Test 3: HEENT (Pt. 2/2) Flashcards
What is the fire triad?
Ignition source, Source of fuel, Oxidizer
A chemical reaction of a fuel rapidly combining w an oxidizer to release energy in the form of heat & light —- do not allow all 3 elements join together
Fire
What are Ignition sources?
ESU, lasers, end of fiberoptic light cord
What are Fuel sources?
paper drapes, dressings, facial hair, ETT
What are Oxidizer sources?
air, oxygen, nitrous oxide
What are risk factors/red flags regarding airway fire?
-No free flow of O2 unless truly required
-Do not cover face unless truly required
-Prep solutions containing alcohol must have time to dry
-Use moist gauze/sponge near ignition source
How do you prevent Airway Fires?
-determine whether high risk situation exists
-perform a fire timeout
-identify risk factors (open delivery O2, ignition source, head/neck/ENT surgery, alcohol prep solution) → if >3 factors present, high risk situation!
How do you manage an Airway Fire? (!!!!)
1) Extinguish ASAP, Call for Help, Interrupt fire triad!!
2) Stop oxidizer (O2 flow) & ignition source
3) Stop ventilation to limit lung exposure to flame & heat
4) Remove burning ETT: place in water bucket or away from flammable material
5) Extinguish fire with NS, remove drapes
6) Mask ventilate w air until fire extinguished, then FiO2 100%
7) If stable, assess airway for damage w bronchoscopy
8) Re Intubate if needed or significant damage noted
9) Arrange for ICU and supportive therapy
Explain a Le Fort Class 1 Fx?
horizontal fracture of the maxilla extending from floor of nose, hard palate, septum, pterygoid plates
Explain a Le Fort Class 2 Fx?
triangle fracture from bridge of nose through the medial and inferior wall of the orbit, beneath the zygoma through lateral wall of maxilla and pterygoid plates
Explain a Le Fort Class 3 Fx
separates the midface skeleton from the cranial base, traversing the root of the nose, ethmoid bones, eye orbits, and sphenopalatine fossa
For Le Fort Class 2&3, avoid?
**No nasal airways, NG tubes, NETT for 2 or 3!!
T/F: stable facial fracture is an emergency.
False
What do you need to assess for a stable facial fracture?
-Airway assessment, Oral opening (pain related or mechanical related)
-Mandibular and maxillary fractures may require NETT
-Fixation process (jaws wired) closes teeth in proper occlusion
-Cutters must be readily available in case of emergency
-Anesthesia induced w IV agent (maintained w narcotics, NMBA, INH agents)
-PONV prophylaxis
What kind of procedures often require a Le Fort 1 or 2 osteotomy?
Orthognathic Procedures
What is an orthognathic procedure?
-Sagittal splitting of mandible to move lower jaw forward or back
-NETT preferred over oral intubation
-Blood loss can be extensive, may require hotn technique w head elevated position
What are the indications for an emergent tracheostomy?
-severe airway compromise → cannot ventilate, cannot intubate
-Surgeon standby if worried about complex airway mgmt
What are the indications for an elective tracheostomy?
prolonged ICU ventilation, chronic aspiration risk, super morbid obesity, free flap or neck dissection surgery requiring surgical visualization
What is the anesthetic technique for tracheostomy?
-May be performed awake under LA, MAC, or GA
-Manage FiO2 <30%, Slowly remove ETT under surgeon guidance while simultaneously inserting trach tube
What is a retropharyngeal abscess?
Infection of the retropharyngeal space after dental or tonsillar infection.
-Can expand & occlude the airway.
-Treatment w ABX or surgical I&D
-Emergency if S&S of obstruction, dysphagia, trismus, swelling, pain
What do you need to anticipate for intubation of a patient with a retropharyngeal abscess?
**Anticipate a difficult airway and consider awake FOB!
-Careful not to rupture the abscess during intubation
What do you need to assess pre-op for patient having thyroid surgery?
Ensure patient is euthyroid, assess degree of end-organ complications, determine extent of airway involvement
What is the preferred anesthetic management for Thyroid Surgery?
-GETA (potential for difficult airway)
-Nerve preservation (NIM ETT w no NMBA)
-Hypotension managed w phenylephrine (no ephedrine)
-Positioning concerns w special attention to eye care (d/t exophthalmos)
-Supine w HOB elevated 30 degrees, neck extended (Rose position)
What are the common postoperative complications associated with thyroid surgery?
1) Hypocalcemia
2) Iatrogenic trauma to RLN (Unilateral or bilateral)
3) Postop Surgical Site Bleeding
What causes hypocalcemia after thyroid surgery?
Removal of parathyroid glands.
What are the S/sx of Hypocalcemia?
-numb/tingle/paraesthesia
-abdominal pain
-spasm
-laryngospasm
-LOC changes
-seizure
-QT prolonged
-cardiac collapse
-Chvostek’s Sign
-Trousseau’s Sign
What is Chvostek’s Sign?
Facial contractions elicited by tapping facial nerve
What is Trousseau’s Sign?
Carpal spasm on inflation of BP cuff
Describe unilateral injury to the RLN?
ipsilateral VC dysfxn = hoarseness
Describe bilateral injury to the RLN?
Unopposed adduction of VC, glottic closure requiring immediate airway intervention
What risks are associated with postop surgical site bleeding after thyroid surgery?
Neck hematoma causing obstruction, Emergent evacuation followed by airway mgmt
What nerve is monitored during a mastoidectomy?
Facial Nerve
Removal of infected air cells within the mastoid bone (middle ear surgery)
An air filled space between the tympanic membrane and the oval window traversed by the facial nerve.
Middle Ear
Describe surgical considerations for Middle Ear Surgery.
-Surgery here requires bloodless field, specific head position, mgmt PONV
-Maintain normocapnia
-Deliberate hotn
-Head elevated 20 degrees to avoid venous obstruction
-Multimodal PONV prophylaxis
Why should N2O be avoided during Middle Ear surgery?
Nitrous oxide = 34x more soluble than nitrogen in blood and enters the middle ear cavity more rapidly than nitrogen leaves, causing an increase in middle ear pressure if the eustachian tube is obstructed.
What are the airway considerations for middle ear surgery?
LMA or ETT, may need NIM ETT, EMG monitor, avoid N2O (also n/v risk), avoid coughing/straining w extubation (soft suction catheter, IV lidocaine, deep extubation)
Why can you use N2O with Myringotomy (exception to usual rule about not using N2O with Middle Ear surgeries)?
Myringotomy = relatively short & a tube will be placed through tympanic membrane into the middle ear to relieve pressure so N2O effects are irrelevant
What is acute epiglottitis?
**Pediatric airway emergency!! Secondary to bacterial infection
-Swelling of supraglottic structures; Presents with sore throat, difficulty swallowing, inspiratory stridor
-Child often in a tripod position to relieve obstruction — keep the kid calm!!
What is the anesthesia management of acute epiglottitis?
-Do not manipulate the airway until in the OR!!!
-Mask induction (sevo, o2)
-Anticipate difficulty: VL or FOB, smaller ETT, standby surgeon
-Consider NETT for post op ICU
Where is the most common pulmonary location to find aspirated foreign bodies?
Foreign body aspiration = common problem in pediatrics
Most common location = Right bronchus
What are the S/Sx of foreign body aspiration?
wheezing, choking, coughing, tachycardia, aphonia, cyanosis
What are the indications for tonsillectomy & adenoidectomy (T&A) surgery?
Repeated URI, adenotonsillar tissue hypertrophy affecting breathing, OSA
Most common pediatric surgery
What is the anesthetic mgmt of tonsillectomy & adenoidectomy (T&A) surgery?
-Mask induction (sevo/o2/n2o)
-IV insertion
-d/c n2o
-intubation w FiO2 100% (ETT or LMA)
-Maintain w sevo/o2/air (fio2 <30%)
-multimodal pain mgmt
-PONV (zofran, decadron, OG suction)
-midline soft suction
-extubate (awake or deep)
When do most post-tonsillectomy bleeds occur?
Post Tonsillectomy hemorrhage = most common emergency pediatric airway surgery.
-75% occur within 6 hours of surgery
-25% within 24 hours postoperatively
-Bleeding may occur up to the 6th day postoperatively (slow ooze is more common than profuse bleeding)
What is the anesthetic mgmt of postop tonsillar bleeding?
-Patient lean forward to keep blood out of airway
-Watch for S&S of hypovolemia, N/V if swallowed blood
-Lab analysis (hgb/hct, coags) & IV access, may need volume resuscitation
-**RSI indicated w significant risk of aspiration!!
-Suction immediately available & gastric decompression
-Emergence & extubation w airway reflexes intact
How do you transport a pediatric patient who is postop from a T&A surgery?
Transported to PACU in tonsil position (side lying w slight head down) with blowby O2 (allows bleeding/drooling to come out of mouth)
T/F: Child who is here for bilateral myringotomies has a current URI, so you should cancel the case.
False; **Frequently the eradication of middle ear fluid/inflammation resolves the URI therefore surgery should not be delayed*
What are the indications for a myringotomy?
-Young healthy children w recurrent OM (recurrent URI/antibiotic regimen)
-Myringotomy allows pressure to equalize between middle ear & atmosphere
What is the anesthetic mgmt for Myringotomy?
Mask induction, tylenol for analgesia, Turn head to one side/operate/add steroid abx drops w cotton ball/turn head to other side/repeat, D/c inhalation agent, 100% FiO2, emergence, transport to pacu w blowby O2
How does Cocaine have vasoconstrictive ability?
**Cocaine = only local anesthetic w vasoconstrictive ability*
-Blocks reuptake of NE/Epi at adrenergic nerve endings
What happens when you give topical Cocaine & epinephrine?
Epinephrine + Cocaine = sympathetic nervous system stimulation
-Severe HA, HTN, tachy, dysrhythmias
-Cocaine may be best omitted w significant cardiac dz/risk factors
-Toxic levels of epi may result
What is the purpose of performing a uvulopalatopharyngoplasty (UPPP)?
UPPP = for obesity and redundant pharyngeal tissue (often present w tonsillectomy).
-Chronic obstruction & infections can lead to systemic cardiopulmonary anomalies
What are the anesthetic considerations associated with a uvulopalatopharyngoplasty (UPPP)?
-Caution w induction, intubation, extubation
-Routine IV induction vs VL vs awake
-Ensure all protective reflexes have returned prior to extubation
-Multimodal analgesia & PONV prophylaxis
-Consider IV or topical lidocaine to reduce coughing w extubation
-Topical spray of 2% lidocaine on glottic/supraglottic areas
-Transport to PACU semi-fowler position w O2
