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ANSM 500 (Case Conference) > Test # 2 > Flashcards

Test # 2 Flashcards

1
Q

Definition of Laryngospasm

A

A primitive protective laryngeal reflex, a magnified glottic closure reflex in response to a glottic stimuli.
(a lot of reasons, bumping, moving, loud noises, touch, moving of ETT, etc)

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2
Q

Superior Laryngeal Nerve Has what two branches?

A

Internal and External

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3
Q

Internal branch of superior laryngeal nerve

A

Supplies SENSORY innervation to hypo-pharynx ABOVE glottic opening (vocal cords). (INSENSE) internal = sensory

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3
Q

Physiology of Laryngospasm

What nerve stimulation causes this? (2)

A

caused by noxious stimuli
precise mechanism not known
involves combined contraction of laryngeal muscles

  1. Superior Laryngeal Nerve
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4
Q

External branch of superior laryngeal nerve

A

Supplies MOTOR function to cricothyroid muscles.

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5
Q

Physiology of laryngospasm resembles what?

What 2 responses occur?

A

Shutter-effect and “ball-valve” effect.

glottic closure (intermittent) and laryngeal close (complete obstruction)

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6
Q

What are the pre-operative risk factors for laryngospam?

A 
Smoking (or second hand)
Recent URI, infections, inflammation
GERD
Mechanical irritants - (ie secretions, blood, coughing, frequent suctioning, artificial airways, bronchospasm.)
Obesity
OSA
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7
Q

What are the intra-operative risk factors for laryngospasm?

A

Difficult intubation
“excitement” phase of anesthetic
intubation or extubation during “light anesthesia” (phase 2)
Upper airway surgical procedures

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8
Q

What is the incidence of Larygnspasm?

A

Visvanathan - 0.78-5%

Nagelhaut -
GREATEST in recent URI (95.8/1000)
Children exposed to smoking (9.4%)
Children NOT exposed to smoking (0.9%)

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9
Q

What are the signs and symptoms of laryngospasm?

6 categories

A
  1. Oxygen desaturation (hypoxia) cyanosis
  2. No ETCO2
  3. Inadequate:
    a. chest rise
    b. ventilation
    c. breath sounds
  4. Agitation, respiratory distress, CROWING sound, stridor
  5. Cardiac dysrhythmias (tachy, brady, and asystole)
  6. Negative pressure pulmonary edema (pink frothy foam!) -eww!
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10
Q

What do you do when your patient has a laryngospasm??

A
  1. FIRST AND FOREMOST - RAPID INTERVENTION IS KEY -
  2. Remove noxious stimuli
  3. Administer PPV with 100% O2 (continuous)
  4. Jaw thrust and/or pressure on laryngospam notch.
  5. IV propofol (small doses only)
  6. Succs (IV or IM - subparalytic doses) (10-20 mg doses)

POSSIBLY: lidocaine, but not used much anymore.

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11
Q

What exactly is a bronchospasm?

A

An acute and reversible closing of the broncho-pulmonary segments.

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12
Q

What does a bronchospasm result from?

A

An INCREASE in bronchial smooth muscle tone (from a number of different stimuli), resulting in closure of the small airway.

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13
Q

(Bronchospasm)

As a result of the increased inspiratory force against a closed airway, what develops?

A

Airway edema, causing secretions to build up in the airway.

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14
Q
  1. What makes bronchiolar dilation occur, SNS or PNS?

2. Vice versa, what makes it contract?

A
  1. SNS (sympathetic nervous system)

2. PNS (parasympathetic nervous system)

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15
Q

Risk Factors/Causes of Bronchospasm

A
  1. Smoker, COPD, Lung disease
  2. Asthma
  3. Aspiration, suctioning, intubation
  4. Histamine release from medication reaction
  5. Stress of surgery
  6. Light anesthesia
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16
Q

Incidence of bronchospasm?

A

In adults 0.4%

In Children 4.1%

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17
Q

Management of bronchospasm

A

100% O2 administration
Maintain adequate ventilation and oxygenation
Ongoing assessment of lungs, color, tube placement, overall status
Increase anesthetic depth
Bronchodilators
Identify and TREAT cause
(can give Epi 1-10 mcg/kg)

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18
Q

Recurrent Laryngeal nerve

A

Provides MOTOR function to the rest of the pharynx BELOW the glottis (vocal cords).

Loops around 2 anatomic areas:

R side loops around the brachiocephalic (innominate) artery
L side loops around the aorta

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19
Q

The Vagus nerve is the source of what nerves?

A

Superior and Recurrent Laryngeal nerves

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20
Q

What is the definition of a difficult airway?

A

A clinical situation in which a trained anesthetist experiences difficulty with facemask ventilation, laryngoscopy, intubation, or all of these.

21
Q

People don’t die from not being able to be __, people die from not being __.

A

intubated

ventilated

22
Q

Incidence of a difficult/failed airway -

MAJOR COMPLICATION

A

1:22,000 with a mortality rate of 1:180,000

23
Q

Incidence of a difficult/failed airway -

FAILED TRACHEAL INTUBATION

A

0.05 to 0.35%

24
Q

Incidence of a difficult/failed airway -

DIFFICULT FACEMASK VENTILATION

A

0.9 to 7.8%

25
Q

Incidence of a difficult/failed airway -

CICV

A

1:2250 in nonparturient (not pregnant), and 1:300 in parturients (pregnant).

26
Q

Major complications of airway assessment?

A

Death, brain damage, Emergency surgical airway placement, unanticipated ICU admission

27
Q

So what patients are at increased risk for being a “difficult airway”

A
  1. Beards
  2. edentulous, dental abnormalities, TMJ
  3. Obese redudant tissue
  4. Pregnancy - why? (airway swelling, enlarged breast tissue, increased abdominal size causing more pressure on lungs and airway.
  5. Altered head/neck anatomy (wide variety)
  6. OSA, snoring
  7. Large tongue
  8. Short neck/decreased cervical movement
  9. Mallampati 3 or 4
  10. Head, neck mass, hematoma
  11. Vomiting, blood in airway
  12. Small mouth opening, TMD < 3 fb
  13. Poor view of glottis
  14. Foreign body in airway

Probably more, but is this enough?

28
Q

1 cause of airway obstruction?

A

Large tongue

29
Q

Signs of difficulty with facemask ventilation

A

gas flow leaks out, increased use of FLUSH valve
Poor chest rise
Absent or inadequate breath sounds
Gastric air entry
Poor CO2 return and altered capnograph waveform
SaO2 trending below 92% with 100% oxygen
Necessity to use oral/nasal airway and perform 2-handed mask ventilation.

30
Q

Signs of difficult laryngoscopy/other airway

A

Inability to visualize any portion of the vocal cords (Cormack and Lehane grade III or IV)
Difficult placement or ventilation with a LMA
Difficult cricothyrotomy or surgical tracheotomy

31
Q

1 cause of unexpected difficult airway is?

A

Enlarged LYMPHOID tissue at base of the tongue (lingual tonsils)

32
Q

Prep for a difficult airway include what?

A 
Airway assessment
Equipment
ALTERNATIVE plan (plan b,c )
Positioning (sniffing, blankets, pillows, move PANIS out of the way, etc)
Adequate pre-oxygenation (ALWAYS)
Ensure assistance is available
33
Q

Always MAINTAIN ___, is the cornerstone of difficult airway management.

A

OXYGENATION

34
Q

Philosophy regarding difficult airways according to Nagelhout p. 439

A

Plan ahead, be prepared
suspicious = intubate awake
get into trouble and can ventilate = wake them up
intubation choices = do what you do best

35
Q

Know ASA difficult airway algorhythm

A

… but are NOT set in stone, always do what is appropriate for that situation…

36
Q

Good things about an LMA?

A 
HIGH likelihood of success
Conduit for ventilation and intubation
Buys additional time for intubation
Usually atraumatic
High level of comfort of use by anesthesia providers
37
Q

Airway obstruction

A

Upper and/or lower airway
Impaired ventilation
Decreased tissue oxygenation
Decreased removal of CO2

IF NOT TREATED = CEREBRAL AND MYOCARDIAL ISCHEMIA and/or INFARCT!

38
Q

What are the three components required for a fire?

A

Oxygen, Heat, Fuel

39
Q

What are some oxygen sources?

A

Room air
Nasal Cannula (remember gas in NC is 100% oxygen, but once it leaves the cannula itself is when it mixes with the other gases)
Endotracheal tube
Oxygen tanks
Nitrous oxide
Oxygen flush valve (flushes HIGH levels of O2 into the room)

40
Q

What is heavier, room air or oxygen?

A

Oxygen (more likely to pool in low spots)

41
Q

What are some HEAT sources?

A

ESU (electrosurgical unit)
Fiberoptic light sources or cables
High-speed drills
Lasers
Electrical sparks from malfunctioning equipment
Desiccated soda lime (when dried out it doesn’t remove the Co2, CHECK YOUR SODALIME)

42
Q

What are some FUEL sources?

A 
Prep solutions
Petroleum-based ointment
Facial Hair
Surgical drapes
Gloves
Sponges, gauze, dressings
ETT, LMA, nasal cannula, breathing circuit
NGT
Suction catheters
Pneumatic tourniquets
Silastic stents, tracheostomy tubes
Bowel Gas (farts?)
Alcohol
Acetone
Ether
Alcohol-based hand sanitizers
Anything that is flammable
43
Q

Flame-retardant means something is fire proof. True of False?

A

FALSE - it does NOT mean it’s fire proof… just resistant.

44
Q

Incidence

A

Estimate 600 OR (surgical) fires a year in the US (and is increasing)
Fires in the Airway 0.4% occurance

45
Q

Airway Fires incidence and causes

A

Airway fires: the MOST COMMON site of surgical fires - 38%
Head or Face 28%

Of these 68% are caused by ESU
13% by Lasers

46
Q

Prevention of airway/OR fires… how do we do it?

A

EDUCATION of all staff in OR
use caution with Lasers
- eye protection
- NO nitrous, try to keep oxygen levels below 30%, low flow rates (if you must go above 30% deliver 5-10 L of AIR to washout O2 levels)
-Stop use of O2 1 minute before use of lasers/ESU devices.
- Laser ETT, and cuff filled with saline and methylene blue

47
Q

Prevention continued….

A

Vented drapes
Use water-soluble gel on pt. face/hair
Soak towels or gauze with sterile water/saline
Avoid petroleum based ointments
Active smoke evacuation with suction
FULLY ALLOW PREP SOLUTIONS TO DRY
Jet ventilation or intermittent apnea/extubation

48
Q

How do you treat an Airway Fire?

A

SIX SECONDS IN RAPID SUCCESSION:

  1. Call for help
  2. Remove ETT, and anything else on fire. (I thought we weren’t supposed to do this immediately… but this is what it says)
  3. Discontinue gases
  4. Saline poured into patients airway
  5. Resume ventilation with low oxygen % (assess need for reintubation, maybe a smaller ETT?)
  6. Verify degree of injury
49
Q

Treatment of Surgical Fire

A 
R.A.C.E.
Anticipate, prevent
Early recognition
STOP THE PROCEDURE
remove burning material from patient
extinguish
call for help
If fire engulfs patient, disconnect circuit and stop O2 flow.  MANUALLY VENTILATE
Evacuate
Continually maintain airway and provide CARE FOR YOUR PATIENT

ALWAYS ALWAYS ALWAYS AIRWAY!

50
Q

How do you calculate O2 percent?

A
  1. Calculate TOTAL 02 content
  2. Calculate AIR content
  3. Calculate liters of Oxygen flow needed

If you need 30% of oxygen with 3 Liters (3000) of total air/oxygen flow.

  1. 0.30 x 3000 = 900
  2. 3000 - 900/0.79 = 2658 (or 2.66 L air)
  3. 3000 - 2658 = 342 (or 0.342 L O2)

so, for 30% oxygen delivery using 3 liters of total flow = 2.66 L of Air and 0.34 L of Oxygen

ANSM 500 (Case Conference) (1 decks)

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