Difficult Airway Flashcards
5 Ind. Risk Factors for diff Face mask Ventilation
Age > 55 Beard Teeth BMI> 26 kg/m2 Hx of Snoring
What 4 things can define Diff Tracheal Intubation
Time taken to intubate
Number of attempts
View at laryngoscopy
Requirement for special equipment
Failed intubation rate is ____ times higher in _______ surgical patients
8; obstetrical
Physiologic and anatomical Changes of pregnancy affect:
Airway
Oxygenation
Metabolism
2 examples of causes of worsened glottic view in parturients
1) Excessive cricoid pressure
2) Left Lateral Tilt positioning
What are the risk factors for airway complications during pregnancy
Airway edema Dec FRC Inc O2 consumption Weight gain Breast enlargement Full dentition Dec LES tone In labor: delayed gastric emptying.
Oral component of the airway
Incisors to oropharyngeal junction
Pharyngeal component of airway
Oropharyngeal junction to Glottis
Airway narrowing more significant in with Pregnant women with …
Preeclampsia
In pregnant women at the end of pregnancy and start of labor they have changes in…
Their oral mucosa, usually due to swelling
Always reevaluate the airway before induction of GA rather than prelabor assessment
May labor for 12 hrs or so and changed in airway from prelabor assessment on admission happens
Patient is not able to Intubate:
Wake them up and discuss fiberoptic intubation.
Pregnancy weight gain
10 to 15 kg ( 22 to 33lbs )
3 things that contribute to pregnancy weight gain
Fat
Blood and Instertitial fluid volume inc
Uterine and Fetal mass
High BMI means
Diff mask and tracheal ventilation
Inc risk for req. emergency c-section
Rapid O2 desaturation during apnea
Full dentition, Protuding Maxillary Incisors and smal TMD
Interfere on DL
When does LES tone return to normal postpartum ?
1 - 4 weeks postpartum
Two types aspiration Pneumonitis :
Solids: asphyxiation
Liquids : more severe when highly acidic
Morbidity and mortality of aspiration depends on 2 things :
Chemical nature of aspirate
Physical nature of aspirate
Volume of aspirate
Pts who aspirate while breathing spontaneously will..
Breath holding then …tachypnea, tachycardia , slight Resp acidosis ,
Aspiration Pneumonitis aka Mendelson’s syndrome
Chemical Injury to the tracheobonchial tree and alveoli by sterile acidic gastric content
Aspiration Pneumonia
Infectious , Inhaled colonized oropharyngeal secretions
What causes the slight PO2 dec and inc in shunt seen in Aspiration
Bronchospasm ; disruption of surfactant
Large particle aspiration lead to
Atelectasis
Smaller particulate matter aspiration lead to ——and resembles ——
Exudative neutrophilic response at bronchioles and alveolar ducts; resembles acidic liquid aspiration
3 Management of aspiration
1) Tracheal suction
2) Rigid bronch if large aspiration or solid
3) manage Hypoxemia with C-pap in those not intubated and PEEP in those ventilated= restores FRC, reduce shunting, reverses Hypoxemia
Post aspiration : Why C-pap in spont and PEEP in ventilates pts?
Restores FRC
Decreases Pulmonary shunt
Reverses Hypoxemia
For aspiration prophylaxis : Before surgical procedures consider timely admin of
Non-particulate antacid
H2 Blockers
And/or Reglan
Efficacy of non-particulates depend on
Baseline gastric volume
Acidity of gastric fluid.
30 ml bicitra will neutralize
225ml of HCl acid with a pH of 1.0
Duration of bicitra depends on rate of gastric emptying
H2 blockers reduce both ___and _____but ______minutes required for max effect when given IV
Acidity And Volume ; 60-90 minutes
* onset 30 mins
Advantages of PPI are_____;_______;______.
Long DOA; Low toxicity ; low maternal/fetal blood concentration
Metoclopramide great because_____but effect antagonized by ______potential s/e is _____
10 mg can inc LES tone & Inc peristalsis= Dec volume in 15 mins
Opioids and atropine
Extrapyramidal Effects
Elective C-section for prevention of aspiration give : 3 options
P.O. or IV H2B/ Pepcid 20mg 60-120 mins b4 induction
And Bicitra 30 ml with 30 mins of surgery
Some may give
Reglan 10mg PO at the same time as H2B or IV 15mins b4 induction
Emergency C-section Under GA
30 ml of Bicitral just after transfer to OR
Plus
Raniditine 50 or Pepcid 20 or Omeprazole 40 + Reglan 10mg IV when time allows
Bicitra short DOA unless given to
Mothers with delayed gastric emptying because of opioids
H2 receptor antagonists block____ receptors on the ______ and thus diminishes____
Histamine; Oxyntic cell; gastric production
What is Postpartum headache ?
C/O cephalic, neck, and/or shoulder pain during 1st 6 weeks after delivery .
Most common postpartum complications of neuraxial anesthesia
PDPH
Tension Headache
1) Mild to moderate Headache
2) lasting 30 mins to 7 days
3) Bilateral;Non-Pulsating; not aggravated by physical activity
Migraine
1) Recurrent Mod or Severe
2) Lasting 4 to 72 hrs
3) Unilateral ;Pulsating; agg. By physical activity
4) Nausea/Photo and Phonophobia
Musculoskeletal Headache
1) Mild to Mod
2) Neck and Shoulder pain
Preeclampsia/Eclampsia headache S/S & Diag.
1) HTN and/or HELLP
2) Bilateral; pulsating; aggravated by physical activity
* H&P + labs
What labs for pre & eclampsia ? (5)
1) Alanine aminotransferase ( ALT)
2) Aspartate Transminase ( AST)
3) Uric Acid
4) Platelet Count
5) Urine Protein
What is HELLP syndrome
Hemolysis, Elevated Liver enzymes, Low Platelet count syndrome
PRES syndrome headache S/S and Dx
1) Severe to Diffuse
2) acute or gradual onset
3) Focal neuro deficit and seizures
Dx: MRI + H&P
What is PRES syndrome
Posterior , Reversible (leuko) Encephalopathy Syndrome
Stroke Headache S/S and Dx; 2 types headache
Cerebral ischemia:
1) New headache overshadowed by focal signs and/or disorders of consciousness.
Subarachnoid Hemorrhage :
1)Unilateral, abrupt and Intense& Incapacitating
2)Nausea, nuchal rigidity , altered consciousness
Dx of Stroke headaches
H&P + CT w/o contrast or MRI ( FLAIR sequence )
Subdural Hematoma Headache S/S and Dx
1) without typical features
2) Overshadowed by focal neuro S/S and/or alt. Consciousness
Dx: H&P + CT/MRI
Carotid Artery Dissection Headache
1) late developing & constant
2) Bilateral or Unilateral
Dx: H&P + Carotid US or MRA
Cerebral venous and Sinus thrombosis headache S/S and Dx:
1) Non-Specific + may have post Dural component
2) Focal neuro signs & seizures
H&P + MRV+ Angiography
Brain tumor headache S/S and Dx
1) Progressive Localized
2) Worse in Morning
3) aggravated by cough/straining
Dx: H&P + CT or MRI
Idiopathic Intracranial HTN headache (pseudotumor cerebri or benign )
1) Progressive non pulsating
2) Aggravated by cough/straining
3) Ass. With Inc CSF pressure ;normal CSF chem
Dx of Idiopathic Intracranial HTN
H&P + Lumbar Puncture
Spontaneous intracranial Hypotension S/S only (5)
1) No hx of Dural trauma
2) Diffuse, Dull Headache
3) worsen w/n 15 mins of sitting out standing
4) Neck stiffness , nausea, tinnitus, photophobia
5) CSF opening pressure <60 mm H2O in the Sitting position
Spontaneous Intracranial Hypotention
H&P + Lumbar Puncture + Radioisoptope cisternography + CT Myelography
Pneumocephalus Headache
1) Frontal Headache
2) Abrupt onset immediately after Dural puncture
3) Symptoms worsen w/ upright position
Meningitis Headache
1) headache itself most frequent symptom
2) Diffuse
3)Intensity diffuses with time
4) nausea, photo and phonophobia
5) general malaise
6) fever
Dx: H& P + Lumbar puncture
Sinusitis Headache
1) Frontal Headache w/ facial pain
2) Dev of headache w/ nasal obstruction
3) Purulent nasal discharge , anosmia and fever
lactation headache
1) Mild to Mod
2) Temporarilly with onset of breast feeding or breast engorgement
Zofran Headache
Mild to Mod associated w/ zofran intake
PDPH headache s/s
1) Headache within 5 days of Dural puncture
2) Worsens w/in 15 minutes sitting or standing
3) Neck stiffness, tinnitus, photophobia , nausea
Primary headaches
Recurring activities: coughing, sex etc..
20 times more common than secondary headaches in women in 1st week postpartum.
Tension, Migraine, Trigeminal, cluster , other primary.
Secondary Headaches
Underlying pathological process
Most common postpartum headaches are :
Tension
Migraine
Pregnant with sever Migraine
C-section < Adverse labor and delivery : i.e.preterm, *preeclampsia, LBW
Eclampsia
Hypertensive encephalopathy : Headache, Visual dist., N/V, seizures, stupor, coma
* Headache serious pre-monitoring sign .
Why are Pregos at risk for strokes ?
Venous stasis, hypercoag , edema . Headache common sign of stroke too. 50% strokes within 1st6 weeks postpartum
6 risk factors for Gestational Diabetes
Age> 30 Prior Hx Large Fetus Prior abortions Still births Obesity
What H&P & lab seen in Gestational Diabetes ?
1) Fetus LGA and mom asymptomatic in H&P
Lab: Glycosuria, Abnormal hyperglycemia, Abnormal glucose tolerance test
Treatment for Gestational DM
Diet
Insulin
NO ORAL agents= fetal hypoglycemia
Preterm labor - Mother
Macrosomia - Fetus
Polyhydramnios- Mother
Shoulder dystocia - Fetus
C/S for macrosomia- Mother
Perinatal Mortality 2-5%- Fetus
Preeclampsia/eclampsia - Mother
Congenital defects - Fetus
DM type II- Mother
Hypoglycemia- Fetus
