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airway management Flashcards

1
Q

normal inter incisor gap

A

2-3 finger breadths or 4 cm

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2
Q

TMD less than ____cm or greater than ___ cm can pose difficulty

A

6cm, 9cm

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3
Q

identify the number that corresponds with this mandibular protrusion test

A

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

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4
Q

pediatric conditions that impair AO joint mobility

A

kippel feil
down syndrome

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5
Q

3 3 2 rule

A

inter incisor gap 3fb
thyromental distance 3fb
thyrohyoid distance 2fb

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6
Q

label these with appropriate cormack lehane scores

A

grade 3: epiglottis only. cannot see any part of glottic opening
grade 4: soft palate only. cannot see any part of larynx

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7
Q

what’s the difference between grade 2a and grade 2b

A

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

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8
Q

which cormack lehane score can you visualize the anterior commissure?

A

grade 1

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9
Q

risk factors for difficult mask ventilation: BONES

A

Beard
Obese (BMI >26)
No teeth
Elderly (>55)
Snoring

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10
Q

most current fasting guidelines include

A

2 hours: clear liquids
4 hours: breast milk
6 hours: regular solids, non human milk, infant formula
8 hours: fried or fatty foods

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11
Q

difficult laryngoscopy and intubation: LEMON

A

Look externally (shape of face, morbid obesity, pathology of head and neck, pierre robin)
Evaluate 3-3-2 rule
Mallampati score
Obstruction
Neck mobility

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12
Q

difficult SGA placement: RODS

A

Restricted mouth opening
Obstruction
Distorted AW
S: stiff lungs or C spine

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13
Q

Difficult surgical aw placement: SHORT

A

Surgery (neck surgery or previous scar)
Hematoma
Obesity
Radiation or other deformation
Tumor

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14
Q

pressure for RSI

A

before LOC: 20 newtons or 2kg
after LOC: 40 newtons or 4kg

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15
Q

congenital conditions associated with c spine abnormalities

A

Kids Try Gold
goldenhar
klippel feil
trisomy 21

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16
Q

3 reasons for angioedema

A
  1. anaphylaxis
  2. ACEI’s
  3. C1 esterase deficiency
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17
Q

tx for ACEI related angioedema (inhibition of bradykinin breakdown) OR C1 esterase deficiency related angioedema (4 options)

A

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)

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18
Q

ludwigs angina and aw securement tactics

A

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

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19
Q

congenital conditions that impact aw management: big tongue

A

big tongue
Beckwidth syndrome
Trisomy 21

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20
Q

congenital conditions that impact aw management: small/under developed mandible

A

please get that chin
pierre robin
goldenhar
treacher collins
cri du chat

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21
Q

congenital conditions that impact aw management: cervical spine anomaly

A

kids try gold
klippel feil
trisomy 21
goldenhar

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22
Q

characteristics of pierre robin syndrome

A

small/under developed mandible
tongue that falls down and backwards (glossoptosis)
cleft palate
neonates usually require intubation

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23
Q

characteristics of treacher collins

A

small mouth
small under developed mandible
nasal aw blocked by tissue (choanal atresia)
ocular and auricular anomalies

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24
Q

characteristics of trisomy 21

A

small mouth
large tongue
atlantoaxial instability
small subglottic diameter (subglottic stenosis)

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25
characteristics of goldenhar
small under developed mandible cervical spine abnormality
26
characteristics of cri du chat
small/under developed mandible laryngomalacia stridor
27
modifications for intubation with obesity: what's another name for ramping
help position (head elevated laryngeal position)
28
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.
29
how can supraorbital nerve be affected by aw management?
ETT laying in patients face. presentation: pain, forehead numbness, photophobia
30
which le fort fractures contraindicate use of NPA's
le fort 2 and 3
31
name these OPA's
32
which two OPA's are tailored for the use of FOB and ETT's
williams and ovassapian
33
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
34
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
35
ETT cuff pressure should stay less than
25cmH2O
36
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)
37
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
38
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
39
VAL's that have a NON channeled design (3)
C-Mac, Mcgrath, glidescope
40
max classic LMA cuff pressure
60cmH2O (40-60 is goal)
41
nerves at risk of injury when LMA is used (3)
lingual, hypoglossal, and RLN
42
LMA size, patient size, max cuff inflation pressure, largest ett that fills ID, largest flexible endoscope
43
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
44
ID this LMA and its unique features
LMA fastrach metal handle (cant use in MRI) specific ETT tube pusher epiglottic elevating bar
45
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
46
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
47
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
48
tendency of AW device placement to activate SNS in order from most to least stimulating
combitube > DVL > FOI > LMA
49
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
50
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
51
ID this airway type
king LTS-D. distal cuff obstructs upper esophagus while proximal cuff seals oral and nasal pharynxes (like combitube)
52
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)
53
for FOI, which hand holds scope
non dominant hand moves lever dominant hand moves cord
54
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
55
other names for bougie
eischmann introducer
56
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
57
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
58
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
59
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
60
complications related to retrograde intubation (6)
bleeding pneumomediastinum pneumothorax trigeminal nerve neuralgia breath holding wire travels in wrong direction
61
what PSI is necessary to ventilate patient when performing a percutaneous cricothyroidotomy
50PSI (because catheter of needle is so small)
62
contraindications r/t transtracheal jet ventilation (2)
upper aw obstruction laryngeal injury
63
complications r/t percutaneous cricothyroidotomy
hemorrhage aspiration tracheal injury esophageal injury barotrauma/PTX
64
contraindications to cricothyroidotomy (2)
children less than 6 laryngeal fx or neoplasm
65
a reasonable approach during the difficult aw algorithm is limit attempts to how many
3 attempts from you and 1 attempt from skilled provider
66
if you cannot ventilate or intubate what is the immediate next step per the algorithm
call for help
67
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
68
4 techniques for extubating difficult aw
1. extubate fully awake 2. extubate over flexible FOB 3. extubate over an aw exchange catheter 4. extubate then place LMA
69
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)
70
what can you do with AEC in place? (3)
EtCO2 monitoring jet ventilation O2 insufflation
71
the glide scope has what degree of anterior bend?
60 degrees
72
click on the part of the LMA that rests on the cricopharynxgeus muscle of the upper esophageal sphincter
73
in the obese patient, intubation is best when what two things are aligned
sternum and external auditory meatus
74
can you do retrograde intubations with tracheal stenosis
NO HOE STOP TRYING TO SAY YES

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