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Principles 2 Exam 1
Airway Management Part 2 Weird Techniques
| Question | Answer |
|---|---|
| List contraindications for LMA use | pharyngeal pathology or obstruction, full stomach, low pulmonary compliance, obesity, pregnancy> 14 weeks, massive injury, acute abdomen, thoracic surgery, delayed gastric emptying, pt who are not unconscious |
| At what pressure will an LMA leak? | >20cmH2O |
| Is it safe to use an LMA on a 100kg patient undergoing thoracic surgery? | No |
| Is it safe to use an LMA on someone who is spontaneously breathing? | Yes |
| Is it safe to use an LMA on a patient who requires NMB throughout surgery? | No |
| Is it safe to use an LMA on a patient with a hyper irritable airway? | Yes |
| Is it safe to intubate a pt with an ETT through an LMA? | Yes |
| What anatomical place does the LMA sit? | posterior pharynx |
| What secretions can LMAs protect against? What secretions can they NOT protect against? | nasal; gastric |
| Does LMA insertion require neck manipulation? | Not as much as laryngoscopy |
| You insert an LMA and accidentally overinflate the cuff. What injuries could result for the pt? | hypoglossal nerve injury or vocal cord paralysis |
| What could possibly occur if you place the wrong LMA size? | tongue cyanosis |
| What is the intubating drug and dose for LMA insertion? | Propofol 2.5-3 mg/kg |
| Where should the tip of the LMA be positioned? | Over the esophagus |
| What LMA size should a 30-50kg adult have? what is the max cuff volume? What is the largest ETT size you can use? | #3, 20cc, 6.0 cuffed |
| What LMA size should a 50-70kg adult have? what is the max cuff volume? What is the largest ETT size you can use? | #4, 30cc, 6.0 cuffed |
| What LMA size should a 70-100kg adult have? what is the max cuff volume? What is the largest ETT size you can use? | #5, 40cc, 7.0 cuffed |
| What LMA size should a >100kg adult have? what is the max cuff volume? What is the largest ETT size you can use? | #6, 50cc, 7.0 cuffed |
| Generally, what sized LMAs do adult women need? | #4 |
| Generally, what sized LMAs do adult men need? | #5 |
| If you use fiberoptic to place an ETT through an LMA, what do you need to remember to do before you begin? | thread the ETT through the fiberoptic before you insert it |
| What is a fastrach? | advanced LMA for tracheal intubation |
| What is a different feature included in a ProSeal LMA? | a separate lumen through which a gastric tube can be inserted to evacuate contents from the stomach |
| T/F- You cannot give positive pressure ventilation through a ProSeal LMA. | False- you can because if you instill air into the esophagus, you can suck it out and studies show that it has a higher airway leak pressure |
| What 3 ventilation techniques can you use with LMA? | spontaneous ventilation, CPAP with 3cmH2O pressure, pressure support with CPAP |
| What 2 drug classes do you need to be careful of giving with LMA? | opioids and inhalation agents: opioids reduce CO2 response and inhalation agents create shallower breathing |
| Can you steam autoclave an LMA? | yes- up to 275 degrees F |
| What is the detergent used to clean non reusable LMA? | endozime |
| When is a combitube most often used? Why? | trauma or in the field- allows for quick intubation and does NOT have to directly be placed in the trachea |
| What is the gold standard for expected difficult airways? | Fiberoptic intubation |
| List the indications for fiberoptic intubation | airway tumors, infections, C spine fractures or instability, C spine fixation, conscious intubation, difficult intubation |
| Can you place an ETT fiber optically on an awake patient? | Yes |
| Which of the following patients would you use fiberoptic to intubate... Down's syndrome pt, thoracic spine fusion, a patient undergoing a pharyngeal tumor removal, profoundly sedated pt. | downs syndrome, pharyngeal tumor removal |
| What can you do with the aspiration channel on the fiberoptic? | suction, insufflation of O2, injection of local anesthetic |
| For an awake patient, how can you blunt their airway reflexes? | Nebulize Lidocaine 4%, cetacaine spray to posterior pharynx, lidocaine gel to numb mouth |
| When you use Cetacaine spray to numb a patient for fiberoptic intubation, what nerve are you trying to affect? | glossopharyngeal nerve |
| What do you need to do to the nasal airway before you insert fiberoptic nasally? | vasoconstrict it with neosinephrine, Aphrin, or mechanically |
| Which type of fiberoptic intubation has the greatest chance of tongue and epiglottis blocking cords, awake, nasal, or asleep? | asleep fiberoptic intubation |
| Do you have to manipulate the pt neck to use a glidescope? | No |
| Do you have to manipulate the pt neck to use a Bullard? | No |
| Does a glidescope have a suction channel? | No |
| Does a Bullard have a suction channel? | Yes |
| Which intubation technique is most like using a Miller: LMA, glidescope, fiberoptic, bullard, light wand? | Bullard |
| For unstable cervical vertebrae, burn strictures of the neck, and/or congenital airway problems, what intubation technique is the best? | light wand |
| What does it mean if the light on the light wand dims or disappears? | ETT has entered the esophagus |
| When do you withdraw the stylet and allow insertion of the ETT while using a light want? | when the light is below the cricoid cartilage |
| What is retrograde intubation? | insertion of a guide wire through the cricothyroid membrane, through the mouth, over which the ETT is inserted |
| How do you confirm placement of the needle during a retrograde intubation? | aspirate air to confirm |
| What is the most common complication when doing a retrograde intubation? | bleeding in the airway |
| Your patient is chronically on ASA. How would you minimize bleeding if you were forced to do a retrograde intubation on him? | be as close to the center of the cricothyroid membrane as possible |
| What is the technique called when you instill a needle through the cricothyroid membrane for temporary oxygenation with 15L/m of O2? | jet ventilation |
| What ventilation parameters should you keep when performing jet ventilation? | 6-8 breaths per minute with an I:E time of 1:4 |
| When performing Jet ventilation, which period do you want to be longer, inspiration or expiration? Why? | Expiration- to allow the patient the passively exhale |
| Jet ventilation is great for _________ (oxygenation or ventilation) but is not great for ________(oxygenation or ventilation) | oxygenation; ventilation |
| What are the major complications of jet ventilation? | air entrapment, pneumothorax, bleeding, thyroid gland puncture, esophageal perforation, subcutaneous emphysema |
| Jet ventilation can ________ intrathoracic pressure | increase |
| You placed a LMA in your patient for a case that was over 2 hours long. In PACU, the patient is c/o tongue and hard palate numbness. What could have happened? | Glossopharyngeal nerve was injured |
| What does the glossopharyngeal nerve innervate? | the roof of the pharynx, the tonsils, soft palate, sensory information to the back of the tongue |
| Which nerve gives sensory information to the epiglottis and the interior of the larynx down to the vocal cords? | the internal branch of the superior lingual nerve |
| Which nerve gives motor information to the cricothyroid muscles? | external branch of the superior lingual nerve |
| Which muscles effect the pitch of the voice? | cricothyroid muscles |
| What does the recurrent laryngeal nerve do for sensory information? | innervates below the vocal cords |
| What does the recurrent laryngeal nerve do for motor information? | innervates all of the motor responses in the larynx except cricothyroid muscles |
| You are about to start a fiberoptic awake case. Which nerve do you need to block in order for the patient to be comfortable and for you to successfully complete the intubation? | glossopharyngeal nerve block |
| For a glossopharyngeal nerve block, where do you stand in order to reach the nerve? | contralateral side |
| What medication is instilled in a glossopharyngeal nerve block? | 2ml of 1% Lidocaine |
| What is the landmark for a glossopharyngeal nerve block? | posterior tonsillar pillar at the floor of the mouth, lateral to the base of the tongue |
| When performing a glossopharyngeal block, when you aspirate your syringe before instilling Lido, you pull back air. What does this mean? Should you proceed with the block? | if air is aspirated, the needle has passed through the membrane- you should not proceed with the block |
| When performing a glossopharyngeal block, when you aspirate your syringe before instilling Lido, you pull back blood. What should you do? | redirect the needle more medially |
| How far do you insert the needle for a glossopharyngeal block? | 0.5cm |
| Which nerve block should be performed first: glossopharyngeal or superior laryngeal nerve block? | superior laryngeal nerve block |
| What is the result of a glossopharyngeal nerve block? | paralysis of the pharyngeal muscles and relaxation of the tongue |
| Where do you stand when performing a superior laryngeal nerve block? | ipsilateral side |
| Where do you displace the hyoid bone and the carotid artery when performing a superior laryngeal nerve block? | Hyoid- displaced toward the side being blocked; Carotid- laterally and posteriorly |
| From the hyoid bone, which direction should you aim your needle when performing a SLN block? | anterior and caudad |
| Which structure should you aim for when performing a SLN block? | thyroid ligament- into the space between the thyrohyoid membrane and the pharyngeal mucosa |
| You think you have passed through the thyroid ligament while performing a SLN block. Is this ok? Should you proceed with the block? | yes! |
| How deep do you insert your needle for a SLN block? | 1-2cm |
| What medication and dose is given for a SLN block? | 2ml of 2% Lidocaine with epinephrine |
| After you have instill 2ml of 2% Lido with Epi for a SLN block, what do you do next? | as the needle is withdrawn, inject 1ml of Lido |
| What does a SLN block block? | all laryngeal mucous membranes above the rim glottides including the epiglottis and the arytenoepiglottic folds |
| Which patient population should a SLN block be used with caution? Why? | full stomach- the block removes some of the protective reflexes |
| What are some potential complications of a SLN block? | local anesthetic toxicity and hematoma formation |
| What is the maximum safe dose of Lidocaine in the trachea? | 4mg/kg |
| Your patient has developed ringing in the ears and sympathetic cardiac effects after an oral nerve block. What do you think is going on? | local anesthetic toxicity |
Created by:
Meghann Redmon