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Endotracheal Intubation

  • Blade: Mac 3 or 4; Tube: F:7-8 mm; M:7.5-8.5; depth:21-23 cm
  • Preoxygenate 3-5mim
    •  Etomidate: 0.3 mg/kg (20/30), 15-45sec, 3-12min
    • Midazolam: 0.1 to 0.3 mg/kg (7/10), 30-60s, 15-30m
    • Propofol: 1.5 to 3mg/kg (100/150), 15-45s, 5-10m
    • Succinylcholine: 1.5 mg/kg (100/150),45-60s, 6-10m
      • avoid: CVA,HyperK+,Rhabdo,MG
    • Rocuronium: 1 mg/kg (70/100), 45-60s, 45min
    • Vecuronium: 0.1 mg/kg (7-10), 75-90s, 45min
    • asdf

ACLS - Pressor q 3-5 min (Epi first, then vasopressin)

VF/ pulseless VT
  • 100-200 J biphasic defibrillator (360 for mono)
  • Epinephrine 1mg (10 ml of 1:10,000) q3-5min
  • Vasopressin 40 U
  • Amiodarone 300mg ± 150mg in 3-5min or
  • Licodaine 1-1.5 mg/kg
  • Mg++: 1-2g (if torsades)
Asystole/PEA
  • Epinephrine 1mg (10 ml of 1:10,000) q3-5min
  • Vasopressin 40 U
Narrow-Tachycardia
  • Sinus Massage / Vagal maneuvers
  • Adenosine 6mg, then 12mg
  • Diltiazem 15-20mg, 5-15mg/h
  • Metoprolol 5mg q5min
  • Sync Cardiovert 100 J biphasic (A-fib: 200 J)
Wide- Tachycardia (Regular)
  • Adenosine 6mg once, then 12mg
  • Amiodarone 150mg
  • Licodaine 1-1.5 mg/kg
  • Sync Cardiovert 100 J biphasic
Brady
  • Atropine 0.5mg q3-5min
  • Transcutaneous pacing (Mobitz 2 or 3rd °) or
  • Dopamine 2-10 mcg/kg/min or
  • Epinephrine 2-10 mcg/min

Shock:

  • Norepinephrine 1-30mcg/min (α1 > β1)
  • Vasopressin 0.04units/min (V1)
  • Phenylephrine 10-100mcg/min (α1)
  • Epinephrine 2-10mcg/min (α1, α2, β1, β2)
  • Dopamine 2-20mcg/kg/min (D → β → α)
  • Dobutamine  2-20mcg/kg/min (β1 > β2)

Arrhythmias:

  • Amiodarone 150mg bolus → 1mg/min x6h → 0.5mg/min
  • Diltiazem 5mg bolus, then 5-15mg/h
  • Esmolol 500mcg/kg bolus, then 50-200mcg/kg/min

HTN:

  • Nicardipine 5-15mg/h
  • NTG 2-20mcg/min
  • Nitroprusside 0.5-8mcg/kg/min

Sedation:

  • Midazolam 1-4mg IV bolus, then 1-2mg/hr (max 10mg/hr)
  • Lorazepam 1-4mg IV bolus, then 1-2mg/hr (max 10mg/hr)
  • Propofol 5 mcg/kg/min IV (max 80mcg/kg/min)
  • Haldol 2-10 mg q 20-30 min (for acute agitation; monitor QTc)

Analgesia

  • Morphine 2-4mg IV bolus, then 1-5mg/hr (max 10-15mg/hr)
  • Fentanyl 25-50mcg IV bolus, then 25-100mg/h (max 300-500mg/hr)

A-a Gradient

  • Normal ≤ (Age/4) + 4 OR 0.3 x Age
  • DA-aO2 = (713 x FiO2) – (PaO2 + 1.25PaCO2)
    • 713 x .21 = 150
    • 713 x .35 = 250

Deciding to Intubate

  • failure of airway protection: GCS ≤ 8, pooling secretions
  • failure of ventilation
  • failure of oxygenation: restlessness, agitation, cyanosis
  • anticipated need for intubation
  • pulse ox, vs, mental status, resp status

Recognize the Difficult Airway

Look externally: facies, unusual anatomy, or significant obesity

Evaluate: 3-3-2; fingers btwn incisors, mandible, laryngeal notch

Mallampati score: inability to visualize uvula predicts difficulty

Obstruction of airway: mass, hematoma, injury

Neck mobility: ability to achieve the sniffing position

NIPPV:

  • Uses: HF (acute cardiogenic pulmonary edema), COPD
  • Eligibility: Alert, able to protect airway/clear sections, RR<24, pH<7.35, PaCO2>45mmHg, SpO2<90%
  • Contraindications: Arrest, arrhythmia, airway obstruction, SBP<90, pH<7.2, FiO2>0.5
  • Initial Setting: IPAP: 8-20 cmH2O; EPAP: 5 cmH2O; Rate ≥ 4

Vents:

  • Initial Settings:
    • Mode: Pressure/Volume/Dual Control
    • Volume: 6-8ml/kg IBW
    • FiO2: titrate for Sp O2 > 90%
    • Rate: 12-20
    • PEEP: 0-5cmH2O
  • Improve ventilation: (↓ CO2): Increase frequency or VT
  • Improve oxygenation: (↑ O2): Increase FiO2 or PEEP

Vent Weaning

  • Criteria: Follows commands; Good cough & gag; PaO2 ≥ 60 mmHg; FiO2 ≤ 0.4-0.5; PEEP ≤ 5, RR<30

 

Acid Base

AG Met Acid: Methanol, Uremia, DKA/EtOH KA, Paraldehyde, Isoniazid, Lactate, Etoh/Ethylene Glycol, Rhabdo/Renal Failure, ASA

Non AG Met Acid: Hyperalimentation, Acetazolamide, RTA, Diarrhea, Uretero/Pelvic Shunt, Post-Hypocapnia, Spironolactone

Resp Acid: CNS Depression, Airway Obstruction, PNA, Pulm Edema, PTX, Myopathy

Met Alk: Contraction, Licorice, Endo, Vomiting, Excess Alkali, Refeeding, Post-Hypercapnia, Diuretics

Resp Alk: CNS disease, Hypoxia, Anxiety, Mech Ventilators, Progesterone, ASA/Sepsis

Normal AG = Albumin x 3

Toxicology

  • Gastric lavage if within 1 hr or if TCA
  • Activated charcoal 50g orally
  • Β-blocker:  Glucagon 0.05 mg/kg IV then 0.07 mg/kg/hr
  • Calcium channel blocker: Calcium Chloride 10% sol 5-10ml IV
  • Cocaine: Benzos; severe HTN: phentolamine 5-10mg IV q10m or nitroprusside or labetalol
  • Benzo: flumazenil 0.2 mg IV over 30s (watch for seizure)
  • Opioid: naloxone 0.2mg IV (up to 2mg)
  • APAP: Mucomyst 140 mg/kg, then 70 mg/kg q4hr
  • ASA: AC 50g, sodium bicarbonate keep urine pH>8, HD
  • TCA: NaHCO3- 2 amps in 1 L D5W ~ 100 cc/h keep pH >7.5

Pulmonary Artery Catheter Normal Values

  • RAP pressure 1-7 mm Hg
  • RVP systolic 15-25 mm Hg     
  • RVP diastolic 8-15 mm Hg
  • PAP systolic 15-25 mm Hg
  • PAP diastolic 8-15 mm Hg
  • PAP mean 10-20 mm Hg
  • SVRI 1600-2400
  • CI 2.4-4

SAH

  • Intubate if GCS ≤ 8 w/ etomidate
  • Nimodipine 60mg PO q4° x 21d
  • NS 3-5 L/day
  • SCD/TEDs
  • +/- steroids, AEDs, statin
  • Tx BP w/ labetalol or hydralazine prn or nicardipine
  • Tx vasospasm w/ HHT: ↑ MAP by 15-20%

A-fib

  • Cardiovert: ongoing CP, pulm edema, hemodynamics unstable
  • Sync Cardiovert Biphasic 100-200J (50-100 AFlutter)
  • Metoprolol 2.5-5mg IV q5-10 min - good for post op, if EF reduced or unknown
  • Diltiazem 0.25mg/kg IV (15mg), then 5-15mg/hr
  • Digoxin 0.25mg IV q2hr (max 1.5mg) good for HF, caution AKI
  • Amiodarone 150mg IV, then 1mg/min x6h, then 0.5 x18h
  • (maintenance 200mg/d)
  • Esmolol 500ug/kg IV, then 60-200ug/kg/min