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Health Assessment Spring 2024 > Exam 2 Airway Assessment > Flashcards

Exam 2 Airway Assessment Flashcards

1
Q

The internal nose is dived by the ______.

A

Septum

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2
Q

The internal structure of the nose is composed of what structures?

A

Cribriform Plate
Turbinates (Superior, Middle, and Inferior)

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3
Q

The internal nasal cavity is very vascular. What do you need to use before nasal intubation to mitigate bleeding?

A

Vasoconstrictors (Afrin, Coke)

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4
Q

The roof of the mouth consist of what four structures?

A

Maxilla and palatine bones
Hard palate
Soft palate
Teeth

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5
Q

What makes up the floor of the mouth (3 structures)?

A

Tongue
Mandible
Teeth

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6
Q

What is a muscular tube that extends from the base of the skull to the lower border of the cricoid cartilage?

A

Pharynx (Responsible for airway patency and a common site of airway obstruction.)

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7
Q

What can be performed to elongate pharyngeal muscles and maintain airway patency?

A

Chin lift

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8
Q

What are the 3 parts of the pharynx?

A

Nasopharynx -nose to the soft palate
Oropharynx- soft palate to the epiglottis
Hypopharynx- epiglottis to the cricoid cartilage

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9
Q

The larynx extends from the __________ to the lower end of the circoid cartilage at the ______ cervical vertebrae.

A

The larynx extends from the epiglottis to the lower end of the cricoid cartilage at the 6th cervical vertebrae.

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10
Q

What are the functions of the Larynx?

A

Phonation
Airway Protection
Inlet to the Trachea

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11
Q

Name the unpaired Laryngeal cartilage

A

Thyroid cartilage (This is the largest of the three and supports most of the soft tissue.)

Cricoid cartilage - (complete ring)

Epiglottis cartilage

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12
Q

Name the paired Laryngeal cartilages.

A

Arytenoid
Corniculate
Cuneiform

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13
Q

The vocal cords are attached to what two cartilages?

A

Thyroid cartilage at the thyroid notch and posteriorly in the arytenoid cartilage.

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14
Q

The trachea extends from the __________ membrane to the carina.

What is the length of the trachea in an adult?

A

inferior cricoid

10-15 cm

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15
Q

The trachea anteriorly is bounded by __________ and closed posteriorly by ___________ muscle.

A

The trachea anteriorly is bounded by tracheal C-shape rings and closed posteriorly by longitudinal trachealis muscle.

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16
Q

Actions to take when you know you can not mask ventilate a patient during an airway assessment?

A

Maintain spontaneous ventilation
Use awake endotracheal intubation
Create a surgical airway (emergency situation)

Airway assessment should be conducted before the initiation of anesthesia in all patients thoroughly.

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17
Q

History concerns for airway assessment (6 factors).
What is the most predictive factor?

A
  1. Past difficult intubation (most predictive factor)
  2. Report of excessive sore throat
  3. Report of cut lip/broken tooth
  4. Recent onset of hoarseness - issue with vocal cords or tumor
  5. History of OSA - related to anatomy or size
  6. Lesions intra-orally…. base of the tongue, lingual tonsils
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18
Q

Airway evaluation components (6 components).

A
  1. Visual inspection of the face and neck
  2. Assessment of mouth opening
  3. Evaluation of oropharyngeal anatomy and dentition
  4. Assessment of neck range of motion (sniffing position)
  5. Assessment of the submandibular space
  6. Assessment of the patient’s ability to slide the mandible anteriorly
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19
Q

What visual inspections will indicate difficult intubation?

A

Short or thick neck (>43 cm = difficulty w/ intubation, more predictive than high BMI)
Facial deformities
Head and neck cancers
Burns
Goiter
Receding mandible
Beard (Santa Claus)
C-collar (Don’t touch C-collar, have the MD do it, chart it.)

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20
Q

How do you assess mouth opening?

A

Inter-incisor distance
Prefer > 6 cm (3 finger breadths)

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21
Q

What are pathologic characteristics that can be identified during oropharyngeal anatomy assessment?

A

Tumor
Palate deformities (High arched palate, cleft palate)
Macroglossia - giant tongue

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22
Q

What do you look for during a dental assessment?

A

Long upper incisors - (fangs, work around them.)
Poor dentition/loose teeth
Cosmetic work
Edentulousness (lack of teeth)

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23
Q

Dental injuries account for _____% of closed insurance claims against anesthesia providers.

______% of dental injuries occur during tracheal intubation. A lot of these are related to difficult and emergency airway management.

A

25%
75%

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24
Q

What are the factors that can cause dental injuries (5 factors)?

A

Laryngoscope blade
Rigid suction catheters
Oropharyngeal airway placement
Rigorous removal of airways
Biting down on ETT/LMA/airways during emergence

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25
Q

What two teeth have the highest incidence of dental injuries?

A

Left Central Incisor (47%)
Left Lateral Incisor (20%)

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26
Q

What does the sniffing position evaluate?

What three axis are aligned in a perfect sniff position?

A

Cervical flexion and atlanto-occipital extension. How well does the head move on the neck?

Alignment of the oral, pharyngeal, and laryngeal axis (Letter C in the picture)

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27
Q

What is the position called?

A

‘Ramping’
The ideal ramping position is to bring the ears up to the level of the sternum so that they are leveled.

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28
Q

What is the sternomental distance?
What is the preferred distance?

A

Distance between the sternal notch and chin with head in full extension and mouth closed.

> 12.5 cm preferred

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29
Q

What is the thyromental distance?
What is the preferred distance?

A

Assess submandibular compliance. Measurement is from the tip of the chin to the thyroid notch.

Basically, do we have a chin that is not connected to the neck?

Prefer > 6.5 cm (3 finger breadths)

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30
Q

How do you test prognathic ability (two movements)?

A
  1. Extension of lower incisors beyond upper incisors.
  2. Upper lip bite test.
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31
Q

What is the Mallampati Test?
How many classes are there?
How do you perform the test?

A

Visibility of oropharyngeal structures
Class I - IV

The patient is seated upright with head neutral
Mouth open
Tongue protruded
No phonation (Phonation will lift the uvula up)

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32
Q

What can be visualized in a Mallampati Class I?

A

Fauces (arch opening in the back of the throat)
Pillars (tonsils)
Entire Uvula
Soft palate

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33
Q

What can be visualized in a Mallampati Class II?

A

Fauces (arch opening in the back of the throat)
A portion of the Uvula
Soft palate

34
Q

What can be visualized in a Mallampati Class III?

A

Base of the uvula and soft palate

35
Q

What can be visualized in a Mallampati Class IV?

A

Only hard palate

36
Q

What are the two types of Laryngeal Manipulation?

A
37
Q

What is the Cormack-Lehane classification?

A

Classification of laryngeal view
Grade I-IV

38
Q

What is seen with a Cormack-Lehane Grade 1 View?

A

Entire Glottis

39
Q

What is seen with a Cormack-Lehane Grade 2 View?

A

Only the posterior portion of the glottis

May need to lift the blade up more, or perform laryngeal positioning

40
Q

What is seen with a Cormack-Lehane Grade 3 View?

A

No part of the glottis and only the epiglottis

41
Q

What is seen with a Cormack-Lehane Grade 4 View?

A

Epiglottis cannot be seen. All you see is the tongue.

42
Q

Criteria associated with difficult mask ventilation (OBESE).

A

O: Obesity, BMI > 30 kg/m2
B: Beard
E: Edentulous
S: Snorer, OSA
E: Elderly, male, age > 55

Mallampati 3 or 4

43
Q

Criteria associated with difficult airway (11 of them)- Overview Flashcard.

A
44
Q

Difficult Airway Algorithm
During pre-intubation choose between ________ or ________ strategy.

A

During pre-intubation choose between an awake or post-induction airway strategy.

45
Q

What are the 5 questions asked in the Difficult Airway Algorithm?

A
  1. Suspected difficult laryngoscopy?
  2. Suspected difficult ventilation with face mask/supraglottic airway?
  3. Significant increased risk of aspiration?
  4. Increased risk of rapid desaturation?
  5. Suspected difficult emergency invasive airway?

Any one factor alone may be clinically important to warrant awake intubation. Minimize airway risk.

46
Q

Optimize _________ throughout the difficult airway algorithm.

A

oxygenation

47
Q

If an intubation attempt after induction of general anesthesia is a failure. What is the next step according to the difficult airway algorithm?

A

Limit attempts, consider calling for help
or
Limit attempts, and consider waking the patient up.

48
Q

In the emergency pathway, if mask ventilation is not adequate and the supraglottic airway is not adequate, what should be considered?

A

Call for help for invasive access and attempt alternative intubation approaches as you prepare for an emergency invasive airway.

49
Q

Look at this chart

A
50
Q

When to tube? (B’s)

A
  • Bullets (neck trauma)
  • Bites (anaphylaxis/angioedema
  • Burns (thermal or caustic airway injuries
51
Q

When else to tube? (ABCDEF)

A

-Airway (mouth & neck infections, tumors, foreign bodies, bleeds
-Breathing (failure to oxygenate or ventilate
-Circulation (Support tissue oxygen delivery ie sepsis)
-Disability (CNS depression ie >secretions, FVC <12 ml/kg, NIF <20 cm of h20, vomiting while obtunded
-Expected course (transfer, anticipated decline)
-Feral (prompt sedation for aggressive pt to protect pt and others)

52
Q

When to RSI?

A

-Peri arrest
- Airway deteriorating
-known easy airway
-normal anatomy
-Upper GI bleed
-Bowel obstruction
-Vomiting in ED

53
Q

When to keep pt awake and not RSI?

A

-Stable GI bleed (EGD)
-Slow progressive neuromuscular weakness requiring transfer
-fixed flexion deformity of neck
-cannot open mouth

54
Q

What are awake techniques drugs?

A

-Glycopyrrolate 0.2 mg, or atropine .01 mg/kg given 15 minutes before
-Nebulized lido
-Atomized lido
-Viscous lido lollipop 2%
-Lightly sedated with 2-4mg versed
-or Ketamine 20 mg q2 minutes

55
Q

How to perform a laryngoscopy?

A

-Ear to sternal notch
-equipment ready: suction under right shoulder
-assistant pulls right mouth corner
-find the epiglottis
-optimize head (sniff and head tilt)
-Seat the blade in vallecula or on epiglottis
-Optimize larynx: Use the right hand to manipulate the epiglottis
-Change positions if needed
-use a bougie

56
Q

The bougie

A

-essential
-small tube for small hole
-deflection at the tip
-self-confirming
-can intubate with only seeing epiglottis views
-can leave the larngoscope in
-black stripe is 25 cm marking
-the bougie is your friend

57
Q

What is the black stripe marked on the bougie?

A

25 cm
(this is at the lips, mid trachea in an adult male)

58
Q

What is the most cardioprotective induction drug?

A

Etomidate

59
Q

What are two s/e of the use of etomidate?

A

-adrenal suppression
-lowers the seizure threshold

60
Q

Does propofol disappear before or after the paralytic?

A

Before

61
Q

Can you half-dose the paralytic?

A

No!

62
Q

Is Roc or Vec preferred?

A

Roc is preferred. Only use Vec if Roc isn’t available.

63
Q

What are the absolute contraindications of Sux?

A

-Rhabdo
-hyperkalemia
-MS
-Muscular dystrophies
- >72 hr strokes or spinal cord injuries
- > 72 hr burns
-tetanus, botulism, or other exotoxin infections
-severe infections > 72 hours
-immobilization
-MH history
-bradycardic
-masseter spasm

64
Q

What are the contraindications of Roc?

A

None. Go ahead a give!

65
Q

Succs duration?

A

5-10 minutes

66
Q

Roc duration?

A

30-90 minutes

67
Q

Physocologic killers of anesthesia?

A

-Hypotension
-Hypoxemia
-Metabolic acidosis

68
Q

To counteract hypotension

A

-Have 2 PIVs (use IO if needed)
- IVF bolus wide open
-Aim for SBP at least 140 mmHg

69
Q

What pressors can we push dose?

A

-Epi
-Neo
-Vaso

70
Q

What med can we use to intubate if they are uncooprative?

A

Ketamine 0.5-1 mg/kg

71
Q

Can you sit up a pt to intubate if they can breathe better?

A

-Absolutely, you don’t have to keep them supine

72
Q

Is it safe to intubate a pt with a bad pH?

A

Yes, but try to avoid it until it can be corrected

73
Q

Does bicarb to help correct acidosis cause tachypneia?

A

Yes, which can make things worse

74
Q

Who diseases are at high risk for aspiration?

A

-Upper GI bleeding
-Bowel obstruction
-Preinduction vomiting
(use NGT prior to intubation, intubate semi-upright position, and bag early)

75
Q

Key points to remember why intubating

A

-Have a backup plan
-Initiate rescue maneuvers early to be able to cric with a pt reserve
-LMAs can be your friend
-Bougies also your friend
-Should they stay awake for intubation?
-Use a checklist

76
Q

What is induction drug of choice for patients in shock?

A

ketamine
(gives simultaneous sympathetic surge and pain control)

77
Q

What is the paralytic drug of choice for patients in shock?

A

Rocuronium

78
Q

What is the dose for rocuronium to achieve the same onset as Succynylcholine ?

A

1.6 mg/kg

From slide: Succinylcholine possesses the fastest onset (45sec) and produces the shortest period of muscle relaxation (6 – 10min) compared to all other paralytic agents at standard doses. However, Rocuronium dosed at 1.6mg/kg IV, gives the same onset of muscle relaxation as succinylcholine [7] and gives a longer safe apnea time [8] making it the preferred paralytic of choice in the critically ill.
Rocuronium 1.6mg/kg IV
Succinylcholine 2mg/kg IV

79
Q

You are having difficulty securing a tube. What can you do to make sure patient gets some oxygen?

A

NC @ > 15 LPM+ NRB @ 15 LPM + PEEP valve closed

80
Q

What is delayed sequence intubation?

A

Procedural sedation for the use of preoxygenation of uncooperative patients.

Give 1 mg/kg ketamine->preoxygenate ->paralyze patient ->apneic oxygenation -> intubate

Health Assessment Spring 2024 (24 decks)

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