so, what should you have for emergencies medications handouts... · ucla school of dentistry...
TRANSCRIPT
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Emergency Airway Algorithm For The OMFS
Steven Ganzberg, DMD, MS Director of Anesthesiology,
Century City Outpatient Surgery Center Clinical Professor of Anesthesiology,
UCLA School of Dentistry [email protected]
So, What Should You Have For Emergencies
And Then, Let’s Focus On Airway
Medications
Disclaimer: Specific Medications & Equipment Vary By State
California GA Permit Required l Vasopressor l Corticosteroid l Bronchodilator l Muscle relaxant l IV Tx of
cardiopulmonary arrest
l Appropriate drugs antagonists
l Antihistaminic
l Anticholinergic l Antiarrhythmic l Coronary artery
vasodilator l Antihypertensive l Anticonvulsant l Oxygen l 50% dextrose or other
antihypoglycemic
California GA Permit Required
l Vasopressor – Epi, Ephedrine, Phenylephrine l Corticosteroid –Solu-Cortef, Dex, (Solu-Medrol) l Bronchodilator – Albuterol, Epinephrine l Muscle relaxant – Sux and/or Rocuronium? l IV Tx of cardiopulmonary arrest – Epi, Amio l Drug antagonists – Flumazenil, Naloxone l Antihistaminic - Diphenhydramine
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California GA Required
l Anticholinergic – Atropine (Glycopyrrolate) l Antiarrhythmic – Amiodarone, Adenosine,
Lidocaine? l Coronary artery vasodilator – Nitroglycerin l Antihypertensive – Hydralazine, Nitroglycerin,
Esmolol, Labetalol, Metoprolol l Anticonvulsant – Midazolam, Propofol l Oxygen l 50% dextrose
Antagonists
A Brief Review
Naloxone - Narcan®
l FDA Approved For IV/IM/SC Administration l How Supplied:
l 0.4mg in 1 ml Ampule/Vial l 0.4mg/ml in 10 ml Multidose Vial
l Dosage: l Adult: 0.4mg IV/IM; Repeat to 2mg Total Dose
l Partial Reversal With .04mg q2-3m l Children: 0.1mg/kg IV/IM; Repeat At Higher Doses As
Needed For Full Reversal l With Conventional Opioid Doses → Full Reversal
Will Occur with 0.4 mg (0.1 mg/kg for Children) l No Harm In Additional Doses l Possibility for Re-narcotization Exists!!
Flumazenil - Romazicon®
l FDA Approved For IV Administration Only l 0.1mg/ml in 5ml Vial → 0.5mg per Vial l In Serious Emergency:
l Unconscious, Crashing Patient, Poor Ventilation → 0.5mg l Repeat If Necessary
l In Controlled Emergency: l Unconscious But Breathing → 0.2mg IV Every 1 – 2 Minutes l Pediatric: 0.01 mg/kg → 0.2 mg IV
l Repeat Every 1 – 2 Minutes l Possibility For Re-sedation Exists!! l Caution: Epileptic Patients
l Reversal of GABAergic Antiepileptic Agents???
Reverse Benzo or Opioid First?
Which Is Causing The Most Respiratory Depression?
The Opioid!!!
Reversal Agents
l Must Monitor the Patient LONGER In Recovery Due To Possibility For Re-Sedation
l How Long??? l Most Hospital Protocols Recommend 2 Hours
Observation
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Emergency Equipment l Positive Pressure Ventilation Devices**
l With Supplemental Oxygen l Airway Adjuncts – Adult & Pediatric
l Oropharyngeal Airways** l Nasopharyngeal Airways l Laryngeal Mask Airways? l King LT-D?
l Laryngoscope, Stylets And ET Tubes** l Cricothyrotomy Kit** l Magill Forceps** l Yankauer Suction**
Oropharyngeal Airways
Nasopharyngeal Airways Laryngoscope, Stylet & Tubes
Laryngeal Masks Laryngeal Mask Airway - LMA
l Easier to place in emergency than ETT l Easier to dislodge than ETT l Doesn’t require laryngoscope l Blocks esophagus & helps prevent
regurgitation l Can fold over larynx and obstruct airway l Requires repeated training
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King LT-D
l Size 2: 35 - 45” l 12-25 kg
l Size 2.5: 41 - 51” l 25 – 35 kg
l Size 3: 4 – 5 ft l Size 4: 5 – 6 ft l Size 5: > 6 ft
Combitube
Combitube SA: 4 – 6 ft Tall Combitube: > 5 ft Tall
Transtracheal Jet Ventilator Cricothyrotomy Kit
Yankauer Suction Where To Keep Emergency Drugs/
Equipment
All Common Emergency Equipment And Drugs Could Be
In One Place (Crash Cart)
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How About The Operatory?
• Time Is Of The Essence • Have Items Most Likely To Be
Needed In Each Operatory • Have Sux In Room From
Refrigerator Storage As Needed • Use Crash Cart For Less Likely
Medications/Equipment
Recommended Emergency Drugs/Equipment For Operatory
l Naloxone l Flumazenil l Succinylcholine* l Atropine l Epinephrine l Esmolol l Diphenhydramine?
l Oral Airways l Nasal Airways l PPV for 100% O2
*Store In Refrigerator When Not Needed
For Children In OMFS Office: Important!!!! l Always Keep Succinylcholine and Atropine Immediately
Available l Labeled, Needled Syringes With Drug Vials On Counter
l Better Yet, Have the Drugs Drawn Up. I Do l Positive Pressure Oxygen Must Be Immediately Available l Highly Recommend Styleted ETT Ready l Depending On Technique, Reversal Agents Should Also Be
Immediately Available
Basic Philosophy of Emergency Medicine
Protect the Brain!!!!
l The Brain Needs Two Things Short Term l Oxygen & Glucose
l The Blood Is The Brain’s Oxygen Delivery System
l The Heart Is The Pump For The Blood l The Lungs Deliver Oxygen To The Blood
And If You Don’t Have An Airway………….
You Don’t Got Nothin’
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DS/GA Emergencies
Airway, Airway, Airway!!!
Sedation/GA Emergencies
l If The Patient is Ventilating and Circulating……. l You Not Only Have Time…….. l But The Patient Will Survive.
General Principles
l If Patient Is Conscious, Ask Them How They Feel
l If Very Sedated, Make Them Less Sedated l If Not Conscious, Make Them Conscious l Evaluate Multiple Indicators
Emergency Scenario
Oxygen Saturation Decreasing
Differential Diagnosis
l Hypoventilation l Upper Airway Obstruction
l Tongue l High Foreign Body
l Vocal Cord Obstruction l Laryngospasm l Foreign Body At Vocal Cords
l Lower Airway l Bronchospasm l Foreign Body Below Vocal Cords
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More Differential Diagnosis l Pulmonary Disease l Profound Hypotension
l Any CV Issue Leading to Low BP l E.g. Bradycardia, Heart Block, MI, Hypovolemia
l Acute Congestive Heart Failure l Pulmonary Embolus l Low FiO2 (Fraction of Inspired Oxygen)
l Diffusion Hypoxia l Gas Line Mixup
l Many Others
Case Scenario
Non-Intubated GA/Deep Sedation
20 Year Old Male l Medical History
l History of Asthma With URI Only l Albuterol Only If Bad URI l Used Pulmicort & Albuterol As Child
l Multiple Environmental Allergies/NKDA l Very Anxious l 5‘11” & 176 lbs (80 kg) l Other: + Mild Snoring l Procedure: Extraction Four 3rd Molars
Anesthetic Plan
l Nitrous Oxide For IV Start l Baseline Sedation – Midazolam & Fentanyl l Intermittent Boluses of Propofol l Local Anesthesia
Exam/Monitors/Vital Signs
l Consent, Escort, NPO l Heart – RRR w/o Murmur; CTA Bilaterally l Airway: Mallampati II – 50% Tonsils l NIBP, SpO2, ECG, Nasal Capnography
l HR 110, BP 137/85, RR 18 l Room Air SpO2 98% l 50% N20/50% O2 Via Nasal Hood l 22 G IV Catheter Left ACF; Start Normal Saline
“IV Induction”
l 2.5 mg Midazolam & 50 mcg Fentanyl l 2.5 mg Midazolam l 50 mcg Fentanyl l 1.25 mg Midazolam l 30 mg Propofol l Local Anesthetic Administration
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Initial Medications
l Local Anes. Injection l Patient Movement
l 30 mg Propofol l Place Throat Screen l Start Procedure
20 YO; 80 kg Deep Sedation/GA
l VS: 110/58, HR 85, SpO2 98% l Begin Procedure
l Pulse Oximeter Decreases to 95% l Next Step????
20 YO; 80 kg Deep Sedation/GA
l Capnograph Shows Apnea l Head Tilt/Jaw Thrust l Patient Takes Deep Breath l Pulse Oximeter 98% l What Next??? l Continue Surgery l Consider Nasopharyngeal Airway
Back To Case
l VS: 120/65, HR 98, SpO2 98% l Patient Moving l Additional 30 mg Propofol l Continue Procedure l Pulse Oximeter Decreases to 95%
l Head Tilt/Jaw Thrust Does Not Arouse Patient
20 YO; 80 kg Deep Sedation/GA
Pulse Oximeter Now 93%
What is Most Likely Going On?
Let’s Look At Our Differential Diagnoses
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Differential Diagnosis l Hypoventilation l Upper Airway Obstruction
l Tongue l High Foreign Body
l Vocal Cord Obstruction l Laryngospasm l Foreign Body At Vocal Cords
l Lower Airway l Bronchospasm l Foreign Body Below Vocal Cords
Ventilation Monitors
l Nasal Capnography l Evaluates Expired CO2 l Delay In Apnea Detection l Sometimes Poor Waveform
l Pre-Tracheal (Pre-Cordial) Stethoscope l Continuous, Immediate Evaluation of Ventilation
l Chest Excursions l Difficult with Draped Patient
Is the Patient Ventilating?
l Look For Chest Excursions l Diaphragmatic Breathing vs. Paradoxical
Breathing Pattern? l Respiratory Rate? l If Pre-Tracheal Stethoscope, Breath Sounds
l Not Sure l Turn Off Nitrous Oxide, If On!!
Unsure If the Patient Is Breathing Well?
Open the Airway!!!!!!! Deep Mandibular Angle
Stimulation
Patient Resumes Good Respiration → SpO2 98%
Continue, But What If……….
Patient Does Not Appear To Be Ventilating!!
Even With Deep Jaw Thrust. Pulse Oximeter Now 90%
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95 90
What Now???
Multiple Tasks Simultaneously l Make Sure Nitrous Oxide Is Off l Remove Throat Pack, Pack Surgical Site,
Suction Airway l Get Succinylcholine Ready!! l Start Positive Pressure Ventilation
l Is Airway Adjunct Needed? l Nasopharyngeal vs. Oropharyngeal
l Emergency PPV, Always Use Airway Early! l Is Ventilation Possible?
Differential Diagnosis
l Hypoventilation l Upper Airway Obstruction
l Tongue l High Foreign Body
l Vocal Cord Obstruction l Laryngospasm l Foreign Body At Vocal Cords
l Lower Airway l Bronchospasm l Foreign Body Below Vocal Cords
Yes, With Airway Adjunct
No
If Still Unable To Ventilate ………….
Assume Laryngospasm l Occurs During Deep Sedation/Light GA l Usually Due To Secretions on Vocal Cords l Usually Respiratory Effort
l But Paradoxical Breathing Pattern l Management
l Stimulate Patient With Vigorous Jaw Thrust l Suction Airway (Yankauer) l Positive Pressure Oxygen l For Children → Don’t Wait To Give Succinylcholine → Give It!!!
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Succinylcholine l Low Dose vs. High Dose; What’s the O2 Sat???
l Low: 20 mg = 1 ml = 0.25 mg/kg for 80 kg Patient l If Atropine Not Drawn Up, Get It Ready
§ Especially for Children
l Intubating Dose 1 mg/kg = 80 mg = 4 ml for 80 kg Patient l Continue Positive Pressure Ventilation
l With Oral Airway!!! l 2nd Dose of Sux May Cause Bradycardia
l MUST Pre-Treat With Atropine 0.04 – 0.5 mg l Children 0.01 mg/kg (Minimum 0.2mg) MUST Get
l If Ventilation Possible, Suction Again (Emesis?) l If Yes, Continue Case?
But What If Still Unable To Ventilate ………….
Differential Diagnosis
l Hypoventilation l Upper Airway Obstruction
l Tongue l High Foreign Body
l Vocal Cord Obstruction l Laryngospasm l Foreign Body At Vocal Cords
l Lower Airway l Bronchospasm l Foreign Body Below Vocal Cords
No
Ventilatory Emergency
l Direct Laryngoscopy l Determines Foreign Body At Vocal Cords l Vocal Cords Should Be Open
l IF You Gave A Full Intubating Dose of Sux l Allows Placement of Endotracheal Tube l DO IT!!! l Consider Atropine If Hypoxia Progressing And
Heart Rate Slowing
Ventilatory Emergency
l If Unable to Ventilate Through ETT….. l ETT In Esophagus l Bronchospasm l Foreign Body
l Consider LMA/King LT-D l Consider TTJV For Oxygenation
Differential Diagnosis
l Hypoventilation l Upper Airway Obstruction
l Tongue l High Foreign Body
l Vocal Cord Obstruction l Laryngospasm l Foreign Body At Vocal Cords
l Lower Airway l Bronchospasm l Foreign Body Below Vocal Cords
No
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Treat As Bronchospasm l Assume Saw ETT Pass Vocal Cords &
Unable to Ventilate l More Likely In Patient With Hx of Asthma l But Can Occur In Any Patient With Aspiration l Treatment??
l Epinephrine l CV Stimulation May Help or Hurt
l If Hypoxia Profound, Will Treat Bradycardia Too
What About Epinephrine? l Adult: IV 0.025 – 0.05 mg (25 – 50 mcg); Titrate
l ¼ - ½ ml of 1:10,000 Solution l Double Dose As Needed l Rapid Onset But Short Duration of Action
l Pediatric IV 0.01 – 0.025 mg (10 - 25 mcg); Titrate l Dilute 1:10,000 by 1:10 to 10 mcg/ml
l Consider Intramuscular Administration In Addition l Intramuscular** (Subcutaneous) 0.01mg/kg (Max 0.3 mg)
l Use 1:1000 Solution IM** l Allows Slow Release l IM Faster Onset Than SC
What About Epinephrine? l 1:1000 = 1 mg/ml for SC/IM/IV (Ampule) l 1:10,000 = 0.1 mg/ml for IV (Pre-filled Syringe) l 1:100,000 = 0.01 mg/ml for Local Hemostasis l Adult IV Doses:
l 0.05 mg (50 mcg ) → Urgencies (Start 25 – 50 mcg) l 0.5 mg → Near Death Dose l 1 mg → Death Dose
l Pediatric IV Doses l 0.001 mg/kg → Urgencies (Start 10 – 25 mcg) l 0.005 mg/kg → Near Death Dose l 0.01 mg/kg → Death Dose
l Caution: Cardiovascular Effects
What About Epinephrine? l Anaphylactic Shock
l Requires Multiple, High Doses of Epinephrine l Airway!! l IV Fluids l IV Corticosteroids, Antihistamines Secondary
l ACLS for Cardiac Arrest l Ventricular Fibrillation l Pulseless Ventricular Tachycardia l Asystole l PEA l 1 mg Every 3 - 5 minutes With CPR and Defibrillation
Back To Case
ETT Tube In Place
l ETT In Place & Able to Ventilate l Wheezing?
l Bronchospasm Or Aspiration l Negative Pressure Pulmonary Edema?
l ETT In Place & Unable to Ventilate l Despite Epinephrine → Foreign Body l Push Endotracheal Tube Past Carina?
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But, Patient Does Well………… EMERGENCY AIRWAY
ALGORITHM FOR OMFS
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SpO2!Dropping!or!<!95%!With!Supplemental!Oxygen!2!:4!l/m!nasal!cannula/hood!
!
PRIMARY!ASSESSMENT:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Airway,!Breathing!
Normal!Chest!Excursions,!!!!!!!!!!!!!!!!!!!!!!!!!!!!Breath!Sounds!Heard,!+!ETCO2!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Diagnosis:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!MILD!OBSTRUCTION/HYPOVENTILATION!
Paradoxical!Breathing!Pattern,!!!!!!No!Breath!Sounds/No!EtCO2!!!!!Diagnosis:!OBSTRUCTION!
Absent!Chest!Excursions,!!!!!!!!!No!Breath!Sounds,!No!EtCO2!!!!
Diagnosis:!APNEA!
Head!Tilt/Jaw!Thrust,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Assist!Ventilation!PPV!10!L/m!If!Hypoventilation,!Simulate/Consider!IV!Reversal!Agents/Assist!Until!
Spontaneous!Respiration!Adequate/!!!!!!!!!!!!!!!!!!!!!!!!!Place!Nasopharyngeal!Airway!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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! !
SpO2!Dropping!or!<!95%!With!Supplemental!Oxygen!2!:4!l/m!nasal!cannula/hood!
!
PRIMARY!ASSESSMENT:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Airway,!Breathing!
Normal!Chest!Excursions,!!!!!!!!!!!!!!!!!!!!!!!!!!!!Breath!Sounds!Heard,!+!ETCO2!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Diagnosis:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!MILD!OBSTRUCTION/HYPOVENTILATION!
Paradoxical!Breathing!Pattern,!!!!!!No!Breath!Sounds/No!EtCO2!!!!!Diagnosis:!OBSTRUCTION!
Absent!Chest!Excursions,!!!!!!!!!No!Breath!Sounds,!No!EtCO2!!!!
Diagnosis:!APNEA!
Head!Tilt/Jaw!Thrust,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Assist!Ventilation!PPV!10!L/m!If!Hypoventilation,!Simulate/Consider!IV!Reversal!Agents/Assist!Until!
Spontaneous!Respiration!Adequate/!!!!!!!!!!!!!!!!!!!!!!!!!Place!Nasopharyngeal!Airway!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Head!Tilt/Jaw!Thrust,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ventilation!With!PPV!10!L/m!,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Stimulate/Consider!IV!Reversal!Agents!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Diagnosis:!OVERDOSE/GA!
If!Unable!to!Ventilate!
!
!
! !
SpO2!Dropping!or!<!95%!With!Supplemental!Oxygen!2!:4!l/m!nasal!cannula/hood!
!
PRIMARY!ASSESSMENT:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Airway,!Breathing!
Normal!Chest!Excursions,!!!!!!!!!!!!!!!!!!!!!!!!!!!!Breath!Sounds!Heard,!+!ETCO2!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Diagnosis:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!MILD!OBSTRUCTION/HYPOVENTILATION!
Paradoxical!Breathing!Pattern,!!!!!!No!Breath!Sounds/No!EtCO2!!!!!Diagnosis:!OBSTRUCTION!
Absent!Chest!Excursions,!!!!!!!!!No!Breath!Sounds,!No!EtCO2!!!!
Diagnosis:!APNEA!
Head!Tilt/Jaw!Thrust,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Assist!Ventilation!PPV!10!L/m!If!Hypoventilation,!Simulate/Consider!IV!Reversal!Agents/Assist!Until!
Spontaneous!Respiration!Adequate/!!!!!!!!!!!!!!!!!!!!!!!!!Place!Nasopharyngeal!Airway!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Insert!Oral!Airway!
(Patient!Unresponsive)!!!!!!!!!!!!!!!!!
Head!Tilt/Jaw!Thrust,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ventilation!With!PPV!10!L/m!,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Stimulate/Consider!IV!Reversal!Agents!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Diagnosis:!OVERDOSE/GA!
If!Unable!to!Ventilate!
Head!Tilt/Jaw!Thrust!Effective!
Yes!
No!
Emergency!Airway!Algorithm!For!The!Oral!&!Maxillofacial!Surgeon!
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Breathing!Resumes?!!!!!Normal!Respiratory!Pattern?!
Assist!Ventilation!!BVM!10!L/m,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Stimulate/Consider!IV!Reversal!Agents,!
Diagnosis:!!DEEP!SEDATION/GENERAL!ANESTHESIA!WITH!
UPPER!AIRWAY!OBSTRUCTION!
Continue!Positive!Pressure!Ventilation10!L/m,!Tonsillar!Suction,!!
Administer!Succinylcholine,!Differential!Diagnosis:!
LARYNGOSPASM/BRONCHOSPASM/POSSIBLE!FOREIGN!BODYPVOMITUS!
Ventilation!Successful?!
Diagnosis:!LARYNGOSPASM!Assist!Ventilation!with!BVM!10!L/m,!
Tonsillar!Suction;!Consider!IV!Reversal!Agents?!!
Proceed!With!Surgery?!
ACTIVATE!EMS???!Laryngoscopy!and!Intubation,!
Consider!Supraglottic!Airway!If!Poor!DVL,!Positive!Pressure!Ventilation!Via!Airway,!(Consider!Jet!Ventilation!Via!Needle!
Cricothyroid!Puncture)!
Yes! No!
Yes! No!
Important Take Home Lessons
l During Emergency PPV, Always Use Oropharyngeal Airway If Unable To Ventilate
l Keep Needed Emergency Drugs In Operatory l For Children, Have Atropine & Sux On
Counter With Labeled Syringes l Always Have PPV 100% O2 In Operatory l If You Can’t Intubate, What Is Plan B?
And there you have it!!
Questions?