Anes for Otorhinolaryngologic Surgery Flashcards
Ear surgery–what is it called when an ear infection extends to ossicles and mastoid bone?
Cholesteatoma
How is cholesteatoma usually discovered?
During hearing exam or when child is symptomatic (i.e.: hearing loss)
What is a major consideration for inner ear surgery?
Serious PONV
What does BMT stand for?
Bilateral myringotomy and tubes
BMT surgery involves a small incision made in the ___; tube is inserted to drain ___
BMT surgery involves a small incision made in the eardrum; tube is inserted to drain fluid
Local anesthetic for ear surgery–infiltration with ___ and ___; ___ lido on tympanic membrane; ___ cream to tympanic membrane
Local anesthetic for ear surgery–infiltration with lido and epi; topical lido on tympanic membrane; EMLA cream to tympanic membrane
Local can be applied to what (4) sensory nerves for ear surgery?
- Auriculotemporal nerve
- Greater auricular nerve
- Auricular branch of vagus nerve
- Tympanic nerve
General anesthesia for ear surgery–because an operating microscope is utilized, any movement is greatly magnified–T/F?
True
Because BMT cases are typically very short, you will usually ___ the patient for the whole case; longer cases can use ___
Because BMT cases are typically very short, you will usually mask the patient for the whole case; longer cases can use LMA
General anesthesia for ear surgery–what (2) types of ETT can be used to prevent kinking or compression of tube with head rotation?
- South-facing tube (RAE tube)
- Reinforced (armored) tube
Why is nitrous oxide good to use for BMT surgery?
Because it diffuses into middle ear and increases pressure
Increased middle ear pressure from nitrous oxide use is relieved by ___ or by ___
Increased middle ear pressure from nitrous oxide use is relieved by reabsorption of NO after it is discontinued or by Eustachian tube venting
What can happen to BMT graft as nitrous oxide is rapidly reabsorbed?
Negative pressures produced by rapid reabsorption can displace the graft
Most avoid nitrous oxide for ear surgery or limit it to < ___%
Most avoid nitrous oxide for ear surgery or limit it to < 50%
Positioning for ear surgery–___ and ___ of head; avoid compression of ___ and ___ jugular veins and ___ artery; ___ tilt of table may improve access; arms ___, secured and well padded; head up ___ degrees to reduce ___ pressure
Positioning for ear surgery–rotation and extension of head; avoid compression of internal and external jugular veins and carotid artery; lateral tilt of table may improve access; arms neutral, secured and well padded; head up 15 degrees to reduce venous pressure
Facial nerve monitoring is used during ___ ear, ___, and ___ ear procedures near facial nerve
Facial nerve monitoring is used during middle ear, mastoid, and inner ear procedures near facial nerve
What is the name of the monitor used to monitor the facial nerve?
NIM–nerve integration monitor
How does NIM work?–provides ___ and ___ signal to identify movement close to or at the nerve
NIM–provides audible and visible signal to identify movement close to or at the nerve
How does partial or complete neuromuscular block affect NIM?
Partial or complete neuromuscular block ABOLISHES nerve activity…so you won’t be able to reliably assess NIM
What should you do if patient is partially or completely paralyzed and you are trying to monitor the facial nerve?
Reverse the paralytic to increase reliability of NIM
What drug can be used to maintain depth of anesthesia without having to use neuromuscular relaxant?
Remifentanil
Because significant bleeding obscures the field (especially when magnification is used), how can you position the patient’s head to reduce venous pressure and bleeding?
Head up to reduce venous pressure and bleeding
ASA I hypotensive technique (although Rachel said this is not typically used)–MAP ___-___; intraop systolic > preop ___; HR ___
ASA I hypotensive technique (although Rachel said this is not typically used)–MAP 50-60, intraop systolic > preop diastolic; HR 60
What (3) agents can be used for the ASA I hypotensive technique to reduce significant bleeding on the surgical field?
- Beta blocker (metoprolol, labetalol)
- Clonidine
- Opioids–remi drip
___ is very common with ear surgery
PONV is very common with ear surgery
PONV increases ___ and ___ pressure; causes ___
PONV increases ICP and venous pressure; causes bleeding
Treatment of PONV for ear surgery–keep patient ___; prophylaxis with ___ antagonists, ___ones, ___ patch, ___one (steroid), ___ide
Treatment of PONV for ear surgery–keep patient hydrated; prophylaxis with serotonin antagonists, butyrophenones, scopolamine patch, dexamethasone, metoclopramide
Butyrophenones = D2 antagonists, antipsychotics like haldol
(2) techniques for nasal sinus surgery
- FESS–functional endoscopic sinus surgery
- Nasal antrostomy/Caldwell-Luc
Nasal fractures are fixed within ___ days, after initial swelling goes down
Nasal fractures are fixed within 10 days, after initial swelling goes down
What is an important consideration for patient with nasal fracture?–movement of patient can lead to ___ness, ___ artery damage, intra___ damage
Movement of patient can lead to blindness, carotid artery damage, intracranial damage
Samter’s triad = ___ sensitivity in patients with ___ and ___ polyps leading to severe ___spasm
Samter’s triad = NSAID sensitivity in patients with asthma and nasal polyps leading to severe bronchospasm
So an important consideration in patients with asthma and nasal polyps–use ___ cautiously
So an important consideration in patients with asthma and nasal polyps–use NSAIDs cautiously (b/c Samter’s triad, NSAID use can lead to bronchospasm)
What are (4) common nasal vasoconstrictors used to reduce bleeding and localize?
- Cocaine
- Epi
- Phenylephrine
- Lido with epi
Cocaine has a ___ (slow/rapid) onset, excellent vaso___ (dilator/constrictor)
Cocaine has a rapid onset, excellent vasoconstrictor
Small doses of cocaine are ___tonic, ___ (increase/decrease) HR; higher doses cause ___cardia, ___tension, ___ (what lethal arrhythmia?) and direct myocardial ___ (depression/excitation), leading to sudden ___
Small doses of cocaine are vagotonic, decrease HR; higher doses cause tachycardia, hypertension, VFib and direct myocardial depression, leading to sudden death
The CV effects of cocaine (at higher doses) result from the blockage of reuptake of ___ (what catecholamine) at the sympathetic nerve terminal; this leads to a potentiation of ___ (sympathetic/parasympathetic) activity
The CV effects of cocaine (at higher doses) result from the blockage of reuptake of EPI at the sympathetic nerve terminal; this leads to a potentiation of SYMPATHETIC activity
Cocaine should be avoided in patients with a history of what (5) things?
- CAD
- MI
- CHF
- HTN
- MAOI
Cocaine dose–___-___ mg/kg; max dose ___ mg; ___% commonly used; adding ___ slows systemic absorption
Cocaine dose 1.5-3 mg/kg; max dose 200 mg; 4% commonly used; adding epi slows systemic absorption
Nasal surgery–potential significant bloody contamination of lower airway–can use ___ tube or ___ in experienced hands; extubate when patient is ___ after thorough suctioning, remove LMA when ___
Nasal surgery–potential significant bloody contamination of lower airway–can use RAE tube or flexible LMA in experienced hands; extubate when patient is awake after thorough suctioning, remove LMA when awake (protecting the airway)
Nasal surgery–flexible LMA may result in LESS lower airway blood contamination than ETT–T/F?
True
Cuffed ETT for nasal surgery may result in blood in airway up to cuff; uncuffed ETT will result in blood in airway beyond cuff–T/F?
True
Point is that LMA (when placed properly) will result in less lower airway blood contamination than a cuffed or uncuffed ETT
What should you make sure is removed before extubation after nasal surgery?
Throat pack
Before extubation after nasal surgery, oral cavity and postnasal space should be inspected for blood by standard laryngoscopy; direct visualization of the passage of a suction catheter behind the soft palate should be observed too–T/F?
True
Neck ___ encourages any clot to fall past the soft palate
Neck FLEXION encourages any clot to fall past the soft palate
___ clot is any clot left behind that can be inhaled after ETT is removed, leading to total airway obstruction and death
Coroner’s clot is any clot left behind that can be inhaled after ETT is removed, leading to total airway obstruction and death (hence the name)
Why it is important to remove throat pack, examine oral cavity/postnasal space for blood, and suction behind the soft palate before extubation
Nasal packs may be used post op which can cause partial or complete obstruction of nasal airway; if used, instruct patient to breath through ___
Nasal packs may be used post op which can cause partial or complete obstruction of nasal airway; if used, instruct patient to breathe through mouth
Nasal packs are more problematic in ___ patients
Nasal packs are more problematic in OSA patients
Post op pain for nasal surgery ___ (is/is not) severe
Post op pain for nasal surgery is NOT severe
If respiratory depression occurs post op after removal of ETT, consider dislocation of ___ blocking airway
If respiratory depression occurs post op after removal of ETT, consider dislocation of nasal packing blocking airway
(3) divisions of throat, head, and neck surgery
- Intraoral–tonsillectomy, adenoidectomy, palatal surgery
- Laryngeal–laser, endoscopic, benign, malignant, stenosis
- Head and neck–parotid, thyroid, nasopharyngeal wall, neck dissection, laryngectomy
Tonsils and adenoids are part of ___ ring of lymphoid tissue around pharynx
Tonsils and adenoids are part of Waldeyer’s ring of lymphoid tissue around pharynx
Tonsillectomy is frequently performed for recurrent ___itis, pertionsillar ___, ___, and ___
Tonsillectomy is frequently performed for recurrent tonsillitis, peritonsillar abscess, OSA, and bariatrics
Adenoidectomy is needed ___ (more/less) as kid grows; why?
Adenoidectomy is needed LESS as kid grows
Because postnasal space enlarges in proportion to other pharyngeal structures
Adult tonsillectomy is associated with ___ (more/less) pain
Adult tonsillectomy is associated with more pain from scarring and fibrosis
OSA untreated leads to severe ___emia, ___carbia, ___ hypertension, and ___ (another name for right sided heart failure)
OSA untreated leads to severe hypoxemia, hypercarbia, pulmonary hypertension, and cor pulmonale
What can develop minutes or hours after relief of airway obstruction (after removal of enlarged tonsils/adenoids)?
Pulmonary edema
Preop assessment for tonsils and adenoids–identify if child has ___; ___ teeth or vulnerable implants; ___ disorders; ___ia; active ___ of upper or lower respiratory tract; ___ cell disease status
Preop assessment for tonsils and adenoids–identify if child has OSA; loose teeth or vulnerable implants; bleeding disorders; anemia; active infection of upper or lower respiratory tract; sickle cell disease status
General anesthesia for tonsils and adenoids–goal is to allow insertion of mouth gag and avoid reflex induced ___cardia and ___tension; ___ induction, ___ (slower/faster) with OSA, especially with loss of upper airway tone; ___ tube or ___ LMA; FiO2 < ___%; antibiotics ___ (are/are not) usually used
General anesthesia for tonsils and adenoids–goal is to allow insertion of mouth gag and avoid reflex induced tachycardia and hypertension; mask induction, slower with OSA, especially with loss of upper airway tone; RAE tube or flexible LMA; FiO2 < 30%; antibiotics are NOT usually used
Typical PONV dose of dexamethasone (what we give) is ___ mg/kg; max dose ___ mg
Typical PONV dose of dexamethasone is 0.15 mg/kg; max dose 8 mg
ENT decadron dose is ___-___ mg/kg; max dose ___ mg
ENT decadron dose is 0.5-1 mg/kg; max dose 20 mg
Decadron given for ENT procedures is associated with less postop ___, better ___ tolerance, and reduced ___
Decadron given for ENT procedures is associated with less postop emesis, better diet tolerance, and reduced pain
Even though it is ideal to wait to do surgery on a child a full 6 weeks after a respiratory infection, a lot of times, surgery (i.e.: tonsillectomy) WILL still be done on a child who is not a full 6 weeks infection free…why?
Because you have to eliminate what is causing the infection. The kid may not be able to last a full 6 weeks of being infection free if they have tonsillitis, enlarged tonsils. Need to remove the causative agent.
Because surgery is still done on a child who is not necessarily a full 6 weeks infection free, you need to be aware that the kid will be at a higher risk of what (2) things?
Kid will be at a higher risk of laryngospasm/bronchospasm
PONV treatment–decadron plus another agent does well, typically zofran ___ mg/kg; ___ well; regular ___ analgesia; rectal Tylenol ___-___ mg/kg
PONV treatment–decadron plus another agent does well, typically zofran 0.1 mg/kg; hydrate well; regular non-opioid analgesia; rectal Tylenol 10-15 mg/kg
Postextubation laryngospasm and stridor has a 12-25% incidence–T/F?
True–look out for it
How to prevent postextubation laryngospasm and stridor–extubate ___ or ___, avoid stage ___; IV ___ may help prevent; sub hypnotic doses of ___; ___ maneuver
How to prevent postextubation laryngospasm and stridor–extubate deep or asleep, avoid stage 2; IV lidocaine may help prevent; sub hypnotic doses of propofol; Larson’s maneuver
What is Larson’s maneuver?–gentle positive pressure with anterior pressure at the angle of ___
Larson’s maneuver–gentle positive pressure with anterior pressure at the angle of ramus
(This is basically a jaw thrust with fingers positioned at the back of the ear)
Postop bleeding incidence after T&A ___ (increases/decreases) with age; higher in ___ (peds/adults), ___ (male/female), and if there is inflammation of the throat, especially with an ___
Postop bleeding incidence after T&A increases with age; higher in adults, males, and if there is inflammation of the throat, especially with an abscess [another word for this is quinsy]
Primary bleeds after T&A occur within ___ hours, usually ___ or ___ in origin
Primary bleeds after T&A occur within 6 hours, usually venous or capillary in origin
Bleeding 7-8 days postop T&A is usually due to ___ that falls off
Bleeding 7-8 days postop T&A is usually due to scab that falls off
Postop T&A bleeding is not always obvious as blood is swallowed–T/F?
True
Postop T&A bleeding can occur up to ___ days after surgery
Postop T&A bleeding can occur up to 14 days after surgery
Suggestive S&S of bleeding tonsil include unexplained ___cardia, excessive ___, ___or, ___ness, ___ing, ___ (increased/decreased) capillary refill time
Suggestive S&S of bleeding tonsil include unexplained tachycardia, excessive swallowing, pallor, restlessness, sweating, increased capillary refill time
What is a late sign of bleeding?
Hypotension
Hypotension in a kid without anesthesia is CONCERNING!!!
Bleeding tonsil management–get experienced help; give ___; ___ resuscitate; check ___, ___, ___ (labs); ___ (how many) suctions; ___ induction, head ___ if tolerated; ___ induction with patient lateral or head down is an option for experienced provider; ___ stomach; extubate ___
Bleeding tonsil management–get experienced help; give O2; fluid resuscitate; check H&H, coags, T&C; 2 suctions; rapid sequence induction, head down if tolerated; mask induction with patient lateral or head down is an option for experienced provider; decompress stomach; extubate AWAKE
Vocal cord pathology–granulomas may occur from ___ or ___ trauma
Granulomas may occur from intubation or extubation trauma
Vocal cord pathology–malignant tumors are often ___lateral and in the ___ of vocal cords; ___% men, ___% alcohol abusers/smokers
Malignant tumors are often unilateral and in the middle third of vocal cords; 80% men, 97% alcohol abusers/smokers
Preop assessment for vocal cord pathology–presence of stridor indicates >___% reduction in airway diameter; in adults, stridor suggests < ___-___ mm airway diameter
Presence of stridor indicates > 50% reduction in airway diameter; in adults, stridor suggests < 4-5 mm airway diameter
Stridor is a significant finding–T/F?
True
Inspiratory stridor suggests ___ (intra/extra) thoracic airway obstruction
Inspiratory stridor suggests extrathoracic airway obstruction
Expiratory stridor suggests ___ (intra/extra) thoracic airway obstruction
Expiratory stridor suggests intrathoracic airway obstruction
If a patient has stridor and then that stridor suddenly stops, what should you consider?
Total airway obstruction!!! NOT a good sign if stridor suddenly stops because it means the airway is completely blocked–there is insufficient airflow to generate enough turbulent flow for stridor
What does microlaryngoscopy involve?–airway is held in ___ position by suspension of scope on a frame
Microlaryngoscopy–airway is held in sniffing position by suspension of scope on a frame
Microlaryngoscopy tube (MLT) is ___, has small internal and external diameter, sizes ___-___ mm
Microlaryngoscopy tube (MLT) is long, has small internal and external diameter, sizes 4-5 mm
Laser tubes help protect from airway ___; made of all ___ except for cuff and connector (vulnerable points); these tubes have ___ (single/double) cuffs, filled with ___ and ___ which act as a heat sink and help to identify ___ of cuff
Laser tubes help protect from airway fire; made of all metal except for cuff and connector (vulnerable points); these tubes have double cuffs, filled with normal saline and methylene blue which act as a heat sink and help to identify breeching of cuff
What are (2) vulnerable points of laser tubes?
Cuff and connector because they are only parts of the tube that are not made of metal
What are the double cuffs on laser tubes filled with?
normal saline and methylene blue
What is most commonly used technique for microlaryngoscopy?
CO2 laser
CO2 laser for microlaryngoscopy is hazardous to patient and OR personnel–T/F?
True
CO2 laser–patients face and neck should be protected with what?
Wet gauze or towel
What are (3) components of airway fire? Fires need ___, ___, and ___ source
Fires need fuel, oxidant, and ignition (heat) source
Eliminate one of these factors and you will have no fire!
To avoid airway fire, you should utilize lowest O2 setting to maintain oxygenation–T/F?
True
To avoid airway fire, avoid ___, use ___, maintain FiO2 < ___%
To avoid airway fire, avoid N2O, use air, maintain FiO2 < 30%
YAG laser = ___ lens goggles
YAG laser = green lens goggles
Argon laser = ___ lens goggles
Argon laser = amber lens goggles
CO2 laser = ___ lens goggles
CO2 laser = clear lens goggles
Steps for airway fire–___ circuit; ___ and submerge tube in ___; ventilate patient with ___ and new ___; re___/bronchoscope to assess and remove debris; maintain anesthesia with ___ agents; extensive pulmonary care–high ___, ___, ___oids, anti___, racemic ___
Steps for airway fire–disconnect circuit; extubate and submerge tube in water; ventilate patient with mask and new circuit; reintubate/bronchoscope to assess and remove debris; maintain anesthesia with IV agents; extensive pulmonary care–high humidity, PEEP, steroids, antibiotics, racemic epi
Nonintubation techniques (for vocal cord pathology/ML)–Sander’s type jet injector is a ___ gauge jet on side arm of laryngoscope or bronchoscope
Sander’s type jet injector is a 16 gauge jet on side arm of laryngoscope or bronchoscope
Jet injector–___ effect entrains air along with pressurized O2 @ ___-___ psi
Venturi effect entrains air along with pressurized O2 @ 30-50 psi
With jet injector, use ___ agents only; place ___ for emergence
With jet injector, use IV agents only (propofol, Remi, precedex, NMBD); place LMA for emergence
Jet injector is not meant for patients who are ___, have ___ or large ___
Jet injector is not meant for patients who are obese, have emphysema or large tumors
Supraglottic jet ventilation is placed ___ (above/below) cords via suspension laryngoscope
Supraglottic jet ventilation is placed above cords via suspension laryngoscope
Misalignment of supraglottic jet ventilation leads to poor ___
Misalignment of supraglottic jet ventilation leads to poor ventilation
You can monitor ETCO2 with supraglottic jet ventilation–T/F?
False–you CANNOT monitor ETCO2 with supraglottic jet ventilation
Risks of supraglottic jet ventilation include ___mediastinum, ___thorax, ___ emphysema
Risks of supraglottic jet ventilation include pneumomediastinum, pneumothorax, subcutaneous emphysema
Subglottic jet ventilation is a small catheter through ___ into ___; ___ (increased/decreased) driving pressures; ___ (little/a lot of) vocal cord movement; ___ (greater/lesser) risk of barotrauma compared to supraglottic jet vent
Subglottic jet ventilation is a small catheter through glottis into trachea; decreased driving pressures; little vocal cord movement; greater risk of barotrauma compared to supraglottic jet vent
What must you assure with subglottic jet ventilation?–___ of air and ___ of air out of the airway
Must assure entrainment of air and egress of air out of the airway
Ventilator types–high frequency ventilation (HFV) = ___ (small/large) tidal volumes with ___ (slow/rapid) rates via ___-___ mm catheter
High frequency ventilation (HFV) = small tidal volumes with rapid rates via 3.5-4 mm catheter
HFPPV = respiratory rates ___-___
HFPPV = respiratory rates 60-120
HFJV = respiratory rates ___-___ tidal volumes less than dead space
HFJV = respiratory rates 100-400 tidal volumes less than dead space
High frequency is achieved with jet ventilators by use of specialized ventilators with preset ___
High frequency is achieved with jet ventilators by use of specialized ventilators with preset pressure pauses
Spontaneous ventilation is useful for ___ removal, evaluation of ___, removal of simple ___ lesions
Spontaneous ventilation is useful for foreign body removal, evaluation of airway, removal of simple glottic lesions
Rigid bronchoscope offers better ___, ___ and control of ___
Rigid bronchoscope offers better visualization, suction and control of bleeding
If rigid bronchoscope is being used, observe chest rise for adequacy of ventilation as tidal volume and ETCO2 will not return via circuit–T/F?
True
Adequate oxygenation equals adequate ventilation–T/F?
FALSE–adequate oxygenation does not necessarily equal adequate ventilation
Apneic oxygenation for rigid bronchoscopy–limited to ___ minutes, scope then removed and patient ventilated
Apneic oxygenation for rigid bronchoscopy–limited to 2 minutes, scope then removed and patient ventilated
OR remove scope and ventilate patient anytime PaO2 drops
PCO2 accumulates ___-___ torr/minute of apnea
PCO2 accumulates 3-4 torr/minute of apnea
Other ways to ventilate patient undergoing rigid bronchoscopy–___ ETT; ___ bronchoscope
Other ways to ventilate patient undergoing rigid bronchoscopy–small ETT (cuff is deflated and scope is slid down trachea right next to it); Venturi bronchoscope (same principles as Sander’s type injector)
Fiberoptic bronchoscopy uses a ___ scope; good for ___ or ___ lesions; well tolerated under ___, although blunting of gag reflex predisposes patient to ___
Fiberoptic bronchoscopy uses a flexible scope; good for deep or peripheral lesions; well tolerated under local, although blunting of gag reflex predisposes patient to aspiration
Patient undergoing fiberoptic bronch with local should remain NPO until return of ___
Patient undergoing fiberoptic bronch with local should remain NPO until return of gag reflex
General anesthesia for fiberoptic bronchoscopy–use adult tube size no smaller than ___-___
General anesthesia for fiberoptic bronchoscopy–use adult tube size no smaller than 8-9 mm
Complication of fiberoptic bronchoscopy–resistance to ventilation if FOB occupies too much cross section of ETT or scope too tight in larynx–___ occurs, which ___ (increases/decreases) venous return and CO
Complication of fiberoptic bronchoscopy–resistance to ventilation if FOB occupies too much cross section of ETT or scope too tight in larynx–PEEP occurs, which decreases venous return and CO
Esophagoscopy–___ anesthesia needed for rigid scope, often done with ___; use ___ (smaller/larger) size ETT because you may need to drop cuff to allow passage of scope; assess patients for ___ bleed, ___, full ___; complications include perforation of hypo___, massive ___, ___mia as heart is stimulated by passage of scope
Esophagoscopy–general anesthesia needed for rigid scope, often done with panendoscopy; use smaller size ETT because you may need to drop cuff to allow passage of scope; assess patients for GI bleed, reflux, full stomach; complications include perforation or hypo pharynx, massive hemorrhage, dysrhythmia as heart is stimulated by passage of scope
If there is a foreign body in the esophagus, what can occur if cricoid pressure is applied?
Perforation of the esophagus–especially if the object is sharp
Esophageal foreign body can cause ___ of trachea if it presses on the posterior tracheal wall d/t absence of ___ support
Esophageal foreign body can cause perforation of trachea if it presses on the posterior tracheal wall d/t absence of cartilage support
Inhaled foreign bodies are more common in ___-___ year olds, ___>___
Inhaled foreign bodies are more common in 1-3 year olds, males > females
Which is worse–organic or inorganic inhaled foreign body? Why?
Organic inhaled foreign body is worse because it can soften, expand, and fragment (and thus occlude more lung area)
S/S of airway foreign body–___or, ___nea, ___ing, ___ing; localized ___ and ___ing seen later in diagnosis; ___ (inspiratory/expiratory) CXR helpful–may see unilateral ___ trapping and mediastinal shift ___ (away from/toward) affected side or atelectasis ___ (away from/toward) affected side
S/S of airway foreign body–stridor, dyspnea, coughing, wheezing; localized pneumonia and wheezing seen later in diagnosis; expiratory CXR helpful–may see unilateral air trapping and mediastinal shift away from affected side or atelectasis toward affected side
Treatment of urgent foreign body removal–___% O2, ___ or ___, ___ (yes/no) preop sedation, ___ (yes/no) N2O; ___ (awake/asleep) laryngoscopy
Treatment of urgent foreign body removal–100% O2, robinul or atropine, NO preop sedation, NO N2O; awake laryngoscopy
In near complete occlusion from foreign body, pushing laryngeal/tracheal foreign body into mainstream bronchus has resulted in reducing obstruction temporarily–T/F?
True
For less urgent foreign body removal, can do ___ or ___ induction and maintain ___ respiration until foreign body is identified
For less urgent foreign body removal, can do IV or inhalation induction and maintain spontaneous respiration until foreign body is identified
If foreign body is known organic material, position patient ___ with ___ (affected/unaffected) side down to minimize fragment spread
If foreign body is known organic material, position patient lateral with affected side down to minimize fragment spread
If removal of scope is required to retrieve foreign body, brief period of ___ may be needed, otherwise spontaneous respiration is useful to identify tracheal ___
If removal of scope is required to retrieve foreign body, brief period of NMB may be needed, otherwise spontaneous respiratory is useful to identify tracheal occlusion
Complications of foreign body removal–mucosal edema/stridor treat with ___ O2, racemic epi may repeat q ___ mins, decadron ___-___ mg/kg
Complications of foreign body removal–mucosal edema/stridor treat with humidified O2, racemic epi may repeat q 30 mins, decadron 0.5-1 mg/kg
After foreign body removal, patient may need to be intubated until edema subsides–T/F?
True
Epiglottitis = infection of ___ and ___ structures
Epiglottitis = infection of epiglottis and supraglottic structures (arytenoid cartilage mucosa and aryepiglottic folds)
Bacterial etiology of epiglottitis = ___ and ___
Bacterial etiology of epiglottitis = Haemophilus influenza type B (less now) and Group A strep
Viral etiology of epiglottitis = ___ virus
Viral etiology of epiglottitis = parainfluenza virus
Epiglottitis occurs typically in ___-___ year olds
Epiglottitis occurs typically in 3-5 year olds
S/S of epiglottitis (4 D’s)
- Dysphagia
- Dysphonia
- Dyspnea
- Drooling
Kids with epiglottitis have high ___, ___cardia, ___ tender to touch; ___ may be present on inspiration; ___ is not present; often sitting ___, leaning in a ___ position (___); lateral neck x-ray shows ___ sign at epiglottis
Kids with epiglottitis have high fever, tachycardia, neck tender to touch; stridor may be present on inspiration; hoarseness is not present; often sitting upright, leaning in a sniffing position (tripod); lateral neck x-ray shows thumb sign at epiglottis
Without treatment, epiglottitis can progress to life threatening airway obstruction–T/F?
True
Treatment of epiglottitis–administer ___ ASAP; induce with sevo and 100% O2 with patient in ___ position; maintain ___ respiration, add CPAP ___-___ cm H2O
Treatment of epiglottis–administer O2 ASAP; induce with sevo and 100% O2 with patient in sitting position; maintain spontaneous respiration, add CPAP 5-10 cm H2O
You must place an IV pre-induction for child with epiglottitis–T/F?
False–only start IV if it can be done without exacerbating airway compromise
Kids with epiglottitis must be intubated in the OR–T/F?
True!
What is most important thing to not do for kid with epiglottitis?
DO NOT RILE THEM UP–IT WILL MAKE AIRWAY COMPROMISE WORSE
How can you assess adequate depth of anesthesia for child?–___ signs, ___ and ___; loss of prominence of ___ breathing and conversion to quiet ___ breathing
eye signs, BP and HR (both drop); loss of prominence of intercostal breathing and conversion to quiet diaphragmatic breathing
Intubation for epiglottitis–intubate orally or nasally with tube ___-___ size smaller than usual
Intubation for epiglottitis–intubate orally or nasally with tube 0.5-1 size smaller than usual
Patient with epiglottitis normally remains intubated for ___-___ hours
Patient with epiglottitis normally remains intubated for 24-48 hours
Epiglottitis–after airway is secured, draw ___, give ___
Epiglottitis–after airway is secured, draw blood cultures, give abx
Trach ties should not be changed for first ___ days
Trach ties should not be changed for first 7 days–because a collapse of tissue around stoma makes correct passage hard to find
If trach is dislodged in early postop period, what is indicated?
Reintubation through larynx is indicated–try a smaller size tube
If there is an emergent need to ventilate the patient with an uncuffed trach tube in place, what can you do?
Pass a small 5.5 ETT through plastic trach tube to establish positive pressure
