Podcast
Questions and Answers
Anticipating the clinical course of the patient’s condition and assessing the likelihood of deterioration are crucial to the decision to ______.
Anticipating the clinical course of the patient’s condition and assessing the likelihood of deterioration are crucial to the decision to ______.
intubate
Although videolaryngoscopy (VL) has reduced the chance of a failed ______ attempt, assessment of potential difficult intubation is essential.
Although videolaryngoscopy (VL) has reduced the chance of a failed ______ attempt, assessment of potential difficult intubation is essential.
intubation
The mnemonics LEMON, ROMAN, RODS, and SMART can serve as useful ______ for assessing airway management.
The mnemonics LEMON, ROMAN, RODS, and SMART can serve as useful ______ for assessing airway management.
aids
In the absence of a crash patient, rapid sequence ______ is the airway management method of choice for emergency department patients.
In the absence of a crash patient, rapid sequence ______ is the airway management method of choice for emergency department patients.
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Tube placement confirmation using end-tidal carbon dioxide (ETco2) is essential after ______.
Tube placement confirmation using end-tidal carbon dioxide (ETco2) is essential after ______.
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Cricothyrotomy is indicated in the '______, can't oxygenate' failed airway situation.
Cricothyrotomy is indicated in the '______, can't oxygenate' failed airway situation.
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Etomidate is used in more than 90% of all ______.
Etomidate is used in more than 90% of all ______.
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Rocuronium has less potential for adverse effects but a longer duration of ______.
Rocuronium has less potential for adverse effects but a longer duration of ______.
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The ______ scale assesses oral access for intubation.
The ______ scale assesses oral access for intubation.
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ROMAN is a mnemonic for evaluating difficult ______ ventilation.
ROMAN is a mnemonic for evaluating difficult ______ ventilation.
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The 'HEAVEN' mnemonic is used to predict difficulties with ______ and DL.
The 'HEAVEN' mnemonic is used to predict difficulties with ______ and DL.
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Difficult Bag-Mask Ventilation (BMV) is commonly encountered in the ______ and out-of-hospital patients.
Difficult Bag-Mask Ventilation (BMV) is commonly encountered in the ______ and out-of-hospital patients.
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A high ______ classification correlates with challenging rescue mask ventilation.
A high ______ classification correlates with challenging rescue mask ventilation.
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Obstruction, obesity, and obstructive sleep ______ are predictors of difficult Bag-Mask Ventilation.
Obstruction, obesity, and obstructive sleep ______ are predictors of difficult Bag-Mask Ventilation.
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The LEMON mnemonic is recommended for identifying ______ intubations.
The LEMON mnemonic is recommended for identifying ______ intubations.
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The acronym RODS stands for Restricted mouth opening, Obstruction, Distorted ______, and Short thyromental distance.
The acronym RODS stands for Restricted mouth opening, Obstruction, Distorted ______, and Short thyromental distance.
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Advanced age, particularly ______ years and older, increases the risk of intubation challenges.
Advanced age, particularly ______ years and older, increases the risk of intubation challenges.
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A patient without teeth may face challenges due to the lack of a ______ for mask ventilation.
A patient without teeth may face challenges due to the lack of a ______ for mask ventilation.
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The emergency clinician has primary airway management responsibility, and all emergency airway techniques lie within the domain of ______ medicine.
The emergency clinician has primary airway management responsibility, and all emergency airway techniques lie within the domain of ______ medicine.
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Rapid sequence intubation (RSI) is the most commonly used method for emergent ______ intubation.
Rapid sequence intubation (RSI) is the most commonly used method for emergent ______ intubation.
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The decision to intubate should be based on careful patient assessment and appraisal of the clinical presentation with respect to three essential criteria: failure to maintain or protect the ______.
The decision to intubate should be based on careful patient assessment and appraisal of the clinical presentation with respect to three essential criteria: failure to maintain or protect the ______.
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A patent airway is essential for adequate ______ and oxygenation.
A patent airway is essential for adequate ______ and oxygenation.
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The patient must be able to protect against the aspiration of ______ contents.
The patient must be able to protect against the aspiration of ______ contents.
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Historically, the presence of a ______ reflex has been advocated as a reliable indicator of the patient’s ability to protect the airway.
Historically, the presence of a ______ reflex has been advocated as a reliable indicator of the patient’s ability to protect the airway.
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The patient’s ability to ______ or handle secretions is a more reliable indicator of airway protection.
The patient’s ability to ______ or handle secretions is a more reliable indicator of airway protection.
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Ventilatory failure that is not easily reversible or persistent ______ despite maximal oxygen supplementation is a primary indication for intubation.
Ventilatory failure that is not easily reversible or persistent ______ despite maximal oxygen supplementation is a primary indication for intubation.
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Continuous ______ can also be helpful, but is not essential if oximetry readings are reliable.
Continuous ______ can also be helpful, but is not essential if oximetry readings are reliable.
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The need for prolonged mechanical ventilation generally mandates ______.
The need for prolonged mechanical ventilation generally mandates ______.
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Conditions that indicate the need for intubation include those characterized by a moderate to high likelihood of predictable airway ______.
Conditions that indicate the need for intubation include those characterized by a moderate to high likelihood of predictable airway ______.
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Patients with septic shock have high metabolic demand, myocardial ______, and increased peripheral oxygen extraction.
Patients with septic shock have high metabolic demand, myocardial ______, and increased peripheral oxygen extraction.
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A patient with significant multiple traumatic injuries may require intubation, even if the patient is ventilating normally through a patent ______.
A patient with significant multiple traumatic injuries may require intubation, even if the patient is ventilating normally through a patent ______.
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Intubation may be indicated relatively early in the course of certain ______.
Intubation may be indicated relatively early in the course of certain ______.
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Early intubation is advisable when there is evidence of __________ injury.
Early intubation is advisable when there is evidence of __________ injury.
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Difficult bag-mask ventilation (BMV) makes the likelihood of difficult intubation __________ times higher.
Difficult bag-mask ventilation (BMV) makes the likelihood of difficult intubation __________ times higher.
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In elective general anesthesia cases, cricothyrotomy occurs in approximately __________ in 2000 cases.
In elective general anesthesia cases, cricothyrotomy occurs in approximately __________ in 2000 cases.
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Preintubation assessment should evaluate the patient for __________ features that could indicate a difficult airway.
Preintubation assessment should evaluate the patient for __________ features that could indicate a difficult airway.
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Some difficult airways may not be identified by a bedside __________.
Some difficult airways may not be identified by a bedside __________.
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Airway difficulty exists on a __________, meaning some cases are more challenging than others.
Airway difficulty exists on a __________, meaning some cases are more challenging than others.
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Patients with __________ hypoxemia may be intolerant to periods of apnea.
Patients with __________ hypoxemia may be intolerant to periods of apnea.
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The __________ mnemonic is used for evaluating difficult direct laryngoscopy.
The __________ mnemonic is used for evaluating difficult direct laryngoscopy.
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When the glottic aperture cannot be visualized, the intubation success rate is __________ likely.
When the glottic aperture cannot be visualized, the intubation success rate is __________ likely.
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If obstruction or __________ is present, it may complicate the intubation process.
If obstruction or __________ is present, it may complicate the intubation process.
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Awake intubation is preferred in patients with significant __________ difficulty.
Awake intubation is preferred in patients with significant __________ difficulty.
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A patient who exhibits difficult airway characteristics is highly __________ of a challenging intubation.
A patient who exhibits difficult airway characteristics is highly __________ of a challenging intubation.
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Emergency clinicians must be prepared for unanticipated difficulty with every __________.
Emergency clinicians must be prepared for unanticipated difficulty with every __________.
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The combined failure of intubation, BMV, and __________ in elective anesthesia practice is exceedingly rare.
The combined failure of intubation, BMV, and __________ in elective anesthesia practice is exceedingly rare.
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Cricothyrotomy rates have decreased to __________ than 0.5% in recent studies.
Cricothyrotomy rates have decreased to __________ than 0.5% in recent studies.
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On the other hand, VL rarely fails to provide adequate laryngeal ______ but may introduce difficulty with indirect tube placement.
On the other hand, VL rarely fails to provide adequate laryngeal ______ but may introduce difficulty with indirect tube placement.
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The mnemonic ______ is recommended for a standard screening process for difficulty in intubation.
The mnemonic ______ is recommended for a standard screening process for difficulty in intubation.
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The second step in the evaluation of the difficult airway is to ______ the patient’s airway geometry.
The second step in the evaluation of the difficult airway is to ______ the patient’s airway geometry.
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The 3-3-2 rule requires that the patient be able to place three of his or her own fingers between the open ______.
The 3-3-2 rule requires that the patient be able to place three of his or her own fingers between the open ______.
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According to the Mallampati scale, complete visualization including the tonsillar pillars is classified as class ______.
According to the Mallampati scale, complete visualization including the tonsillar pillars is classified as class ______.
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A patient with a receding mandible and high-riding larynx is exceptionally difficult to intubate using ______.
A patient with a receding mandible and high-riding larynx is exceptionally difficult to intubate using ______.
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Upper airway obstruction might make visualization of the ______ mechanically impossible.
Upper airway obstruction might make visualization of the ______ mechanically impossible.
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Obesity alone may not be an independent marker of difficult DL, but it likely contributes to challenges in other areas of airway ______.
Obesity alone may not be an independent marker of difficult DL, but it likely contributes to challenges in other areas of airway ______.
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Neck mobility is assessed by flexion and extension of the patient’s head and neck through a full range of ______.
Neck mobility is assessed by flexion and extension of the patient’s head and neck through a full range of ______.
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A modified mnemonic, LEMONS, has been described, with the 'S' referring to the patient’s oxygen ______.
A modified mnemonic, LEMONS, has been described, with the 'S' referring to the patient’s oxygen ______.
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Conditions such as epiglottitis and neck hematoma can compromise laryngoscopy and passage of the ______.
Conditions such as epiglottitis and neck hematoma can compromise laryngoscopy and passage of the ______.
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The Mallampati score requires an awake, compliant patient for accurate ______.
The Mallampati score requires an awake, compliant patient for accurate ______.
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Severe loss of neck mobility may render ______ impossible.
Severe loss of neck mobility may render ______ impossible.
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Subjective clinical judgment can be highly specific but ______.
Subjective clinical judgment can be highly specific but ______.
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Study Notes
Emergency Airway Management
- Intubation Decision: Crucial to predict patient deterioration, especially for interfacility transfers or diagnostic testing.
- Difficult Intubation Assessment: Essential before neuromuscular blocking agents. Employ mnemonics like LEMON, ROMAN, RODS, and SMART.
- Physiological Optimization: Cardiovascular optimization (fluids, blood, pressors) is a crucial step for reducing risk.
- Rapid Sequence Intubation (RSI): Preferred method for ED patients without a crash situation or a difficult airway.
- Tube Placement Confirmation: End-tidal CO2 (ETCO2) is essential for ensuring proper tube placement in the trachea. Esophageal intubation is assumed if ETCO2 is absent until proven otherwise
- Videolaryngoscopy (VL): VL enhances intubation success rates compared to direct laryngoscopy (DL), leading to fewer complications and better outcomes, therefore is now the preferred option.
- Cricothyrotomy: Indicated for "can't intubate, can't oxygenate" situations. Early intervention for prevention of hypoxia.
- Neuromuscular Blocking Agents (NBMAs): Etomidate highly utilized during RSI. Rocuronium or succinylcholine are reasonable choices (with rocuronium preferred due to fewer adverse effects).
- Extraglottic Devices (EGDs): Rarely used in ED settings but can provide backup oxygenation in failed airway situations; often a prehospital standard in rescue situations.
- Airway Protection: Evaluate level of consciousness, phonation, and ability to manage secretions. Swallowing ability is a more meaningful indicator than a gag reflex.
- Ventilation/Oxygenation Failure: Ventilatory failure, persistent hypoxemia despite supplemental oxygen, are core indications. Clinicians rely on pulse oximetry and general patient status. ABGs are not essential or practical before immediate intubation.
- Anticipated Clinical Course: Intubation is indicated for patients with high predictable deterioration, worsening physiology, or to support procedures.
Difficult Airway Assessment
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LEMON Mnemonic: Used to assess for difficult direct laryngoscopy(DL)
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Look: External signs for difficult intubation (gestalt).
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Evaluate: 3-3-2 rule (mouth opening, submandibular space, thyromental distance)
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Mallampati Scale: Assessing oral access (I-IV).
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Obstruction/Obesity: Screen for upper airway obstruction, obesity.
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Neck Mobility: Assess for limitations in neck flexion/extension.
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ROMAN Mnemonic: Used to assess for difficult bag-mask ventilation (BMV)
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Resistance/Radiation: Assess for airway resistance, and radiation exposure history.
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Obstruction/Obesity: Evaluate airway obstruction and obesity.
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Mallampati/Mask Seal/Male: Assess Mallampati score, mask seal ability and gender.
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Age: Assess age-related physiological indicators
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No Teeth: Assess for edentulous state, critical factor for mask seal
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RODS Mnemonic: Used to assess for difficult extraglottic device placement
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Restricted: Assess for restricted mouth opening
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Resistance: Assess for resistance to ventilation
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Difficult Intubation Considerations: Predictors of difficulty often correlate well, but not exclusively, with direct laryngoscopy; videolaryngoscopy may result in a different outcome. Use multiple assessment tools for the best possible safety assessment.
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"Can't Intubate, Can't Oxygenate" (CI:CO) Situation: Prioritize topical and titrated sedation over NMBAs. This situation necessitates a backup plan, such as cricothyrotomy.
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Awake Intubation: Preferred in refractory hypoxemia or severe metabolic acidosis, or when anatomic difficulty and DL are probable.
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Description
This quiz covers essential concepts in emergency airway management, focusing on intubation decisions and techniques. It includes important assessments, optimization strategies, and verification methods critical for patient safety. Prepare to test your knowledge on rapid sequence intubation and the use of videolaryngoscopy.
