H&N SSU Flashcards
what are the risks of topical use of cocaine of nasal surgery? categorise by organ system, descending order of involvement
Max 1.5mg/kg
CVS
CNS
Local/Nasal
Resp
Other - temp, met acid
Techniques for smooth, cough-buck-free emergence from GA.
Practical Sequence for Smooth Emergence
Ensure full reversal of neuromuscular blockade. Suction airway thoroughly. Administer chosen pharmacological adjunct(s) at appropriate timing. Minimise airway manipulation. Extubate at appropriate anaesthetic depth (deep or awake, as indicated). Provide supplemental oxygen and monitor closely post-extubation.
+ LMA exchange
Indiciations for and anaesthetic implications of intraop facial nerve monitoring
Indications for Intraoperative Facial Nerve Monitoring
- Parotid surgery (e.g., parotidectomy): To identify and preserve the facial nerve, especially when tumor or scarring distorts anatomy.
- Ear surgery (e.g., mastoidectomy, cholesteatoma surgery): To avoid iatrogenic injury to the facial nerve, which is at risk due to proximity.
- Skull base surgery (e.g., acoustic neuroma, cerebellopontine angle tumors): Facial nerve at risk due to tumor location or surgical approach.
- Reconstructive or trauma surgery involving the facial nerve.
- Re-exploration or revision surgery: Increased risk due to altered anatomy and scarring.
- Any head and neck surgery where the facial nerve is at risk of injury
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Management and investigation of continuous bleeding post tooth extraction under GA in PACU
Reapply pressure with haemostatic agents (e.g. oxidized cellulose, collagen sponge, tranexamic acid mouthwash or soaked gauze).
steps involved in setting up and using jet vent and how to ensure done safely
- Preparation and PlanningAssess patient and procedure: Confirm indication (e.g., airway surgery, difficult airway, need for motionless field) and check for contraindications (e.g., airway obstruction)
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Team briefing: Ensure all staff are familiar with jet ventilation technique and emergency plans.
Equipment check: Select appropriate jet ventilator (manual or automated) and delivery route (supraglottic, subglottic, or transtracheal)
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- Equipment SetupConnect jet ventilator: Attach to piped oxygen/air supply (typically at 4 bar)
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Tubing and connections: Secure tubing from ventilator to airway device (catheter, laryngoscope, bronchoscope) using Luer-lock to prevent detachment
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Pressure regulation: Modern devices reduce piped supply pressure (4 bar) to a safer driving pressure (start at 1 bar, titrate up as needed)
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Monitoring: Set up pulse oximetry, ECG, and (if available) airway pressure monitoring and capnography
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- Initiation of Jet VentilationSelect initial settings:
Driving pressure: Start at 1 bar (14.5 psi), increase gradually to achieve visible chest rise
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Frequency: LFJV: ~12 jets/min; HFJV: 120–1600 jets/min
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Inspiratory time: E.g., 1 s insufflation, 4 s exhalation for LFJV; 40% inspiratory fraction for HFJV
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Oxygen fraction: Set as required (often 100% unless laser surgery)
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Commence jet ventilation: Observe for chest rise and fall. Use the lowest effective pressure
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Adjust settings: Titrate driving pressure, frequency, and inspiratory time to optimize oxygenation and CO₂ elimination (see Table below)
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- Intraoperative Monitoring and AdjustmentContinuous monitoring: Observe chest movement, monitor oxygen saturation, and (if possible) CO₂
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Adjust for gas exchange:
To improve oxygenation: optimize jet alignment, increase FiO₂, increase driving pressure, frequency, or inspiratory time. To improve CO₂ elimination: optimize jet alignment, increase driving pressure, reduce frequency (if HFJV), reduce inspiratory time .
Beware of complications: Watch for signs of barotrauma (subcutaneous emphysema, pneumothorax), gas trapping, or inadequate ventilation
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- Weaning and DiscontinuationTransition to conventional ventilation or spontaneous breathing as the procedure allows
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Ensure airway patency and adequate respiratory effort before discontinuing jet ventilation
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Safety Measures (per BJA PDF)
Start with low driving pressure (1 bar/14.5 psi), increase only as needed for visible chest movement
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Allow complete chest recoil between jets (especially with manual LFJV) to prevent gas trapping and barotrauma
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Ensure airway patency: Obstruction can rapidly cause barotrauma and cardiovascular collapse
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Monitor airway pressures: Use devices with pressure monitoring and alarms; automated systems can suspend jet delivery if unsafe pressures are detected
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Have emergency airway equipment ready: Be prepared to convert to conventional ventilation or surgical airway if needed
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Staff experience: Only perform jet ventilation if the team is familiar with the technique and equipment
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Humidification: Not usually required for short procedures, but consider for longer cases to prevent mucosal injury
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Fire risk: Reduce FiO₂ for laser procedures to minimize airway fire risk
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Features of these equipment used in airway surgery and anaesthesia: laryngoflex tube, suspension laryngscope, boyle-davis gag, hunsaker mon-jet tube, MLT
options maintaining oxygenation during shared airway surgical procedures
key features in preop assessment of patient presenting with both emergency and non-life threating airway obstruction who needs GA for airway surgery
key preop assessment features and anaesthetic plan for pt with retrosternal goitre
methods to minimise and manage airway fire.
Describe your approach to minimising and managing airway fire during airway surgery.
What are the key steps to prevent airway fire?
Viva Script: Steps in Airway Fire Management
Examiner: “Describe your approach to minimising and managing airway fire during airway surgery.”
Candidate:
"Airway fire is a rare but potentially catastrophic event during airway surgery, particularly when using lasers or electrocautery. My approach involves both prevention and emergency management."
Prevention:
"Preoperatively, I would brief the surgical and anaesthetic team on the fire risk and emergency procedures." "I would use the lowest possible FiO₂, ideally below 0.3, and avoid nitrous oxide." "For laser cases, I would use a laser-resistant, cuffed endotracheal tube, inflating the cuff with saline." "I would ensure wet gauze is available to protect the airway and have saline or water ready for immediate use." "I would confirm all ignition sources are used judiciously and only when necessary, with clear communication between anaesthetist and surgeon."
If Airway Fire Occurs:
"First, I would immediately recognise and announce the fire, calling for help." "I would instruct the surgeon to stop and deactivate the ignition source." "I would disconnect the breathing circuit to stop the flow of oxygen and remove the burning endotracheal tube." "I would douse the airway with saline or water to extinguish any residual flames." "I would then re-establish ventilation with air initially, then 100% oxygen once the fire is confirmed out, and prepare for urgent reintubation due to likely airway swelling." "I would perform bronchoscopy to assess the extent of airway injury and remove any debris." "I would administer intravenous corticosteroids, obtain a chest X-ray and arterial blood gas, and admit the patient to ICU for further monitoring and management." "I would ensure open disclosure, incident reporting, and debriefing of the team."
Examiner: “What are the key steps to prevent airway fire?”
Candidate:
"Use the lowest possible FiO₂, avoid nitrous oxide, use laser-resistant tubes, keep the airway moist, have saline ready, and ensure team communication and preparedness."
Examiner: “What are the immediate actions if an airway fire occurs?”
Candidate:
"Announce the fire, stop the ignition source, disconnect the circuit, remove the burning tube, douse with saline, re-ventilate, assess and manage airway injury, and escalate care as needed."
key preop planning and anaesthetic induction/considrations and securing airway in patient needing mandibular fracture repair
Preoperative Planning
Assessment:
Full airway evaluation: mouth opening (trismus common), Mallampati, dentition, neck mobility, presence of swelling, bleeding, or deformity.
Assess for associated injuries (especially cervical spine, facial, or basal skull fractures).
Review imaging (CT/X-ray) for airway distortion, fracture pattern, and contraindications to nasal intubation (e.g., midface fractures, CSF leak)
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Comorbidities: OSA, obesity, cardiorespiratory status.
Fasting status and aspiration risk.
Previous anaesthetic history, especially prior airway difficulties
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Optimisation:
Stabilise comorbidities (e.g., control hypertension, treat infections). Correct hypovolaemia, anaemia, and electrolyte abnormalities if present. Multidisciplinary planning: involve surgical, ENT, and anaesthetic teams early.
Consent:
Discuss potential for difficult airway, need for awake intubation or surgical airway, and risks of postoperative airway compromise
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Anaesthetic Induction and Airway Considerations
Airway Management Principles:
Anticipate difficult mask ventilation and intubation due to:
Trismus, pain, swelling, blood, disrupted anatomy, or loose teeth
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Primary goal: maintain oxygenation and avoid loss of airway control
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Plan and Preparation:
Prepare a difficult airway trolley (video laryngoscope, fibreoptic bronchoscope, LMAs, bougies, surgical airway kit). ENT surgeon and second anaesthetist available for emergency airway access. Preoxygenate thoroughly; consider high-flow nasal oxygen if available. Prepare emergency drugs, including those for rapid sequence induction (RSI) and airway rescue .
Securing the Airway:
Awake Fibreoptic Intubation (AFOI):
Indicated if difficult bag-mask ventilation and/or intubation is anticipated, but patient is cooperative and airway is not grossly contaminated with blood
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Allows maintenance of spontaneous ventilation and airway reflexes.
Topical anaesthesia and minimal sedation to maintain cooperation.
Nasal route preferred for surgical access if no contraindications (avoid if base of skull fracture, coagulopathy, or midface disruption)
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Asleep Intubation:
If airway assessment suggests mask ventilation will be straightforward and intubation not anticipated to be difficult. RSI with cricoid pressure if aspiration risk; use video laryngoscopy if available. Avoid muscle relaxants until ability to ventilate is confirmed. If difficulty encountered, follow a stepwise airway algorithm (Plan A: intubate; Plan B: LMA; Plan C: wake up; Plan D: surgical airway) .
Surgical Airway (Tracheostomy/Cricothyrotomy):
Consider early if AFOI is not possible (e.g., uncooperative, bleeding, or grossly distorted airway) or if both mask ventilation and intubation are unsuccessful
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ENT present and ready for emergency tracheostomy.
Other Considerations:
Avoid nasal intubation if contraindicated (midface fractures, CSF leak, coagulopathy).
Submental intubation may be considered if both oral and nasal routes are not feasible and surgical access is needed.
Prepare for significant intraoperative bleeding—ensure IV access, crossmatch blood, and have suction ready
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Throat pack to reduce risk of aspiration during surgery.
Postoperative Airway Management
Extubation:
Delay extubation if significant airway swelling, bleeding, or anticipated difficult reintubation.
Ensure patient is fully awake, with intact airway reflexes and minimal swelling.
Have wire cutters/scissors at bedside if intermaxillary fixation is used
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Consider HDU/ICU monitoring postoperatively for airway observation.
anaestheitc consideration for ECT. GA technicqie and influence on ECT effectiveness
Anaesthetic Considerations for ECT
Preoperative
Assess for contraindications: recent MI, unstable cardiac disease, raised ICP, major cervical instability, severe osteoporosis, phaeochromocytoma, retinal detachment, glaucoma, DVT, or active infection
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Review comorbidities: cardiac, respiratory, neurological, aspiration risk, dental status, medication interactions (especially antidepressants, antipsychotics, lithium, benzodiazepines, anticonvulsants)
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Fasting: standard fasting guidelines apply (6 hours for solids, 2 hours for clear fluids)
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Informed consent: ensure patient (or guardian) understands risks and benefits
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Premedication: generally avoided; anticholinergics (e.g., glycopyrrolate) may be considered to reduce secretions and bradycardia risk
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Intraoperative
Remote location: ensure full resuscitation equipment, airway adjuncts, and emergency drugs are available
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Monitoring: ECG, SpO2, NIBP, capnography, EEG (for seizure monitoring)
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Airway: bag-mask ventilation is standard; intubation rarely required unless high aspiration risk or anticipated airway difficulty
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Bite block: to prevent dental/tongue trauma
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General Anaesthesia Technique for ECT
Induction
IV induction agent: methohexital is gold standard (not available in Australia/NZ; propofol or thiopentone commonly used)
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Dose: titrate to loss of consciousness; avoid excessive dosing as this can reduce seizure duration
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Muscle relaxation: suxamethonium (0.5–1 mg/kg IV) to prevent musculoskeletal injury; non-depolarising agents only if sux contraindicated
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Ventilation
100% O2 pre- and post-induction; hyperventilation may prolong seizure duration
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Bag-mask ventilation is standard; intubate only if high aspiration risk or prolonged procedure anticipated
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Adjuncts
Anticholinergic (glycopyrrolate/atropine) to reduce bradycardia and secretions
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Bite block inserted after induction and before stimulus
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Emergence
Rapid recovery expected; monitor for agitation, confusion, or prolonged apnea
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Extubate or remove airway adjuncts when awake and protective reflexes return
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detailed phhysiological response to ECT. categorise by organ system, sort by decreasing involvement
