Head & Neck A

Question 1

Definitive airway

Answer 1

Tube placed within the trachea, the cuff inflated, connection to oxygen enriched, ventilation and the tube secured externally with tape.

Question 2

Patient with gastric contents in the oropharynx must…

Answer 2

….be immediately turned to the lateral position and suctioning of the contents to prevent aspiration.

Question 3

maxillofacial trauma: Facial fracures risks (3)

Answer 3

1) Haemorrhage2) Increased secretions3) Dislodged teeth

Question 4

Mandibular fractures

Answer 4

Bilateral body fractures can cause airway compromise.

Question 5

neck trauma

Answer 5

Vascular, laryngeal, tracheal involvement can cause rapid loss of the airway and therefore a surgical airway is required. Endotracheal airway must be employed cautiously to prevent furthering any airway compromise

Question 6

Laryngeal Fracture triad

Answer 6

1) Hoarseness2) Subcutaneous emphysema3) Palpable fracture

Question 7

Options available in laryngeal trauma compromising airway (3)

Answer 7

1) Prompt endoscopic intubation2) Emergency tracheostomy3) Surgical cricothyroidectomy

Question 8

Objective signs of airway obstruction

Answer 8

1) Inspection for agitation (hypoxia) and cyanosis (obtunded).2) listen for noisy breathing3) Palpate position of trachea

Question 9

Airway management: Chin lift

Answer 9

Prevents a cervical fracture without spinal cord involvement become one with spinal core impingement

Question 10

Non definitive airway adjuncts (6)

Answer 10

1) oropharyngeal airway2) Nasopharyngeal airway3) Laryngeal mask airway (if endotracheal intubation and bag/mask ventilation fails)4) Multilumen oesophageal airway5) Laryngeal tube airway (extraglottic) 6) Eschmann tracheal tube introducer/Gum elastic bougie

Question 11

Eschmann tracheal tube introducer/Gum elastic bougie describe (3)

Answer 11

1) 40 degree angled tip2) 10 cm graduations3) used when vocal cords not visible via laryngoscope

Question 12

Eschmann tracheal tube introducer/Gum elastic bougie. Usage

Answer 12

1) Placed passed the epiglottis and number of tracheal rings can be counted as clicks2) Once tube begins to deviate right or left into bronchi3) becomes held at the bronchial tree (Approximately 50cm) 4) endotracheal tube is passed over the bougie, if held at arytenoids or aryepiglottic folds then rotate 90 degress and then pass forward.

Question 13

Definitive airways (3)

Answer 13

1) Orotracheal tube2) Nasotracheal tube3) Surgical airway (Cricothyroidectomy/Tracheostomy)

Question 14

Criteria for definitive airway

Answer 14

A) Unconscious B) maxillofacial fractures C) Aspiration D) Obstruction1) Presence of apnoea2) Failure of other means to maintain airway3) Aspiration/vomitus protection4) Impending airway compromise (seizures, inhalation injury, facial fracture)5) GCS

Question 15

Orotracheal tube

Answer 15

1) Apply cricoid pressure to prevent aspiration2) BURP technique to visualise vocal cords (Backwards, upwards and right sided pressure) laryngeal manipulation3) In apnoea orotracheal intubation is indicated.

Question 16

Checking position of orotracheal tube (Unconfirmed III)

Answer 16

.1) Insert using laryngoscope, inflate and begin ventilaion2) Auscultate chest for equal breath sounds3) Auscultate stomach for the presence of borborygmi. If present suggests oeseophagus has been intubated4) Capnograph or CO2 colorimetry device-suggests that airway has been intubated if CO2 is present. 5) Blood gas best detection for physiological blood CO2 levels

Question 17

Checking position of orotracheal tube (confirmed)

Answer 17

Chest xray once excluded that oeseophagus has not been intubated

Question 18

Equipment required (11)

Answer 18

1) Suction 2) Oxygen 3) Bag-mask 4) Laryngoscope 5) Bougie 6) Laryngeal tube airway 7) Cricothyroidectomy kit 8) Endotracheal tube 9) Pulse oximetry 10) CO2 detection device 11) Drugs

Question 19

Step 1) Preoxygenate

Answer 19

Oxygen + oropharyngeal or nasopharyngeal airway

Question 20

Step 2) Able to oxygenate?

Answer 20

NO—> definitive airway/Surgical AirwayYes—> Assess Airway

Question 21

Step 3) Assess Airway difficulty

Answer 21

LEMONLookEvaluateMallampatti scoreObstructionNeck

Question 22

Airway Difficulty?

Answer 22

Difficult-ask for assistance, consider awake intubationIf Easy attempt with drug assistance or cricoid pressure

Question 23

Unsuccessful

Answer 23

Bougie, LMA, LTAIf still unsuccessful-Definitive/surgical airway

Question 24

nasotracheal tube requirements and contraindication?

Answer 24

Requires spontaneous breathing and contraindication in apnoea and cribriform fracture (Look for badger’s sign, battle’s sign and CSF leak) Periorbital ecchymoses, Postauricular ecchymoses and rhinorrhoea/otorhoea

Question 25

Rapid Sequence Intubation

Answer 25

1) Prepare for surgical airway in case of failure2) Suction and positive airway pressure ready3) Preoxygenate the patient with 100% oxygen4) Apply cricoid pressure5) Administer sedative (Etomidate 0.3mg/kg or 20mg6) Administer muscle relaxant (1-2mg/kg or 100mg7) Intubate8) Check endotracheal tube position9) Release cricoid pressure 10) Ventilate

Question 26

LEMON AssessmentL

Answer 26

L=Look for characteristics of difficult intubation e.g. 1) Cervical fracure/Immobilisation2) Cervical arthritis3) Facial/Maxillofacial trauma4) Thick muscular neck5) Small mouth

Question 27

LEMON AssessmentE

Answer 27

E=Evaluate3-3-2 Rule1) Distance between incisors should be 3 finger breadths2) Distance between Chin and hyoid bone is 3 finger breadths3) Distance between floor of mouth and thyroid notch is 2 fingers

Question 28

LEMON AssessmentM

Answer 28

Mallampati ScoreI) Soft palate, uvula, fauces and pillars are visibleII) Soft palate, uvula and faucesIII) Soft palate and base of the uvulaIV) Hard palate only

Question 29

LEMON AssessmentO

Answer 29

O=ObstructionEpiglottitis, peritonsilar abscess and trauma etc

Question 30

LEMON AssessmentN

Answer 30

N=Neck mobilityPlace chin onto chest and then look up towards ceiliing

Question 31

Etomidate affects and doesnt affect…

Answer 31

…affects adrenal function (depresses)No effect on blood pressure or intracranial pressureProvides sedation

Question 32

Succinylcholine

Answer 32

Onset of paralysis 1 min and lasts for approximately 5 mins.Due to risk of severe hyperkalaemia avoided in…crush injury, major burns, electrical injury, CRF, chronic paralyiss and chronic neuromuscular disease.

Question 33

Thiopental and other sedatives are dangerous to use in….

Answer 33

hypovolaemia

Question 34

Diazepam and midazolam uses and reversal?

Answer 34

Appropriate to reduce anxiety, flumazenil to be used to reverse.

Question 35

Surgical Airway indications

Answer 35

1) Severe oropharyngeal bleeding2) Oedema of the glottis3) Laryngeal fracture

Question 36

Jet insufflation of airway

Answer 36

Insertion of a needle through the cricothyroid membrane below the level of obstruction to provide oxygen on a short term basis.Jet insufflation can provide temporary supplemental oxygenation by large bore cannula (12-14 gauge in adults, 16-18 in children).Cannula then connected to a Y-connector or a side hole cut in the tubing attached between oxygen source and cannula.Insufflate 4s off, 1s on.Only for 30-45 min and only in patients with good lung function and no chest injury.Is slow accumulation of CO2 due limited exhalation, so technique poor for head injury patients.To avoid pulmonary rupture with tension pneumothorax low flow rates of 5-7 l/min should be used when persistent glottic obstruction is present.

Question 37

Surgical Cricothyroidotomy

Answer 37

Surgical incision through the cricothyroid membrane, dilate with curved haemostat and insert endotracheal tube/tracheostomy tube (5-7mm)

Question 38

Why avoid Surgical Cricothyroidotomy in children under 12?

Answer 38

Risk of damaging the cricoid cartilage-only circumferential support for the upper trachea

Question 39

Pulse oximetry pitfalls

Answer 39

1) Intact peripheral perfusion2) Oxyhaem/Carboxyhaemoglobin no difference3) Severe anaemia/Cyanosis and hypothermia reduces reliability