Na Lab 1/7

Front 1

What are the three main skills we will cover in anesthesia?

Back 1

airway management (most important), anesthesia machine, spinal anesthesia

Front 2

what are the four major parts of airway anatomy?

Back 2

pharynx, larynx, trachea, lung

Front 3

what is the function of the pharynx?

Back 3

heat, humidity, filtration

Front 4

what is the larynx?

Back 4

An organ that houses the vocal cords. It is the valve between the pharynx and the respiratory zone.

Front 5

What is the function of the larynx?

Back 5

it prevents food from going down

Front 6

what are the other two names for the larynx?

Back 6

vocal cords, glottis

Front 7

what are the three divisions of the larynx anatomy?

Back 7

supraglottis, glottis, subglottis

Front 8

what does the supraglottis consist of?

Back 8

mucosal glands, arepiglottic folds, false vocal cords, ventricle

Front 9

what are the arpiglottic folds and where are they located?

Back 9

they are bits of tissue that are prominent in obese people. They extend from the epiglottis to the arytenoids

Front 10

what are the false vocal cords?

Back 10

they are mucosal folds superior to the vocal cords. It is red tissue that closes above the cords. Their function is protection

Front 11

what is the ventricle?

Back 11

it is a mucosal sac that separates the false and true chords. It is a space

Front 12

what is the narrowest point in the adult airway?

Back 12

the glottis (except in prepubescent children, in which case it is the cric ring, just below the cords

Front 13

what do the vocal cords due on inspiration?

Back 13

abduction

Front 14

what do the vocal cords due on expiration?

Back 14

adduction

Front 15

where is the subglottis?

Back 15

below the vocal cords, to the cricoid ring.

Front 16

What is the significance of the subglottis in children?

Back 16

this is where post intubation edema forms in children

Front 17

what two nerves in innervate the larynx?

Back 17

superior laryngeal nerve, recurrent laryngeal nerve

Front 18

where does the superior laryngeal nerve come from?

Back 18

it is a branch of Vegus cranial nerve X

Front 19

what cardiac SE can happen when the superior laryngeal the is stimulated? why?

Back 19

patient may become bradycardia

Vegus stimulation.

Front 20

What is the function of the superior laryngeal nerve?

Back 20

sensory to the glottis and supraglottis, motor to the cricothyroid muscle

Front 21

what is the function of the cricothyroid muscle?

Back 21

it's tenses the vocal cords

Front 22

what is the significance of the superior laryngeal nerve with intubation?

Back 22

you can block it for intubation, so that the glottis and supraglottis are not stimulated (which we will not do.)

Front 23

What is the unique path of the recurrent laryngeal nerve?

Back 23

it reaches up under the aorta

Front 24

where does the recurrent laryngeal nerve come from?

Back 24

it is a branch of the vagus nerve

Front 25

where does the recurrent laryngeal nerve received sensation from?

Back 25

the subglottis

Front 26

where does the recurrent laryngeal nerve provide motor to?

Back 26

the intrinsic muscles of the larynx

Front 27

what bad thing may happen if the recurrent laryngeal nerve is injured?

Back 27

there may be Stridor

Front 28

what are the 8 articulated elements of the larynx skeleton?

Back 28

critcea cartilage,comiculate cartilage,arytenoid cartilage, thyroid facet,cricoid cartilage, thyroid cartilage, epiglottis, hyoid bone (see picture one) as

Front 29

where is the hyoid bone attached to?

Back 29

the epiglottis and strap muscle (see picture one)

Front 30

where is the thyroid cartilage attached to?

Back 30

there is an anterior attachment to the vocal cords and there is a posterior articulation with the cricoid (see picture one)

Front 31

what is the cricoid cartilage?

Back 31

a complete ring that articulates with the thyroid cartilage and arytenoids

Front 32

what are the arytenoids?

Back 32

they are articulated elements that attach posterior to the vocal cords (see picture one)

Front 33

where is the epiglottis in relation to the ventricle?

Back 33

it is above the ventricle. It is above the false chords, which are just above the ventricle (see picture two)

Front 34

where is the subglottis in relation to the ventricle?

Back 34

it is below the ventricle, below the true chords which are just below the ventricle (see picture two)

Front 35

draw a picture of the ideal view of the larynx with a mac 3 blade. Label the following 1. The blade, 2. The tongue, 3. The vocal chords, 4. The piriform sinus 5. The arytenoid cartilage, 6. Epiglottis:

Back 35

(see picture three)

Front 36

draw the four laryngoscopy grades:

Back 36

see picture four (we will be able to intubate grade 3 after six months of clinical)

Front 37

what is the first question you ask when considering a patient for intubation?

Back 37

"could this patient be a difficult intubation?"

Front 38

What effect will muscle relaxants have on the vocal cords?

Back 38

they will make them open wide

Front 39

how do the vocal cords behave in a breathing patient?

Back 39

they open and close

Front 40

describe vocal cord spasm:

Back 40

aka: laryngospasm. Cords are closed tight. Cannot intubate

Front 41

what tool is used to relieve obstruction with mask ventilation?

Back 41

oral airways

Front 42

what kind of pressure should we deliver with mask ventilation?

Back 42

synchronized with patient. Avoid high pressures.

Front 43

Describe hand placement with mask ventilation:

Back 43

left thumb and index finger are placed firmly on body of mask. Remaining three fingers are hooked around the mandible, with a tight grip promoting a seal so that you can bag with your right hand

Front 44

if a patient is not ventilating well with mask ventilation, what are the two most common problems?

Back 44

poor mask fit, airway obstructed. We must figure out which problem it is

Front 45

what effect does a dose of anesthetic have on the tongue and the airway anatomy?

Back 45

everything relaxes. The tongue falls back.

Front 46

What are the three steps to laryngeal mask airway insertion?

Back 46

1. Tilt head back, 2. Scissors mouth open, 3. Hold lma like a pen and pass along the roof of the mouth (keep tip pointed up, if pointed down will get hooked on glottis.)

Front 47

With laryngeal mask airway insertion, where does the tip end up?

Back 47

into the esophagus

Front 48

with intubation preparation, what does salt stand for?

Back 48

suction (2), airway (op airway,lma backup), laryngoscope (correct size),tube (several sizes, check cuff, sty let, McGill)

Front 49

which pneumonic can we use to remember all of the equipment for intubation?

Back 49

salemscot

Front 50

what does salemscot stand for?

Back 50

S -- suction, A -- airway, L -- laryngoscope, E -- ett, M -- magill forceps, S -- stylet, C -- cuff syringe, O -- oxygen, T -- tape

Front 51

which type of anesthetist is best to imitate in the clinical setting?

Back 51

someone who is not to experienced, and rigid

Front 52

what is the name of the straight blade?

Back 52

Miller

Front 53

what is the name of the curved blade?

Back 53

mac

Front 54

which size mac is normally used with adults?

Back 54

mac 3 (4 would be for a big person with a big jaw.)

Front 55

which size Miller is normally used with adults?

Back 55

Miller 2 (3 is big.)

Front 56

Which blade do we always use with babies under nine months old?

Back 56

straight blade

Front 57

which blade do most anesthetists use with adults?

Back 57

MAC 3

Front 58

describe correct sniffing position:

Back 58

rolled towel under her head. This aligns the airway for better visualization

Front 59

how do you insert a laryngoscope into the mouth?

Back 59

insert on the right side of the mouth

Front 60

which way do you apply pressure when the blade is inserted into the mouth?

Back 60

up and to the opposite corner of the room.

Front 61

How far down does the straight blade go?

Back 61

farther than the curved blade. It holds up the epiglottis. (The straight blade is more stimulating.)

Front 62

How far down does the curved blade go?

Back 62

not as far as the straight blade. You insert it into the vallecula

Front 63

what is the vallecula?

Back 63

it is a space in front of the epiglottis

Front 64

what advantage does the curved blade have?

Back 64

it avoids touching the larynx. It is less traumatic because you are on the underside of the epiglottis.

Front 65

Which intuitive motion is bad while holding a laryngoscope?

Back 65

rocking back and forth. You can break teeth.

Front 66

Name one potential complication of laryngoscopy:

Back 66

dental or soft tissue damage

Front 67

name 4 potential complications of ett insertion:

Back 67

mucosal damage, obstruction, irritation, barotrauma

Front 68

name 8 potential complications post intubation:

Back 68

laryngospasm, horse voice, nerve damage from ischemia, sub-glottic edema, granuloma, arytenoid cartilage dislocation, tracheitis, aspiration

Front 69

are lmas more or less stimulating?

Back 69

less. There is an advantage because you can use less anesthetic because of this. (The main focus of anesthesia is to keep the patient deep enough so that they are not coughing over the vent.)

Front 70

Name three types of patients that may be difficult to mask ventilate:

Back 70

obese, large tongue, no teeth

Front 71

name 4 types of patients that may be difficult for laryngoscopy:

Back 71

difficult mouth opening, loose/missing teeth, overbite, trauma

Front 72

name three types of patients that may be difficult for intubation:

Back 72

anterior larynx, combination of anatomical factors, neck immobility

Front 73

when you have a difficult airway, what two things do you need to do while working?

Back 73

keep calm and keep the patient breathing

Front 74

what six things should you have on standby with a difficult airway?

Back 74

1. Difficult airway tray, 2. Fiber-optic bronco scope, 3. Special sty lets/guide wires, 4. bullard laryngoscope, 5. Intubating lma (100% success) 6. Emergency trach kit.

Front 75

What type of medicine could you give to a patient with a difficult airway?

Back 75

topical to airway

Front 76

when asked if you checked the patient's airway, what is the answer?

Back 76

tell them exactly what you saw

Front 77

describe awake intubation:

Back 77

patient will be breathing. Takes time. Not a two minute procedure, tell the surgeon it will be more like 25 minutes, since the locals need a while to work.

Front 78

When do you do awake intubation?

Back 78

when you are afraid the patient will be a difficult intubation that you will not be able to mask ventilate (gastric bypass, obese etc. you cannot mask these patients)

Front 79

describe trans tracheal block:

Back 79

four to 5 cc of 2% lidocaine. You stick a needle through the cartilage where you would do a trach. Inject the lidocaine into the trachea (patient will cough.)

Front 80

Describe superior laryngeal nerve block:
(what is given?)

Back 80

blocks superior laryngeal nerve which is sensory to vocal cords.

2cc 2% Xylocaine bilaterally. You do this if you do not want them to feel it.

Front 81

How is tube inserted with awake intubation?

Back 81

after the block, tell the patient to take a breath. They will "breath" the tube in. They may have remi fentanyl or some other straight narcotic to help improve cooperation

Front 82

What are the three types of artificial airways we will use?

Back 82

oral airways, nasal airway, laryngeal mask airway

Front 83

what does an oral airway do?

Back 83

it holds the tongue down

Front 84

what undesirable effect can an oral airway have?

Back 84

it may stimulate airway reflexes

Front 85

where does a nasal airway pass?

Back 85

it passes through the nasal pharynx behind the tongue

Front 86

what drug should we consider help a nasal airway pass?

Back 86

neosynephrine .25% into the nares

Front 87

what two dimensions do we consider with nasal airway size?

Back 87

make sure we have the correct diameter and length

Front 88

name to contraindications to the use of nasal airways:

Back 88

anticoagulation, nosebleeds

Front 89

what role do nasal airways have with intubation?

Back 89

they may be used to dilate nares before nasal intubation

Front 90

where does the laryngeal mask airway form its seal?

Back 90

above the cords

Front 91

what type of aspiration protection does the laryngeal mask airway provide?

Back 91

none

Front 92

what effect does the laryngeal mask airway have on airway reflexes?

Back 92

less stimulation than with intubation

Front 93

what if you have an air leak with a laryngeal mask airway?

Back 93

try to fix it, but if you cannot then you can still ventilate with it as long as you are getting good air exchange and good numbers

Front 94

which cases are best to use laryngeal mask airway's?

Back 94

cases where spontaneous ventilation is planned

Front 95

what different features can be found in special types of laryngeal mask airway's?

Back 95

stylet intubation through LMA, ng tube

Front 96

what type of grip do you need while inserting a laryngeal mask airway?

Back 96

Hold like a pencil, push in on roof of the mouth with cuff deflated

Front 97

what type of pips do we desire with laryngeal mask and airways?

Back 97

less than 20

Front 98

with ng laryngeal mask and airways, what is the concern with the NG tube?

Back 98

it will open the cardiac sphincter, allowing gastric contents to pass upward

Front 99

How can an lma help with intubation?

Back 99

you can intubate through an lma.

Front 100

Describe the use of a bullard fiber-optic laryngoscope:

Back 100

a stylet is used. Patient is positioned flat, not sniffing. Midline insertion. It is good for a rigid neck. You use indirect laryngeal visualization.

Front 101

Describe retrograde wire technique for difficult intubation:

Back 101

little equipment is needed. You puncture the cricothyroid membrane with a large needle. pass a guide wire through the needle, then retrieve the guide wire from the pharynx. Pass the ett over the guide wire, holding taut.

Front 102

Give situations where a fiber-optic bronco scope would be indicated:

Back 102

upper airway obstruction (tumor, abscess, prior surgery, trauma), mediastinal mass, subglottic stenosis, congenital airway abnormalities, immobile cervical vertebrae (fusion, arthritis, chronic subluxation, traction.) Also used to verify ett of double lumen tube position

Front 103

do you perform fiber-optic bronchoscopy oral or nasally?

Back 103

you can do both

Front 104

what is an advantage to doing fiber-optic bronchoscopy on an awake patient?

Back 104

airway is not lost to intubation. Requires topical anesthetic, however, and team effort.

Front 105

Where is emergency tracheostomy performed?

Back 105

through crico-thyroid membrane, unless surgeon is present for lower tracheostomy (see picture five.)

Front 106

Draw basic picture of cricothyroidotomy:

Back 106

see picture six

Front 107

describe needle cricothyroidotomy:

Back 107

emergency procedure to secure airway. Number 14 or 12 gauge needle inserted through cricothyroid membrane. Number five ett end fits three cc syringe. co2 will build up but you can save the patient's life with oxygen until a trach can be done.

Front 108

If you cannot see the cords when looking with a laryngoscope, what might you see instead?

Back 108

the arytenoids

Front 109

which cartilage has a notch?

Back 109

thyroid

Front 110

which cartilage is a complete ring?

Back 110

cricoid

Front 111

where do you do an emergency trach?

Back 111

cricoid/thyroid membrane

Front 112

what happens when you press on the cricoid?

Back 112

it pushes back to the esophagus

Front 113

with a difficult airway, what is the problem with deciding to go with regional anesthesia instead?

Back 113

if the patient needs to be intubated, it will be emergent.

Front 114

How many times should we attempt intubation before calling someone else?

Back 114

two tries by experienced people. Person with the first look has the best opportunity.

Front 115

Give three instances where we would use mask ventilation:

Back 115

respiratory failure but breathing, apnea, any cessation of respiration

Front 116

name three caution situations with mask ventilation:

Back 116

facial trauma, open eye injury, stomach contents pushed back in

Front 117

which type of facemask is most preferable?

Back 117

the kind that is transparent (so you can see the color of the lips.)

Front 118

What do you call the soft part of the mask the goes against the face?

Back 118

the rim

Front 119

what is one drawback to straps on a ventilation mask?

Back 119

they prevent rapid removal for suctioning

Front 120

how do you confirm there is oxygen flowing through the bag valve mask?

Back 120

listen at the plastic accordion. There must be oxygen flowing (reservoir bag filling) through this system to use it

Front 121

how do you test a bag valve mask?

Back 121

seal the hole and then squeeze the bag. If it is difficult, it works

Front 122

what is the most common obstruction with mask ventilation?

Back 122

the tongue

Front 123

what method do you used to secure the mask in mask ventilation with c spine injury?

Back 123

jaw thrust

Front 124

which type of patients are difficult to mask ventilate?

Back 124

bearded or obese.

Front 125

What is the best approach to mask ventilate a difficult patient?

Back 125

two person approach. Use two hands to secure the mask and a second person to squeeze the bag.

Front 126

How do you confirm ventilation with mask ventilation?

Back 126

rise and fall of the chest, positive lung sounds at the mid-axillary line

Front 127

when do you use an oral airway?

Back 127

when the cough/gag is absent

Front 128

how do you measure an oral airway?

Back 128

start at the mouth and name the tip toward the angle of the mandible

Front 129

what can happen if your oral Airway is too small?

Back 129

it will push the tongue down

Front 130

what is a good airway option for when the patient has cough/gag reflexes?

Back 130

nasal laryngeal airway

Front 131

how do you measure a nasopharyngeal airway?

Back 131

with the anatomy on the side of the face

Front 132

which direction to insert a nasopharyngeal airway?

Back 132

avoid the roof of the nose

Front 133

which lab value should we check before inserting a nasopharyngeal airway?

Back 133

coagulation

Front 134

what is the best approach when providing mask ventilation with a spontaneous breathing patient?

Back 134

synchronize with the patient (avoid gastric inflation)

Front 135

name 2 bad things that can happen with increased gastric inflation due to mask ventilation:

Back 135

vomiting, need for increased pips in order to ventilate

Front 136

what adverse nerve effect can prolonged mask ventilation have?

Back 136

compression of the trigeminal/facial nerve secondary to prolonged pressing

Front 137

which negative side effect can a patient have with an op airway when they are asleep?

Back 137

laryngeal spasm

Front 138

what is a common question you will hear in the operating room regarding op airway?

Back 138

"is a patient ready for op airway?" if not, may need more propofol

Front 139

who watches the monitor when you intubate?

Back 139

your assistant

Front 140

what level should the head of the bed be when you intubate?

Back 140

at your sternum

Front 141

what goes under the head for positioning when you intubate question Mark

Back 141

a towel at the occipital

Front 142

describe pre-oxygenation with intubation:

Back 142

non rebreather or ambu for at least three minutes

Front 143

how far do you put the ett in?

Back 143

22 at the teeth

Front 144

what is the Sellic maneuver?

Back 144

pushing the cricoid to close off the esophagus

Front 145

with the Sellic maneuver, how long do you maintain pressure on the cricoid?

Back 145

until placement is confirmed

Front 146

which hand to hold the laryngoscope in?

Back 146

left

Front 147

where do you insert the laryngoscope?

Back 147

the right side of the mouth, pushing the tongue to the left

Front 148

how do you apply pressure with the laryngoscope?

Back 148

holding the knurl on the handle, lift to the axis of the handle (do not tilt or rock.)

Front 149

Before reaching for your endotracheal tube, what can you do with your right hand to help visualize?

Back 149

pull out the right cheek

Front 150

which side of the mouth do you insert the tube?

Back 150

the right side of the mouth, so as not to obstruct the view of the vocal cords

Front 151

how far beyone the vc do you insert the tube?

Back 151

3-4 cm

Front 152

where do you listen after intubatuion?

Back 152

midaxilla bilat, at the esophagus (try to hear stomach ventilation.)

Front 153

what if you only hear l/s on one side after Intubation?

Back 153

pull the tube back

Front 154

what does espophageal intubation look like on cxr?

Back 154

you cannot tell espohageal intubation by cxr