Head And Neck

Front 1

Treatment hyperthyroid

Back 1

- PTU and carbimazole: block synthesis of thyroxine and conversion of T4-> T3 (work within 2-3/52)
- propranolol prevent conversion of T4 ->3 (work within 12/24)

Front 2

Triggers for thyrotoxic storm

Back 2

- surgery
- sepsis
- induction of anaesthesia
- drugs eg NSAIDs, anticholinergics,
- abrupt withdrawal of anti-thyroid meds
- vigourous manipulation of gland during surgery

Front 3

Management of thyrotoxic storm

Back 3

- call for help
- ABCDE - 100% O2, increase MV, fluid bolus
- specifics
B blockers eg propranolol or esmolol
PTU down NGT
IV iodine
dantrolene
hydrocortisone
check electrolytes
check temp and active cooling
post op HDU/ICU

Front 4

Post-op differential for stridor post thyroid

Back 4

Anaesthetic
- residual paralysis
- laryngospasm
- allergy

Surgical
- RLN paralysis
- bleeding with airway obstruction
-tracheomalacia

Patient:
- asthma

Front 5

Risk factors for dental damage

Back 5

Patient:
- poor dentition
- dental prosthesis
- prominent front teeth
- other markers of difficult intubation eg neck circumference, short TM

anaesthetic/surgical:
- poor technique
- inexperience
- use of gags by surgeons
- GA with ETT
- post op shivering
- biting at extubation

Front 6

LASER

Back 6

light amplification by stimulated emission of light

Front 7

Risks of laser

Back 7

- eye damage (to both patient and staff)
- tissue damage
- fires incl airway fire
- laser plume (vapour and cellular debris)
- gas embolism (only with Nd:YAG)
- inadequate ventilation (if using jet ventilation)

Front 8

Fire

Back 8

requires triad of fuel eg ETT and circuit, oxidiser eg O2 and ignition eg laser

Front 9

Laser harm minimisation

Back 9

Institutional
- accordance with laser safety policy
- designated laser safety officer
- signs on all doors to theatre when laser in use with minimal traffic into/out of theatre

general
- use of instruments with matte finish
-presence of non-water based fire extinguisher

specific
- eye safety with goggles for correct laser wavelength with side protection. Patients eyes covered with goggles or saline soaked gauze
- tissue burns - skin covered
- avoid flammable skin prep
- laser plume - use of masks and efficient smoke evacuation
- airway fires
consideration to technique
laser resistant ETT eg laserflex, benjet, hunsucker
inflate cuff with blue dye or use double cuff ETT in case one is damaged
minimise FiO2

Front 10

Management of airway fires

Back 10

• Notify staff immediately
• Switch off laser
• Disconnect anaesthetic circuit
o If feasible remove and replace ETT (even laser ETTs can ignite)
• Flood field with N saline
• Ventilate patient via bag mask technique
• After fire out, surgeon should inspect airway via rigid bronchoscope
• Airway fires associated with significant lung injury and gradual worsening hypoxaemia over 48/24
• Therefore keep patient intubated for a few hours and transfer to ICU in order to continue monitoring and make assessments of respiratory function
• Treat with dexamethasone to decrease swelling, humidified O2 and repeat airway inspection in a few days time

Front 11

Bleeding tonsil

Back 11

- 2% risk of bleed
- may be early (poor surgical technique) or late (2/52 due to infection)
- risks: hypovolumic patient, stomach full of blood, difficult laryngoscopy
- PRIMETIME
- resuscitate patient, swallowing a lot means ongoing bleeding
- large bore IV access
- monitoring: standard
- equipment: 2 suckers, 2 working laryngoscopes, pump set, FAWB
- induction can either be standard RSI or inhalational on side
- maintenance: use NGT to empty stomach of blood (emetogenic)
- extubation awake

Front 12

Throat pack

Back 12

- tell surgeon and nurses putting it in
- tie to ETT
- part of nursing count sheet
- sticker on head and anaesthetic machine

Front 13

Epiglottitis

Back 13

P - prepare theatre, call senior anaesthetic help + ENT consultant
R - resus equipment available, machine checked
I - IV access after induction
M - SpO2 for induction, apply others after asleep
E - DAT, smaller than expected ETT
T - transfer to theatre
I - inhalational induction, intubate once deep. Expect cherry red epiglottis. Push on chest and look for bubbles if poor view
M - ceftriaxone
E - extubate once leak around ETT, should go to ICU for monitoring
M -

Front 14

Tracheostomy

Back 14

- ABCDE approach
- A: grade laryngoscopy and size of ETT
- B - gas exchange, presence of ARDS, ventilator settings
- C - inotrope dependence, anti-coagulation
- D - sedation being used
- E - location (theatre vs ICU)

Front 15

Cartilages of laryx

Back 15

3 paired
- arytenoids
- cunieform
- corniculate

3 unpaired
- epiglottis
- thyroid
- cricoid

Front 16

Muscles

Back 16

extrinsic
- sternothyroid
-thryohyoid
- inferior constrictor

intrinsic
- abductors: posterior cricoarytenoids
- adductors: interarytenoids, lateral cricoarytenoids
- tensors: cricothyroid
- relaxors: vocalis, thyroarytenoid

Front 17

Innervation

Back 17

Motor
- RLN (branch of X) does all except cricothyroid
- external branch of SLN (branch of X) does cricothyroid

Sensory
- internal branch of superior laryngeal nerve does sensation above vocal cords, and inferior surface of epiglottis (superior surface from CN IX)
- RLN does sensation below cords