pharmacologic adjuncts to airway management and ventilation ems 352 dr aqeela bano
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Pharmacologic Adjuncts to Airway Management and VentilationEMS 352DR AQEELA BANOPharmacologic Adjuncts to Airway Management and VentilationDecrease the discomfort of intubationDecrease the incidence of complications Make aggressive airway management possible for patients who are unable to cooperateSedation in Emergency IntubationReduces anxiety, induces amnesia, decreases gag reflexUndersedation:Inadequate cooperationComplications of gagging Incomplete amnesia Sedation in Emergency IntubationOversedation:Uncontrolled general anesthesiaLoss of protective airway reflexesRespiratory depressionComplete airway collapseHypotensionSedation in Emergency IntubationDesired level of sedation dictates doseTwo major classes:Analgesics: decrease perception of painSedative-hypnotics: induce sleep, decrease anxiety
ButyrophenonesPotent, effective sedatives Haloperidol and droperidol relieve anxiety.Do not produce apnea Little effect on cardiovascular systemNot recommended to induce anesthesiaBenzodiazepinesSedative-hypnotic drugsDiazepam and midazolamProvide muscle relaxation, mild sedationUsed as anxiolytic and antiseizure medicationsProvide anterograde amnesiaBenzodiazepinesNeuromuscular blockers preferred for muscle relaxationPotential side effects:Respiratory depressionSlight hypotensionFlumazenil: benzodiazepine antagonistBarbituatesSedative-hypnotic medicationsThiopentalShort actingRapid onset MethohexitalUltra-short actingTwice as potent Can cause Respiratory depressionDrop in blood pressurePotentially irreversible in hypovolemic patientsOpioids/NarcoticsPotent analgesics with sedative propertiesTwo most common: fentanyl, alfentanilCan cause respiratory and central nervous system depression Naloxone: narcotic antagonistNonnarcotic/NonbarbituateEtomidate Hypnotic-sedative drugOften used in induction of general anesthesiaFast-acting, short durationLittle effect on pulse rate, blood pressure, intracranial pressure (ICP)Nonnarcotic/NonbarbituateEtomidate (contd)No histamine release and bronchoconstrictionHigh incidence of myoclonic muscle movementUseful induction agent in patients with:Coronary artery diseaseIncreased ICPBorderline hypotension/hypovolemiaNeuromuscular Blockade in Emergency IntubationCerebral hypoxia can make patients combative and uncooperative.Requires aggressive oxygenation, ventilationNeuromuscular blocking agents are safer.Neuromuscular Blocking AgentsAffect every skeletal muscle Within about 1 minute, patient is paralyzedMust be able to secure the airwayNo effect on LOC.Pharmacology of Neuromuscular Blocking AgentsSkeletal muscles are voluntary.Impulse to contract reaches a motor nerveAcetylcholine (Ach) is released.Diffuses, occupies receptor sitesTriggers changes in electrical properties of the muscle fiber (depolarization)Pharmacology of Neuromuscular Blocking AgentsParalytic medicationsRelax the muscle by impeding the action of AchTwo categories: depolarizing and nondepolarizing
Depolarizing Neuromuscular Blocking AgentCompetitively binds with ACh receptor sitesNot affected as quickly by acetylcholinesteraseSuccinylcholine chloride is the only agent.Fasciculations can be observed during its administration.Depolarizing Neuromuscular Blocking AgentVery rapid onset of total paralysisShort duration of action Use with caution in patients with burns, crush injuries, and blunt traumaCan cause bradycardiaNondepolarizing Neuromuscular Blocking AgentsBind to ACh receptor sites but do not cause depolarization of the muscle fiber. Prevent fasciculations before a depolarizing paralyticNondepolarizing Neuromuscular Blocking AgentsMost commonly usedVecuronium bromide (Norcuron)Pancuronium bromide (Pavulon)Rocuronium bromide (Zemuron)Do not give before the airway is secured.Rapid-Sequence Intubation (RSI)Safe, smooth, rapid sedation and paralysis followed immediately by intubationGenerally used for patients who are unable to cooperatePreparation of the Patient and EquipmentExplain procedure, reassure the patientApply a cardiac monitor and pulse oximeter.Check, prepare, assemble equipmentHave suction availablePreoxygenationAdequately preoxygenate all patients.If the patient is breathing spontaneously and has adequate tidal volume: Apply high-flow oxygen via nonrebreathing mask.If patient is hypoventilating: Assist ventilations with a bag-mask device and high-flow oxygen.PremedicationStimulation of the glottis with intubation can cause dysrhythmias and increase ICP.If your initial paralytic is succinylcholine, administer nondepolarizing paralytic.Atropine sulfate should be administered to decrease potential for bradycardia. Sedation and ParalysisAs soon as patient is sedated, administer paralytic agentOnset should be complete within 2 minutes.Signs of adequate paralysis include:ApneaLaxity of the mandibleLoss of the eyelash reflexIntubationIntubate trachea as carefully as possible.If you cannot intubate within 30 seconds, ventilate for 3060 seconds before trying again.If ventilating with a bag-mask device, do so slowly.IntubationOnce tube is in the trachea:Inflate cuff.Remove stylet.Verify position of the ET tube.Secure the tube.Continue ventilations.IntubationIntubate trachea as carefully as possible.If you cannot intubate within 30 seconds, ventilate for 3060 seconds before trying again.If ventilating with a bag-mask device, do so slowly.IntubationOnce tube is in the trachea:Inflate cuff.Remove stylet.Verify position of the ET tube.Secure the tube.Continue ventilations.Maintenance of Paralysis and SedationAdditional paralytic administration may be necessary after intubation.If you administered succinylcholine, administer a nondepolarizing agent to maintain paralysis.If you administered a long-acting paralytic, additional dosing is usually not necessary.Maintenance of Paralysis and SedationModification for unstable patientsIf oxygen saturation drops, ventilate slowly.If patient is hemodynamically unstable, judge whether sedation is appropriate.
Maintenance of Paralysis and SedationAdditional paralytic administration may be necessary after intubation.If you administered succinylcholine, administer a nondepolarizing agent to maintain paralysis.If you administered a long-acting paralytic, additional dosing is usually not necessary.