Exam 1 Reading (N.Ch24) Flashcards
Under what structure does the right recurrent laryngeal nerve pass?
Innominate artery
Which branch of the trigeminal nerve provides sensation to the anterior 2/3 of the tongue?
Lingual nerve
When you ramp a patient prior to induction, what axes are you attempting to align?
Pharyngeal
Oral
Laryngeal
Goal of aligning the POL (pharyngeal, oral and laryngeal) axes is to
Align the level of the TRAGUS OF THE EAR with the level of the sternum
Which of the following statements regarding the use of a first generation laryngeal mask airway (LMA) is true? (contraindications)
It is contraindicated in pharyngeal pathology such as tumor or abscess.
LMA is contraindicated in ventilation requiring
Excess of 20 cm H2O
LMA is contraindicated in ventilation requiring? Why?
Excess of 20 cm H2O, may results in insufflation of the stomach
Which complication of an esophageal intubation is associated with the highest mortality rate?
Mediastinitis (50% mortality)
Esophageal intubation associated with 5 complications
Esophageal Tear Subcutaneous Emphysema Retropharyngeal abscess Pneumo Mediastinitis
What is the invasive airway technique of choice in emergency airway situations?
Surgical Cricothyrotomy
Surgical tracheotomy isnt the first choice in the emergeny situation why?
Requires a surgeon and may take up to 30 minutes
In PACU, a pediatric patient exhibits a barking cough and a stridorous sound during respirations. What would be the most appropriate initial treatment?
Racemic epinephrine, Dexamethasone and humidified oxygen
Pediatric patient exhibits a barking cough and a stridorous Sound, what is the likely diagnosis ?
Laryngotracheobronchitis (croup)
When is croup most likely to occur?
within 3 hours of extubation
What is the treatment goal of croup
Decreasing airway edema and inflammation
Other treatment of croup
Mixture of helium and Oxygen (Heliox)
Following a difficult intubation, you suspect that a patient may have obstruction of the submandibular duct due to trauma establishing the airway. This condition would present as
Massive Swelling of the Tongue
Cause of obstruction of submandibular duct?
Impingement by the ETT, extreme flexion of the head or trauma during airway management
What is the primary advantage of the video-assisted laryngoscope (ex. Glidescope)?
Better visualization without manipulation of the head into sniffing position
What structure is most at risk for damage from a tracheotomy?
Recurrent Laryngeal Nerve
Other structure at risk for damage from a tracheotomy other than the RLN
Damage to the blood vessels of the neck
You have injected 4 mL of 2% lidocaine using a needle inserted through the cricothyroid membrane. What nerve are you anesthetizing?
The recurrent laryngeal nerve
What is transtracheal block?
A transtracheal block is performed by injecting 3-5 mL of 2% lidocaine through a needle penetrating the cricothyroid membrane into the trachea.
During a transtrecheal block, The needle is advanced until
air is aspirated
When is the lidocaine injected during a transtracheal block?
At the end of expiration, the lidocaine is injected.
After injection of lidocaine during Transtracheal block this will usually cause a
This will usually precipitate a cough, which will spread the anesthetic throughout the airway.
Which of the following is a description of the linear percent of the glottis that is visible during laryngoscopy?
POGO score
With a POGO score, The clinician describes the
linear percentage of the glottis that is visible from the anterior commissure to the interarytenoid notch.
The Left RLN branches off the vagus nerve and passes where? and the Right passes under where?
under the aorta; innominate artery
Performing a glossopharyngeal block will anesthetize the
posterior 1/3 of the tongue
The glossopharyngeal block is performed by having the patient
open their mouth while using a 25-gauge needle to inject 2 mL of local anesthetic
Where is the local injected during a glossopharyngeal block?
bilaterally at the base of the palatoglossal arch (also called the anterior tonsillar pillar)
Glossopharyngeal block blocks what?
lingual and some of the pharyngeal branches of the glossopharyngeal nerve that provide sensation to the posterior third of the tongue and oropharynx.
Which of the following statements regarding transtracheal block is correct?
appropriate dose is 3-5 mL of 2% lidocaine
The first point in the airway where cartilage tissue is no longer present is the
Respiratory bronchiole.
To block sensory innervation to the nasal cavity, you would need to anesthetize the
V1 and V2 branches of the trigeminal nerve
The sensory innervation for the nasal cavity is provided by the
opthalmic (V1) and maxillary (V2) branches of the trigeminal nerve
Anesthesia airway trauma that leads to a malpractice claim most commonly involves the
Dentition
The mucous membranes of the nose are innervated by what nerve?
Trigeminal nerve
The mucous membranes of the nose are innervated ANTERIORLY by the and posteriorly. These nerves are also known as the anterior ethmoidal and sphenopalatine nerves respectively.
opthalmic division of the trigeminal nerve (V1) anteriorly a.ka Anterior Ethmoidal
The mucous membranes of the nose are innervated POSTERIORLY by
the maxillary division of the trigeminal nerve (V2) aka. SPHENOPALATINE nerves
You are preparing to induce an obese patient with a potentially difficult airway and will ramp the patient prior to induction. You know that the term ramp refers to
elevating the shoulders, head, and neck
Injecting 2 mL of local anesthetic at the base of the palatoglossal arch would anesthetize
the posterior 1/3 of the tongue
The posterior 1/3 of the tongue and tonsillar pillars can be anesthetized by blocking
the lingual and pharyngeal branches of the glossopharyngeal nerve
Which intervention would be least appropriate for a cannot-intubate, cannot-ventilate situation?
Perform a retrograde intubation
The retrograde intubation technique utilizes a
guide wire passed through an intravenous catheter or central line introducer in the cricothyroid membrane. The wire is passed into the upper airway, and the endotracheal tube is placed over the guide wire so that it is directed into the trachea.
The retrograde technique is useful for situations where
traditional intubation is not possible, but ventilation is possible.
Endobronchial intubation occurs most frequently in ______why?
in infants and children because the length between their glottis and carina is shorter.
Transtracheal block anesthesize the _____nerve
RLN
A cricothyrotomy is performed by inserting a cannula into
The membrane between the thyroid cartilage and cricoid cartilage
Where does the cricothyroid membrane lie?
cricothyroid membrane which lies between the inferior border of the thyroid cartilage and the superior border of the cricoid cartilage.
Explaiin croup presentation
Patients exhibit stridor, which is characterized by a high-pitched noise during both inspiration and expiration.
Why does a patient with croup has a high pitched noise during inspiration and expiration?
This occurs when there is turbulent airflow through an upper airway that is partially obstructed.
Another manifestation is the hallmark of croup ‘
barking cough’.
Injection of 3 mL of 2% lidocaine bilaterally 1 centimeter below each greater cornu of the hyoid anesthesizes airway
below the epiglottitis
Superior laryngeal nerve block which is the injection of ____-where?
Injection of 3 mL of 2% lidocaine bilaterally 1 cm below each greater cornu of the hyoid
SLN block anesthesizes
anesthetizes the airway below the epiglottis as well as a portion of the epiglottis itself.
What is considered the minimum adequate interincisor gap in an adult?
4 cm ; 2-3 fingerbreadths.
The interincisor gap describes the
degree to which a patient can open their mouth.
What is the largest size ETT the LMA Fastrach (intubating LMA) will accommodate?
8.5 ID endotracheal tube.
You have performed an emergency needle cricothyrotomy. Which airway device would be most appropriate for ventilating the patient?
Jet ventilator
Procedures that may be employed as an emergency invasive airway in a ‘cannot intubate/cannot ventilate’ situation.
A needle cricothyrotomy may be employed as an emergency invasive airway in a ‘cannot intubate/cannot ventilate’ situation.
After needle cricothyrotomy Once the catheter is in place, it can be connected to a .
high pressure jet ventilator in order to ventilate the patient.
Standard ventilation and needle cricothyrotomy devices
do not generate adequate flow for ventilation through a small cannula
The JET ventilation settings are
Typically, a 1-second inspiration at a psi of 25 and a rate of 20/min will deliver approximately a 285 mL tidal volume (a minute ventilation of 5.7 L/min).
What is the most reliable indicator that the endotracheal tube HAS NOT inadvertently been placed in the esophagus?
persistent end-tidal carbon dioxide
Which nerve provides sensation to the larynx below the vocal cords?
Recurrent laryngeal nerve
The recurrent laryngeal nerve also provides motor innervation to all_______ except for the ______
of the laryngeal muscles ; cricothyroid muscle,
Cricothyroid is innervated by the
which is innervated by the external laryngeal nerve.
During surgery, a patient’s endotracheal tube exhibits complete obstruction. The tube is not visibly kinked and the patient exhibits zero twitches on a train-of-four test. What action should you take first?
Attempt to insert a stylet into the endotracheal tube
If the ETT exhibits complete obstruction, you should
try to pass a stylet or airway exchange catheter into the endotracheal tube.
If the ETT obstruction cannot be removed quickly, you should
remove the endotracheal tube and begin the procedure for reintubating the patient.
Which of the following is considered a retroglottic airway device?
Combitube
Combitude are positioned?
Below the level of the glottis.
2 airway devices that are both considered retroglottic or infraglottic devices.
Combitube and King Laryngeal Tube
What is the first step you should take when treating laryngospasm?
Remove the offending stimulus (suction the pharyngeal space).
Steps for treating laryngospasm? RAPJACA
Remove offending stimulus Administer 100% oxygen Place an oral airway, Jaw thrust maneuver, Apply positive pressure, Consider deepening the anesthetic and/or Administering succinylcholine.
Which of the following patients would most likely need to be evaluated for limited mobility of the atlanto-axial joint prior to induction of anesthesia?
A patient with Down syndrome
Patients with Down syndrome are at risk for
atlantoaxial instability as are patients with degenerative cervical disease, rheumatic disease, or those who have had prior surgery on their neck.
Which scoring system is used to objectively describe the difficulty of a laryngoscopy?
Cormack and Lehane
Cormack and Lehane Grade I
With a Grade I view, the entire glottic opening is visible.
Cormack and Lehane Grade II
only the posterior glottic opening is visible and the anterior commissure is not visible
Cormack and Lehane Grade III
only the epiglottis can be seen.
Cormack and Lehane Grade IV
only the soft palate is visible.
2 are used to predict airway management difficult
The Mallampati classification and thyromental distance
Stanford classification is used to
describe the severity of an aortic dissection.
Croup involves edema of the
airway below the vocal cords
Which Mallampati score involves the visualization of only the uvula, fauces, and soft palate?
II
MALLAMPATI: In a class I airway, the
entire oropharynx including the tonsillar pillars can be seen.
What nerve provides sensory innervation to the anterior two-thirds of the tongue?
Sensory innervation to the ANTERIOR two-thirds of the tongue is provided by the mandibular (V3) branch of the trigeminal nerve.
Sensory innvervation to the POSTERIOR one-third of the tongue is provided by the
glossopharyngeal nerve.
You are using an airway exchange catheter to change out an endotracheal tube for an unconscious patient. You are oxygenating the patient via jet ventilation through the catheter during the procedure. What intervention is most appropriate prior to this procedure?
Administer a neuromuscular blocker
When using jet ventilation through an airway exchange catheter, it is appropriate to administer a neuromuscular blocker to
prevent the glottis from closing around the catheter and leading to possible barotrauma due to lack of egress of insufflated air.
What method can help prevent lens fogging when using a flexible fiberoptic laryngoscope?
Soaking the scope in warm water prior to procedure to prevent fogging.
Secretions and blood can obstruct the view of the fiberoptic laryngoscope. It contains a
suction channel that runs the length of the scope that can be irrigated with normal saline to wash secretions out of the viewing area.
What are the advantages of the use of a lighted stylet over traditional laryngoscopy? (select three)
It is less affected by anterior airway
It is associated with a lower incidence of sore throat
It is less stimulating than traditional laryngoscopy
Optimally, the thyromental distance for an adult should be between ___ and ___ centimeters.
6-9 cm
Measuring the thyromental distance, which is the distance from the
thyroid notch to the mentum with the head extended and the mouth closed
Tongue displacement may be inadequate if the thyromental distance is
less than 6 centimeters (about three fingerbreadths).
A thyromental distance of ? can also be an indicator of a potentially difficult airway. why?
greater than 9 centimeters The larger spaces between the pharyngeal and laryngeal structures can result in the vocal cords being beyond the line of site for direct visualization.
A cricothyrotomy is not suitable for
long-term airway management
Indications for a cricothyrotomy include:
Cannot intubate-cannot ventilate scenarios, traumatic head, neck or facial injuries that make intubation difficult or impossible, upper airway obstruction, or definitive airway management when intubation is not possible.
Prior to performing an awake fiberoptic intubation, you inject
3 mL of 2% lidocaine below the cornu of the hyoid bone on either side of the neck.
Prior to performing an awake fiberoptic intubation, you inject 3 mL of 2% lidocaine below the cornu of the hyoid bone on either side of the neck. This is done to
anesthetize the airway below the epiglottis (SLN)
What is the only laryngeal muscle that does not receive its motor innervation from the recurrent laryngeal nerve?
cricothyroid (external laryngeal nerve)
Which of the following indicates a proper understanding of how to apply the thumb and forefinger against the cricoid cartilage when performing the Sellick maneuver?
Pressing backward, upward, and to the right until the fingers blanch directly on the cricoid cartilage
Proper application of the Sellick maneuver calls for application of what method?
BURP method (Back, Upward, and Rightward Pressure) directly on top of the cricoid cartilage until the fingers blanch.
The reason for the directional component of BURP method
because in about 75% of patients, the esophagus is slightly to the right of the trachea, so moving the cricoid cartilage downward, upward, and to the right should occlude the esophagus in most patients.
What muscles are involved in lengthening and increasing the tension on the vocal cords?
CricoThyroids (T for tension)
A tracheotomy is typically placed between the
4th and 6th tracheal rings
The LATERAL and MEDIAL cricoarytenoid muscles are innervated by the
recurrent laryngeal nerve
Unilateral paralysis of the recurrent laryngeal nerve will result in
Hoarseness
Bilateral paralysis of the recurrent laryngeal nerve result in
Acute airway compromise
A POGO score is most closely related to
Cormack and Lehane grading
