Extra From Class Flashcards
What are the four DAS plans?
A: face mask ventilation and tracheal intubation
B: maintain oxygenation - SAD
C: face mask ventilation
D: emergency front of neck access
What is DAS plan A?
Face mask ventilation and tracheal intubation - optimise position - pre O2 - adequate NMB - direct/video laryngoscopy (3+1) - external manipulation (BURP) - bougee - remove cricoid - maintain O2 and anaesthesia Success --> confirm capno Fail --> declare failed intubation
What is DAS plan B?
Maintain oxygenation: SAD - 2nd generation - change device or size (max 3) - O2 and ventilate Success --> wake, intubate via SAD, proceed on device, Trache/crico Fail --> declare failed SAD
What is DAS plan C?
Face mask ventilation - if can't - paralyse - final attempt - 2 person technique with adjuncts Success --> wake Fail --> declare CICO
What is DAS plan D?
Emergency front of neck access
- scalpel bougee
- call for help
- 100% O2
How is a scalpel bougee technique performed?
Help 100% O2 upper airway Ensure NMB Position to extend neck Laryngeal handshake to ID membrane Transverse stab with scalpel Turn blade 90 degree caudal (sharp) Slide bougee tip along blade into trach Railroad lubricated 6.0 Parker ET Ventilate, cuff up and confirm Secure in place
What is is a scalpel bougee pack?
Scalpel size 10
Bougee
6.0 Parker tip
Chlorhexidine swab
How is the scalpel bougee technique handled in a non-palpable neck?
8-10cm vertical incision caudad to cephalad
Blunt dissect with fingers to separate tissue
ID and stabilise larynx
Continue as with palpable neck
What is the post op care following a DI?
Make airway management plan Monitor for complications Complete airway alert form Explain to patient Send report to GP
What is the post op care following cricothyroidotomy?
Postpone surgery unless life threatening
Urgent surgical review of site
Document and follow up as in DI
What is the cuff and collar system?
On a sleeve index system
Ring placement and diameter is individualised for each gas on the gas hose and bollard connector
Outlet sleeve and corresponding groove on hose can couple
What must you know about the anaesthetic agent in order to make a safe vaporiser?
SVP: in order to know what splitting ratio is required
MAC: in order to know range for the dial
How does ET control differ from simply setting a vaporiser?
On ET the machine varies the amount of vapour delivered so that the ET is always the same even if the exhaled amount or circulating flow changes. If simply set then the same amount is constantly delivered but may differ in circulation due to changing flow rates. You may deliver much less.
Why is ET better measurement than Fi?
ET reflects patient blood level well and is easier to measure.
What are the valves on an ambu bag?
End:
+p valve (outside) to relieve
-p valve to entrain
One way valve so gas goes forward when squeezed
Front:
Duckbill valve: open on insp and close once delivered, pulls back on refill to prevent air entrainment and ensure expiratory gases flow out peep valve. One way valve prevents expiratory gas entering bag.
How does the aisys anti hypoxic system work?
Programmed not to allow a mix of less than 25% O2
Electronic system
Cannot select a mixture less than 25%
Gas analyser alerts if occurs
What is a total spinal?
High dose LA in the CSF causing it to travel high and block vital pathways. Intercostals/diaphragm get blocked Tingling arms/hands Dyspnoea Hypoxia Hypotension Blocked nose (sympathetic vasoD) Reduced conscious state
What is intra osseous?
Into bone marrow Non-collapsible Systemic venous access Compares to IV for dosing For emergencies, difficult IV and paediatrics Lasts 24 hours Can deliver drugs and fluids Hand bolus or P bag fluids
What are the general principles to placing an IO?
Prep skin prior Consider LA Appropriate needle Push needle through skin to bone The IO hub has a black line which should be visible above the skin prior to penetrating the bone (good size) Pull trigger and apply pressure until a change in R is felt Remove stylet; needle should be firm Secure with supplies dressing Attach flushed EZ connector Aspirate for marrow/blood Flush IO before use (ensure no oedema) Need pressure bag for fluids
How is an IO placed for proximal tibia?
Adult: 3cm below patella 2cm medial along flat aspect Paed: 1cm below and 1cm medial along flat aspect
How is an IO placed in the proximal humerus?
Place patient hand on abdomen to get 90degree at elbow
Palpate for “ball”
Locate surgical neck (ball on tee)
1-2cm higher than the neck is the greater tubercle and this is insertion point
Aim 45 degree down and drill until hub meets skin
What areas can the IO be placed?
Antero-medial tibia
Distal tibia
Distal anterior femur
Proximal humerus (superior site for speed and flow rate)
Proximal/distal ends of long bones where spongy bone exists
Sternum not ideal!!!
What are the risks of IO?
Extravasation of fluid or drug into tissue Compartment syndrome Necrosis Infection Fracture Growth plate injury Fat microemboli
What are the contraindications of IO?
Fracture in bone Absence of landmarks Infection at site Previous attempt on same bone within 48 hours Osteoporosis or other bone disease Elderly high risk fracture
What is an AED?
Delivers electrical energy to heart to simultaneously depolarise cells to allow stable rhythm to establish
Automated external defibrillator
What are the properties of modern AED?
DC energy: more effective, less damage, less arrhythmia
Transformers (to increase V) converters (turn AC to DC) and capacitor (store)
Biphasic: electrical current in one direction for set time then reverses for remaining time. Optimal delivery. Uses less peak current so low damage
What is a cheat drain?
Into the pleural space
Drains air, blood and reinflates lung
Air tight system with underwater seal allows air exit without re-entry
Chamber kept 100cm below cheat to maintain -P
If lifted, fluid can siphon into chest
Oscillations indicate patency. Absence may indicate blocked, kinked, lost -P or lung has fully re-expanded
How does a paediatric airway and respiratory system differ to an adult?
Narrow at cricoid vs glottis Large structures Larynx C2-C3 anterior vs C3-C6 Fast/slow and deep/shallow cycle 7-10ml/kg vs 10ml/kg Low FRC High RR: 24- (age/2) 2x the metabolic rate
How does the paediatric CVS system differ to that of an adult?
Higher compliance Large blood volume (80ml/kg vs 70) More TBW (75-80% vs 55-60%) Higher hb >130 Higher HR >60 Lower BP (sys= 80 + (agex2) Higher CO
Why do paeds desaturated quickly?
Reduced alveolar cluster Underdeveloped intercostals CC within TV Low FRC High metabolic rate
What other body systems are considered in paeds for anaesthetic?
Immature liver and kidney function Low carb stores so hypoglycaemia occurs BBB more permeable to agent Thermoregulation: high SA to volume Minimal SC fat Reduced vasoC and shiver mechanism Brown fat metabolism in infants to produce heat - high energy and O2 use
What are the paediatric emergency drug doses?
Suxamethonium
1-2 mg/kg (-3 for IM)
Atropine
10-20 mcg/kg (-30 for IM)
Adrenaline
10 mcg/Kg IV/IM
What is the normal CO2 range?
35-45
> 45 is hypercarbia
<35 is hypocarbia
What can cause a high CO2?
Hypoventilation Hyperthermia/sepsis Tourniquet release High CO Bronchial intubation Soda lime exhausted
What can cause a low CO2?
Hyperventilation
Reduced CO (caution not treading to arrest/PE)
Hypothermia
System leak
What can cause an inclined plateau on CO2 trace?
Obstructive lung disease
Blocked airway/tube
Aspiration, spasm, anaphylaxis
What can cause a raised CO2 baseline?
Exhausted like Rebreathing Sticky valves Insufficient FGF Excessive dead space
What can cause decreasing co2?
PE
Cardiac arrest
Tamponade
What does oesophageal and bronchial intubation look like on CO2?
Oesophageal:
Small ETCO2 dropping off
Bronchial:
A bifid wave noticed in phase III
What are the phases of CO2 tracing?
1 is the baseline and is end inspiratory phase
2 is the upstroke and is expiration
3 is the alveolar plateau
0 is the downstroke and is the beginning of next inspiration
What are the problems and considerations for prone patients?
High IOP
Difficult airway access
Risk optical nerve/retinal damage resulting in blind
Reduced abdominal compliance limiting diaphragm movement
High airway pressure/reduced vent
Neutral neck position
Neutral shoulders and elbow position
Pressure: genitals, breasts, knees, feet, nose and eyes
What are the problems and considerations for patients in lithotomy or Lloyd Davis position?
Reduced perfusion to legs Increased venous return Pooling/DVT legs Compartment syndrome legs Pressure: peroneal, sciatic nerves Hips should be >90 degrees to body
What are the problems and considerations for patients in lateral position?
Care with lower shoulder - axillary roll for brachial plexus Front and back support at hips to protect and away from abdomen Support upper arm in neutral position Lower arm in neutral/safe position Pillow between knees Pad lower foot Neutral neck Limited airway access
What are the problems and considerations for patients in beach chair position?
Air embolism Stroke/brain injury hypoxic BP reading inaccurate: head is higher than heart Neutral and strapped head/neck Limited airway access Ensure eyes well taped Arm supports padded and at correct height Sciatic nerve Pooling/DVT in legs Reduced venous return
What are the problems or considerations when a patient is head down?
Good venous return
Good brain perfusion
Aspiration protection
Reduced ventilation/high pressures
Low FRC, atelectasis, V/Q mismatch
Likely regurgitation
High ICP/IOP
What are the problems and considerations for head up positions?
Optimal lung compliance
Low CO
Brain injury risk
DVT/pooling in legs
Air manolis M
What is the range for a cuff pressure monitor?
14-24 cmh2o
Keep below 30
Why are uncuffed tubes better in paeds historically?
The narrowest point of the paed airway is the cricoid cartilage and this is where the cuff sits. If damage occurs then swelling could occur I.e causing narrowing of the already narrowest point!! Small airway means small swelling causes closure.
In an adult the narrowest point is the cords and the cuff sits below this therefore doesn’t matter so much
Why is PCV best for paediatrics?
(12-15cmH2O)
Less trauma risk
Compensate for a leak around an uncuffed tube
What is the chest depth, bpm and joules for CPR?
1/3 chest
100 bpm
200J (360 next shock)
What are the differentials to MH?
Sepsis
Thyroid storm
Drug use
Inadequate anaesthesia
How do you change gas cylinder?
Slowly close valve Release remaining P and close Wipe new cylinder; clean hands Check content via label Ensure cylinder restrained Check regulator valve matches cylinder Remove seal and crack cylinder Check intact heat detection tag Ensure regulator clean and attach it Open slowly to full position then closed one quarter turn
What is the process for body fluid exposure and needle stick injury?
Report to coordinator Wash area with soap and water Obtain testing kit Complete the form Test staff members blood Test patients blood (CONSENT) Complete lab forms for tests - send Complete accident form Entry in patients notes (If known HIV+ contact infectious diseases for prophylaxis)
What is an example of isbar?
Identify Self, patient and site Situation What is going on? (DI) Background Clinical background (op, stats) Assessment What do I think problem is Recommend What I recommend, assign responsibility, any risks
What are the 10 standard precautions?
Hand hygiene Gloves Gown/apron Face protection (mask, goggle) Care with sharps Respiratory hygiene/cough etiquette Environmental cleaning Linen Waste management Reprocessing reusables
What are three examples of supine?
Mastectomy
AAA
Appendix
What are three examples of lateral?
Lobectomy
THJR
Nephrectomy
What are three examples of prone?
Spinal fusion/decompression
Posterior fossa surgery
Percutaneous stone removal
Achilles’ tendon repair
What are three examples for beach chair?
Total shoulder replacement
Craniotomy
ORIF humerus
What are three examples of Lloyd Davis?
Hartmans
Anterior resection
Vaginal hysterectomy
