Airway%20Management

1
Airway Management

• Sarah McPherson
• Gord McNeil
• July 17, 2003

2
What are the indications to intubate?

• Failure to protect airway
• Failure to oxygenate or ventilate
• Anticipated course

3
Basic Airway Approach
Needs intubation
yes
Crash Airway
Unresponsive? Near death?
no
yes
Predict difficult airway?
Difficult Ariway
no
RSI
4
Basic Airway Approach
Attempt Oral Intubation
yes
Post-intubation Management
Successful?
no
BMV maintains SpO2 gt 90?
no
Failed Airway
yes
gt3 Attempts at OTI by attending MD?
yes
5
Airway Anatomy
Epiglottis Aryepiglottic folds Arytenoid
cartilage False vocal cords True vocal cords
6
Anatomy

• Pediatric Airway Differences
• Larger tongue
• Large occiput
• Anterior larynx
• Larger epiglottis/floppier
• Subglottic area narrowest
• Less musculature
• Shorter trachea
• Narrower airway

7
8 Steps to a Successful RSI

• RSI 8 ps
• Preparation
• Peruse
• Preoxygenate
• Pretreatment
• Paralysis
• Protection
• Placement
• Post intubation management

8
Basic Airway Management - 8 PsPrepare SIGMA
D

• What do you need for intubation?
• SIGMA D
• S Suction
• I Intravenous
• G Gas
• M Mask/Bag
• A airway equipment (oral airway, laryngoscope,
  tubes, alternative)
• D Drugs

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Peruse - LEMON LAW

• L Look face, neck, chest
• E Examine mouth, thyromental, floor of mouth
  to thyroid
• M Mallampatti huge tongue?, back of throat?
• O Obstruction tumor, epiglottitis
• N Neck mobility OA, RA, syndromic

10
LEMON - Look

• Look
• Evaluate the pt.
• Obesity
• Micrognathia
• High arched palate
• Narrow face
• Short or thick neck
• Neck trauma
• Large tongue
• Presence of facial hair
• Dentures
• Large teeth

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LEMON Evaluate 3-3-2

• Evaluate 3-3-2
• Evaluate the anatomy
• 3 fingerbreadths of mouth opening
• 3 fingerbreadths between front of chin and hyoid
• 2 fingerbreadths from mandible to thyroid
  cartilage
• CAN I DISPLACE TISSUE SUB-MENTALLY?

12
LEMON Mallampati score

• Mallampati score
• Grade 1 entire post. Pharynx, visualized to
  tonsillar pillars
• No difficulty
• Grade 2 hard palate, soft palate and top of
  uvula only
• No difficulty
• Grade 3 hard and soft palate only
• Moderate difficulty
• Grade 4 no visualization post pharynx or uvula
  (hard palate only
• Severe difficulty

13
LEMON -Obstruction

• Obstruction
• Look for upper and lower airway obstruction
• foreign body aspiration
• Epiglottitis
• croup
• Abscesses
• others surgery,tumors, radiation

14
LEMON Neck Mobility

• Neck Mobility
• Collar, RA, degenerative arthritis, history of
  surgery
• Note get significant movement with BVM
  ventilation also!!

15
Pre-oxygenate - no bagging

• Preoxygenate (nitrogen washout)
• Saturate O2 reservoir, tissues and blood
• 100 NRB (70)
• 5 min healthy adult
• 2.5 min children
• 8 VC breaths

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How much time do I have?

• 70kg adult maintains O2 sat gt90 for 8 min
• From 90 - 0 lt 120 seconds
• Obese adult (gt120kg) desaturate to 0 in less
  than 3 min
• 10kg child desaturate lt90 in 4 min
• From 90 to 0 in 45 seconds

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• Walls graph

18
Pre- medicate - LOAD

• Lidocaine tight heads, tight lungs
• Opioid for blunting sympathetic response (ICP,
  IOP, aortic dissection, aneurysm, IHD)
• Atropine children lt 10
• Defasiculate for increased ICP

19
Lidocaine ?

• Premise
• Laryngoscopy and Intubation
• afferent stim. in post pharynx/ larynx
• increased central stim
• increased ICP
• stim of autonomic system
• increased HR / BP
• upper and lower resp. tract leading to increased
  airway resistance

20
Lidocaine ?

• Literature (supports)
• suppresses cough reflex
• attenuates increase in airway resistance (from
  ET tube irritation)
• prevents increased ICP (normal increase with ETT
  is 22mmHg)
• prevents increased IOP
• decreases dysrhythmias by 30-40

21
Lidocaine ?

• Literature (?doesnt support)
• use to attenuate sympathetic response to
  laryngoscopy
• Use tight lungs / tight brains
• 1.5mg/kg 3 min prior
• Topical 4 lidocaine and ICP ????

22
Drugs to Decrease Sympathetic Response to
Intubation (LOAD)

• Fentanyl
• high dose 5-10 ug/kg (will unequivocally block
  sympathetic response - hypotension, apnea , chest
  wall rigidity)
• 1.5-3ug/kg (2 min prior) blocks increase BP but
  no effect on HR
• Beta-blockers
• will decrease sympathetic response
• prob neg ionotrope, bronchoconstriction

23
Drugs to Decrease Sympathetic Response to
Intubation

• Helfman et al
• compared 200 lido, 200 fentanyl, 150 esmolol
• esmolol only reliably agent in preventing rise in
  HR and BP
• Chung et al
• combination esmolol and fentanyl (2ug/kg and
  2mg/kg) best combo with limited side-effects

24
LOAD - Atropine

• Use with SUX in children under the age of 8 and
  when giving repeat doses to adults
• Sinus brady, junctional, sinus arrest usually
  after a second dose
• Reason Sch mimicks action of Ach at the cardic
  muscarinic receptors
• Dose 0.02mg/kg (no less than 0.1mg), 3 min prior
  to induction

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LOAD - Atropine

• Literature
• Prevents brady in children
• Reduces BUT doesnt eliminate them in infants
• No effect on older children
• Anesthesia literature volatile anesthetics in
  combination with atropine - increased risk of
  arrhythmias
• Bottomline Use atropine on children in the ED

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Defasiculation

• Decrease the rise in ICP from Sch induced
  fasciculation (animal data, limited human)
• Does not attenuate the sympathetic response to
  intubation
• Does not attenuate the increase in airway
  resistance with intubation
• 1/10 intubating dose

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RSI in Adults With Elevated Intracranial
Pressure A Survey of EmergencyMedicine
Residency Programs

• Am J Emerg Med 1995
• 100 programs surveyed
• 67 responses, 65 used RSI in their programs!!!
• Top NMB agents Sux and vecuronium
• Top induction agents - midazolam and thiopental
• Lidocaine - was routine
• Fentanyl - other pretreatment agent
• Defasciculating dose used by most programs

28
Paralysis with induction

• Rapid sequence - intubation before aspiration
• Do not titrate
• Midazolam, ketamine, thiopental or etomidate
• Succinylcholine or rocuronium

29
Induction

• Used to produce anesthesia and unconsciousness
• Many options
• Best choice depends on clinical and
  pharmacokinetic factors

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Etomidate

• Ultrashort acting non-barbiturate hypnotic agent
  (no analgesic effects)
• Adv
• rapid onset and rapid recovery
• hemodynamic stability
• minimal resp depression
• cerebral protection
• Induction Dose 0.3 mg/kg (decrease to 0.15 mg/kg
  if hemodynamic instability)

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Etomidate

• Onset one arm-brain circulation (within 1 min)
• Duration 3-5 min
• Cerebral
• decreases CBF by 35 - decr ICP
• no change MAP
• CPP increases (increased cerebral oxygen/demand
  ratio) - decr ICP

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Etomidate

• Resp
• minimal effects
• doesnt release histamine
• CV
• no change in HR/ MAP/ CI/ PAWP
• Endocrine
• concern re steroid depression

33
Etomidate

• Dose dependant reversible inhibition of 11-beta-
  hydroxylase (converts 11-deoxycortisol to
  cortisol)
• Studies
• transient drop in cortisol levels with induction
  of anesthesia (6hrs), back to normal in 20 hrs
• no reported adverse outcomes

34
Etomidate

• Contraindications age lt 10, known seizure
  disorder, pregnant
• Adverse effects
• nausea and vomiting (30-40)
• pain on injection (similar to propofol)
• myoclonic movement, may cause trismus
• Pregnancy category C
• embryocidal in rats

35
Ketamine

• Phencyclidine derivative (similar to Angel Dust)
• Dissociative anesthetic (dissociation between the
  thalmus and limbic system)
• Sympathomimetic (increased HR and BP)
• Increases cerebral blood flow by 60 potentially
  elevating ICP!
• Reduces airway resistance
• Dose 1-2mg/kg IV, 4-5mg/kg IM
• Onset within 60s

36
Thiopental

• Barbituate, potentiates GABA
• Cerebroprotective
• Dose related potent venodilator and myocardial
  and resp depressant
• Adult 1-4 mg/kg, child 1- 6 mg/kg
• Onset 15 - 30 secs, duration 3- 5 min
• Do not use in hypotension

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Benzos and Narcotics

• Benzos
• Midazolam
• Dose 0.5-2 mg/kg depending on hemodynamics and
  age of patient
• often will cause hypotension
• Narcotics
• Fentanyl
• Dose 1-3 ug/kg
• less hemodynamic effects than midaz but in high
  doses will cause hypotension
• not great anestethic when used alone

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Succinylcholine

• Depolarizing NM agent
• Onset 30-45s
• Duration 5-10 min
• Dosage (IV)
• 1-1.5mg/kg adult
• 2mg/kg child
• 3mg/kg neonate
• Can give IM at twice the dose

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Succinylcholine

• Side-effects?
• Incr IOP, ICP
• Bradycardia
• Trismus-masseter muscle spasm
• Fasciculations
• Malignant Hyperthermia
• Hyperkalemia (mean increase lt 0.4mmol/L)
• Prolonged blockade

40
Succinylcholine Contraindications

• History of MH
• Burns gt 24 hrs old until healed
• Muscle damage (crush) gt 7 days - completely
  healed
• Spinal cord injury, stroke (denervation UMN, LMN)
  gt 7 days - 6 months
• Neuromuscular disease, myopathies indefinately
  as long as disease is active
• Intra-abdominal sepsis gt 7 days - resolution of
  infection
• hyperkalemia

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Sux - Hyperkalemia

• Literature
• Case reports since 1960s
• No case reports of hyperkalemia in the ED
  (multiple trauma, burns, neurological disease)
• Literature poor with chronic renal failure
• Zink et al
• 100 pts (no risk factors)
• Max increase 1.0 meq/L (K increased in 46pts,
  dropped in 46 pts and unchanged in 8)
• 1 pt found to be in a wheelchair!, K dropped from
  4.6 to 4.1

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Sux - Hyperkalemia

• Conclusion
• Non high risk pts
• No problems with administration
• High risk pts
• CRF probably okay
• Others literature is not great but we have good
  NDNM blockers, therefore no point to take risk

43
Sux Raised IOP

• Thought to be a contraindication to an open globe
  injury!
• Pressure elevations do occur, are transient,
  maximal for 2-4 min post administration
• Pressure elevations of 3-8mmHg (never been shown
  to worsen globe injury
• Comparison normal blink increases IOP by
  10-15mmHg, forceful closure of the eyelid gt70
  mmHg
• Anesthesia continues to use Sux in OR with globe
  injuries
• Chiu et al
• if you want to prevent increase in IOP, can give
  defasciculating dose of a NDNM blocker
  (rocuronium 2 min pre RSI)

44
Sux Prolonged blockade

• Pseudocholinesterase Deficiency
• Congenital
• Heterozygous up to 25 min, homozygous up to 5
  hrs after a single dose
• Homozygous 1 in 3000 pts
• Acquired
• Organophosphate poisoning
• Cocaine use
• CRF, severe liver disease, hypothyroidism,malnutri
  tion, pregnancy, cytotoxic drugs, metoclopramide,
  bambuturol(long acting beta 2 anonist)
• Note above none have prolonged blockade over
  20-25 min

45
Sux Trismus/Masseter muscle Spasm

• Occasionally can get spasm
• Especially in children
• Transient
• If prolonged, severe and other muscle involved
  should think of MH

46
Malignant Hyperthermia

• Genetic skeletal muscle membrane abnormality -
  never been an ED case reported
• Onset acute or delayed - 60 mortality
• Clinically
• Muscle rigidity
• Autonomic instability
• Hypoxia
• Hypotension
• Hyperkalemia
• Lactic acidosis
• Temp. elevation is a late sign
• treat with dantrolene (2mg/kg iv q 5min to max
  10mg/kg)

47
Rocuronium

• Aminosteroid, non-depolarizing neuromuscular
  blocker
• Agent of choice when sux is CI
• Onset 1.2-1.8 min (sux 0.8-1.2)
• Dose 0.6 mg/kg
• Duration of action 30 -45min

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Rocuronium

• Cannot depend on neostigmine in failed intubation
  - time to recovery will be too long
• Histamine related hypotension
• Primary use of non-depolarizing agents is for
  defasiculation and paralytic maintenance
  post-intubation

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Paralytics (table)
Agent Class Dose(mg/kg) Onset Duration
Vecuronium Intem. 0.1 3-5 30-45
Atracurium Intem. 0.5 3-5 30-45
Pancuronium Long 0.1 3-5 60-90
Rocuronium Intem. 0.6 1-2 30-45
Mivacurium Short 0.15 2.5-4 10-20
Rapacuronium Short 1.5 1-2 10-15
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Timing

• 10 minutes out
• Prepare (SIGMA D) Peruse (LEMON)
• 5 minutes out Pre-oxygenate
• 3 minutes out Pre-treat (LOAD)
• Zero Paralysis with induction
• Zero 30 sec Pressure and position
• Zero 45 sec Pass tube - jaw flaccidity
• Zero 1 minute Post-tube mngmt

51
RSI Sequence
52

• Video clip here

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Pressure and position

• Sellicks maneuver BURP
• Sniffing position - cervical extension and
  atlanto-occipital flexion

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BURP

• The Efficacy of the "BURP" Maneuver During a
  Difficult Laryngoscopy. Takahata O Anesth Analg
  - 1997 Feb 84(2) 419-21

The difficult intubation. The value of BURP and
3 predictive tests of difficult intubation
Ulrich B - Anaesthesist - 1998 Jan 47(1) 45-50
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Basic Airway ManagementPositioning
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Pass tube with proof

• How do you know it is in????
• Thru cords
• Misting
• Chest rising and falling
• ETCO2
• Esophageal detector

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Pass tube with proof

• Position of Tube During Intubation

58
End Tidal CO2

• Qualitative
• Colorimetric
• When color change (yellow yes) virtually 100
  specific
• False negative with cardiac arrest
• Quantitative
• Capnography
• Measures amount of CO2 in the expired air (direct
  indicator of CO2 elimination by the lungs)
• Again false negative with cardiac arrest

59
Esophageal Detection Devices (EDD)

• Premise
• Esophagus will collapse with suction
• Trachea rigid structure with lots of air (no
  collapse
• Not as reliable as end tidal CO2 therfore should
  be used as a 2nd line device to confirm tube
  placement

60
Bulb Aspiration

• Turkey baster
• Round compressible ball
• Deflate the bulb and attach to end of ETT
• Esophagus delayed or sluggish inflation
• Trachea expands rapidly (within 2 seconds)

61
Syringe Technique

• Same principle
• Use larger volume of air
• Withdraws 30 cc of air
• Use rapid aspiration os syringe

62
Post-intubation

• Use a one third therapeutic dose of benzo and
  non-depolarizing paralytic when any signs of
  patient awareness detected
• Appropriate vent settings PEEP, rate, volume
• Post-intubation bradycardia is an esophageal
  intubation until absolutely proven otherwise.

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Postintubation Hypotension

• Tension pneumothorax
• Incr PIP, difficulty bagging, decr B/S, poor sats
• Rx Chest tube
• Induction agents
• Exclude other causes
• Rx Fluid bolus, expectant

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Postintubation Hypotension

• Decreased venous return
• High PIPS secondary to high intrathoracic
  pressure
• Rx Fluid bolus, bronchodilator, incr exp time,
  decr tidal volume and rate
• Cardiogenic
• Usually in compromised patient EKG exclude
  other causes
• Rx cautious fluid bolus. pressors

65
Post-tube complication

• A patient becomes hypoxemic 2 minutes after you
  intubate him. What is your differential?

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Post-intubation Hypoxia

• D Dislodged
• O Obstruction
• P PTX
• E Equipment failure

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Difficult Airway

• Emergency Physicians
• National Emergency Airway Registry
• 6294 intubations
• 85 successful on first attempt
• 99 ultimately successful
• 1 failed airway requiring rescue maneuvers

68
Difficult Airway

• Sakles Jc et al Ann Emergency Med 1998
• Intubations over 1 yr in their ED (N610)
• 569 (93)by staff/residents
• 515(84) used RSI
• 98.9 intubated successfully

69
Difficult Airway

• Paralytics and Aeromedical Transport
• Program A (RSI) success rate 93.5
• Program B (no RSI) 66.7
• Same program after institution if RSI
• Success 90.5

70
Difficult Airway BARF

• B(5) Best view, Best person, Bougie, Blade
  change, BURP manueuver
• Alternative airway LMA, lighted stylet
• Rescue BMV
• Failed airway TTJV if lt8 years old, crich if gt8

71
Best View

• Cormack-Lehane laryngoscopy grading system
• Grade 1 2 low failure rates
• Grade 3 4 high failure rates

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Blade Change

• Macintosh (curved)
• McCoy articulating tip
• Miller (straight)
• Use with children younger than 8y/o, and people
  with anterior larynx (short mental- hyoid
  distance)
• Wisconsin and Guedel blades
• Larger more rounded barrel

73
Blade Change

• Laryngoscopy and Intubation
• the single greatest obstacle to successful
  intubation is the tongue the tongue is the
  enemy
• Paraglossal technique
• Step 1 (blind) insert blade blindly into the
  esophagus
• Step 2 (visual) withdraw blade until you
  visualize the cords /epiglottis

74
Alternative Airway technique

• LMA
• Orotracheal or nasotracheal
• Lighted stylet
• Digital
• Retrograde
• Fibreoptic

75
Alternative Airway - Laryngeal Mask

• Does not constitute definitive airway management
• Temporizing measure in the ED
• Size
• 3 teenagers and small female adults
• 4 average size adult
• 5 large adults

76
Alternative Airway-Laryngeal Mask

• Inflate cuff
• 3 20cc
• 4 30cc
• 5 40cc
• Or until no leak
• Note no literature describing the
• success rate in the ED(OR success gt95)

77
Alternative Airway - LMA

• Zideman D - Ann Emerg Med - 01-Apr-2001 37(4
  Suppl) S126-36
• Not studied in infant/child resuscitation
• Complications more frequent in peds
• Correct size
• 1 smallest 3-4 adult female 4-5 adult
  male
• May be dislodged during transport/CPR
• Aspiration little protection

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Alternative Airway Nasotracheal Intubation

• Indication
• A potentially difficult intubation who is
  spontaneously breathing - epiglottitis
• Pt you do not want to paralyze
• Contraindicated
• Combative pts
• Anatomically deranged airway
• Neck hematomas
• Raised ICP
• Severe facial trauma
• Coagulopathy

79
Alternative Airway Nasotracheal Intubation

• Pearls
• Sniffing position
• Pull tongue forward by grasping with gauze
• Only 60-70 successful on first attempt (10-20
  of NTIs are simply not possible

80
Alternative Airway Lighted Stylet

• Use if cannot directly visualize the larynx with
  laryngoscopy
• Relies on transillumination of the soft tissues
  of the neck
• Trachea well defined glow
• Esophagus diffuse light glow

81
Alternative Airway Lighted Stylet

• Success rates consistent with or exceed that of
  conventional laryngoscopy

82
Rescue Airway

• BVM
• BONES - predicts difficult mask ventilation
• B Beard
• O Obese
• N No teeth
• E Elderly (gt55 y/o), or cachectic (sunken
  cheeks)
• S Snores
• 3rd trimester pregnancy
• obstructive lung disease

83
Failed Airway Retrograde Intubation

• Puncture the cricothyroid membrane then thread a
  wire retrograde to the mouth, the tube is then
  inserted over the wire
• Use as rescue technique
• used for failed airway and you have TIME
• Do not use if infection at the site of the needle
  puncture
• Note does take time to do

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85
Failed Airway

• Fiberoptics
• will take time ( 15 min or longer)
• Indications
• predicted difficult airway
• C-spine immobility
• failed intubation cant intubate, CAN oxygenate
• Contraindications
• excessive blood or secretions
• upper airway obstruction
• cant oxygenate patient

86
Failed Airway

• Surgical
• Needle crich TTJV, cricothyrotomy
• used for failed airway that needs IMMEDIATE
  management
• Difficult crich SHORT
• S Surgery
• H Hematoma
• O Obese
• R Radiation
• T Tumor

87
Failed Airway

• Cricothyroidodomy not recomm. age lt8
• crichoid cartilage space is VERY small and high
  larynx
• complication rate 10-40
• Retrograde?
• Transtracheal jet ventilation
• surgical method of choice in emergency
• allows ventilation for 45-60 mins
• risk aspiration, subcutaneous emphysema,
  barotrauma, bleeding, catheter dislodgment, CO2
  retention

88
Failed Airway Surgical Airway

• Cricothyrotomy
• NEAR Study
• Only 1 of 4000 Ed intubations required cric.
• 20 complication rate (mostly minor)
• 4 step process
• Pediatrics age gt8 y/o
• 4 Shiley cuffed tube
• Needle cricothyrotomy (age lt8)

89
Crichs

• Contraindications
• age lt 8-12
• preexisting laryngeal pathology (tumor)
• hematoma over site
• destruction of landmarks
• infection of abscess over site
• coagulopathy
• lack of procedural knowlege

• Indications
• failure of nasal or OTI
• immediate need for airway management

90
Complications of surgical airway management

• Major hemorrhage
• pneumomediastinum
• infection
• voice change
• subglottic stenosis
• laryngeal/tracheal injury

91
Steps for crichothyrotomy

• Identify landmarks
• identify laryngeal prominence then feel one
  finger breadth below
• four fingers breadth above the sternal notch
• Prepare the neck
• antiseptic solution
• local anesthesia if awake patient and enough time

92
Steps for crich

• Immobilize Larynx
• place thumb and 3rd finger on opposite sides of
  the superior laryngeal horns
• Incise the skin
• 2 cm
• through skin but not through deep structures
• Reidentify the membrane

93
Steps for crich

• Incise the membrane
• horizontal incision
• 1 cm
• incise lower half of membrane because less
  vascular
• insert tracheal hook
• hook inferior aspect of thyroid cartilage and
  apply light anterior traction

94
Steps for crich

• Insert dilator
• insert the tracheostomy tube
• inflate cuff and ensure tube position

95
Failed Airway Surgical Airway

• Needle cricothyrotomy/ TTJV
• Temporizing measure
• Surgical airway of choice for age lt8 y/o
• Need supraglottic patency (exhalation)
• No airway protection

96
Needle crich - the steps

• Identify landmarks
• immobilize larynx
• transtracheal needle insertion
• large-bore catheter (12-16)
• attach 10-20cc syringe
• direct needle caudally at 30 degree angle through
  crichoid membrane
• when the needle enters the trachea the syringe
  will easily fill with air

97
Needle crich - steps

• Catheter advancement
• DO NOT advance the needle with the catheter
• connect to jet ventilator
• What if no jet ventilator???
• Connect to 3cc syringe and ETT connector of an
  8.0 ETT then to a bagging unit

98
Failed Airway Surgical Airway

• Needle cricothyrotomy/ TTJV
• 12-16G needle
• lt5 y/o ventilation only by bag
• 5-12 y/o 30 psi
• 12 adult 30-50 psi

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100
Awake intubation

• Lidocaine spray
• 5cc 4 lido neb
• 4 lidocaine on pledgets
• Titrated dose of midazolam and fentanyl
• Take a look - can turn into a formal RSI

101
Pediatric Pointers

• Broselow tape
• Avoid 2nd dose of sux
• infants/children exquisitely sensitive ?
  intractable brady/arrest
• Pierre Robin and Treacher Collins syndrome
• Small mandibles and posteriorly fixed tongues
• Down syndrome - large tongue

102
Positioning the Peds patient

• NB-6 months
• neutral or elevation of the shoulders
• 6 mo-5yr
• elevate head, no to minimal head extension
• 5-10 yrs
• elevate and extend head

103
Peds airways

• BVM
• be careful not to put pressure on the
  submandibular tissues because you may cause
  obstruction
• use an oral airway whenever possible
• be careful not to put pressure over the eyes
• children will desat faster so preoxygenation
  phase to intubation must be shorter
• decompress the stomach with an NG tube
• under age of 8 use uncuffed tubes

104
Case 1

• 30 yo male brought to ED after MBA. He has blood
  coming from his ears, GCS 5 and is ina C-collar.
  His vitals are HR 110, BP 120-50, RR 25, O2 Sat
  94
• What would you do????

105
Case 2

• A five yo girl with known asthma presents with
  worsening dyspnea. On arrival to the ED she has
  a RR of 40, O2 Sat 88, extensive accessory
  muscle use BP 80-35, HR 110
• After 2 hours of cont vent nebs, iv salbuatmol,
  steroids she now looks worse RR 15, O2 Sat 83,
  altered LOC
• What would you do???

106
Case 3

• 22 yo male has a known nut allergy. He was
  eating at Dairy Queen and thought he was only
  eating peanuts when his lips became tingly. His
  sister brings him to the ED. He is stridorous on
  arrival, not able to speak in full sentences and
  has a BP of 100/60, HR 120
• What would you do????

107
Case 4

• A 55 year old women collapsed in the shower. Her
  husband states that she had been complaining of a
  severe headache. On arrival to the ED she is
  unresponsive, GCS 5, HR 110, BP 150/60
• What would you do?????