ENT/Laser/Ophtalmic/Dental Flashcards
1
Q
Turbinates
A
Folds in lateral aspect of nose, increase the surface area of the nasal cavity
-High vascular, prone to bleeding especially during nasal intubation
2
Q
4 paired sinuses
A
Frontal Ethmoidal Maxillary Sphenoid -Serve as resonators of the voice, susceptible to facial trauma
3
Q
Nasopharynx separates ___
A
Nasopharynx separates oropharynx by an imaginary plane, extends posteriorly
4
Q
Epiglottis separates ____
A
Epiglottis separates oropharynx from hypopharynx/laryngopharynx
5
Q
Sensory and motor nerve supply to the airway
A
Trigeminal, facial, glossopharyngeal, and vagus nerves
6
Q
Vascular supply to palatine tonsils
A
Branches of external carotid, maxillary, and facial arteries
-Very vascular, can cause serious bleeding issues with tonsilectomies
7
Q
Narrowest part of the larynx in children <8 and >8
A
<8: Cricoid ring
-Also cartilage is soft/pliable and more prone to edema, uncuffed tubes can help avoid this but cuffed ETT are used more often in practice now (otherwise need to switch out ETT if too much of a leak)
>8: Vocal cords
8
Q
Hyoid bone
A
Small U shaped bone that joins larynx and tongue
-Provides structural support for the larynx
9
Q
Recurrent laryngeal nerve sensory and motor innervation
A
Sensory -Laryngeal mucosa below vocal cords -Gives vagal response Motor -All intrinsic muscles except the cricothyroid
10
Q
Nerve that gives vagal response vs gag reflex vs laryngospasm
A
Recurrent laryngeal: Vagal response
Gag reflex: Glossopharyngeal
Laryngospasm: Internal branch of superior laryngeal nerve (X), mediated by external branch
11
Q
Distance from incisors to carina
A
26 cm
12
Q
N2O must be avoided for ____ ENT cases
A
Ear procedures, laser, foreign body procedures
13
Q
NIM-EMP for ENT cases
A
Facial nerve monitoring
- Recurrent laryngeal and vocal cord function
- Avoid muscle relaxants
14
Q
Emergence for ENT procedures
A
Smooth, rapid with intact reflexes
15
Q
How to minimize intraoperative blood loss for ENT cases
A
Use cocaine or epinephrine containing LA for vasoconstriction
Slight head up position
Provide mild controlled hypotension
-For vascular tumors with long OR time
-Reduce starting BP by 20%
-May need A line
-Watch UO, ECG, MAP, ABG, cardiac and cerebral pressure
16
Q
Metal impregnated ETT
A
For laser surgery: prevents burns and fires
-Fill cuff with saline or dye
17
Q
Nausea and vomiting with ENT procedures
A
High incidence
- Swallowing blood (sxn with OG before extubating)
- Generous IVF
- Generous antiemetics (ondansetron and dexamethasone)
- Consider Propofol
- Minimize opioids, avoid NDMR reversal if possible
18
Q
Children with OSA and surgery
A
Smaller than expected doses of opioids may cause exaggerated respiratory depression
19
Q
Anticholinergic use for ENT procedures
A
Glycopyrrolate
- Antisialogogue effect for oral procedures where a dry oral field is needed
- Or smokers or African American patients who are more prone to increased secretions, could lead to mucous plug
- Does cause complaints of dry mouth post op
20
Q
Corticosteroids and ENT procedures
A
Dexamethasone
-Decrease laryngeal edema, reduce pain (inhibit prostaglandins), decrease N/A, prolong analgesic effects of LA
21
Q
NSAID use for ENT procedures
A
Consult with surgeon before giving
-Reported increase in postop bleeding but reviews haven’t supported this (only aspirin does)
22
Q
Ketamine use for ENT procedures
A
May decrease need for opiates
23
Q
Lidocaine use for ENT procedures (Max doses)
A
Max dose: 4mg/kg or 7mg/kg with epi
24
Q
Max epi dose in LA and effect it has being added to LA
A
200 mg or 1.5mcg/kg
-Produces vasoconstriction, limits absorption and makes LA last longer (lidocaine duration of action 50% longer), decreases bleeding
25
Myringotomy and PE tube placement
Short procedure, mask induction and airway, no IV
| *Have IM anectine and atropine ready
26
Max IM and sublingual Anectine (succs) dose
IM Anectine: 3-4mg/kg (takes 2-3 mins to work)
Sublingual Anectine: .5-1mg/kg (works in 30secs-1min)
*Have IM atropine ready, succs stimulates muscarinic receptors at SA node and can cause SB-not good in young kids who are HR dependent
27
Tonsillectomy and Adenoidectomy/Uvuloplasty (T&A) indications and preop evaluation
Indications
-Recurrent acute tonsillitis, peritonsillar abscess, tonsillar hyperplasia, OSA
Preop Eval
-OSA Hx
-Current antibiotics
-Audible respirations, mouth breathing, nasal speech, chest retractions
-URI
-Evaluate tonsillar size to determine ease of mask ventilation/tracheal intubation
-Hct/Hgb preop based on case (PMH, physical exam)
28
T&A Anesthesia considerations
- Usually done on young kids-inhalation induction (Sevo/O2 30%/N2O 70%)
- Cuffed ETT preferred to minimize leak and need for resize/reintubation (Oral RAE midline or reinforced LMA)
- Know if/when surgeon placed throat pack and that it is removed
- Carefully monitor EBL
- Suction oropharynx and stomach for blood-decrease N/V
- Quick, smooth emergence (know if surgeon places LA at end, may be harder to wake up due to decreased stimulation from ETT)
- Place on side after extubation to promote drainage of blood out of mouth
29
Anesthesia meds for T&A
```
Antiemetics
Decadron (higher dose usually requested by surgeon)
IV Tylenol
Antisialagogue per surgeon
Toradol per surgeon
```
30
Controlled ventilation with muscle relaxant on induction for T&A/Uvuloplasty (Advantages and disadvantages)
MR not done much in peds
Advantages
-Guarantee immobility during surgery
-Facilitates easy intubation
Disadvantages
-Need to reverse NDMB-risk N/V and residual neuromuscular blockade
-Unable to gauge titration of postop analgesia (usually done based off of respirations)
31
Spontaneous ventilation (no MR) for T&A/Uvuloplasty (Advantages and Disadvantages)
Advantages
-RR and ETCO2 can guide titration of opioid/other analgesics during the case, achieve smoother emergence
-Faster emergence-no need to wait for return of spontaneous respirations
Disadvantages
-May require deeper anesthesia to prevent movement that interferes with surgery
-Might not be possible if paralysis was necessary for induction (short procedure)
32
T&A/Uvuloplasty complications
Laryngospasm
-Treat with positive pressure, hold it
-If this doesn't work try pushing on laryngospasm notch behind earlobe (effective 99% of the time within 60 seconds)
-IV lidocaine, succs
Bleeding tonsil
-S/Sx: Increased RR, color change, increased HR, decreased BP
-High risk for aspiration
-May need RSI and volume resplacement (crystalloid before induction), decreased induction drug doses
-May need to replace blood loss
-Extubate them fully awake
33
Cleft Palate/Lip (Intubation, oral airway)
Intubation may be difficult-blade might get caught in cleft-pack it
NO oral airway, may damage repaire. Get nasal airway ready and give it to the surgeon
34
Acute Epiglottitis signs and symptoms
Sudden onset fever, dysphagia, drooling, thick muffled voice
- Preference for sitting position with head extended, leaning forward
- Respiratory obstruction present: Retractions, labored breathing, cyanosis
35
Treatment for acute epiglottitis
- Give O2
- Get lateral neck xray to diagnose
- Keep the patient calm
- Don't do DL or sedation outside the OR
- Respiratory distress: OR, inhalation induction while sitting up, maintain spontaneous respiration, put IV in, use smaller size ETT by 1 size
- Extubate when significant air leak
36
Indications for Sinus and Nasal surgery
Chronic sinusitis, polyp removal, deviated septum, fractures
37
Anesthesia considerations for endoscopy (and complications and meds)
Keep airway quiet, give 100% O2 since you can't guarantee ventilation all the time
Complications: Eye trauma, epistaxis, laryngospasm, bronchospasm, dental damage
Meds: Zofran, decadron, scopolamine patch, glycopyrrolate, H2 blockers, metoclopramide
38
Foreign body aspiration signs, and what to do with obstruction at larynx vs distal to larynx
Signs: Coughing, tachycardia, aphonia, cyanosis, wheezing (all indicate obstructive severe irritation and swelling in the airway)
Obstruction at larynx: Do DL with magill forceps to remove
Distal to larynx: Surgeon will use rigid bronchoscope (gold standard) or flexible bronchoscope
Do mask induction with spontaneous ventilation (no positive pressure or N2O)
*Be prepared for worst case scenario
39
Meds for foreign body aspiration
Antisalagogue: Dry up secretions that could obscure bronchoscope view
H2 blockers
Metoclopramide: Promote gastric emptying
TIVA is best with rigid bronchoscope use, gasses will leak when different things are attached to bronchoscope for object removal
40
Complications of foreign body aspiration and meds
Complications: Trauma with intubation (dentition, gum, teeth, lip damage), hypoxemia, hypercarbia, barotrauma, vagal response with extreme neck extension
Meds: Steroids, inhaled racemic epinephrine, bronchodilators
41
Checking airway edema after foreign body aspiration retrieval
Deflate ETT cuff, listen for air movement around ETT for 2 breaths (inspiration and expiration with precordial stethoscope)
-If no movement airway edema can persist up to 24 hours post object retrieval
42
Nerve preservation for face and ear procedures (Nerve isolation, N2O, extubation, meds)
Nerve isolation can be accomplished with EP and EMG monitoring
-MR should be avoided (after succs for intubation) and volatile anesthetics should be used sparingly
No N2O for ear cases
-Increase middle ear pressure, displace graft
Quiet extubation
-Lidocaine before extubation, avoid moving head or oropharyngeal suctioning while awake
Meds
-Antiemetics, low dose opioids (should get LA)
-TIVA with Propofol and alfenta gtts is great choice
43
Potential complications during radical neck procedure
- Vagal response from carotid sinus stretch detected by baroreceptors
- Pneumothorax with low neck dissection, get CXR
- Venous air embolism if head up and veins exposed (positive pressure decreases likelihood)
- Recurrent laryngeal nerve damage
- High circuit airway pressure if surgeon manipulating the trachea too much
- Prolonged QT
44
Maxillofacial trauma anesthesia considerations
Don't perform nasal tracheal intubation (or insert NG)
-Could go to base of skull and cause meningitis
-Positive pressure ventilation can induce foreign material or air into the skull
Should be considered to have Cspine injury, stabilize head during intubation
-Consider awake fiberoptic intubation if airway problems are anticipated
45
What to have available if mouth is wired shut post op
Wire cutters with patient at all times
| -In case of vomit or breathing problems to be able to open airway
46
High frequency jet ventilation
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Low TV high RR
Tip of needle below or above the glottis
Inspiration is active with 50-60psi
-On for 1 second, off for 2
-Expiration is passive
```
47
Jet ventilation complications and contraindications
Complications: Barotrauma, SQ emphysema, pneumothorax, pneumomediastinum, hypercarbia, esophageal puncture, airway mucosal damage, blood or mucus obstruction, gastric distention if not accurately aimed
-Patients with decreased lung compliance are at risk for hypoventilation
Contraindications: Unprotected airways: full stomach, pregnancy, hiatal hernia, trauma
48
Anesthesia technique for jet ventilation
TIVA must be used
| -Propofol with short acting narcotic
49
Benefits of laser surgery
Lasers are precise and have minimal edema or bleeding
50
3 components of a laser
Laser medium
-Determines wavelength
-Contains atoms to create the laser light (solid, liquid, or gas)
Optical Cavity
-Enhances efficiency
-Provides feedback/mirrors
Pump Source
-External energy (thermal, electrical, or optical)
-Raises energy of atoms enough to produce laser light
Actual laser=tube with reflective mirrors (optical cavity) at either end and amplifying medium (gas) between them to generate electron activity and produce light
51
What depends on laser medium
Wavelength or color depends on laser medium
| -Effect it has on tissue depends on the wavelength
52
Argon gas laser use (what type of surgery)
Microscope or endoscope surgery
| -Ophthalmology, plastics, dermatology, gynecology, otolaryngology
53
KTP gas laser use (what type of surgery)
Fiber optics, scanners, or microscopes
| -Cut tissue and remove vascular lesions - dermatology
54
CO2 gas laser use
Most widely used
-Produces infrared light undetected by human eye - can cause corneal injury
-Use clear goggles
Very precise
General surgery, orthopedics, gynecology, urology, otolaryngology, plastics
55
YAG laser use
ENT surgery
Shorter wavelength=deeper penetration
Can burn retina, use green lens glasses
Gastroenterology, pulmonology, urology, ophthalmology, dermatology
56
Anesthetic considerations for laser use
- Fire prevention: ENT surgery higher risk for fire
- Potential eye injury for staff and patient (wear correct glasses)
- Atmospheric contamination of noxious fumes (surgical tech should evacuate fumes, wear special masks)
57
Color goggles for CO2 vs YAG laser
CO2: Clear
YAG: Green
58
ETT use for laser surgery fire risk
Fire occurs when laser penetrates ETT and is exposed to O2
- Use the least O2 needed
- Avoid N2O
- Use double cuffed tube with NS/Methylene blue in cuff to dampen ignition
- Use laser resistant ETT
59
3 layers of the eye
Outer
-Sclera (White, forms optic sheath encircles optic nerve)
-Cornea (Tough, colorless outer layer, injured)
-Conjunctiva (Outer mucous layer, limbus at edge of cornea, keeps objects from sliding behind eyeball, where topical ophthalmic drugs are given)
Middle
-Choroid
-Iris
-Ciliary body
Inner
-Retina (Neurosensory membrane, converts light to neural impulses via optic nerve II)
-Vitreous gel fills center of the eye, attaches to blood vessels and optic nerve, traction here=retinal detachment
60
Uveal tract
3 middle layers of the eye, provides most nutrients to the eye
-Choroid plexus, iris, ciliary body are all continuous
Choroid plexus: Blood vessels (where hemorrhage can occur), supports the retina
Iris: Pigmented, controls light entry with muscle fibers to change pupil size (sympathetic dilates, parasympathetic constricts)
Ciliary body: Behind iris, secretes aqueous fluid and control the shape of the lens (Ciliary muscles provide tension to zonule of zinn)
61
3 chambers of the eyeball
```
Anterior
-Inner cornea to iris
-Schlemms canal: where aqueous humor is drained
Posterior
-Iris to lens
-Where aqueous humor is formed
Viterous chamber
-Where vitreous humor is: gelatinous substance that determines IOP
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62
Tenon capsule
Fibrous connective tissue from corneal limbus to behind the eye orbit
-Serves as a cavity in which the eye moves
63
Myopia vs hyperopia
Myopia: Nearsighted
-Eye is long, focal point is nearer to the lens
Hyperopia: Farsighted
-Eye is short, focal point is further from lens
64
Four rectus muscles of the eye
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Originate from annulus of zinn, pull the eye in the direction of their attachment
CN III (Oculomotor) controls the superior, medial, and inferior muscles (parasympathetic)
CN VI (Adbucens) controls the lateral rectus muscle (Abducts the eye)
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65
Two oblique muscles of the eye
Superior: Originates in posterior orbit
-CN IV (Trochlear) rotates toward the nose
Inferior: Originates from orbital floor
-CN III (Oculomotor) rotates sideways
66
Which eye muscles don't originate from the annulus of Zinn
All ocular muscles (rectus) except the oblique muscles
67
Optic nerve
CN II
Conveys visual information from retina to occipital lobe
-Not a true cranial nerve, outgrowth of the brain (covered in meninges, myelinated)
*Anything injected here can get back to the brain/CNS->depression
68
Facial nerve
CN VII
| Controls tears, closes eye lids
69
Vagus nerve
CN X
| Efferent pathway for oculocardiac reflex, bradycardia and dysrhythmias
70
Blood supply to rectus muscles
1st branch of internal carotid
Primarily from ophthalmic artery
-MII: Medial muscular branch -> medial rectus, inferior rectus, inferior oblique
-LSS: Lateral muscular branch -> lateral rectus, superior rectus, superior oblique
Ciliary arteries
-Short posterior: Globe, choroid, optic N head, external retina
-Long posterior: 7 anterior ciliary vessels, supplies anterior eye
71
Irreversible cholinesterase inhibitors ophthalmic medications
Echothiopate
- Used for glaucoma
- Produces miosis (Ach stimulates iris/ciliary muscles)
- Improves outflow of aqueous humor
* May prolong effects of succinylcholine up to 3-7 weeks after d/c
72
Carbonic anhydrase inhibitors ophthalmic medications
Acetazolamide (Diamox)
- Used for glaucoma
- Reduces aqueous humor production
- Side effects: Diuresis, hypokalemic metabolic acidosis
73
Osmotic diuretics for ophthalmic medications
Glycerin, mannitol
- Used for glaucoma
- Reduce IOP
74
Cholinergic agonists for ophthalmic medications
Acetylcholine
- For miosis
- Constricts pupils during surgery
75
Cycloplegics/anticholinergics for ophthalmic medications
Atropine
- For mydriasis, ophthalmic capillary decongestion
- Pupil dilator
- Can get central anticholinergic syndrome: mad as a hatter, hot as a hare, dry as a bone
76
Mydriatics for ophthalmic medications
Phenylephrine, epinephrine
- For mydriasis, ophthalmic capillary decongestion
- Pupil dilator, decreases bleeding
77
Intraoccular glasses for ophthalmic procedures
Sulfur hexafluoride (SF6)
- Used for retinal detachments
- Intravitreal insufflation, tamponades retina into place
- Avoid N2O (gas bubble insertion)
78
Eye drop absorption speed
Absorbed readily, slower than IV but faster than IM
79
Topical medications for ophthalmic procedures
```
Cocaine
Tetracaine
-Onset 1 min, duration 30 mins
-Stings on administration
Proparacaine
-Onset 15 secs, duration 15 minutes
Can add sodium bicarb to decrease onset time
Hyaluronidase
-Protein enzyme, speeds onset by promoting even spread especially in peribulbar technique
```
80
Ocular anesthesia techniques
MAC
-Local/topical
Cataract extractions
Most popular, faster, safer
Need to be able to hold still and cooperate
-Regional
3 different types
When need to suppress oculocardiac reflex
General only used for invasive prolonged procedures or in pts that can't stay still
81
Retrobulbar vs peribulbar blocks (space, volume)
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Retrobulbar
-Intraconal
-Deep needle placement in orbit
-Small volume (2-4mL)
-May need facial nerve or eyelid block
-Causes the most eye akinesia (no movement)
Periobulbar
-Extraconal
-Larger volume (10-12mL)
-Most painful on injection
```
82
Patients who aren't candidates for regional ophthalmic procedures
```
Peds
Unable to cooperate
Claustrophobic
Communication barriers
Inability to lie flat
Open eye injury
>2 hours
```
83
Which patients are at higher risk for complications during ophthalmic blocks
Patients with myopia/nearsighted
| -Eye ball is longer
84
Oculocardiac reflex
Trigeminal-vagal reflex "five and dime"
-Trigeminal afferent pathway
-Vagal efferent pathway
-Traction of extraocular muscles (especially medial rectus), pressure on the globe, ocular manipulation
S/Sx: Bradycardia, junctional rhythym, ventricular ectopy, asystole
Treatment
-Stop surgical stimulation/release muscle traction
-Give IV Atropine (10mcg/kg) -> faster onset than glycol
-Ocular blocks/deep sedation can block this response
85
Strabismus surgery concerns
- High risk for occulocardiac reflex
- Increased risk for malignant hyperthermia, avoid succs
- Higher risk of N/V (80%) - multimodal antiemetics
86
Retinal surgery
Use sulfur hexafluoride to tamponade the retina
| -Avoid N2O 20 mins prior to gas injection and 10 days after
87
Throat packs for dental procedures
Always check to make sure they're accounted for
| -Will not be able to pass OG to decompress stomach
