test 3 part 5 Flashcards
sx of lambert eaton syndrome
- proximal muscle weakness in pelvic and truncal areas
- bulbar dysfx
- decreased DTR
- posttetanic potential of muscle contraction
- muscle weakness is more significant in the morning and usually improves throughout the day
Eaton-Lambert syndrome is most often associated with carcinomas, particularly ___________________
small cell lung cancer
with myasthenia gravis sx are improved with ________________ or ___________; with eaton-lambert syndrome, sx are improved with _______________
anticholinesterases; steroids; activity
tx of Eaton-Lambert syndrome?
- therapeutic goal is to increase amount of ACh in the synaptic cleft
- potassium channel blockers
- acetylcholinesterase inhib
- immunologic therapies
- Tx underlying malignancy
________________ is a group of x-linked recessive mutation in the dystrophin gene
muscular dystrophy
_______________, pts will present with progressive proximal muscle weakness and wasting. most are wheelchair bound by age 12
muscular dystrophy
what do most patients with muscular dystrophy die from? and by what age?
2ndary cardiopulmonary failure by age 30
treatment for muscular dystrophy
no cure, supportive tx
perioperative complications to expect with muscular dystrophy
rhabdomyolysis
hyperkalemia
malignant hyperthermia
cardiac arrest
__________________ is characterized by an elevation in serum creatinine and myopathic pattern on EMG
muscular dystrophy
muscular dystrophy anesthetic complications
- CV evaluation for progressive cardiomyopathy and fx’al status
- pulmonary eval for restrictive lung disease/compromise
- risk for aspiration
- avoid succ
- avoid malignant hyperthermia triggering agents (succ, halogenated inhalation agents)
what should be your anesthetic plan for pt with muscular dystrophy
TIVA
anesthesia considerations for myotonia
- cold environment may trigger
- high incident of PPC
- avoid DMR
- NMDR okay
- Avoid etomidate
- risk for malignant hyperthermia
T/F: over 80% of perioperative strokes occur in the postoperative period
true
where doe most nose bleeds occur
anterior portion of the nose of the ICA and ECA (kiesselbachs plexus)
which type of nose bleed can you typically stop by holding pressure on the cartilaginous part of the nose or with some neosynephrine
anterior
which type of nose bleed is hard to treat, may require embolization, surgery, silver nitrate, ballooning and/or packing
posterior
which nose bleed has greater risk of airway compromise d/t blood in both nostrils and the posterior pharynx
posterior
posterior nose bleed is usually due to damage to which artery
sphenopalantine
larynx of an adult is located at C__________
4-6
enlargement of this tonsil is usally a compensatory mechanism after tonsillectomy or with autoimmune d/o and if enlarged will cause UNANTICIPATED difficult airway
lingual tonsils
at what cervical vertebrae is the larynx located in an infant
C3-C4 (more anterior)
what is the only complete ring in the upper airway
cricoid cartilage
the cricoarytenoid joint is a _____________ joint; thus can be an issue with what disease process
synovial; RA
if you do a lot of vigorous manipulation of an airway (ex: jaw thrust) you risk injuring what nerve
hypoglossal (XII)
there is a risk of nerve palsy of the ______________ nerve when using LMA and N20
hypoglossal (XII)
glossopharyngeal nerve provides sensory innervation to what structures
velleculae
base of the tongue
roof of the pharynx
tonsils
undersurface of soft palate
describe the process of a glossopharyngeal nerve block
- anesthetize the tongue with topical anesthesia
- inject where the tongue meets the palatoglossal arch using 23 or 25 g needle
- ASPIRATE
- inject 1-2 cc of lidocaine on both sides
____________ nerve runs transverse to the palatoglossal folds
glosspharyngeal
what is the risk with a glossopharyngeal nerve block
that you do an intracarotid injection
describe the physiological process of the gag reflex
- glossopharyngeal, vagus, and spinal accessory nerves share nuclei in the medulla
- stimulation like suctioning the back of the oropharynx sends afferent impulses via glosspharyngeal N to medulla
- vagus nerve via efferent impulses send signals for all muscles to contract –> + gag reflex
what are the 2 main branches of the vagus nerve that innervate the larynx
- superior laryngeal nerve
- recurrent laryngeal nerve
_______________ is responsible for sensation above the vocal cords, and ______________ is responsible for sensation below the vocal cords (subglottic)
superior laryngeal nerve; recurrent laryngeal nerve
the external branch of the superior laryngeal nerve is responsible for?
motor innervation to the cricothyroid muscles
tenses the vocal cords
unilateral superior laryngeal nerve damage
usually no tx
over time cords will move medial –> changes in voice/voice tiring
bilateral superior laryngeal nerve damage
- aspiration risk, may need tracheostomy
- loss of sensation above cords
- inability to adduct –> floppy cords
the recurrent laryngeal nerve provides sensory innervation ________________; and motor innervation to all intrinsic laryngeal muscles except _________________
below cords; cricothyroid muscle
____________ is the ONLY nerve responsible for ABDUCTION of the vocal cords
recurrent laryngeal
unilateral damage to the recurrent laryngeal nerve will cause ?
hoarseness
bilateral damage/bilateral partial damage to the recurrent laryngeal nerve will cause?
- unopposed adduction by the cricothyroid via the SLN
- inability for cords to abduct
- aphonia
- stridor which can lead to death
you extubate a patient, you hear immediate stridor. The patient is away but cannot speak. you stick the glidescope down to visualize the cords, they are closed (adducted). What do you think has happened? what is your intervention?
bilateral damage to recurrent laryngeal nerve
immediately reintubate and use laryngoscopy to evaluate cord fx
describe how you would perform a superior laryngeal nerve block
- find hyoid bone and greater cornu of hyoid bone at angle of the mandible
- walk off the hyoid bone to the thyrohyoid membrane
- here you will inject small amount of local then go about 2-3 mm deep and inject 2mL of lidocaine
- repeat on other side
how would you perform a transtracheal block?
- find cricothyroid membrane. go to middle and do skin wheel of local
- 22 g angiocath with 5 mL syringe, add 3-5 mL of lidocaine
- aspirate constantly - you want air bubbles
- when get bubbles remove the needle while advancing catheter and inject lido
- tell patient to take deep breath as you are injection
- if they cough it will help spread the local
what is the risk of a transtracheal block
tearing the mucosa with the needle
the ______________ muscles lengthen (tense) the vocal cords; the ___________ muscles shorten (relax) the vocal cord
cricothyroid; thyroarytenoid
___________________ muscles abduct (open) the glottis, while ______________ muscles adduct (close) the glottis
posterior cricoarytenoid; lateral cricoarytenoid
length of vocal cords to carina is approximately _____________ cm
10-15`
the __________________ mainstem bronchi diverges at a 20 degree angle is approximately 2.0 cm in length; while the _________________ mainstem bronchi diverges at 45 degree angle is approximately 5.0 cm in length
right; left
you want to do a mallampati assessment on your patient, how would you want them positioned?
sitting upright and open mouth as wide as possible while at same time protruding tongue as far as possible but with no phonation
__________________ is an indirect assessment for relating the size of the base of the tongue in relation to the oral cavity
mallampati
what is the 12 point airway assessment?
- length of upper incisors
- involuntary: maxillary teeth anterior to mandibular teeth
- voluntary: protrusion of mandibular teeth anterior to maxillary teeth
- intercisor distance > 3 cm
- oropharyngeal class (mallampatti) </= class II
- plate should not appear very narrow or high arched
- mandibular space length (thyromental distance) 5 cm or 3 fingerbreadths
- mandibular space complicance
- length of neck
- thickness of neck
- palpation of cricoid membrane and is easily identified
- cervical range of motion - neck flexed to chest and extended to back
what is the definition of a difficult mask ventilation
inability of unassisted anesthesia provider to maintain SaO2 > 92% or to prevent/reverse signs of inadequate ventilation at any point during the anesthetic
indicators that someone is going to be difficult mask ventilation
- > 55 years of age
- presence of a beard
- no teeth
- hx of snoring
- BMI > 26
- additional risk factors: mallampati >2, macroglossia, small TMD
complications from mask ventilation
- injury to buccal branch of facial nerve
- injury to eye
- triggering of oculo-cardiac reflex
- bruising
- inflation of stomach
how do you know you are effectively mask ventilating a patient?
- chest rise
- fogging in the mask
- CO2 waveform
- you will feel it in the bag
- good seal
- quiet air is not seeping out and making noises as it hits between cheeks and mask
what is the goal with preoxygenation/denitrogenation
ETO2 > 90% and ETN2 <5%
when preoxygenating/denitrogenation, you should have fresh gas flow (FGF) of _____________ and FiO2 of ____________
5-8 L/min; 100%
if doing TV preoxygenation/denitrogenation, it should be done for how many minutes
3-5 min
if you do not have time to do TV preoxygenation/denitrogenation for 3-5 min; how would you perform it?
- 8 deep breaths in 2 minutes
- 4 deep breaths in 30 seconds
______________ is noisy inspiration from turbulent gas flow in the upper airways
stridor
