test 3 part 7 Flashcards
disadvantages to nasal intubation
- pain and discomfort
- nasal/paranasal complications (epistaxis, sinusitis, otitis)
- more difficult to place
- smaller tube thus increased resistance
- difficult snoring
indication for nasotracheal tube
- intraoral operation
- operation where oral tube interferes with surgeons access
- when long term ventilation is anticipated
what hx would you need to know/obtain before inserting a nasotracheal tube
- hx of unexplained nose bleeeds
- hx of broken nose
- hx of deviated septum
- nasally inhaled substance abuse
- coagulopathy
preparation steps to take before inserting a nasotracheal tube
- tube should be half size to 1 size smaller than oral ETT
- let sit in warm NS or sterile water to soften tip
- have Magill Forceps
- nasal trumpet that is well lubed
- afrin spray –> do bilaterally
contraindications to nasotracheal intubation
- trauma
- laforte fracture
when is the only time to use a blind placement method when putting in a nasotracheal tube
only with spontaneously breathing ptsq
what tube is best to use for blind nasotracheal intubation
endotrol tube
what is the classification system/grade to classify your view of the cords during intubation
cormack-Lehane classification
Grade 1 cormack-lehane
you can see the anterior commissure
you can see both sides of the cords (i.e. glottis)
Grade 2 Cormack-Lehane
cannot see the anterior commissure, but can visualize glottis
Grade 3 Cormack-Lehane
only epiglottis visualized, no visualization of glottis
Grade 4 Cormack - Lehane
neither glottis nor epiglottis can be visualized
what is the role of video-assisted intubation
- good for failed intubation
- better initial attempt at predicted difficult intubation
- instruction of the novice on normal airway
advantages of video-assisted laryngoscopy
- eliminates need for line of sight
- requires less lifting force
- less stress response
- less cervical instability
- less dental/pharyngeal trauma
- less need for mouth opening
disadvantages of video laryngoscopy
- expensive
- not always easier
- loose depth perception
- become overconfident about the difficult airway
- loose skills on direct laryngoscopy
describe the process of a normal induction sequence intubation
- all airways should always be ready to go
- suction ready and on high
- preoxygenate w/ 100% FiO2 for 3-5 min
- administer induction agents
- evaluate LOC; lash test
- attempt mask ventilation
- administer muscle relaxant of choice/approp for pt condition
- intubate
- confirm breath sounds
- continue anesthetic
- secure ETT
indication for RSI
- full stomach
- Trauma
- pregnancy
- bowel obstruction
- risk of aspiration
technique for RSI
- preoxygenate well
- administer induction agents
- cricoid pressure
- DO NOT VENTILATE
- perform direct laryngoscopy
- confirm placement
- continue anesthetic
- secure ETT
advantages of RSI
prevent aspiration
rapid control of airway
what is a modified RSI
gently ventilate with few breaths prior to intubating, cricoid pressure is maintained
what is a laryngospasm?
spasm of the vocal cord closure and possibly aryepiglottic folds over the glottis d/t sensory stimulation of the vagus nerve via the RLN and SLN
tx of laryngospasm
positive pressure
succinylcholine
larson maneuver (vigorus jaw thrust, pulls false cords and folds away)
__________ most often occurs due to laryngospasm
negative pressure pulmonary edema
sx with laryngospasm
- decreased SaO2
- hypertension
- sx of negative pressure pulmonary edema
causes of bronchospasm
tracheal irritation and stimulation of the vagus nerve
can be allergenic/histamine related
sx of bronchospasm
wheezing
increased CO2
hypoxia
increased peak inspiratory pressure
tx of bronchospasm
deepen the anesthetic with inhalation agents
bronchodialators (albuterol)
B2 agonist (epi, terbutaline)
complications of extubation
- unable to keep SaO2 up
- airway edema/macroglossia
- increased ICP or IOP or bleeding from surgical sites
- NGT removal
- laryngospasm/bronchospasm
complications of intubation
lip laceration
tooth injury
tongue laceration
pharyngeal laceration
laryngeal laceration/injury
what is the optimal depth of tube insertion in women?
20 cm
what is the optimal depth of tube insertion in men?
22cm
how do you know if you have placed the ETT in the bronchiole (endobronchial intubation)
auscultation (may not hear breath sounds on one side)
chest movement (only one side inflating)
sx of negative pressure pulmonary edema
acute respiratory failure
dyspnea
tachypnea
pink frothy sputum
stridor
severe agitation
type I negative pressure pulmonary edema
develops immediately after acute onset of airway obstruction
type II negative pressure pulmonary edema
occurs after relief of chronic airway obstruction
Tx of negative pressure pulmonary edema
PEEP +/- diuretics and steroids
what causes a type I negative pressure pulmonary edeam
post extubation laryngospasm
epiglottitis
croup
LMA or ETT blockage
laryngeal tumor
postop vocal cord paralysis
hanging/strangulation
near drowning
what causes a type II negative pressure pulmonary edema
post tonsillectomy/adenoidectomy
choanal stenosis
post removal of upper airway tumor
hypertrophic redundant uvula
what is aspiration pneumonitis
aspiration of gastric contents
sx with esophageal perforation
dysphagia
neck pain
subQ emphysema
signs of airway obstruction
- snoring, grunting
- stridor around larynx
- loss of breath sounds
- loss of CO2
- loss of fog in mask/ETT
- nasal flaring
- Retractions
- desaturation
causes of airway obstruction
- OSA / soft tissue relaxation
- foreign body/trauma
- issues with vocal cords/polyps
- infections/swelling
- laryngospasm
interventions for airway obstruction
- jaw thrust, reposition head
- may need to add oral or nasal airway
- if apneic, may need to mask ventilate
- determine underlying causes
Fractures above alveolar ridge and hard palate
runs posteriorly through maxillary sinus to pterygoid plate. may cause detached or floating plate
type I LeForte fracture
pyrimidal fracture of mid face
fracture of: maxillary, nasal bones, frontal bones, orbital rim and ethmoid bones, may extend into mid pterygoid plates
Type II LeForte Fx
face is literally displaced from attachments at cranial base
Type III LeForte Fracture
what surgeries are correlated with having higher incidence of stroke?
cardiac surgery esp valve replacement
what are the three risk factors for perioperative stroke?
- hx of prior stroke or TIA
- advancing age
- renal disease
preoperative anesthesia evaluation of pts with cerebrovascular disease focuses on what?
timing and cause of any previous strokes/TIA
preanesthetic evaluation of pt with cerebrovascular disease
- hx of dz - CVA/TIA
- residual deficits/cause of event
- intrinsic dz or emoblic event?
- neuro exam and documentation of deficits
- auscultation and palpation of carotid bruits
- anticoagulation regimen and risk for reductionq
pt with Cerebrovascular disease, when would it be okay for them to continue to their anticoagulation meds?
when undergoing low risk surgery
if a patient has cerebrovascular disease and is undergoing a moderate - high risk procedure, they should either ______________ or __________ their anticoagulation meds
bridge or stop
what is the most common cause of dementia
alzheimers
types/causes of dementia
parkinsons
vascular
alzheimers
reversible
if pt presents with dementia for surgery, you should perfrom a comprehensive assesment of cognition during preop visit. this would include?
- assessment of decision making capacity
- assess cognition using minicog test
- identify risk factors for post-op delirium
- identify reversible causes of dementia
- communication and corrdination with care of geriatrician when appropriate
all types of dementia are associated with ___________, ___________, and/or ___________ decline
behavioral; cognitive; functional
what is the cause of alzheimers dementia
abnormal beta-amyloid deposits, intracellular neurofibrillary tangles, and neuronal loss
what are the risk factors for vascular dementia
HTN and DM
what is a mixed demenita
vascular infarcts + alzheimers
_________________ is affiliated with dementia and is a progressive degeneration of the basal ganglia associated with deficiency in dopamine
parkinsons dementia
