Apex- Airway Management Flashcards
What does the mallampati exam evaluate?
The size of the oropharyngeal space
- The more space the tongue occupies, the less space there is to work
What airway exam assesses how easy or difficult it will be to align the oral, pharyngeal, and laryngeal axes?
Inter-Intercisor gap
(Normal = 2-3 fingerbreaths ~4cms)
*long incisors reduce the gap
Mallampati score > ____ is associated with a more difficult intubation
3-4; but by itself is a poor predictor- got to look at other stuff too
What is visibile with Mallampati
1:
2:
3:
4:
1: Pillars, Uvula, Soft palate, Hard palate
2: Uvula, Soft and Hard palates
3: Soft and Hard palates
4: Hard palate
PUSH!
Identify oropharynx structures
You know the hard and soft palates and uvula
- The empty space is fauces
- the tonsilar pillar you automatically think of is the posterior one
- and the most forward structure = anterior tonsilar pillar
What is this patient’s mandibular protrusion test classification? (enter a number)
3
What does the thyromental distance help estimate the size of?
The submandibular space
AKA: where you will need to displace the tongue in order to get a view of the glottic opening
A Thyromental distance < ___cm or > ___cm correlates with an increased risk of difficult intubation
<6cm
>9cm
The ability to place the pt in the sniffing position is highly dependent on the mobility of what?
The alanto-occipital joint
3 main conditions that can impair atlanto-occipital joint mobility, making it difficult to get the patient into a sniffing position
(5 other ones that may affect it)
- Arthritic disease
- Trauma
- Downs Syndrome
Normal Atlanto-Occipital Joint extension = ____ degrees
DL will be difficult if < ____degrees
normal = 35 degrees
difficult = 23 degrees
-okay so 23 bronchial generation splits and 23 degrees difficult intubation
Normal AO flexion and extension
90-165 degrees
3-3-2 rule includes what
inter-incisor gap >3FB
TMD >3FB
Thyohyoid > 2FB
Only the epiglottis can be visualized during DL. What’s the patient’s cormack and lehane score?
3
Cormack and Lehane score 2A vs 2B
2A = better > can see posterior region of the glottic opening
2B = worse > can only see corniculates and the posterior vocal cords but cant see glottic opening
What can’t you see with a grade 2 view?
Anterior commisure
Can you see any part of the larynx with a Grade 4 view? What can you see?
No - soft palate only
What are the BEST predictors of difficult mask ventilation (select 3)
- Mallampati 3
- Old age
- Edentulous
- Small mouth opening
- High, arched palate
- Presence of a Beard
Beard, old age, edentulous
Mnumonic for predictors of diffuclt mask ventilation
BONES
- Beard
- Obese (BMI > 26)
- No teeth
- Elderly (>55)
- Snoring
5 things you should ask yourself before providing airway management:
- Can I mask ventilate (BONES)
- Can I intubate (LEMON)
- Can I place an SGA (RODS)
- Can I place a surgical airway (SHORT)
- How fast must I secure the airway (2-4-6-8)
Most current recommendations for preop fasting guidelines
2: clear liquids
4: breast milk
6: regular milk, infant formula, solid food
8: fried or fatty foods
How can clear liquids 2 hours before surgery be benificial?
It actually has been shown to reduce gastric volume and increase gastric pH
(decreases risk for mendelson syndrome [gastric pH < 2.5, volume >25ml (0.4ml/kg)]
Risks for difficult SGA placement + mneumonic
Cricoid pressure:
The esophagus is compressed by applying pressure to the cricoid ring agisnt which vertebra?
C6
C5 = adult glottis
C6 = cricoid
C7 = Vertebral prominens
Cricoid pressure is applied (before/after) the patient loses consciouness and maintained until when?
before they lose consciousness and maintained until intubation is confirmed
20newtons>40
Cricoid pressure prior to LOC:
Cricoid pressure after LOC:
before LOC: 20 newtons ~ 2kg
after LOC: 40 newtons ~ 4kg
What congenital conditions are associated with C-Spine anomalies (select 2):
- Treacher Collins
- Klippel-Fiel
- Goldenhar
- Pierre Robin
Goldenhar
Klippel-Feil
+Trisomy 21
3 key causes of angioedema
- Anaphylaxis
- ACE inhibitors
3. C1 esterase deficiency
How would you treat angioedema caused by anaphylaxis vs ACE inhibitors or C1 esterase deficiency
Anaphylaxis:
- Epi
- Antihistamines
- Steroids
ACE inhibitors or C1 esterase deficiency:
- icatibant (bradykinin receptor antagonist)
- ecallantide (plasma kallidrein inhibitor - stops the conversion of kininogen to bradykinin)
- FFP (contains enzymes that metabolize bradykinin)
- C1 esterase conentrate
What is ludwig’s angina?
What is your most significant concern with this?
A bacterial infection characterized by a rapidly progressing cellulitis in the floor of the mouth
-concen for posterior displacement of the tongue which can result in complete, supraglottic airway obstruction
(also, inflammation and edema can compress the submandibular spaces)
Best way to secure the airway in someone with Ludwig’s angina
AWAKE NASAL INTUBATION
Or AWAKE TRACH
Angioedema is the result of increased ___________ that can lead to swellign of the face, tongue, and airway.
increased vascular permeability
What is Icatibant and what is it used for?
It is a bradykinin receptor antagonist
-it is used to treat angioedema (increased bradykinins and were blocking the receptor they bind to)
What is Ecallantine and what is it used for?
it is a plasma kallidrein inhibitor
- stops the converstion of kininogen to bradykinin*
- used for angioedmea (bradykinin excess)
When someone asks you why would you give FFP to an angioedema patient what would you say?
Bc it contains enzymes that break down bradykinins
What is the enzyme people are deficient in that can lead to angioedema?
C1 esterase
Retrograde intrubation is contraindicated in patietns with an infection where?
Above the level of the trachea
(so no retrogrades for ludwigs angina)
2 congential conditions that have a large tongue
BT - Big Tongue
Beckwicks syndrome
Trisomy 21
T/F - Micrognathia and mandibular hypoplasia can be used interchangably
True
What is glossoptosis
a tongue that falls back and downward
(Pierre robin)
What is choanal atresia and what congential condition is associated with it?
a nasal airway blocked by tissue (choanal atresia)
Treacher collins
What is congential fusion of the cervical vertebrae that leads to neck rigidity called?
Klippel-Feil
Optimal positioning for the obese patient is achieved when what 2 landmarks are in alignment?
- Sternum
- External auditory meatus
When you go into steep trendelenburg, are you more at risk for endobronchial intubation or extubation?
endobronchial intubation bc the abdominal contents shift up towards the chest, reducing thoracic volume
Which nerve is being compressed by this excessive traction at the angle of the mandible?
What 3 symptoms may this pt present with?
- stretching of the facial nerve (mandibular i think)
- saggy face on that side
- drooling
- unable to chew
What facial nerve is being compressed here?
How would this patient present?
buccal branch of the facial nerve
-difficulty openign and closing lips (impaired function of the orbiculares oris)
An ETT extender laying on the patient’s face can compress what nerve?
-pt presentation? (3)
supraorbital nerve
-eye pain, forehead numbness, photophobia