Chapter 11 Airway Management Flashcards
The essential component of the airway management skill set is ?
Critical thinking
Early intubation may be extremely beneficial in what type of patients?
Particularly patients with septic or hypovolemic shock.
Who published the emergency airway algorithms that use a clinical critical-thinking approach?
The (National Emergency Airway Management)
What are the algorithms intended as?
Guidelines in the approach to the emergency airway.
What are the 5 airway algorithms?
1- universal emergency airway algorithm 2-Main emergency airway algorithm 3-crash airway algorithm 4-difficult airway algorithm 5-failed airway algorithm
Excessive secretions place the patient at risk for?
Serious aspiration and an edematous epiglottis may obstruct the upper airway.
The understanding now is that hyperventilation reduces??
ICP by causing cerebral vasoconstriction and a subsequent reduction in cerebral blood flow.
Limiting the use of hyperventilation after severe TBI may help improve neurologic recovery after injury’s or at least avoid??
Iatrogenic cerebral ischemia.
What is the two part process of the airway assessment?
The Primary survey is (quick and crude)
The secondary is (slower and refined)
An altered level of consciousness may indicate?
Hypoxia
The transport team asses the patient by??
- looking
- listening
- feeling for spontaneous respiration’s
Tachypnea and tachycardia are caused by stimulation of what nervous system?
Sympathetic also known as fight or flight.
What is an indicator of shock for adult and pediatric?
Pallor
The skin is considered a minor or major organ?
Minor.
What are the major organs?
The heart and brain.
The chest wall should be palpate for what findings?
Tenderness,crepitus,subcutaneous air, and symmetry of movement.
The normal lung sound is?
Resonant.
A hemothorax is?
Dull.
A tension pneumothorax is?
Hyperresonant.
The history of MOI or progression of illness may also provide?
Subjective and objective data.
Which assist the transport team in determination of a course of action.
Recognition that bradypnea and bradycardia are critical signs of?
Impending realities failure in the pediatric patient essential .
Cardiac arrest usually caused by?
Realities failure.
Children’s with respiratory insufficiency may show herbal signs of?
- Fatigue
- restlessness
- irritability
- confusion may cling the child to their parents with anxiety and apprehension.
- A weak cry is also typical.
Cyanosis is a result of ? For peds
Desaturated hemoglobin.
A thorough examination consist of?
- Palpation
- percussion
- high index of suspicion
The chest wall and mediastinal structures are more mobile in adults?
True or false.
False.
-they are more common in children.
Can children withstand severe blunt chest trauma without sustaining rib fractures?
True or False
True.
-but the heart and lungs may be severe contused.
A child with a tension pneumothorax may experience?
A shift of the mediastinal structures much faster than adults.
If the patients mandible is not intact, the tongue can protracted directly with?
- Traction with a towel clip
- Suture
- Clamp
When the tongue is properly positioned an opa rest in??
The lower posterior pharynx.
NPA may be used in patients with?
- Marginal stupor
- coma
Where does the nasals tip lie?
In the posterior pharynx behind the tongue.
Traumatic insertion of NPA causes?
- Severe epistaxis or
- adenoid bleeding, especially in children.
How is the NPA inserted?
With the beveled edge along the nasal septum.
When using the Left nostril how do you insert it?
Must be inserted upside down to maintain the beveled edge against the septum and then rotate once the upper airway tip is in the posterior pharynx.
The BVM device with a reservoir can deliver a fractional concentration of oxygen in inspired gas of?
-(Fio2) of 90% to 100% at rates of 10 to 15 L/min.
What can be applied to the mask area in contact with beard that surprisingly gives a much better seal?
Water-soluble lubricant.
Children normally have three times the metabolic demand for oxygen as so adults and have a larger reserve capacity?
true or false
- False.
- they usually have twice the metabolic demand for oxygen as do adults and have a smaller reserve capacity.
Endotracheal intubation entails?
Manipulation of the anatomy to allow of an Endotracheal tube through the larynx , either blindly or thorough direct visualization with a laryngoscope.
The larynx or voice box is??
An intricate arrangement of nine cartilages, three single and six paired
How are the cartilages connected?
By membranes and ligaments.
How many muscles is the cartilages composed of?
Nine muscles.
In an adult, it extends from?
The level of the fourth to the sixth cervical vertebrae.
What cartilage is commonly known as the Adam’s apple?
Thyroid cartilage.
Manipulation of the cartilage can displace?
Vocal cords posteriorly and improve laryngeal visualization during laryngoscopy.
Pressure on the cricoid from the anterior neck, is known as?
Sellick maneuver.
-compresses the esophagus and may prevent passive regurgitation of stomach contents during laryngoscopy.
What membrane forms the vocal cords?
-The upper free edge of the cricothyroid membrane.
What is the third single cartilage?
The epiglottis.
-a spoon-shaped structure that lies directly over the glottis opening and prevents anything other than sire from entering the tracheal inlet!
What is a major visual landmark for performance of tracheal intubation?
Epiglottis.
The most important cartilages of the larynx are?
Arytenoids.
The ______________ are pyramid-shaped and anchor the vocal cords in the larynx?
Arystenoids.
What color are the vocal cords?
Pearly white.
What stimulates the airway and activate the defense reflex??
- Excessive secretions or
- spasmodic closure. (Means closure of vocal cords).
What are the two remaining pairs of cartilages?
-the cuneiform and
_the corniculate
Which form the posterior wall of the larynx.
What’s considered the gold standard for artificial airway support?
Intubation of the trachea.
-
Trachea intubation provides protection against?
-aspiration.
And allows for controlled and precise ventilation,and provides drug administration.
Complication of oral and nasal endotracheal intubation can be both ________ and ___________ ?
- Significant and
- Disastrous
The process of intubation increases?
ICP.
Unrecognized right mainstem bronchus intubation is a complication that may lead to inadequate ventilation and _______________
Left lung atelectasis.
_______________ intubation is the most common method of airway management for all age groups?
Orotracheal intubation.
What intubation is used almost exclusively in children?
Orotracheal intubation.
What is the narrowest portion of the airway in an adult?
Glottic opening.
What is the narrowest portion of the airway in children?
Cricoid cartilage.
-Located below the cords.
The _______ of a child is considered to be cone shaped?
Larynx.
In Cormack Lehane scale, grade 1 is?
-Visualization of the entire glottic opening.
In Cormack Lehane scale, grade 2 is?
-Is just the arytenoids cartilages or posterior glottic opening.
In Cormack Lehane scale, grade 3 is?
-Is only the epiglottis.
In Cormack Lehane scale, grade 4 is?
-only tongue visible.
What grade views are associated with high intubation success rates?
Grade 1, and 2.
What grade views are associated with lower intubation success rates?
-grade 3, and 4.
What does (POGO) mean?
-percentage of glottic opening that is visible during glottic opening.
Which blade is more difficult to control the tongue?
Miller blade.
The _________ blade has an advantage in viewing the glottic opening of patients who are considered to have an anterior positioned Larynx.
-straight blade.
What is the adult size blades?
-number 3 and 4.
The curved tip of the macIntosh is inserted into the ___________?
Vallecula.
Lifting of he blade lifts the __________ ligament and indirectly lifts the __________ to expose the Larynx.
- Epiglottis ligament
- Epiglottis
The ____ _____ blade is passed so that the tip lies beneath the laryngeal surface of the epiglottis.
Straight blade.
The space between the base of the tongue and the pharyngeal surface of the epiglottis is?
Vallecula.
At what angle do you pull the laryngoscopy blade?
45 degrees.
Mucosal ischemia starts to occur when?
Pressures are greater than 25 mm hg.
The average adult female airway can accommodate a ?
7mm to 8mm.
(The size refers to the inside diameter of the tube).
The average adult male airway can accommodate a ?
8-mm to 9 mm tube.
In the patient who is spontaneously breathing, the procedure requires an adequate seal on the mask and use of BVM device with reservoir to deliver the highest _________ for ________.
Fi o2 for 3 to 5 minutes.
Preoxygenation washes out the _________ in the patients lungs and supersaturated them with oxygen,which allows for as much 5 to 8 minutes of apnea.
Nitrogen.
In patients who needs ventilatory assistance, avoidance of peak airway pressure greater than __ to — mm Hg aids in minimizing gastric distention.
20 to 25mm.
Gastric distention increases the risk of?
Vomiting leading to aspiration and hypoxia.
The _____ method is an additional maneuver to improve visualization of the glottis during intubation?
- (BURP)
- backward,upward,rightward,pressure.
What method can you use that involves pressure on the thyroid cartilage?
BURP
What maneuver is considered an integral part of Rapid sequence tracheal intubation during emergency airway management?
The Sellick maneuver
For females the tube is placed so that the teeth are approximately at the?
21 cm mark.
For males the tube is placed so that the teeth are approximately at the?
24 cm mark.
The cuff for the tube is inflated with how many ml’s?
5 to 10 ml’s
Tube placement confirmation begins with auscultation of breath sounds in what order?
Right and left chest areas and over the stomach.
A patients first priority in confusion is?
Extubation.
Side note: Patients who were previously hypoxic may have an increased level of consciousness and may become combative.
What can be used to prevent the patient from butting down on the ETT?
An oral airway.
Why should the bite block be secured in place separately from the ETT?
If the bite block and the ETT are secured together, the patient may inadvertently cause extubation by lodging the tongue behind the oral airway and pushing it and the ETT out.
What intubation is referred to as a blind procedure because the larynx is not visualized as in the orotracheal method?
Nasotracheal Intubation
__________ technique has been replaced with inline cervical immobilization together with rapid sequence intubation (RSI) and oral intubation?
Nasotracheal Intubation Technique
_________ techniques can produce airway trauma that includes laryngeal and glottic damage,esophageal intubation,and significant bleeding that leads to a “can’t breath, can’t intubate” situation?
All blind techniques
What are true indications for the application of nasotracheal intubation?
- Spontaneous respiration’s and limited oral access.
- Cooperative patient.
- Severe dyspnea who cannot tolerate lying supine such as those with pulmonary edema, congestive heart failure, or chronic obstructive pulmonary disease (COPD) exacerbation.
What intubation method is applied and is useful in patients in whom neuromuscular blockade is hazardous?
Nasotracheal intubation
What is a disadvantage of blind nasal intubation?
Is that the upper airway bleeding induced by this technique can obscure visualization during subsequent attempts at direct laryngoscopy should the blind technique fail.
What is the only absolute contraindication to the standard blind nasotracheal technique of intubation?
Apnea or near apnea.
What is the most common complication of nasotracheal intubation?
Hemorrhage.
What are the five contraindications to nasotracheal intubation that are considered relative?
1- A suspected basilar skull fracture (may risk cranial intubation) or other closed head injury.
2- Acute epiglottitis.
3- Severe nasal or maxillofacial fractures.
4- Upper airway foreign body,abscess, or tumor.
5- Anticoagulation therapy or other blood clotting abnormalities that can cause epistaxis.
________ intubation puts the patient at risk for the development of?
Meningitis or encephalitis.
Special considerations must also be given to the patient for whom bacteremia would be detrimental, such as the patient with immunocompromised condition or the patient with a cardiac valve abnormality or prosthesis.
Traumatic intubation may cause epistaxis through?
Abrasion of nasal mucosa or rupture of a nasal polyp.
In nasotracheal intubation bleeding could be minimized with the use of?
A tube 1mm smaller than would be used in orally and with the use of vasoconstrictive agent to the nasal mucosa, such as topical phenylephrine.
The 2 vasoconstrictive topical meds for nasotracheal intubation are?
- Phenylephrine.
- Oxymetazoline.
In __________, relatively larger size of the tonsils and adenoidal tissue may produce severe bleeding if ruptured.
Children
- Perforation and dissection of the posterior pharyngeal wall have also been reported.
What is the proper head position for the patients who undergoes nasotracheal intubation is?
Sniffing position with a bit less extension than when an oral intubation is performed.
If cervical spine injury is suspected, the head and neck must be maintained in the?
Neutral position
The beveled edge of the tube should be introduced against?
Nasal septum of the nostril chosen
The tube is advanced through the nose and into the?
Pharynx with continuous forward pressure and gentle rotation.
As the tube approached the _______, breath sounds are heard maximally.
Glottis
On _____________, the tube is advanced through the cords?
Referring to nasotracheal intubation
Inspiration.
Devices that aid nasotracheal intubation?
- Endotrol tube.
- Beck Airway Airflow Monitor.
What is another blind intubation technique that was the original method of intubation beginning in the mid 1700’s?
Digital intubation, or tactile orotracheal intubation.
What does (ETI) stand for?
Endotracheal Tube Introducer.
Many anesthesia care providers consider the _______ the first choice in conditions where only the posterior arytnoids or the epiglottis are visualized during the intubation attempt.
ETI
Endotracheal Tube Inteoducer
What device permits it to be steered behind the epiglottis and into the glottic opening?
ETI
The ETI is ___ cm long and is curved at a ____ degree at the end?
60cm long and is curved at 35 degrees.
If hold up is noted, which may or may not be accompanied with clicks,it is nearly ____ % confirmation that the introducer is in the trachea.
100%
Clicks are confirmed in ___% of tracheal intubations with the ETI.
90%
Hold up may possibly occur in a patient with?
Esophageal stenosis with a false positive result or with cricoid pressure.
When using an ETI at times the ETT may resist passing through the cords. If this should occur?
- Rotate the tube 90 degrees to the left (the Murphy eye is now in the upright position),then advance.
- If this maneuver is unsuccessful, rotate the tube to the right 90 degrees.
- In rare situations, the tube may need to be rotated 180 degrees to pass through the cords.
The lighted stylet is Referred as ?
The transillumination method.
What has a light bulb at the distal end and is powered by a small battery source in the proximal end?
Lighted stylet.
This technique relies on transillumination of the neck tissue to guide the placement of the ETT?
Lighted stylet.
The lighted stylet was originally designed for?
To aid in blind nasotracheal method of intubation.
They lighted stylet is most commonly used as a _________________ where other more traditional airway management techniques have failed.
Rescue tool.
In reference to the lighted stylet, when a bright midline glow is observed, the tube stylet is advanced until the glow is located at the ________________?
The sternal notch.
What is (EOA) esophageal obturator airway?
The original EOA was a two-part device, a mask and a tube, that required one person to maintain tight seal on the mask and a second person to provide ventilation’s.
The combitube is?
A double-lumen system that,when inserted blindly,allows for either tracheal or esophageal intubation without ventilatory compromise.
During blind placement, the distal tube enters the esophagus approximately ___% of the time.
98%
Bending the combitube at the pharyngeal portion between cuffs for a few seconds, is known as ?
The Lipp maneuver.
- It enhances the performed curvature and eases insertion.
The ___________ incorporates a dual-cuff system that serves as airway seals.
Combitube
What supraglottic airway device could tamponade oral bleeding with the pharyngeal ballon which holds 12 to 20 ml and prevent aspiration of blood in trachea?
Combitube.
In reference to the combitube, which tube is ventilated first?
Tube 1
When ventilating a combitube, what are the recommended to ventilate at?
6 and 12 times.
Side note: the stomach may occasionally harbor residual carbon dioxide from esophageal ventilation of expired air into the stomach during bad-valve-mask ventilation’s.
If placement of combitube fails?
Pulling back 3 to 4 cm usually corrects the situation.
Side note: the most likely cause is that the perforated pharyngeal section has been placed too deep and positioned in the esophagus.
