Airway

Question 1

Name 2 indications cricothyroidotomy

Answer 1

1. Inability to provide other emergency airway control eg orotracheal intubation
2. Severe airway obstruction eg severe tbi, maxillo-facial injuries , penetrating neck injuries etc

Question 2

Name 3 indications tracheostomy

Answer 2

1. patients undergoing prolonged use of endotracheal tube (long ventilation)
2. After cricothyrodotomy
3. Severe maxillo facial trauma: “primary” tracheostomy

Question 3

Name 3 differences between cricothyroidotomy and tracheostomy procedures and techniques

Answer 3

1 Crycothyroidotomy is emergency procedure, tracheostomy is elective
2. Cricothyroidotomy keep neck immobilised in-line neutral, tracheostomy extend
3. Cricothyroidotomy no anaesthesia; tracheostomy in the theater under general anaesthesia

Question 4

Name 2 types tracheostomies

Answer 4

Open and percutaneous

Question 5

Name 6 complications tracheostomy

Answer 5

1. local haemorrhage (minor vessels)
2. Oesophageal injury, tracheo-oesophageal fistula
3. Injury to carotid arteries and jugular veins
4. Injure thyroid
   5-loss of airway
5. Pneumothorax

Question 6

What is the triple airway manoeuvre?

Answer 6

Head tilt-chin lift, then jaw thrust, then maintain mouth in open position

Question 7

Indications for oropharyngeal (guedel) airway? (2)

Answer 7

1. Unresponsive pt with absent gag reflex. (tongue causing obstruction)
2. During bag mask ventilation typically, before intubation

Question 8

Contraindication for oropharyngeal airway?

Answer 8

Intact gag reflex because can cause laryngospasm

Question 9

Label picture 2

Answer 9

See picture 3

Question 10

Name 5 predictors of difficult BVM ventilation

Answer 10

BOOTS
Beard (solution: ky jelly, opsite, 2-person BVM)
Obesity bmi >26 (solution:ramp)
Old age >55
Toothless
Snoring

Question 11

Name 4 indications for intubation and give 3 examples of each

Answer 11

1. Ventilation during anaesthetic for surgery eg if muscle relaxant required, long case, abdo surgery, head positioning may be required in head head and neck surgery
2. Pt can’t protect airway eg gcs <8, high aspiration risk, given muscle relaxation
3. Potential airway obstruction eg airway burns, epiglottitis, neck haematoma
4. Inadequate ventilation or oxygenation eg copd, head injury, ards

Question 12

Label picture 4 and indication

Answer 12

Rigid yankauer suction for mouth, visible pieces of food, hard items etc

Question 13

Label picture 5 and indication

Answer 13

Soft catheter suction for suction inside endotracheal tube

Question 14

How measure size of orophanyngeal airway?

Answer 14

Distance between middle of lip and angle of mandible

Question 15

Nasopharyngeal airway indication?

Answer 15

Reduced gcs and intact gag reflex.

Question 16

Name 2 contraindications nasopharyngeal airway

Answer 16

• base of skull fracture
• Nasal polyps

Question 17

How to measure size of nasopharyngeal airway?

Answer 17

Distance between tragus of ear and tip of nose. Little finger for diameter
Usually 7 for male, 6 for female

Question 18

Name 5 predictors difficult intubation

Answer 18

• Oropharyngeal burns
• previous surgical airway
• previous neck surgery
• facial injury
• c spine injury
Inability to open mouth properly, high bmi, short neck

Question 19

Name 5 complications intubation

Answer 19

• Trauma to lips and teeth
• bleeding
• esophageal intubation
• barotrauma to lungs by hyperventilation/ too high pressure. Can cause tension pneumo
• tracheal stenosis if >10 days

Question 20

Where should incision be made for cricothyrodotomy?

Answer 20

Crico-thyroid membrane

Question 21

Which conditions push trachea away to opposite side? (5)

Answer 21

• Massive pleural effusion
• tension pneumothorax.
• neck or thyroid mass
• large mediastinal mass
• upper lung tumours
( any thing that increase pressure or volume in hemithorax will push away)

Question 22

Which conditions pull trachea toward same side? (5)

Answer 22

•Atelectasis (collapse lung) !
• pneumonectomy
• diaphragmatic paralysis
• pleural Fibrosis
• agenesis of lung
• spontaneous pneumothorax : non-tension or open.

Question 23

Name 6 complications of mechanical ventilation

Answer 23

• Barotrauma
• air trapping
• Infection
• cardiovascular effects - decreased co
• oxygen toxicity
• Diaphragmatic dysfunction

Question 24

Name 7 risk factors and signs post-trauma for airway obstruction

Answer 24

• Low GCS <8
• maxillo-facial trauma and mid- face fractures
. Penetrating neck injury (haematoma compress trachea)
• SBP < 60 - poor brain perfusion
• Burns to face and neck, especially inhalation injury
• high C spine cord injury above c5
• hanging

Question 25

Which type of intubation is contraindicated in trauma?

Answer 25

Nasal

Question 26

How assess patients for difficult intubation?

Answer 26

Lemon
Look for known factors that cause difficult intubation: beard, short neck, obese, receding mandible, advanced age
Evaluate the 3-3-2 rule.
Mallampati test - class 3 difficulty, class 4 very difficult
Obstruction trauma is a major cause of obstructed airway
Neck mobility -majority should not move necks, nb to immobilize.

Question 27

What is the 3-3-2 rule of intubation?

Answer 27

• Distance between incisors should be at least 3 finger breadths
• distance between hyoid and chin at least 3 finger breadths
• distance between thyroid notch and floor mouth at least 2

Question 28

Name the 4 classes of the mallampati test and what they indicate

Answer 28

• Class 1: see entire hypopharynx- easy intubation
• class 2: soft palate, uvula and fauces only visible - normal
• class 3: soft palate and base uvula visible - difficult
• class 4: hard palate only-very difficult

Question 29

Name 6 alternatives to rescue airway during difficult intubation

Answer 29

•video laryngoscope
• Gum elastic bougie
• Laryngeal mask airway
• intubating bronchoscope
• needle cricothyroidotomy
• Surgical cricothyroidotomy

Question 30

Why is tension pneumo dangerous? (4)

Answer 30

Displacement of mediastinal structures away from injured side cause:
• compression superior and inferior vena cava heart and contralat lung
. Drop venous return (preload) to heart
• reduced ventricular end diastolic filling pressures
. Drop cardiac output-cardiac compressive shock

Question 31

Name 10 clinical manifestations of tension pneumothorax

Answer 31

• Respiratory distress- tachypnoea, nasal flare, use accessory muscles
. No chest movement affected side!
• hypotension
• reduced or absent breath sounds affected side!
• tracheal deviation contralateral side!
. Hyper-resonant percussion!
. Significant surgical emphysema
• tachycardia and hypoxia
• speak in short interrupted sentences-gasping for air
• decreasing GCS
• chest wound may be present

Question 32

The maximum length of time spent attempting to intubate patient should not exceed?

Answer 32

5 minutes