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lunes, 29 de enero de 2018 Bolsa de Reanimacion Manual AMBU, GUIA DE OXIGENOTERAPIA Y NEBULIZACIONES by Dr. Ramon REYES, MD "El Panchito"

Bolsa de Reanimacion Manual AMBU, GUIA DE OXIGENOTERAPIA Y NEBULIZACIONES Esta y otras informaciones en; Sociedad IberoAmericana de EMERGENCIAS en TELEGRAM https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

Ventilación Bolsa Válvula Mascarilla. Un dispositivo de bolsa válvula mascarilla es un resucitador manual que se usa para provee una presión positiva ventilatoria. La bolsa válvula mascarilla consiste de una bolsa autoinflable, una válvula unidireccional, una mascarilla facial, un puerto de entrada de oxígeno, y un reservorio de oxígeno.

Muchas de las bolsas válvulas mascarillas para adultos tienen un volumen aproximado de 1,600 mililitros. Cuando se usa sin oxígeno, el dispositivo solo va a entregar 21% de

oxígeno, o sea la cantidad de aire que se encuentra en el medio ambiente. Agregando oxígeno y un reservorio, vas a proporcionar casi un 100% de oxígeno al paciente, una de las ventajas mayores de este dispositivo.

Las ventajas principales de usar la bolsa válvula mascarilla sobre la ventilación boca a mascarilla son la conveniencia para el Paramédico y la habilidad de entregar una mezcla de oxígeno más enriquecido. Sin embargo, la bolsa válvula mascarilla muy pocas veces nos proporcionan volúmenes tidales que son posibles utilizando la ventilación boca a mascarilla. El dispositivo bolsa válvula mascarilla es más difícil de usar de lo que parece y es más cansado para el operador. El Paramédico tiene que provenir simultáneamente un buen sellado de la mascarilla, manteniendo abierta la vía aérea colocando la cabeza del paciente hacia atrás y levantando la mandíbula, oprimiendo la bolsa para entregar la ventilación. Toma mucha practica mantener los conocimientos necesarios para realizar una ventilación adecuada con este dispositivo. A causa de la dificultad para trabajar con la bolsa válvula mascarilla, es muy recomendable utilizar este dispositivo con dos personas, aunque no siempre es posible. Una mascarilla para un solo operador, como la mascarilla de bolsillo, tiene muy poco de estas desventajas, toma menos práctica y conocimiento, y es más fácil usarse para cualquier socorrista con o sin experiencia.

Una bolsa válvula mascarilla debe de tener estas características:

Una bolsa auto inflable que es fácil de limpiar y esterilizarse. Un sistema de válvula que no se atore, y que permita la entrada de un flujo de 15 lpm. Tiene o no tiene una válvula de escape (pop off) que puede ser inhabilitado manualmente. Una válvula de escape (pop off) que no puede ser inhabilitada puede provocar una ventilación inadecuada en algunos pacientes. Conexiones estándar de 15/22 mm que permite el uso con una variedad de mascarillas de ventilación y otros accesorios. Una entrada de oxígeno y un reservorio que puede conectarse con una fuente de oxígeno para dar mayor concentración durante la ventilación. Un reservorio de oxígeno debe ser usado cuando se ventila a cualquier paciente. Una verdadera mascarilla no recirculante que permite la salida de la exhalación del paciente pero no permite la respiración de esos gases nuevamente. Adaptabilidad a toda condición ambiental y a temperaturas extremas.

Una variedad de tamaños de mascarillas en infantes, niños y adultos. Una mascarilla correctamente colocada debe de permanecer fija sobre el puente de la nariz y debajo del mentón. Mascarillas transparentes para permitir la detección de vomito, sangre o secreciones durante la ventilación. Nota que las cánulas naso y orofaringeas permiten mantener abierta la vía aérea y deben considerarse en cualquier momento que se use la bolsa válvula mascarilla.

Técnica

Bolsa

Válvula

Mascarilla.

Un dispositivo de bolsa válvula mascarilla puede ser usado por uno o dos Paramédicos. Por razones mencionadas arriba, el uso de este dispositivo con dos Paramédicos es preferible. Un Paramédico sujeta la mascarilla asegurando un buen sello con las dos manos, mientras el otro Paramédico utiliza las dos manos para oprimir la bolsa para entregar un volumen pleno de aire oxigenado. Esta técnica es la más efectiva que con la operación por una persona y se utiliza siempre, a menos que la disponibilidad de personal y las circunstancias no lo permitan (ej. cuando no hay suficiente espacio para maniobrar con dos Paramédicos). Los procedimientos para el uso de la bolsa válvula mascarilla son: Si es posible, colócate sobre la cabeza del paciente. Si no hay sospecha de lesiones espinales, abra la vía aérea usando la inclinación de la frente hacia atrás y elevación del mentón. Levanta un poco la cabeza del paciente con una toalla o almohada para llegar a una mejor posición de olfateo. Selecciona la mascarilla correcta y el dispositivo de la bolsa válvula. Si el paciente no responde, inserta una cánula oro o nasofaringea para mantener la vía aérea permeable. Coloca la parte más angosta de la mascarilla sobre el puente de la nariz y la parte más anchasobre la boca y el surco del mentón. Si la mascarilla tiene un mango redondo alrededor del puerto de ventilación, céntralo sobre la boca. Coloca tus dedos pulgares sobre la mitad superior de la mascarilla y el índice y el resto de los dedos se colocan en la mitad inferior de la mascarilla. Usa el dedo anular y meñique para levantar la mandíbula del paciente hacia la mascarilla. Los dedos medios, dependiendo del tamaño de las manos del Paramédico, puede ser colocados bajo la mandíbula o encima de la mascarilla. Los bordes de las palmas (del lado de los pulgares) se colocan sobre las orillas de la mascarilla para mantenerla en su lugar y lograr un buen sellado. Otro Paramédico debe conectar la bolsa válvula a la mascarilla si no ha sido ya conectada. Comience la ventilación lo más pronto que sea posible. El otro Paramédico, o otra persona capacitada, debe de oprimir la bolsa con las dos manos mientras observa la subida y

bajada del pecho. La ventilación debe de ser entregado en un periodo de 1.5 a 2 segundos en un adulto, y 1 a 1.5 segundos para infantes y niños. La ventilación debe de ser dada como mínimo cada 5 segundos en un adulto y 1 vez cada 3segundos en infantes y niños. Debes monitorear constantemente la subida y bajada del pecho para ver si es adecuada. Si la bolsa válvula mascarilla no ha sido conectado al oxígeno suplementario, el paciente debe recibir ventilaciones de presión positiva por un minuto. En este punto, el otro Paramédico debe de conectar la mascarilla, ajustar el flujo a 15 litros por minuto, conectar el reservorio si no ha sido conectado y resumir ventilación.

En aquellas situaciones cuando estas utilizando la bolsa válvula mascarilla solo, coloque la mascarilla a la boca del paciente con una mano. Debe colocar su dedo pulgar sobre la parte de la mascarilla que cubre el puente de la nariz, y su dedo índice sobre la parte que cubre el mentón. Asegura un buen sello en la cara empujando hacia abajo con los dedos pulgar e índice, mientras levantas el mentón con lo demás de los dedos para efectuar la inclinación de la cabeza y elevación del mentón.

Oprime la bolsa con la otra mano mientras observas la subida y bajada del pecho para asegurar que ambos pulmones están ventilados efectivamente. Se puede oprimir la bolsa alternativamente contra su cuerpo, antebrazo o el muslo para entregar un volumen tidal mejor al paciente. Problemas de la Bolsa Válvula Mascarilla Si el pecho del paciente no sube y baja, hay que re evaluar el dispositivo de Bolsa Válvula Mascarilla y la vía aérea del paciente, considerando estos problemas posibles y sus remedios:

Verifica la posición de la cabeza y mentón. Reposiciona la vía aérea y trata de ventilar otra vez. Verifica el sello de la mascarilla para asegurar que no hay una cantidad excesiva de aire escapando alrededor de la mascarilla. Reposiciona los dedos y la mascarilla para obtener un sello más adecuado. Evaluar por una obstrucción. Si hasreposicionado la vía aérea y el sello es el adecuado, debes considerar una obstrucción de la vía aérea. Inspecciona la boca en busca de una obstrucción. Si encuentras una obstrucción, retírala mediante un barrido digital. Si no encuentras nada, hay que comenzar la maniobra de Heimlich hasta que pueda ventilar efectivamente otra vez. Verifica el sistema de la bolsa válvula mascarilla para asegurar que todas las partes están conectadas correctamente y están funcionando como debe ser. Algunos sistemas con una

bolsa reservorio se van a llenar muy despacio si hay un flujo de oxígeno inadecuado. Este causa una reducción en el volumen tidal entregado al paciente y subsecuentemente produce una mínima elevación y descenso del pecho. Si el pecho no sube y baja, hay que utilizar un método alternativo para ventilar con presión positiva, por ejemplo una mascarilla de bolsillo, o un dispositivo ventilatorio impulsado por oxígeno y con flujo restringido. Si tienes problemas manteniendo una vía aérea permeable, inserta una cánula orofaringea o nasofaringea. Cualquier de los dos va a prevenir que la lengua caiga hacia atrás semibloqueando la vía aérea. Si notas que el abdomen del paciente sube con cada ventilación o está distendido, hay dos causas posibles.

La inclinación de la cabeza con elevación del mentón no está bien hecha permitiendo una cantidad excesiva de aire entrar el esófago y al estómago. Reposicionar la cabeza y cuello, y tratar de ventilar otra vez. Se está ventilando al paciente demasiado rápido o con demasiado volumen tidal. Estas ventilaciones excesivas aumentan la presión en el esófago y permite la entrada de aire al estómago. Oprime la bolsa lentamente para entregar el volumen sobre un periodo de 2 segundos y dejar suficiente tiempo para la exhalación después de cada ventilación. Fuente

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Emergency Airway Controversies

There are so many emergency airway controversies in emergency medicine! Dr. Jonathan Sherbino, Dr. Andrew Healy and Dr. Mark Mensour debate dozens of these controversies surrounding emergency airway management. A case of a patient presenting with decreased level of awareness provides the basis for a review of the importance, indications for, and best technique of bag-valve-mask (BVM) ventilation, as well as a discussion of how best to oxygenate patients. This is followed by a discussion of what

factors to consider in deciding when to intubate and some of the myths of when to intubate. The next case, of a patient with severe head injury who presents with a seizure, is the fodder for a detailed discussion of Rapid Sequence Intubation (RSI). Tips on preparation, pre-oxygenation and positioning are discussed, and some great debates over pre-treatment medications, induction agents and paralytic agents ensues. The new concept of Delayed Sequence Intubation is explained and critiqued. They review how to identify a difficult airway, how best to confirm tube placement and how to avoid postintubation hypotension. In the last case of a morbidly obese asthmatic they debate the merits of awake intubation vs RSI vs sedation alone in a difficult airway situation and explain the best strategies of ventilation to avoid the dreaded bradysystlolic arrest in the pre-code asthmatic. Finally, some key strategies to help manage the morbidly obese patient’s airway effectively are reviewed.There are so many emergency airway controversies in emergency medicine! Dr. Jonathan Sherbino, Dr. Andrew Healy and Dr. Mark Mensour debate dozens of these controversies surrounding emergency airway management. A case of a patient presenting with decreased level of awareness provides the basis for a review of the importance, indications for, and best technique of bag-valvemask (BVM) ventilation, as well as a discussion of how best to oxygenate patients. This is followed by a discussion of what factors to consider in deciding when to intubate and some of the myths of when to intubate. The next case, of a patient with severe head injury who presents with a seizure, is the fodder for a detailed discussion of Rapid Sequence Intubation (RSI). Tips on preparation, pre-oxygenation and positioning are discussed, and some great debates over pre-treatment medications, induction agents and paralytic agents ensues. The new concept of Delayed Sequence Intubation is explained and critiqued. They review how to identify a difficult airway, how best to confirm tube placement and how to avoid post-intubation hypotension. In the last case of a morbidly obese asthmatic they debate the merits of awake intubation vs RSI vs sedation alone in a difficult airway situation and explain the best strategies of ventilation to avoid the dreaded bradysystlolic arrest in the pre-code asthmatic. Finally, some key strategies to help manage the morbidly obese patient’s airway effectively are reviewed.

Written Summary and blog post by Lucas Chartier, edited by Anton Helman October 2010

In this episode on Emergency Airway Controversies, Dr. Sherbino, Dr. Healy and Dr. Mensour answer questions like: Does Delayed Sequence Intubation have a role in airway management? Which is the best induction agent for patients with head injury? Asthma? What are the pros and cons of Roccuronium vs Succinylcholine? What is the evidence for pre-treatment using lidocaine and fentanyl and head injured patients? Is the new drug Suggamadex useful? Should we be using Video Laryngoscopy (eg: Glidescope) as the primary tool for endotracheal intubation? What is the newest evidence for what constitutes a difficult airway? What are the best methods for confirming Endotracheal Tube placement? How can we best prevent and treat post-intubation hypotension? What

is the best positioning for obese patients for intubation? What are the best ventilator settings for patients in status asthmaticus? and many more…..

General approach to patient with respiratory depression Transport patient to resuscitation area, notify the whole team (RNs, RTs, etc), and have all the equipment ready (IVs, advanced airways, cardiorespiratory monitors) Consider 500cc to 1L bolus IV of NS; consider 4‐point restraints before giving the naloxone to protect the patient and medical staff, as well as one attempt at bag‐valve‐mask ventilation (BVM) to rule out laryngospasm, which could cause negative pressure pulmonary edema if the patient inspires against a closed glottis once the naloxone is given

Oxygen delivery Nasal prongs deliver only slightly more than the 21% of O2 containted in air because of the entrainment effect it creates, and “100% non‐rebreather mask” only delivers 65‐70% O2 at best To get better oxygenation, a better seal is needed, whether through BVM, non‐ invasive positive pressure ventilation (NIPPV), or endotracheal intubation

Tips for good BVM technique A health care provider (experienced with BVM) delegated exclusively to this task in order to perform it adequately (RR = 8‐12/min, not more!) with the right sized equipment, and consider using an oropharyngeal airway and/or 2 nasopharyngeal airways (trumpets) 2‐handed, 2‐person technique (2 hands on the mask, and a second person squeezing the bag) is much more effective at opening up the airway by moving the mandible forward into the mask, i.e. jaw thrust, instead of driving the mask down on the face, which makes the soft tissue obstruct the airway two_person_bvm_1

Two methods for 2‐handed technique: (a) mirror image of what is usually done for onehanded technique (image 1), which allows 3 fingers per hand to lift the mandible;and (b) thenar eminences holding the mask with the thumbs in the direction of the patient’s feet, with 4 fingers per hand to lift the mandible (image 2) For bearded patients, consider putting a tegaderm patch on the beard (with a hole for ventilation!), or lubricant jelly in order to improve the seal; for edentulous patients, keep the dentures in for BVM (and remove for intubation), or put gauzes inside the cheeks Mnemonic for difficult BVM: BOOTS – Bearded, Obese, Old, Trauma (eg, obstruction), Stiffness (eg, OSA, COPD); also consider the effects of radiation therapy, which increases stiffness and decreases mouth opening

Indications for intubation

General indications: obtain and maintain an airway in the setting of obstruction; correct deficient gas exchange (hypoxia or hypercarbia); prevent aspiration of blood, saliva, or other secretions; and predicted clinical deterioration Additional pearls Dogmatic approach like “GCS less than 8 means intubate” is inappropriate because it neglects the expected clinical course of the patient, and also because the GCS scores have only been validated in the setting of trauma (although GCS can still be used as a universal language to communicate with other team members) Patient not protecting his/her own airway is assessed by pooling of secretions in the oropharynx or absence of cough reflex; the presence or absence of gag reflex is not reliable (many elderly patients don’t have it at baseline, and shown to have no correlation with passive aspiration in patients undergoing swallowing studies) Other reasons to intubate: completely unresponsive patient with no expected early improvement; airway protection needed to decontaminate a patient with overdose; and severe sepsis and refractory shock, where the mechanical ventilation is meant to decrease the energy used by the patient for breathing, energy which can then be diverted towards other productive uses by the patient’s body

Sellick’s maneuver Cricoid pressure (different than BURP – see below) to prevent passive aspiration by occluding the esophagus against the vertebral bodies The evidence supporting it is poor: it does not decrease passive aspiration, it does not improve intubation success rates, it increases air trapping, it distorts of laryngopharyngeal landmarks, and it decreases venous return from the heart by occluding jugular veins In order to decrease the likelihood of aspiration, Sellick’s maneuver may be used but should be abandoned quickly if it impairs intubation attempts, and better techniques to avoid aspiration include keeping a low positive pressure during ventilation in order to decrease gastric insufflation

BURP maneuver Backwards, Upwards, Rightward Pressure used by intubator or assistant to improve laryngoscopic view by pushing the larynx towards the patient’s right while the laryngoscope pushes the tongue towards the patient’s left

Difficult airway Predictors of difficult laryngoscopy: LEMON Look externally for gestalt assessment of difficulty (not sensitive but quite specific) such as small mandible, large teeth, large tongue and short neck Evaluate 3‐3‐2, with 3 of patient’s own fingers between the teeth during mouth opening, 3 fingers of mandibular length between the chin and the hyoid bone, i.e. the base of the tongue, and 2 fingers between the hyoid bone and the thyroid cartilage

Mallampati: Class I when all buccal structures visible with mouth opening and tongue out; Class II when tonsillar pillars not visible; Class III when minimal pharyngeal wall visible; Class IV when only palate visible Obstruction or Obesity Neck mobility: C‐spine collar or rheumatoid arthritis preventing C‐spine movement

Predictors of successful intubation Experienced intubator, patient’s lack of muscle tone, optimal positionining of intubator and patient (see below), optimal blade length and type, adequate laryngeal manipulation (eg, BURP)

7 Ps of Rapid Sequence Intubation (RSI) Preparation, Pre‐oxygenation, Pretreatment, Paralysis and induction, Position, Placement with proof, Postintubation management Preparation

SOAP ME: Suction, Oxygen, Airways (BVM, blades, with plan B and C – eg, Glidescope, Trach light, intubating LMA), Pharmacology, Monitors, Escape plan (anticipate 2‐3 steps down a worst‐case scenario for each individual patient) Preoxygenation

Non‐rebreather mask or BVM in order to replace the patient’s FRC (functional residual capacity) from nitrogen to oxygen, which will allow for more time before arterial desaturation Delayed Sequence Intubation (DSI): DSI is a form of procedural sedation for means of pre‐oxygenation with positive pressure ventilation when traditional pre‐oxygenation is unsuccessful (due to alveolar shunting seen in primary pulmonary or septic conditions) Method: insertion of behavioural control of the patient (i.e. calm him/her) before paralysis with ketamine sedation while still maintaining spontaneous respirations in order to tolerate oxygenation with PEEP (eg, CPAP), which will ultimately result in better pre‐ oxygenation and better intubation conditions for more on Delayed Sequence Intubation go to EMCrit website

Pretreatment (3min before induction)

Lidocaine 1.5mg/kg IV used in reactive airway diseases and elevated intracranial pressure (ICP), but theevidence is poor

Fentanyl 3μg/kg IV used in elevated ICP and patients with cardiovascular disease to prevent the reflex sympathetic response to laryngoscopy, which raises both heart rate and blood pressure Volume rehydration with 12cc/kg of crystalloid to correct the patient’s relative dehydration Avoiding hypotension, hypoxia and hypercarbia is even more important than the above methods, and therefore an individualized approach to each patient should be done (eg, if patient is hemodynamically unstable and propofol is the only available induction agent, then foregoing fentanyl would be reasonable as it will create even more hypotension) Non‐defasciculating dose of non‐depolarizing neuromuscular blocking agent (when succinylcholine will be used as the paralytic agent) should not be used as pretreatment Induction agent choices

Etomidate (might lower seizure threshold), Ketamine (can be used in head‐injured patients as the concerns about raised ICP are unfounded), Propofol (probably best in the setting of seizures given antiepileptic properties, although it might cause hypotension), Ketofol (not recommended by EMC experts as an induction agent) Paralytic agent choices

Neurologic assessment needs to be performed before paralysis in order to assess serial changes, including GCS score (including best motor response), pupillary size and reaction, and reflexes The 3 EMC experts use rocuronium (1mg/kg) because of the lack of contraindications attached to succinylcholine (SCh), and they feel that the longer time to action (60sec compared to the 45sec of SCh) is not clinically significant; moreover, they feel that the longer time of action (40‐60min compared to 7min) is irrelevant because the patient will need paralysis to go to the CT scan, and the neurological status of the patient cannot have changed so dramatically that another neurological assessment is necessary within minutes of intubation Suggamadex is a new medication that completely reverses the effects of rocuronium in 1‐ 2min at a dose of 4mg/kg; in most cases, however, unlikely that reversal of paralysis is needed immediately after intubation Succinylcholine (dose of 1.5mg/kg) is favoured by the Cochrane database for RSI due to better intubating conditions and less post‐paralysis pain, but contraindications need to be remembered: hyperkalemia (eg, dialysis); burns, crush injuries and neurological dysfunction (eg, stroke) starting at 5 days after the insult Positioning

Optimal position: bed at the level of the intubator’s belt line, straight back and arms at a distance from the patient, holding the laryngoscope blade at the base of the handle, with

the appropriate blade type (curved blade allows for better tongue control, but straight may be used if attempt is unsuccessful with straight blade) Optimal patient position: sniffing position (although simple head extension without lower C‐spine flexion may be just as good); for trauma patients, C‐collar removed while assistant is providing manual in‐line stabilization from below, to allow for movement of the mandible forward and optimization of the glottic view Consider using adjuncts – Video laryngoscope (which may lead to less C‐spine mobilization than direct laryngoscopy), Trach light (light wand), intubating LMA or fiberoptic scope – and don’t repeat the exact same sequence twice if you fail: something has to be changed to provide better intubating condition and be successful

emcases-update

Update 2017: A recent prospective observational study by Turner et al. (2017) has shown elevating the head of the bed, particularly to ≥45degrees, helps facilitate first-pass success for endotracheal intubation performed by residents in the ED. This correlates with recent literature questioning the traditional supine method – which suggests head-elevated positioning improves pre-oxygenation, glottic view, and reduces risk of intubation complications. Abstract

emergency airway controversies

Medications for Airway Management card PDF 2017

Placement with proof

Reference standards: End‐tidal CO2 monitoring, either with capnography (number and waveform) or colorimetric (Yellow color = “Yes”, and purple = “The colour of the patient when tube in the wrong place”, but has a 4‐7% failure rate) – ETCO2 will be negative in ⅓ of cardiac arrests due to lack of cardiac output; anotherconfirmation method is confidently seeing the endotracheal tube going through the vocal cords confirmation method is confidently seeing the endotracheal tube going through the vocal cords

Other methods: Esophageal detector device (squeeze the bulb and apply to tube – it will stay collapsed if in the esophagus, but pop open if in the trachea), auscultation, misting of the tube Placement of the tube at 21cm of length at the upper teeth (or alveolar ridge if edentulous) in women will result in the tip being at 3cm from the carina in 95% of individuals; the number in males is 23cm Immediate postintubation management

First step: adequate analgesia with fentanyl 25‐50μg IV q5min PRN based on vital signs Second step: sedation (especially if patient paralyzed) with midazolam 5mg (±2mg depending on patient’s weight and hemodynamics) or lorazepam 1‐2mg IV puss; assess degree of sedation with facial muscle tension, movements and increased heart rate and blood pressure Third step: start propofol or midazolam drip, volume resuscitation, NG tube, consider using ketamine or phenylephrine IV push for hypotension, and wrist restraints in case the patient wakes up

Tips for emergency airway management of obese patients Optimize preoxygenation because of RAPID desaturation (decreased FRC and increased metabolic rate, with resting hypoxemia and hypercapnia even without underlying lung pathology), higher likelihood for and worse consequences from aspiration (larger gastric volumes with lower pH); all of BVM, laryngoscopy, intubation and surgical airway will be difficult, so prepare plans B and C (and D) Consider putting a “ramp of blankets” under obese patients (eg, 7 blankets under the occiput, 5 under the shoulder and 3 under the scapula) so that the external auditory canal is on an horizontal line with the sternum, as well as reverse Trendelenburg position (to push the abdominal content away from the lungs) Remember that other types of patients also desaturate quickly: pregnant, extremes of age, CHF, COPDIn the setting of severe asthma: In the setting of severe asthma: Intubate only if all treatment modalities have been optimized and are still unsuccessful – getting the air out of the lungs is the patient’s problem and a ETT will likely not help so much for that; eg, patient is peri‐arrest and will go into PEA if not intubated (have ENT or anesthesia back‐up present), and consider using ketamine

For EM Cases main episode on Managing Obese Patients with Rich Levitan, Andrew Sloas and David Barbic go to Episode 69

Ventilation of the asthmatic or COPD patient Permissive hypercapnia: low tidal volume, low plateau pressure and low peak inspiratory pressure in order to protect the lungs from barotrauma and ventilator‐induced lung injury, with low respiratory rate and long expiratory phase in order prevent air trapping, hyperinflation and subsequent cardiovascular compromise; results in higher than normal CO2 and lower than normal pH (down to 7.2) If an episode of hypotension occurs, you should (1) disconnect the patient from the ventilator to allow for full exhalation of the air that is likely trapped (manual chest pressure may help), (2) assess the DOPE mnemonic – Displacement of tube, Obstruction of tube, Pneumothorax and Equipment failure Do not forget to continue standard therapies such as volume resuscitation, inhaled bronchodilators, and consider using inhaled anesthetics in the OR as a last ditch effort

Airway poster for your ED by Dr. Caroline Shooner summarizing all EM Cases airway related resources

Dr. Sherbino, Dr. Helman, Dr. Healy and Dr. Mensour have no conflicts of interest to declare.

Key References Walls RM, Murphy MF. Manual of Emergency Airway Management. Lippincott Williams & Wilkins; 2008.

Ovassapian A, Salem MR. Sellick’s maneuver: to do or not do. Anesth Analg. 2009;109(5):1360-2.

Snider DD et al. The “BURP” maneuver worsens the glottic view when applied in combination with cricoid pressure. Can J Anaesth 2005 Jan; 52:100-4.

El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anesth Analg. 2009 Dec;109(6):187080.

Ni chonghaile M, Higgins B, Laffey JG. Permissive hypercapnia: role in protective lung ventilatory strategies. Curr Opin Crit Care. 2005;11(1):56-62.

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Tactical Medicine TACMED España https://emssolutionsint.blogspot.mx/2016/06/guia-de-oxygenoterapia-ynebulizaciones.html