Airway assessment 2/13 Flashcards
test 1
What is the part that’s inside your nose that bleeds? What is it?
Turbinates
Thin cartilage structures in the nose covered w/ vascular tissues
The _____ divides the nasal cavities
Septum
What are vasoconstrictors that help w/ bleeding & trauma in nasal cavity? What considerations should I have w them?
Cocaine: analgesia effects & SNS –> increase HR
Phenylephrine (afrin)
Epi
Put lidocaine to help with the PAIN
The L & R nasal passages are called ______, they are separated by _______
fossae
septum
What is the preferred pathway for nasal airway devices? Where is it?
Inferior meatus
between inferior turbinate & floor of nasal cavity
T/F: You can poke a hole in the septum
T
can also poke a hole in tonils & soft palate
What forms the hard palate?
Maxilla & palatine bones
how much of the roof of the mouth is the hard palate?
Anterior 2/3 of the roof of the mouth
Can you put nasal airway into a patient with head trauma?
Yes
Use caution because it can go into the head
What is the primary cause of upper airway obstruction during anesthesia?
pharyngeal muscle tone
What muscle helps maintain airway patency?
pharyngeal muscle
What technique increases longitudinal tension in the pharyngeal muscles, decreasing the risk for airway collapse (obstruction)?
chin lift with mouth closure
The nsaopharynx ends at the _________ which is called ___________. This is a common site for what?
Soft palate
Velopharynx
This is a common site for obstruction
The pharynx starts at _______ and ends at the _________. What does it join together?
base of skull
lower border of cricoid cartilage
Joins together nasal&oral cavities w larynx & esophagus
Oropharynx starts at the ______ and ends at the _______
soft palate
epiglottis
Hypopharynx starts at the ___________ and ends at the ___________
Epiglottis
cricoid cartilage
The _____ prevents aspiration
epiglottis
Larynx starts at the ______ and ends at the ______. It is the inlet to __________.
epiglottis
cricoid cartilge
trachea
Where are your vocal cords?
Larynx
If you have a larynectomy, what must you also get? Why?
some sort of feeding tube/PEG tube/etc
you no longer have a epiglottis to prevent aspiration.
What are your unpaired laryngeal cartilages?
Cricoid
Epiglottis
Thyroid
What are your paired laryngeal cartilages?
Cuneiform
Arytenoid
Corniculate
What is the only complete laryngeal cartilage ring in the trachea?
Cricoid
Where are the true vocal cords attached to?
arytenoids & thyroid cartilages (thyroid notch on the thyroid cartilage)
What is the largest laryngeal cartilages?
Thyroid
Why do we cric?
Cant intubate/ventilate
The trachea starts at the _________ & ends at the _________
inferior crioid membrane
carina
How long is an adult trachea? What shape is it?
10 - 15 cm
C- shaped
Is intubating or ventilating more important?
ventilating
What should I do if im afraid im not going to be able to ventilate the pt?
intubate awake
What is more important, history or assessment? Why?
Hx
Can directly ask about experiences
Can review chart to see about bad experiences w anesthesia/intubations
What can cause subglottic stenosis?
Having to use a smaller ETT and increase the amount of air in the cuff
What is the submandibular space? Why is this area important?
between thyroid & mandible
When blade in mouth –> tissue is displaced here
What is the test of mandibular prognathism or prognathic ability? How is this tested? What does this indicate?
being able to slide mandible anterior
Bitting upper lip test or “bulldog test”
Indicates easy intubation
Are goiters internal or external? How do they affect intubation?
external
-Hard to get normal size ETT in bc sitting over larynx –> use smaller ETT
-NMB may relax muscle & drop goiter onto larynx and compress airway –> just use sedatives until ETT is in
Which is more predictive of a diff intubation, short/thick neck or high BMI?
short/thick neck
A neck that is greater than ______ cm indicates a difficult intubation
> 43 cm
Receding mandibles & facial hair can make what difficult?
Mask ventilating –> air leak
What is inter-incisor distance? What is the prefered distance? What suggests difficult intubation?
distance from upper to lower incisors (teeth) when mouth is opened all the way
preferred: > 6 cm or 3 fingers
diff: < 3 cm or 2 fingers
Big tongues can be caused by _______
ACE-I
What considerations and Tx should we have for angioedema dt ACE-I or a big tongue?
If big tongue –> NASAL INTUBATION
Tx: Vasoconstrictors
antihistamines
FFP
Tranexamic Acid (TXA)
What is macroglossia?
abnormally large/swollen tongue
The laryngoscope goes over the __________. What considerations should I have with this?
upper incisiors (teeth)
If they are big/long and im putting alot of pressure on them —> could cause trauma to their teeth
What is Edentulousness mean? How does this affect ventilation?
Means no teeth
teeth provide structure –> diff mask ventilation –> mostly likely will need an oral airway bc all soft tissue will collapse into airway/mouth
____% of insurance claims against anesthesia providers are dental claims. ____% of them ocur during induction
25%
75%
What side of mouth has an increased risk of dental injuries? Which teeth in general are more likely to be injured?
Left
anterior maxillary central (bunny teeth) & lateral incisors
(collectly, these are the front 4 teeth)
What teeth should we use if we have to scissor?
molars
What is the sniffing position? Describe the position
perfect intubating position
Aligns oral, pharyngeal, & laryngeal axis
Ear to be level w chest
What is the sternomental distance? What position do you need to be in? What is the preferred distance?
Distance between sternal notch & chin
head in full extension (head back completely)
> 12.5 cm –> indicator for easy intubation
What is the thyromental distance? What is the preferred distance? What is its relevance?
Tip of chin to thyroid notch (head in neutral position)
> 6.5 cm or 3 fingers
Measure submandibular compliance (space where tissue is displaced when blade in mouth during intubation)
What is the gold standard for airway eval?
Mallampati test
Mallampati test compares the _______ to views of the external _________ structures
Tongue
oropharyngeal
How do you conduct the Mallampati test?
Pt seated upright in neutral position
Mouth open
stick tongue out
no phonation
Describe Mallampati class I
Able to view everything:
Fauces, pillars, uvula, soft palate
Describe Mallampati class II
Fauces, portion of uvula, soft palate
Describe Mallampati class III
Base of uvula, soft palate
Describe Mallampati class IV
Hard palate only
What does BURP refer to? What does it mean?
Laryngeal manipulation –> better view for intubation
Backwards –> towards esphogas
Upwards
Rightwards
Pressure
What does OELM refer to? What does it mean?
Laryngeal manipulation –> better view for intubation
Optimal external laryngeal manipulation –> randomly moving the larynx to get a better view
What are the 2 accronyms for laryngeal manipulation?
BURP and OELM
What is the Cormack-Lehane (CL) classification?
View of internal structures –> laryngeal view
What is CL grade I?
Entire glottis
What is CL grade II?
only posterior portion of glottis
What is CL grade III?
Only epiglottis
No part of glottis
Whats the difference between pediatric and adult vocal cords?
Peds vocal cords dont have calcification on them so tissue is all the same color.
Easy to mistake esphogas & trachea
What is CL grade IV?
Epiglottis or glottis cannot be seen
What is the accronym OBESE-M associated with? What does it mean? What does it indicate?
Criteria for diff mask ventilation & airway
Obesity: BMI > 30
Beard
Edentulous
Snorer/OSA
Elderly/Male > 55 yo
——
Mallampati 3 or 4
If you have 2 or more of the OBESE symptoms –> you’re more likely to have a Mallampati class 3/4 and like to have a diff mask vent/airway
What is the accronym BOOTS-I associated with? What does it mean? What does it indicate?
Predict diff airway/BMV
Beard
Obesity
Older
Toothless
Sounds: snoring/stridor
—-
Inability to maintain O2 sats > 90% w BMV
If you have 2 or more of these you’re like to not be able to maintain a sat of >90% w BMV and have diff airway
What is the accronym LEMONS associated with? What does it mean? What does it indicate?
diff intubation
Look: face/neck visual abnormalities
Evaluate: 3-2-2 rule
Mallampati score
Obstruction/Obesity
Neck mobility
What is the 3-3-2 rule?
3 finger mouth opening
3 fingers along floor of mandible
2 fingers between the space between the superior notch of the thyroid cartlidge and neck/mandible junction
Mallampati _____ indicates diff airway
3 or 4
When should I consider intubating awake?
Suspected difficult laryngoscopy
-suspected difficult ventilation with BMV or LMA
-significant increase risk of aspiration
-increase risk of rapid desaturation
-suspected difficult emergency invasive airway (cant identify cric area)
What are considerations we should have in a cant intubate/ventilate situation?
Optimize O2 throughout
-Call for help ASAP
-Limit attempts at intubating –> trauma
-Dont give additional NMB/sedatives –> maybe meds will wear off & pt spontaneous breathes
-KNOW WHEN YOU NEED TO CRIC –> time is brain
When should we intubate prophylactically? Why?
Bullets
Bites
Burns
Neck trauma
anaphylaxis
angioedema
thermal airway injuries
Want to secure an airway before we cant or very diff to
What is common in high cervical fx? What should we do?
Ascending paralysis
electively intubate early
When should I RSI vs awake intubation?
RSI: peri arrest
-deteriorating
-easy airway w normal anatomy
-upper GI bleed + NGT
-bowel obstruction + NGT
-vomiting + NGT
awake: stable GI bleed
-difficult airway but stable
What is the technique for awake intubation?
Glycopyrolate 0.2 mg or atropine 0.01 mg/kg
- 4cc of 4% Nebulized lidocaine (or 8cc of 2%) @ 5 lmp –> can give other methods of lidocaine
-preoxygenate
-sedate w/ versed 2-4 mg or ketamine 20 mg q 2min & 20 mcg of precedex
-intubate awake or place bougie –> then paralyze –> pass tube
What does “set the table” refer to?
Positioning for the pt ready to intubate:
Ear to sternal notch (in line w chest)
-equipment ready (suction near)
-assistant pulls right mouth corner –> helps to see better
Where does the blade sit during laryngoscopy (intubation) for a Mac & miller blade?
Mac: under Valleculla (can see epiglottis)
Miller: under Epiglottis (only see vocal cords)
Before attempting to intubate again, what should you do?
Ventilate pt
consider using bougie
What does the black stripe on the bougie represent?
25 cm
at lip usually mid trachea in adult male
Ketamine is contraindicated in what? What other things should we avoid it in?
IICP
HTN/Tachycardia
Etomidate _______ seizure threshold
lowers
What are contraindications to Rocuronium?
Spinal cord injury
-allergy
What does literature support regarding rocuronium?
Increase dose = decrease onset time
We can go a little above the 1.2 mg/kg dose
What Succs DOA? Roc?
Succs: 5-10 mins
Roc: 30-90 mins
We shoud ___________ before intubation
resuscitate
What are the physiological killers prior to intubation in deteriorating pts?
Hypotension
Hypoxemia
Metabolic acidosis
We want a ________ than normal BP prior to intubation. Why?
higher
> 140 SBP
Preintubation hypotension is the biggest indicator of of cardiac arrest
To keep BP high before intubation, keep your sedatives ______ & paralytics ______
low
high
What is your DOC for induction in shock patients? What are your doses?
Sedative: Ketamine
0.5 mg/kg
(can give subsequent doses to make sure pt is adequately sedated)
Paralytic: Rocuronium
1.6 mg/kg
What is your dissociative dose for ketamine?
1-2 mg/kg IV
What are your push dose pressors?
Vasopressin
Epi
Phenylephrine
What is your push dose for Epi? How do you create it?
5 - 20 mcg
1mg/1ml –> draw 0.1 ml (100 mcg) in 10cc flush –> 100 mcg/10cc –> push 1cc –> giving 10 mcg
What is your push dose for Phenylephrine? How do you create it?
50 - 100 mcg
10 mg/1 ml –> put in 100 ml bag –> 100mcg/1ml –> push 1 cc –> giving 100 mcg
or
10 mg/1 ml –> put in 250 ml bag –> 40mcg/1ml –> push 2 cc –> giving 80 mcg
What is your push dose for vasopressin? How do you create it?
1-2u
20u –> draw up in 20cc flush –> 20u/20cc –> 1u/1cc –> push 1-2 cc –> giving 1-2 units
what are additional things I should do to help keep patient from desating while trying to intubate?
Keep PEEP valve closed –> allows for max O2 to fill the lungs
If I cant get O2 sat > 95%, what should I consider?
Lung shunt –> Pulm edema or PNA
Tx with nitroglycerine or lasix
What is intervention 1?
NC 15 lpm
BMV 15 lpm
PEEP valve 5 - 15 cm H2O
What is intervention 2-“cooperate before intubate”?
used for uncooperative/combative pts
Delayed Sequence Intubation:
Ketamine 1mg/kg –> preoxygenate –> paralyze –> apneic oxygenation –> intubate
What is intervention 3-“BUHE”?
Back up head elevated –> intubate
this method needs external validation in ED setting
In what condition do we want to try to avoid intubation in? What can we do to fix it before intubation?
Acidosis
NIPPV while trying to correct causes of metabolic acidosis
Acidosis = ________ CO2
Increased
What is intervention 1-bicarbonate?
Make sure if giving bicarb for acidosis –> ventilating patient very very well
If given, could worsen acidosis –> arrhymias
Also give bicarb slow
What is intervention 2-vapox?
“ventilator assisted pre-oxygenation”
Brief period of apnea can worsen acidosis
NC 15 lpm
setup vent to SIMV + PSV
tidal volume: 8 ml/kg
fio2 100%
Pressure support 5-10 cmH2O
PEEP 5
How many people do you need at head of bed for C-collar intubation?
3
For high risk aspiration situations, what considerations should we have? What conditions are these?
Place an NGT prior to intubation & topicalize everything!!!!
Intubate in upright position
Conditions: upper GI bleed
bowel obstruction
pre induction vomiting
