Quiz 2 Flashcards
Mnemonic for tense and relaxing vocal cords
CricoThyroid “cords tense” THyroaRytenoid “they relax”
Mnemonic for abduct/adduct vocal cords
Posterior CricoArytenoid “please come apart” Lateral CricoArytenoid “lets close airway”
Name these structures
Name these structures
What are the unpaired cartilages?
epiglottis, thyroid, cricoid
What are the paired cartilages?
corniculate, cuneiform, arytenoid
What is the LEMON law?
Look at airway, Examine airway, Mallampati, Obstructions, Neck mobility
What are some anatomy features associated with airway complications?
obesity, pregnancy, facial hair, large/jagged teeth, narrow face with high arch palate (small diameter), large tongue, false teeth
What should the thyromental distance be?
5-6 cm or 3 fingerbreadths
What is the PUSH mnemonic for Mallampati?
Class I: Pillars, Uvula, Soft, Hard palates Class II: Uvula, Soft, Hard palate Class III: Soft, and Hard palate Class IV: hard palate
What can you see with different Cormack and Lehane scores?
Grade I: complete glottic opening Grade II: posterior region of glottic opening Grade III: epiglottis only Grade IV: soft palate only
What is the BONES mnemonic?
for difficult mask ventilation- Beard, Obese (BMI >26), No teeth, Elderly (>55), Snoring
What are characteristics with Treacher Collins that make them a difficult airway?
cheek hypoplasia, small mandible
What are some characteristics of Pierre Robins that make them a difficult airway?
mandible hypoplasia (micrognathia), cleft palate, glossoptosis (posteriorly displaced tongue)
What are some characteristics of Goldenhar’s Syndrome that make them a difficult airway?
micrognathia, asymmetry
What is Ludwigs angina?
infection of the airway
What are some airway considerations with penetrating neck trauma?
evidence of injury to air containing structures or vascular injury- use FOB if enough time, if not do RSI with surgeon readily available for possible cric
How do you intubate in a patient with cervical spine injury?
second provider provides in line immobilization (may take off front half of collar)- use Glidescope to prevent movement of neck
What is a consideration for patients with rheumatoid arthritis?
limited head and neck mobility- obtain neck films before surgery if possible
What are some considerations when intubating a patient with intracranial injury?
Avoid sudden increases in ICP- use IV lidocaine, fentanyl, and beta blockers if needed
What is a consideration with intraocular injury?
need to use defasciculation dose if using succs, as succs can increase IOP
What are some indications for an awake intubation?
history of difficult intubation, finding on H&P (neck mass, limited mouth opening), risk of aspiration, trauma, neuro case with halo/cervical collar
What are the essential features of RSI?
preoxygenation, administration of predetermined induction dose, succs/roc, application of cricoid pressure, avoidance of PPV until airway secured
What is a modified RSI?
uses gentle PPV (may be needed in cases of limited respiratory reserves or those with large beards)
Why is cricoid pressure used and what is it?
used in patients with full stomach, GERD, pregnancy, trauma, emergency case- pressure to cricoid cartilage with thumb and first finger to occlude the esopaghus
What is the BURP maneuver?
backward, upward, rightward pressure- it is NOT cricoid pressure
Should you apply cricoid pressure before or after loss of consciousness?
before, because loss of consciousness and NMBs relax the upper esophageal sphincter
Does cricoid pressure decrease lower esophageal pressure?
yes, cricoid pressure mimics food bolus
What should you keep peak airway pressures below when using an LMA?
20 cmH2O
What are some contraindications to LMA?
obesity, high pulmonary pressures, GERD, surgical positions, airway avoidance
What are some benefits to using an iGel?
easy insertion, reduced trauma, superior seal, integral bite block, non inflatable cuff, can use for bronchoscopy
Describe the combitube
Double lumen, placed blindly- lungs can be inflated no matter where the tip is, usual placement of tip is in the esophagus, may offer protection against aspiration when both balloons inflated
What are some contraindications to using a Combitube?
intact gag reflex, prolonged use, esophageal disease, ingestion of caustic substances
When do you know you’re in the trachea when using the Trachlight?
should have well defined, circumscribed glow below thyroid prominence
When should you avoid the Trachlight?
foreign body, tumor, polyps, soft tissue injuries, may be difficult in obese patients
When do you know you’re in the trachea when using the Eschman stylet/bougie?
feel stylet “bounce” along tracheal rings
What is the fiberoptic bronchoscope?
flexible laryngoscope that consists of multiple strands of tiny glass fibers that carry light; contains channels for suction, oxygen insufflation, and local anesthetics
What are some limitations to FOB?
view may be limited with blood and other debris; contraindicated in epiglottitis, laryngotracheitis, bacterial tracheitis
What are some considerations with nasal intubation?
high potential for bleeding, ETT is longer and narrower (more resistance)
What are contraindications to nasal intubation?
cribiform plate injury (Lefort, basilar fracture), raccoon eyes, periorbital edema, coagulopathy, hypophysectomy, previous Caldwell Luc procedure, nasal fracture
What are some indications for a double lumen ETT?
deflate lung for better operating conditions, decrease contamination, isolate unilateral pathology (bullae, cysts)
Where should the tracheal lumen lie in the double lumen ETT?
above the carina
Where does the distal portion of a double lumen ETT lie?
fits into appropriate mainstem bronchus
What is the most common sided double lumen tube?
left (right is used rarely)
What should the bronchial cuff of a DLT be inflated to?
no more than 3 cc (can rupture bronchial lumen)
What can you use when you need one lung ventilation but cannot place a DLT due to nasal intubation, difficult airway, or trach?
bronchial blocking device- goes through single lumen ETT
What are some desired and undesired effects of ketamine when using for awake intubation?
desired- potent bronchodilator with minimal respiratory depression, provides pain control undesired- increased HR and BP, increased salivation, can cause extreme dreams/nightmares
What are some desired and undesired effects of precedex when using for awake intubation?
desired- strong sedation with minimal respiratory depression, analgesia, antisialagogue undesired- hypotension and bradycardia
What are names and doses of drugs for antisialagogue effects?
glyco 0.2 mg, atropine 0.4 mg, scopolamine 0.4 mg (IV)
What is a risk of using benzocaine and cetacaine spray?
methemoglobinemia
What drug is usually used for topicalization of the airway due to its rare toxicity and effectiveness?
lidocaine 4%
What is the treatment for methemoglobinemia?
methylene blue
What might you use 4% cocaine for?
ENT cases for local anesthesia and vasoconstriction
Who should you use caution in when using 4% cocaine?
CAD, HTN, pseudocholinesterase deficiency, preeclampsia, hyperthyroidism
What provides sensory innervation to the nares and anterior 2/3 of the tongue?
trigeminal
What provides sensory innervation to the soft palate, oropharynx, posterior 1/3 tongue, tonsils, vallecula, and top of epiglottis?
glossopharyngeal
What provides sensory innervation from the posterior epiglottis to the vocal cords?
internal branch of SLN
What provides sensory innervation below the vocal cords?
RLN
What provides motor innervation to the cricothyroid?
external branch of SLN
What provides motor innervation to all the intrinsic muscles except the cricothyroid?
RLN
Describe a sphenopalatine nerve block
needle inserted into greater palatine foramen of upper posterior palate- blocks greater and lesser palatine nerves (nasal turbinates and posterior 2/3 of septum)
Describe a glossopharyngeal block
2 ml of lidocaine block placed at posterior of lower palate at back edge of the gutter of the mouth- blocks lingual branch of glossopharyngeal nerve (base of tongue, epiglottis, posterior pharynx)
What are some complications of a glossopharyngeal block?
HA, pharyngeal abscess, paralysis of the pharyngeal muscles, airway obstruction, hematoma, dysrhythmias, seizures
How do you confirm placement of your needle when you’re performing a glossopharyngeal block?
aspirate- should not aspirate air or blood
Describe a SLN block
performed above thyroid and below hyoid bilaterally- blocks VC and above cords to base of tongue- 1 ml injected above thyrohyoid membrane and then 2 ml injected 2-3 mm beneath membrane
Describe a transtracheal nerve block
enter space between thyroid and cricoid while aspirating for air at a caudal direction- when air bubbles are aspirated, the needle is in the lumen- inject LA, pt will cough (sprays up onto VC)
Describe retrograde intubation
14 or 18 G needle through cricothyroid membrane in a cephalid direction- wire inserted until it goes up into nose/mouth, ETT is passed over wire and passed into trachea, pull out wire
Describe transtracheal jet ventilation
large bore IV cath inserted through cricothyroid membrane in caudad direction, tubing is connected and oxygen is delivered through regulating valve
What are some considerations of transtracheal jet ventilation?
requires a normal airway for passive expiration; if inspiratory cycles are too rapid, air trapping is possible (use I:E ratios of 1:2 or 1:3); assess frequently for crepitus
Describe percutaneous cricothyrotomy
emergency method for can’t ventilate/can’t intubate situation- tube inserted over guidewire through cricothyroid membrane
Where is a tracheotomy performed, and should it be used in an emergency?
4-6th tracheal ring below thyroid isthmus; no, can take 5-30 minutes
What is a laryngospasm and what is it caused by?
spasm of laryngeal musculature (upper airway), vocal cords close- caused by secretions and noxious stimulus during light planes of anesthesia
What do patients sound like with a partial laryngospasm?
high pitched phonation, crowing sounds
What is the treatment for total laryngospasm?
get help, admin 100% FiO2, apply 15-20 cmH20 continues airway pressure, give 20 mg succs if persistent
What are some complications of laryngospasm?
hypoxemia, aspiration, negative pressure pulmonary edema
What is a bronchospasm?
lower airway obstruction; contraction of bronchial portion of respiratory tree- inability to ventilate in absence of upper airway obstruction
What is the treatment for bronchospasm?
100% FiO2, beta agonists, proventil inhaler, epi, steroids, aminophylline
What are some risk factors for aspiration pneumonitis?
increased gastric fluid volume, delayed gastric emptying, reduced LES pressure, loss of protective airway (LOC, stroke)
Who are some populations at risk for delayed gastric emptying?
obese pts, pregnant, DM, PUD, trauma, stress, acute pain
What are the current NPO guidelines?
clear liquids and carb drink 2 hours before, breast milk 4 hours, formula 6 hours, non-clear liquids 4-6 hours, light meal 6 hours, large meal 8 hours
What does sodium citrate do?
neutralizes stomach acid, but very bitter- works if given earlier rather than later
What does Bicitra do?
neutralizes tomach acid (not as well as sodium citrate), but also may increase gastric volume
What does Pepcid do?
reduces gastric acid production
What does Reglan do?
improves gastric emptying
What are some complications of Reglan?
can cause severe anxiety if given without anxiolytic; can also cause tardive dyskinesias (give benadryl if this happens)
What would be the only situation to strongly consider placing an NG before surgery?
bowel obstruction
What should you do if you suspect aspiration?
supplemental O2, ventilatory support with CPAP and PEEP, use bronchodilators and prophylactic antibiotics if signs of infection
