airway management Flashcards
normal inter incisor gap
2-3 finger breadths or 4 cm
TMD less than ____cm or greater than ___ cm can pose difficulty
6cm, 9cm
identify the number that corresponds with this mandibular protrusion test
class one: patient can bite upper lip
class two: patient can line up upper and lower incisors
class three: patient cannot move lower incisors past upper incisors
pediatric conditions that impair AO joint mobility
kippel feil
down syndrome
3 3 2 rule
inter incisor gap 3fb
thyromental distance 3fb
thyrohyoid distance 2fb
label these with appropriate cormack lehane scores
grade 3: epiglottis only. cannot see any part of glottic opening
grade 4: soft palate only. cannot see any part of larynx
what’s the difference between grade 2a and grade 2b
2a: you can see the posterior region of the glottic opening
2b: you can only see the corniculate cartilages and posterior vocal cords. you cannot see any part of the glottic opening
which cormack lehane score can you visualize the anterior commissure?
grade 1
risk factors for difficult mask ventilation: BONES
Beard
Obese (BMI >26)
No teeth
Elderly (>55)
Snoring
most current fasting guidelines include
2 hours: clear liquids
4 hours: breast milk
6 hours: regular solids, non human milk, infant formula
8 hours: fried or fatty foods
difficult laryngoscopy and intubation: LEMON
Look externally (shape of face, morbid obesity, pathology of head and neck, pierre robin)
Evaluate 3-3-2 rule
Mallampati score
Obstruction
Neck mobility
difficult SGA placement: RODS
Restricted mouth opening
Obstruction
Distorted AW
S: stiff lungs or C spine
Difficult surgical aw placement: SHORT
Surgery (neck surgery or previous scar)
Hematoma
Obesity
Radiation or other deformation
Tumor
pressure for RSI
before LOC: 20 newtons or 2kg
after LOC: 40 newtons or 4kg
congenital conditions associated with c spine abnormalities
Kids Try Gold
goldenhar
klippel feil
trisomy 21
3 reasons for angioedema
- anaphylaxis
- ACEI’s
- C1 esterase deficiency
tx for ACEI related angioedema (inhibition of bradykinin breakdown) OR C1 esterase deficiency related angioedema (4 options)
icatibant (bradykinin receptor antagonist)
encalantide (plasma kallidrein inhibitor- stops conversion of kinogen to bradykinin)
FFP (contains enzymes that metabolize bradykinin)
C1 esterase concentrate
(those with C1 esterase deficiency should receive prophylaxis before AW stimulation- either C1 esterase concentrate or danazol)
ludwigs angina and aw securement tactics
bacterial infection- rapidly progressing cellulitis on floor of mouth. inflammation and edema compresses submandibular, submaxillary, and sublingual spaces. most significant concern is posterior displacement of tongue that causes obstruction
to secure aw:
awake nasal intubation
awake trach
retrograde intubation is contraindicated for patients with obstructions above trachea
congenital conditions that impact aw management: big tongue
big tongue
Beckwidth syndrome
Trisomy 21
congenital conditions that impact aw management: small/under developed mandible
please get that chin
pierre robin
goldenhar
treacher collins
cri du chat
congenital conditions that impact aw management: cervical spine anomaly
kids try gold
klippel feil
trisomy 21
goldenhar
characteristics of pierre robin syndrome
small/under developed mandible
tongue that falls down and backwards (glossoptosis)
cleft palate
neonates usually require intubation
characteristics of treacher collins
small mouth
small under developed mandible
nasal aw blocked by tissue (choanal atresia)
ocular and auricular anomalies
characteristics of trisomy 21
small mouth
large tongue
atlantoaxial instability
small subglottic diameter (subglottic stenosis)
characteristics of goldenhar
small under developed mandible
cervical spine abnormality
characteristics of cri du chat
small/under developed mandible
laryngomalacia
stridor
modifications for intubation with obesity: what’s another name for ramping
help position (head elevated laryngeal position)
2 ways to damage facial nerve during aw management and presentation
aggressive jaw thrust can stretch facial nerve. presentation: affected side of face may sag, patient may drool, chewing may be affected
too tight mask strap can damage buccal branch of facial nerve. presentation: patient will have difficulty opening and closing lips. orbicularis oris function impaired.
how can supraorbital nerve be affected by aw management?
ETT laying in patients face. presentation: pain, forehead numbness, photophobia
which le fort fractures contraindicate use of NPA’s
le fort 2 and 3
name these OPA’s
which two OPA’s are tailored for the use of FOB and ETT’s
williams and ovassapian
name these le fort fractures and when to avoid NPA’s (5)
cribriform plate injury (risk of brain injury) (le fort 2 or 3)
cogulopathy
previous transphenoidal hypophysectomy
previous caldwell luc procedure
nasal fracture
basilar fracture
s/sx of cribriform plate injury (cribriform plate separates nasal cavity from anterior cranial fossa) (5)
le fort 2 or 3 fracture
basilar skull fracture
CSF rinorrhea
raccoon eyes
periorbital edema
ETT cuff pressure should stay less than
25cmH2O
is a low volume high pressure cuff or a high volume low pressure cuff better at protecting against aspiration
the low volume high pressure cuff is better (but does carry a higher risk of tracheal ischemia)
(high volume low pressure though is most common one in everyday practice)
peds ETT size formula with and without cuff (and tube depth)
(age/4) + 4 (without cuff)
(age/4) + 3.5 (with cuff)
depth: tube ID x 3
predictors of difficult video assisted laryngoscopy (5)
neck pathology (radiation, tumor, surgical scar)
short TMD
limited cervical motion
thick neck
mandibular protrusion score of 3
VAL’s that have a NON channeled design (3)
C-Mac, Mcgrath, glidescope
max classic LMA cuff pressure
60cmH2O (40-60 is goal)
nerves at risk of injury when LMA is used (3)
lingual, hypoglossal, and RLN
LMA size, patient size, max cuff inflation pressure, largest ett that fills ID, largest flexible endoscope
ID this LMA and its unique features
LMA supreme (image) and pro seal. supreme is just a disposable pro seal
gastric drain tube for OG
better seal than LMA classic and max pressure for PPV <30cmH2O
ID this LMA and its unique features
LMA fastrach
metal handle (cant use in MRI)
specific ETT
tube pusher
epiglottic elevating bar
ID this LMA and its unique features
LMA flexible
flexible, wire reinforced, longer than LMA classic, but also narrower.
useful for head and neck surgery
ID this LMA and its unique features
(can it help with FOB/intubation?)
iGEL
no inflatable cuff but there is a gastric port
safe for MRI
can provide conduit for FOB/intubation
has complications that include trauma to any surrounding tissue, nerve injury, aspiration, tracheal compression
if patient aspirates with LMA in place, what are the next steps?
leave LMA in place
place patient in trendelenburg
deepen anesthetic
100% O2
use low FGF and low Vt
use flexible suction catheter to suction through LMA
use FOB to assess severity and next steps
tendency of AW device placement to activate SNS in order from most to least stimulating
combitube > DVL > FOI > LMA
ID this tube, benefits, insertion
combitube
blindly inserted into hypopharynx
inflating the distal balloon occludes the esophagus
inflating the proximal balloon occludes the hypo pharynx
since the tip usually enters the esophagus, attempt ventilation via blue lumen
does not require neck extension and can allow for high ventilatory pressures up to 50cmH2O
contraindications of this device (4) and sizing
intact gag reflex
prolonged use (>2-3h) d/t risk of ischemia from oropharyngeal balloon
ingestion of caustic substances
zenkers diverticulum
37fr: 4-6ft
41fr: >6ft
ID this airway type
king LTS-D.
distal cuff obstructs upper esophagus while proximal cuff seals oral and nasal pharynxes (like combitube)
difference between combitube and king LTS-D
King LTD only has:
one lumen for ventilation
only one inflation port that simultaneously inflates proximal and distal cuffs
patient can only be ventilated through fenestrated apertures between the two cuffs
child sizes are available (>10kg)
for FOI, which hand holds scope
non dominant hand moves lever
dominant hand moves cord
ID this laryngoscope and its indications (5)
bullard laryngoscope
indicated for:
small mouth opening (minimum =7mm)
impaired cspine mobility
short, thick neck
treacher collins syndrome
pierre robin syndrome
adult and pediatric sizes available
other names for bougie
eischmann introducer
benefits of lighted stylet
(can it be used during nasal intubation?)
useful in anterior airway and small mouth opening
requires very little manipulation of neck
less stimulating than DVL
can be used for oral or nasal intubation
useful for cspine abnormality, pierre robin, burn contractures
disadvantages of lighted stylet
difficult to use in patients with short thick neck
should not be used in emergencies
blind technique so no tumors, foreign body airways, or epiglottitis
do not use in patient with traumatic laryngeal injury
indications for retrograde intubation (and when its best used as a tactic)
unstable cervical spine
upper aw bleeding
best used when intubation is failed but ventilation is still possible
can also be performed in awake patient
contraindications to retrograde intubation (7)
neck flexion deformity (cannot access CTM)
unable to ID land marks (obesity)
prertracheal mass (thyroid goiter)
tracheal stenosis under puncture site
tumor
coagulopathy
infection
complications related to retrograde intubation (6)
bleeding
pneumomediastinum
pneumothorax
trigeminal nerve neuralgia
breath holding
wire travels in wrong direction
what PSI is necessary to ventilate patient when performing a percutaneous cricothyroidotomy
50PSI (because catheter of needle is so small)
contraindications r/t transtracheal jet ventilation (2)
upper aw obstruction
laryngeal injury
complications r/t percutaneous cricothyroidotomy
hemorrhage
aspiration
tracheal injury
esophageal injury
barotrauma/PTX
contraindications to cricothyroidotomy (2)
children less than 6
laryngeal fx or neoplasm
a reasonable approach during the difficult aw algorithm is limit attempts to how many
3 attempts from you and 1 attempt from skilled provider
if you cannot ventilate or intubate what is the immediate next step per the algorithm
call for help
Plan A through D of difficult aw algorithm starting with attempted intubation
failed intubation–> place SGA
failed SGA placement–>final attempt at face mask ventilation (succeed: wake patient up do not go forward)
failed face mask ventilation –> cricothyroidotomy
4 techniques for extubating difficult aw
- extubate fully awake
- extubate over flexible FOB
- extubate over an aw exchange catheter
- extubate then place LMA
how long does airway exchange catheter (AEC) stay in place for patient who was a plausible failed extubation
72h (insert ~25-26cm at the lip)
what can you do with AEC in place? (3)
EtCO2 monitoring
jet ventilation
O2 insufflation
the glide scope has what degree of anterior bend?
60 degrees
click on the part of the LMA that rests on the cricopharynxgeus muscle of the upper esophageal sphincter
in the obese patient, intubation is best when what two things are aligned
sternum and external auditory meatus
can you do retrograde intubations with tracheal stenosis
NO HOE STOP TRYING TO SAY YES
