuronium
Biliary excretion
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51. RSI: Neuromuscular Blocking Agents (NMB’s): Non depolarizing Agents
Rocuronium
Dose 1mg/kg
Onset: 60 sec
Duration: Up to 35 min
Little CV effects
Comparison of Rocuronium vs Succ
Equivalent provision of acceptable Int cond.
Rates of intubation success similar
Succ better at “excellent” condition
AEM 2002 Perry; Metanalysis 1606 pts
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52. RSI: Other controversial Succinylcholine Issues
Obese Pts?: Use actual body weight
Is there an optimal dose?
Controversial, Rec peds dose stands
Rose et al. Anesth Analg 2000
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53. In addition to direct visualization of an endotracheal (ET) tube passing through the vocal cords, the most rapid and reliable means to confirm tube placement in the trachea after intubation is: A) Capnography B) Oxygen saturation C) Bilateral breath sounds on auscultation D) Condensation in the ET tube E) Fiberoptic bronchoscopy
PEM Board Question!
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56. Transtracheal Needle Ventilation
Alternative to Cric
1) Transtracheal ventilation is difficult.10,11 2) Transtracheal ventilation through a catheter must be done with a high pressure, high flow device.10,12 3) Transtracheal ventilation through a catheter cannot be effectively done using a ventilation bag.12 4) The resistance of air flow through a transtracheal ventilation catheter increases as a 4th power function as the diameter of the catheter decreases.13
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57. LMA-Fastrach™
Sizes 3, 4 & 5 Size 3: Children 30-50kg
Airway tube
Handle
LMA FastrachTM ETT
Epiglottic Elevating Bar
Cuff
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59. Complications: Anticipate Problems before they happen!
DOPE
Displacement
Obstruction
Pneumothorax
Esophageal placement
Medication complications
Take the pt off the vent
BVM
Check connections/Machines
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60. RSI Post Intubation Care
Secure the tube
Order the CXR
Administer sedation
Reconsider longer acting paralysis as indicated
Respiratory Care:
Vent settings
Respiratory Therapy/transport
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61. Resources for help/practice
American Heart Association: PALS Manual
UMHS Clinical Simulation Center
UMHS Annual Anesthesia Airway workshop
UMHS PEM Airway Workshop
UMHS Dept of EM Difficult Airway Workshop
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62. References
Bledsoe GH, Schexnayder SM: Pediatric Rapid Sequence Intubation: A review. Ped Emer Care 20 (5) May 2004
Sagarin MJ. Et al. Rapid Sequence Intubation for pediatric emergency airway management. Ped Emer Care 18(6) Dec 2002
Youngquist S Gausche-Hill. Alternative Devices for Use in Children Requiring Prehospital airway management. Update and Discussion. Ped Emerg Care. 23(4) April 2007
Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005 Feb; 22:99-102.
Zelicof-Paul et al. Controversies in rapid sequence intubation in children. Curr Opin Ped 2005, 17,355-362.
Fastle RK et al. Pediatric rapid sequence intubation incidence of reflex bradycardia and effects of pretreatment with atropine. Ped Emerg Care. 2004;20:651-655
Rothrock, SG. Et al. Pediatric rapid sequence intubation incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2005 Sep;21(9):637-8 (Comment regarding 2004 article above).
den Brinker M, Joosten KF, Liem O, et al. Adrenal insufficiency in meningococcal sepsis: bioavailable cortisol levels and impact of interleukin-6 levels and intubation with etomidate on adrenal function and mortality. J Clin Endocrinol Metab. 2005;90:5110-5117.
Zuckerbraun NS et al. Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department. 1: Acad Emerg Med. 2006 Jun;13(6):602-9
Schenarts CL, Burton JH, Riker RR. Adrenocortical dysfunction following etomidate induction in emergency department patients. Acad Emerg Med 2001;8:1-7
. Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000 Feb;16(1):18-21
Cochrane Database of Sytematic Reviews. Rocuronium versus succinylcholine for rapid sequence induction intubation. 2008. Vol 2
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