exam 1 Flashcards
ENT goal:
Balance ______ relaxation with _______ recovery
DEEP relaxation
RAPID recovery
painful/very stimulation (deep)
short cases (rapid)
ENT
muscle relaxation ___________ paralytics
withOUT
Goals of ENT
preventing fire
minimize blood loss (highly vascular)
specialized techniques
relax the muscle withOUT paralytics
deep but rapid
maintain CV stability
preventing postop airway obstruction
3 types of ET tubes for ENT surgery
RAE
anode
laser tube
ENT
ET tube
Cuffed, uncuffed (rare)
Sometimes difficult to fit, due to BEND
Helps make it less obstructed for the surgeon
The bigger the tube, the further out from the mouth
Nasal tube is good for dentists
RAE (oral or nasal)
ENT
ET tube
Flexible, good at bending, can create knots, resists kinking
However, can be occluded easily with biting (without mouth block)
anode (armored, reinforced)
ENT
ET tube
Metal impregnated tube, reduces risk of fire
However, markings are covered if you wrap it, so need to line it up with another tube; use breath sounds
laser tubes
Most LAs are _______-based
amide
3 drugs used for ENT
LAs
anticholinergics (secretions)
steroids (prolong LA, reduce edema + PONV)
ENT have a high risk of _______
PONV
which ENT case has the highest risk of PONV
middle ear procedures
8th cranial nerve
to decrease blood loss by reducing MAP, while STILL MAINTAINING cerebral and systemic autoregulation
deliberate hypotension
deliberate hypotension
Maintain MAP ≥ greater than or equal to ___
60
true or false
deliberate hypotension
patients with HTN may need HIGHER MAP
true
could need 65 or 75
true or false
deliberate hypotension can be done without aline, unless using nipride
true
2 surgeries for deliberate hypotension
o Extensive dissections
o Functional endoscopic sinus surgery (FESS)
drugs used for deliberate hypotension
Nipride (always use an a-line)
o Dexmedetomidine
o Esmolol
o Nitroglycerin (NTG)
o Nicardipine
o Remifentanil
o Propofol
risk of deliberate hypotension
postop vision loss (irreversible)
laser surgery types (4)
CO2
Nd: YAG
Ho: YAG, KTP
argon
laser surgery drawback
most surgical fires are related to this
What are the 3 biggest concerns with laser surgery)
1) Eye protection (patient + staff)
2) Plume dispersion (viral papillomas); can cause ETT to be dislodged
3) Fires
which ETT is best for fires
laser tube, metal impregnated
safety with laser surgery
matte finish
inflate cuff with methylene blue
shield tissue with wet gauze
suction plume
if patient needs O2 AND needs to respond to verbal commands, do this for O2
deliver minimum amount of O2 (30% or less)
if needed above 30%, deliver 5-10L/min of air under drapes to washout excess O2
stop O2 >1 min before laser use
use adherent incise drape
keep towel edges far away
coat facial hair with jelly
use bipolar
do not use electrocautery to cut into trachea
complications of endoscopy
Eye trauma
o Epistaxis
o Laryngospasm
o Bronchospasm
o Adverse effects to LAs from epi, etc. (LAST)
bronchs require vocal cord ___________*
relaxation
avoid paralytics!
true or false
ONLY use AWAKE extubation with someone who has bleeding in their airway*
true
No ETT involved! It is from an independent source
unprotected airway
High Frequency Jet Ventilation
HFJV, always use lowest ____ possible
O2
<30%
CONTRAindication to HFJV
full stomach
obese
pulm disease (difficult to maintain O2)
difficulties of HFJV
air trapping
SQ emphysema
PTX
type of anesthesia to use for HFJV
TIVA
what bronchus is most common with children for aspiration
Right
gold standard for foreign body aspiration
rigid bronch with GA
foreign body:
inhalational induction with ______________ ventilation
spontaneous
avoid ______ with foreign body
PEEP
postop foreign body
steroids
breathing treatment
mask on face, chin lift
Avoid ETT unless necessary
what 2 drug classes are CONTRAindicated for nerve monitoring/preservation/stimulation
NMBs
LAs
nitrous (avoid >15 min before closing)
2 indications for nerve preservation
parotid glands
mastoidectomies
how long should nitrous be turned off for
> 15 min before closing
myringotomy
ear procedure
usually does NOT require IV access
nitrous is okay to use (short procedure)
nasal fentanyl/dex for calmness
most common ped surgery
tonsillectomy and adenoidectomy (T+A)
true or false
LMAs are NOT recommended for tonsil surgery
true
contraindicated drug for tonsils
NSAIDS (however, studies have not proven they cause worse bleeding)
when are the ONLY times you can use DEEP extubation for ENT cases
“dry field” or VERY NORMAL cases
otherwise, always WAKE them
2 risk factors of bleeding tonsil complication
> 15 years old
within 6 hours (SLOW onset, swallowing blood)
true or false
bleeding tonsils extubate fully AWAKE*
true
true or false
ALL bleeding tonsils are “full stomachs”: MUST HAVE TRUE RSI*
true
thyroid procedures
Increased incidence of myasthenia gravis (increased ____________ to muscle relaxants!)
sensitivity
- Vocal Cords Motor Innervation (2)
o Recurrent laryngeal
o EXTERNAL branch of SUPERIOR laryngeal
gold standard thyroid surgery monitoring
intraop nerve monitoring
ETT with 4 electrodes
NIM tube (neuro inegral monitoring)
NIM electrodes
red: _______
blue: _____
red: RIGHT
blue: LEFT
electrodes should be in contact with vocal cords
thyroid surgery
treat hypotension with _______-________
direct-acting
(phenylephrine)
what can occur following thyroid surgery
HYPOcalcemia
(numb/tingling, laryngospasm, seizures, CV arrest)
treatment for HYPOcalcemia (2)
calcium gluconate or chloride
thyroid hematoma
Post-op hematoma
leads to
ER airway obstruction
leads to
emergent to the OR
true or false
cleft LIP is more difficult
true
difficult to mask and to intubate
done first
facial trauma
assume ___________ injury
cervical spine
use c-collar, F/O
Le Fort fracture
Horizontal, nose/palate, septum, posterior pterygoids
Usually, no issues
Oral or nasal ETT GOOD TO USE
I
Le Fort fracture
Triangular, nose, orbit, below zygoma, lateral maxilla + pterygoids
II
Le Fort fracture
Complete separation of midface from the cranial base across nose, ethmoid, orbit, sphenopalatine fossa
AVOID NASAL ETT without F/O guidance if basilar skull fracture suspected
III
basilar skull fracture signs (4)
o CSF from nose or ears
o Blood behind tympanic membrane (ears)
o “Raccoon eyes”: ALWAYS BILATERAL
o Bruising behind ears: “battle signs”
basilar skull fracture signs are delayed ___-___ days
2-3 days
facial fractures
true or false
ALL are full stomachs
Wire cutters must be available and stay at the bedside throughout the postop course
usually, not an emergency procedure
extubate AWAKE (need to be able to clear the airway)*
true
with any nerve thing, what do we avoid
NMBs or muscle relaxants
radical neck dissection (3)
difficult intubation (due to radiation, movement issues)
LONG procedure
AVOID fluid overload
risk of VAE (due to head-up position
opthalmic surgery
anesthesia type
LAs “epidural”
a little propofol
EXCEPT young children
they cause less PONV
most common + effective for profound analgesia/akinesia (no movement) of eye and eyelids (2)
RETROBULBAR LA*
peribulbar LA
Sub-tenon, infraorbital, supraorbital
which nerves are anesthetized with opthalmic
III, IV, V, VI, VII (3-7)
young children opthalmic surgery anesthesia type
GA
true or false
okay to use anticoags with eye surgery
true
opthalmic surgery
Sch causes transient ____________ IOP
increased
still considered safe
opthalmic surgery
decreases IOP + maintains akinesis
NON-depolarizers
opthalmic surgery
extubate ______
DEEP
2 risks from eye muscles
MH
PONV
opthalmic surgery
Prolonged PONV may be sign of increased ____!
IOP
For FULL stomach, OPEN-EYE INJURY patient
easy airway =
difficult airway =
easy = roc
difficult = Sch
(if sugg is available, use roc, less risk of increased IOP)
Oculocardiac Reflex
Afferent/towards = *
trigeminal (V)
five and dime
Oculocardiac Reflex
Efferent/away = *
Vagus (X)
five and dime
stimulus (4) of Oculocardiac Reflex
Globe pressure
optic nerve pressure conjunctival pressure
muscle traction
true or false
oculocardiac reflex occurs in children more
true
o Sudden, profound bradycardia, asystole, etc
Oculocardiac Reflex
treatment for Oculocardiac Reflex
stop stimulus
Oculocardiac Reflex
If unresolved (the second time it happens) = use ________ (2)
atropine or glycopyrrolate
- CN ____ nerve block = Bell’s Palsy
VII (facial)
Max SQ lidocaine
35 mg/kg
Max SQ epi
70 mCg/kg
1L SQ of tumescent solution
700ml absorbed
max amount of SQ tumescent solution
5L
tumesecent solution (3)
saline + epi + lidocaine
risks with liposuction
VTE*
abd wall perf
sepsis
fluid overload; pulm edema (from tumescent)
hypothermia
LA toxicity
o Highest incidence of death is d/t VTE
abdominoplasty “tummy tuck”
GREATEST risk of VTE
combined procedures
abdominoplasty + liposuction
biggest cause of VTE
smoking
VTE increased risk
long procedures
>__ hr GA
>__hr sedation
> 1 hr GA
2 hr sedation
facial cosmetic surgery
cocaine increases SNS
avoid ____, _________/_________
avoid HTN, swelling/bleeding
fiO2 <30% is =
150-200ml
safety checklist for office based surgery is from
ISOBS (institute for safety in office based surgery)
most common cause of death from OFFICE/PLASTICS based anesthesia
PE
(abdominoplasty)
Only ___ states have guidelines, policies, or position statements regarding office-based surgery and anesthesia (OBA)
33
true or false
standardization of safe practice with adequate safety protocols and practice standards are NOT legal guidelines*
true
true or false
Only 24 states have at least one law that regulated OBA
true
true or false
Heavy/deep or moderate MAC or deep sedation techniques require ETCO2*
however, this is NOT state/legal regulation, this is a standard of practice*
true
- DECREASED cost
- Increased patient and surgeon convenience and satisfaction
- Consistent staffing
- Efficiency
- Patient privacy
- Increased autonomy of practice
- DECREASED risk of infection
- Aging population + drive for cosmetic surgery
advantages of OBA
- Absent or inconsistent state regulations (someone who is not credentialed can perform)
- Lack of peer review and credentialing
- Logistical limitations
- Lack personnel support (solo provider)
- Possible poor quality/amount of equipment
- Lack organizational resources and human infrastructure
disadvantages of OBA
OBA facilities must have
positive pressure ventilation device (bag valve mask)
2 H tanks of oxygen
monitor/defibrilator
- What is the most common cause of death in OBA
inadequate ventilation and oxygenation
what should you keep in mind when monitoring fluids for liposuction
70% of tumesecent is absorbed (so calculate that into the number!)
do not overhydrate
true or false
If a bad trauma event happens, get them to a Level 1 trauma center; it does NOT matter how far it is!
true
modern trauma system has replaced the ________________ _____ ________
community care model
ATLS PRIMARY Survey:
ABCDE’s of trauma care
Vitals
Making sure the patient is stable
o ATLS Secondary Survey
Resuscitation and stabilization in progress
Complete head-to-toe assessment, including neuro exam!
Example: turning on the side, pupils, breath sounds, neuro assessment
Most common type of blunt trauma
MVAs and falls
blunt trauma
Always assume ___________, until confirmed otherwise
unstable C-spine
o What is the worst blunt trauma
thoracic (MVA/steering wheel)
most common symptom of blunt trauma
PTX (40%)
many times, it does NOT show up on x-ray
Tension PTX signs (6)
- HYPOtension
- SQ emphysema
- Unilateral ↓ BS
- ↓ chest wall motion
- Distended neck veins
- Tracheal shift to opposite side
treatment for tension PTX
- Emergent needle aspiration
2nd ICS (above 3rd rib, MCL)
- Beck’s Triad is associated with
pericardial tamponade
Beck’s Triad (3)
PERICARDIAL TAMPONADE
“beck was heart sick”
1) HYPOtension
2) increased CVP
3) jugular distention/muffled heart tones
what is NOT included in becks triad, but IS a symptom of pericardial tamponade
pulsus paradoxus (decreased SBP on inspiration)
what 2 drugs can be given for pericardial tamponade during INDUCTION
ketamine*
etomidate
AVOID PROPOFOL
hemothorax treatment (2)
1st fluid resuscitation
2nd chest tubes
What are common signs of tracheal injury
SQ emphysema
crepitus
most airway injuries occur _______ the carina
below
FAST stands for
Focused Assessment with Sonography in Trauma
great, highly sensitive, 4 views
lethal triad is for what
penetrating trauma, death
lethal triad**
PENETRATING TRAUMA
“lethal trauma”
1) acidosis
2) HYPOthermia
3) coagulopathy
Damage control surgery (DCS) with Damage Control Resuscitation (DCR)
prevent ________ triad
lethal
DCS and DCR
trauma
Limit/decrease _____________, but increase blood products
crystalloids
- DCS examples (2)
abd packing
external fixator
3 things used in Damage control resuscitation (DCR)
POC testing (TEG + ROTEM)
RAPTOR
REBOA
what is RAPTOR
resuscitation with angiography, percutaneous techniques and operative repair
(IR)
what is REBOA
Resuscitative endovascular balloon occlusion of the aorta
3 major assumptions with AIRWAY trauma
1) full stomach
2) c-spine issue
3) hypotensive + hypoxic
what NMBs for patients with AIRWAY trauma
Sch or Roc for RSI
Manual in-line stabilization (MILS)
after front of C-collar removed
* Many people helping!
true or false
AIRWAY trauma
NO outcome difference between DL (miller), VL, and FOB (provider dependent)!
true
you can use any!
what is the LAST resort (avoid it!) for airway trauma
front of neck access (FONA) with crichotomy
what is a dilemma for BREATHING trauma
↓ Decreased compliance (and need for ↑ increased PIP)
vs
barotrauma (with worsening disease)
protected lung ventilation (6)
1) LOW Vt
2) PEEP
3) Permissive HYPERcapnia (hypoventilating) ***
4) Limited fluids
5) Prone positioning
6) NMBs (can help with ventilating)
3 GOALS for breathing trauma
LOW Vt
LOW PIP (<32 cmH2O)
SpO2 90-94% (avoid O2 toxicity!)
excessive oxygen leads to
atelectasis
free radicals, ROS
cellular necrosis/apoptosis
however, ROS is also caused by oxygen toxicity
Current theory: “Golden Hour” is __________ _____ that is age and health status dependent
nonspecific time
Stages of Hemorrhagic Shock
- Blood volume normalized by shifting fluids
Stage I
NONprogressive or compensated
Stages of Hemorrhagic Shock
CV depression due to ISCHEMIA thrombosis, toxins, cellular damage
Stage II
Progressive
Stages of Hemorrhagic Shock
ATP depleted, cellular death with toxins released
o 1) Acute Irreversible: massive hemorrhage death FAST
o 2) SUB-Acute Irreversible: significant shock and cellular ischemia multi-organ failure/death over time/SLOW
Stage III
Irreversible
will die!
treatment of hemorrhagic shock
minimal bleeding:
<2 L crystalloid
(too much fluid can worsen it)
“Hypotensive Resuscitation”
when bleeding is UNCONTROLLED, minimize bleeding by maintaining SBP of ____-____ mmHg
- Controversial; primarily for penetrating trauma
SBP of 85-90
what is the exception to “Hypotensive Resuscitation”
TBI
“Hypotensive Resuscitation”
when bleeding is CONTROLLED, maintain SBP of >____ mmHg and HR <____
> 100 SBP
<100 HR
for CVLs, access ______ the diaphragm when possible
ABOVE
replace EBL with __:__:__
1:1:1 (PRBCs, FFP, PLTs)
IV fluids resuscitation
________ cause rapid restoration but ↑ increased risk of pulmonary edema and bleeding
colloids
IV fluids resuscitation
Avoid ________, except for documented hypoglycemia + peds
glucose
Evidence: BG >____ mg/dL lead to adverse neuro outcomes
> 170
trauma
maintain glucose at ____-____
140-180
trauma
majority of initial injury survivors are _______________ at death
coagulopathic
trauma
elevated ___ on admission = massive injury, hemorrhage, poor perfusion state
PT
prothrombin
(4) Trauma-Induced Coagulopathy (TIC) *
Dilution (too many fluids)
HYPOthermia*
Acidosis
TBI + Shock (coagulopathy)
When labs ARE available/have resulted, transfuse accordingly*
INR <____
PLT >_______
until then, use targeted transfusion (1:1:1)
1.5
PLT >50,000
hypothermia can result in _______
dysfunctional CLOTS
during resuscitation, ______ everything
WARM
acidosis with pH of <____ + hypothermia can result in significant clots
<7.1
true or false
bicarb is NOT effective for clotting issues
true
theory:
TBI + shock releases tissue factor, leading to __-__ complex
T-T complex
T-T complex leads to
activated protein C (APC) pathway
APC pathway inhibits ___ and ____,
+
promotes fibrinolysis
V and VIII
net result of T-T complex and APC pathway
systemic ANTI**coagulation
treatment for TBI and shock
EARLY FFP
assessment of blood consumption score (ABC)
and
trauma-associated severe hemorrhage score
(4)
penetrating injury
SBP <90
HR >120
positive FAST
ABC score of > or = ___
increased RISK of needing massive transfusion (may not be necessary)
2
keep PT level ____
low
TXA
> 12 years = ___ gm bolus over 10 min, then ___ gm over 8 hrs
1 gm over 10 min, then 1 gm over 8 hr
TXA
< 12 years = ___mg/kg bolus, then ___ mg/kg/hr over 8 hours
15 mg/kg
2mg/kg
- TXA should be administered less than < ___ hours post-injury
< 3
what is the up-to-date coagulation pathway
initiation, propagation
intubate with a GCS < __
8
for patients with low GCS score (neuro injury), use ______ IN*tubation
DEEP
diagnosis of ICP
> 10 mmHg
when do you treat ICP
> 25 mmHg
until ICP monitoring is available,
maintain MAP >____ to maintain CPP >____
maintain PaCO2 ___-___
MAP >80
CPP >60
PaCO2 30-35 (HYPO**carbic)
o ACS 3-Tiered Approach
(neuro)
ICP 10 – 20 mmHg
Tier 1
o ACS 3-Tiered Approach
(neuro)
ICP > 20 - 25 mmHg
Tier 2
o ACS 3-Tiered Approach
(neuro)
UNRESOLVED
ICP > 20 – 25 mmHg
Tier 3
o ACS 3-Tiered Approach
(neuro)
- Surgical evacuation, med-induced coma, HYPO**thermia
Tier 3
o ACS 3-Tiered Approach
(neuro)
EVD, mannitol or hypertonic saline, neuromonitoring, CT, NMBs
Tier 2
o ACS 3-Tiered Approach
(neuro)
Elevate HOB 30 deg, short acting sedation/analgesia, monitor ventricular drainage, repeat diagnostics
Tier 1
cushing’s triad is for what
impending herniation
cushing triad (3)
BRAIN HERNIATION
“you want some cushion for your brain”
1) HTN**
2) BRADYcardia
3) irregular respirations
what 2 drugs should you AVOID with increased ICP
nitrous
ketamine
increased ICP, BEST choice for neuro protection, unless myocardial depression is a risk
propofol
drug treatment for ICP (3)
propofol
mannitol (0.25-1gm/kg)
lasix
true or false
Steroids are NOT effective for ↑ ICP
true
Signs of spinal cord injury (6)
1) Paralysis
* 2) Pain
* 3) Position
* 4) Parasthesias
* 5) Ptosis
* 6) Priapism (erection)
Sch
fasciculations can _______ spinal cord injuries
worsen
> ____ hours until forever, AVOID Sch with spinal cord injury
> 24 hours
UP-regulation, hyperkalemia
Be aware of spinal cord injury withOUT radiographic abnormality (_________) and vertebral artery injury (VAI)
this can occur in up to 88% of patients
CIWORA
what is needed for c-spine injury intubation
MILS, c-collar, halos
what 2 drugs do you avoid for spinal injury
Sch
nitrous
spinal cord injury
intra op evoked potentials
maintain _____ anesthetic
LOW
spinal cord perfusion
have MAP at ____-____
85-90
spinal shock triad (3)
1) HYPOtension (dilation)
2) BRADYcardia
3) HYPOthermia (heat loss)
“warm shock”
spinal cord
___ and above leads to major CNS impairment
T6
