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Anesthesia > Lessons 3 & 4 > Flashcards

Lessons 3 & 4 Flashcards

1
Q

How do you size an oral airway?

A

Corner of the mouth to the tip of the ear

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2
Q

Contraindications for a Nasal Airway

A

Bleeding disorder

Base-of-skull fracture

Nasal fracture

Previous nasal surgery or cleft palate repair

Sinusitis

History of frequent nosebleeds

Severe atherosclerosis

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3
Q

Normal thyromental distance

A

6 cm (approximately 3 fingerwidths)

<6cm (some will say 7) means a more difficult intubation

The longer it is, the more room you have to move the tongue forward and expose the glottis

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4
Q

What is the Mallampati score used for?

A

To predict the ease of endotracheal intubation

Think 1-2-3-4:4-3-2-1

For example, Mallampati 1 you can see 4 things, Mallampati 2 you can see 3 things, etc.

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5
Q

Mallampati I

A

Soft palate, uvula, *fauces, tonsillar pillars visible

fauces = throat (opening to pharynx)

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6
Q

Mallampati II

A

Soft palate, uvula, fauces visible

Lose tonsillar pillars

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7
Q

Mallampati III

A

Soft palate, base of uvula visible

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8
Q

Mallampati IV

A

Only hard palate visible

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9
Q

After intubation, where should the tip of the tube be?

A

Generally speaking, place ETT at 23 cm in males and 22 cm in females (measuring from the corner of the mouth)

Goal is 2cm cephalad to the carina on CXR

However, the lip to carina distance best correlates with patient’s height.

Optimal depth of ET placement can be estimated by the formula:

“(Height in cm/7)-2.5.”

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10
Q

Cormack-Lehane Grading System

A

Four grades of laryngoscopic view to predict the ease of intubation

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11
Q

What is the LEMON score used for?

A

To determine which patients might pose airway management difficulties. The score (with a maximum of 10 points) was calculated by assigning 1 point for each of the following LEMON criteria and multiplying by 2 (higher numbers = difficult airway):

L=Look externally (facial trauma, large incisors, beard or moustache, large tongue…any = 1 point)

E=Evaluate the 3-3-2 rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths…abnormal = 1 point)

M=Mallampati (Mallampati score ≥3 = 1 point)

O=Obstruction (presence of any condition that could cause an obstructed airway = 1 point)

N=Neck mobility (limited = 1 point).

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12
Q

How do you verify correct tube placement?

A

Gold Standard = direct visualization of tube through the cords (“second look”)

  • Symmetric chest movement
  • Symmetric breath sounds
  • Fogging of tube
  • End tidal CO2 (>30 for 3-5 breaths)
  • Palpation of cuff in suprasternal notch
  • Fiberoptic bronch
  • CXR
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13
Q

Steps to peforming a RSI (rapid sequence intubation)

A
  1. Monitors
  2. Denitrogenate (preoxygenate)
  3. Induction drug and cricoid pressure* (+/- BURP)
  4. Immediately followed by NMB
  5. Intubation after NMB has taken effect
  6. No ventilation until ET tube is in place
    * *Idea is to close the esophagus to prevent passive regurgitation (the cricoid cartilage is the only cartilage the completely surrounds the airway)*
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14
Q

What medications can be given to decrease the risk/complications of aspiration?

A
  • Metoclopramide
  • PPI
  • Histamine-2 Blockers
  • Sodium citrate

These are all debated and provide theoretical benefit

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15
Q

What is metoclopramide?

A

A gastroprokinetic (makes the stomach empty faster) that works 10-30 minutes after IV administration

Does NOT affect gastric pH

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16
Q

How does omeprazole work?

A

PPI = Increase in gastric pH

In theory, if regurgitation and aspiration does happen, it will do less damage

However, these drugs work slowly (over hours) and do nothing about acidity of contents already in the stomach

17
Q

What type of drugs are cimetadine and ranitidine?

A

Histamine-2 Blockers

Increase gastric pH, but like PPIs, do nothing about the acidity of contents already in the stomach

18
Q

What does sodium citrate do?

A

Neutralizes the acidity of the gastric contents within 15 minutes

Should be given 15-30 minutes prior to induction

19
Q

Define a local anesthetic

A

A subtance which reversible inhibits nerve conduction when applied direcly to tissues at non-toxic concentrations

20
Q

How do local anesthetics work?

A

They limit influx of sodium (i.e., depolarization), thereby limiting propagation of the action potential

They can be thought of as sodium channel blockers on the nerves

21
Q

Why would local anesthetics be relatively useless in an acidic environment (e.g., septic patient or necrotic limb)?

A

Only the ionized form is active

22
Q

Rule of “i’s” for local anesthetics

A

“i” before “caine” = amide

no “i” before “caine” = ester

Amides = bupivacaine, lidocaine, ropivacaine, etidocaine, mepivacaine

Esters = cocaine, chloroprocaine, procaine, tetracaine

23
Q

Allergy vs Systemic Toxicity

for Local Anesthetics

A

A true allergy is very rare, however, most reactions are seen with esters

Systemic toxicity (when it happens) is seen more often with amides

24
Q

Emergency treatment of systemic local anesthetic toxicity

A

Immediate IV injection of Intralipid 20% (1.5 ml/kg)

Can repeat several times or start infusion

25
Q

Relative blood levels after different regional techniques with local anesthetic

A

In descending order = “BICEPS”

Blood

Intercostal

Caudal

Epidural

Peripheral Nerve

Subcutaneous

26
Q

Where should vasoconstrictors (e.g., epi) not be used?

A

Fingers

Toes

Nose

Ear lobes

Penis

Again, this is more theoretical and less in practice

27
Q

Define Regional Anesthesia

A

Rendering a specific area of the body (e.g., foot, arm, lower extremity) insensate to the stimulus of surgery/other instrumentation

28
Q

Application of local anesthetic to mucous membrane (cornea, nasal/oral mucosa)

A

Topical anesthesia

Advantages = technically easy, minimal equipment

Disadvantages = large doses can lead to toxicity

29
Q

What is a “Bier” block?

A

Injection of local anesthetic intravenously for anesthesia of an extremity

Step 1: place a small IV (20 or 22G) into a distal vein in the extremity to be blocked [note: this is not your main IV catheter]

Step 2: Exsanguinate the arm with an Esmarch bandage

Step 3: Inflate the tourniquet and inject local anesthetic

Disadvantages = duration limited by tolerance of tourniquet’s pain

30
Q

Injecting local anesthetic near the course of a named nerve

A

Peripheral Nerve Block

31
Q

2 major types of neuroaxial blocks

A

Subarachnoid (“spinals”)

Epidural

Caudal blocks are a different approach to the epidural space, so they are an epidural sub-type

32
Q

Differences between Epidural and Spinals

A

Epidural: slower onset (potential space w/o fluid until you inject), do not puncture the dura, relatively high dose of local (serious toxicity if injected systemicall), CSF should not return from the needle, can be done at almost any level, 18G needle, more precise control over dermatomal level anesthetized

Spinal: relatively low dose of local (no toxicity), considered safe only in the lumbar spine, 22-27G needle, some control over dermatomal level anesthetized

33
Q

Dermatomes you should know:

T4

T6

T10

L4

S1

A

T4 - Nipple line

T6 - Xyphoid process

T10 - Umbilicus

L4 - Anterior knee, medial foot

S1 - Lateral foot

34
Q

Technical difference between thoracic and lumbar epidural

A

Angle of approach

(sharp downward angulation of thoracic spinous processes)

35
Q

What determines potency of local anesthetics?

A

Lipid solubility

greater lipid solubility = greater potency (unlike inhaled anesthetics)

(tetracaine > bupivacaine > lidocaine > mepivacaine)

36
Q

Complications of spinal/epidurals

A

Backache

Infection

Post-dural puncture headache

Hypotension, bradycardia, cardiac/respiratory arrest

Anesthesia (7 decks)

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