Westminster Anesthesia-Ent/eyes/facial

Front 1

T & A:
Preoperative assessment [3]

Back 1

Patient presentation: ASA/age/status
Medications: premeds

Front 2

T & A:
Intraoperative management [3]

Back 2

Airway: MAC/Regional/General
Medications: pain/nausea/relaxation/etc.

Front 3

T & A: pearls

Back 3

Versed po .5mg kg or nasal preop 5-15 minutes to work
Ussually no sialoagosue
No LMA
Cuffed tubes 6-8 years
You want air leak at about 18cm…..leak at 8 is too much (airway fire)
Zofran .1 per kg, 5years old 2-4 mg (or reglan/anzomet…serotonin)
Agex2+9=wt in kg
Pain fent…..demerol .5 mg/kg…… /morphine .1mg per kg
Mask with sevo/nitrous (start at 5% or se…over pressurize…(mac for 5 year old would be 3)
Mask/transfer to bed,…IV….then propofol 1-3mg/kg…a little narc…..then intubate (in case of laryngospasm)

Front 4

Adenoids are at what location relative to tonsils

Back 4

posterior

Front 5

Cuffed tubes what age?

You want air leak at about _____…..leak at 8 is too much (airway fire)

Back 5

6-8 years

18cm pressure

Front 6

pediatric Zofran dose?

ped's MAC demerol/fenanyl dose?

Back 6

Zofran .1 per kg, 5years old 2-4 mg (or reglan/anzomet…serotonin)

Pain fent…..demerol .5 mg/kg…… /morphine .1mg per kg

Front 7

Frenulectomy

Preoperative assessment [3]

Back 7

Patient presentation: ASA/age/status
Medications: premeds

Front 8

Frenulectomy

Intraoperative management

Back 8

Airway: MAC/Regional/General
Medications: pain/nausea/relaxation/etc

Front 9

Frenulectomy pearls

Back 9

Tongue-tied
Quick-5 minutes
Sevo 6-8% overpressure, mask off, surg…share the airway….

Front 10

Sevo MAC for 5 yr old?

Back 10

3

Front 11

BMT: Bilateral Myringotomy Tubes pearls

Back 11

FAST…..deep and still with Sevo oral airway……
Tylenol supp..10-15mg/kg…give after induction
ALWAYS monitor TEMP on kids

Front 12

eye case pearls

Back 12

Always have atropine ready……

Front 13

Cocaine 4% (40mg/ml) 1.5 mg/kg

Back 13

xxxxxxxxx

Front 14

propofol introcular block dose

Back 14

30-60mg propofol bolus IV

Front 15

orbital fracture pearls

Back 15

Suxx increases IOP secondary to depolarization

1.2 mg per kg for rapid sequence..
No LMA because no access to airway

Front 16

ORIF Mandible Fracture: Open Repair Internal fixation pearls

Back 16

Know laforte’s
NO nasal tube if possible/
Possibly fiberoptic..hard to see secondary to blood.

Front 17

laforte 1?

Back 17

maxillary below nose-lateral

Front 18

laforte 2?

Back 18

max/ethmoid-over nose then down both sides

Front 19

laforte 3?

Back 19

across orbits

Front 20

____________ cant say with recurrent laryngeal nerve damage

Back 20

Eeeeeeee

Front 21

Parotidectomy pearls

Back 21

No paralysis x for sux with intubation
ETT
NIM monitor

Front 22

a candidate for local anesthesia with IV sedation criteria

Back 22

a. Must be able to understand directions, lie flat, and remain still for 45-120 minutes.
b. Poor candidates include squirrels, patients with tremors, claustrophobic patients, orthopneic patients, and patients who are not oriented. Chronic cough, alzheimer’s.

Front 23

2. Remember the coexisting diseases that almost all the elderly patients present with (DM, MI, CHF, CVD). Requires thorough workup by the admitting surgeon and thorough review by you.

Back 23

xxxxxxx

Front 24

Goals for the awake patient: [5]

Back 24

comfort,
cooperative,
intact airway reflexes

maintenance of breathing

decreased anxiety

Front 25

1. Drug choices for sedation during placement of the retrobulbar block (RBB) include but are not limited to: [5]

Back 25

a. Propofol 10-20 mg boluses
b. Midazolam .5-2 mg
c. Alfentanil 200-250 uq
d. Fentanyl 25-50 ug
e. Remifentanyl

Front 26

Remember the slow circulation times for the elderly patient and the synergism between narcotics and benzodiazepines. Apnea is never far off. The goal is to provide some sedation during the placement of the RBB and maintain _________

Back 26

airway reflexes/respirations

Front 27

5. Complications of RBB. Overall complication rate is 1:500, usually seen within 15 minutes. [3]

Back 27

a. Retrobulbar hemorrhage is the most common. Usually noted during injection. Eyeball becomes tense and is displaced anteriorly. Treatment consists of gentle pressure, lateral canthotomy (incising the canthus), or cancellation of the procedure.
b. Oculocardiac reflex is caused by eyeball manipulation or application of the Honan balloon. Treat by releasing the balloon, head down tilt, atropine/glycopyrrolate. Reflex is usually self-limiting and fatigues.
c. trauma to the eye due to poor technique. To avoid, have the patient look straight forward and do not penetrate deep into the orbit with the needle.

Front 28

Respiratory monitor should include at a minimum a precordial stethoscope. CO2 sampling nasal oxygen cannula can be useful. Remember to provide air flow under the drapes to prevent harmful build up of CO2 and an oxygen enriched environment.

Back 28

xxxxxxx

Front 29

Increased IOP is seen with [4]

2 drugs
2 actions

Back 29

ketamine, succinylcholine, laryngoscopy and intubation.

Front 30

Normal IOP is

Back 30

12-20 mmHg.

Front 31

a. Most anesthetic agents decrease IOP by [4]

Back 31

relaxing extraocular muscle tone
decreasing blood pressure
decreasing CVP
improving outflow of aqueous humor

Front 32

IOP and antisialagogues...

Back 32

IV/IM no increase seen, however, topical use on the eyeball may increase IOP via mydriasis (pronounced dilation).

Front 33

narcotic effect on IOP?

Back 33

c. Narcotics: no change or slight decrease

Front 34

CNS depressant effects on IOP...

Back 34

Thiopental, etomidate, and propofol decrease IOP.

Front 35

Volatile agents effects on IOP

Back 35

decreased IOP assuming normocarbia (hypercarbia and hypoxemia will cause vasodilation and increased IOP).

Front 36

Ketamine effects on IOP...

Back 36

early studies show that IM/IV use increased IOP. Later data indicated that after a benzodiazepine premed or narcotic pretreatment that no change in IOP was recorded.

Front 37

Nondepolarizing neuromuscular blockers effect on IOP...

Back 37

decreased IOP

Front 38

Depolarizing neuromuscular blockers effects on IOP...

Back 38

succinylcholine causes a significant transient increase in IOP (10-20 mmHg). Tonic response by the extraocular muscles. No attempts at preventing IOP increase with sux have been successful. However, no case reports exist describing further eye damage or loss of vitreous with the use of sux.

Front 39

Penetrating eye injuries

Back 39

a. Balance aspiration risk against sudden increase in IOP
b. If possible, H2 blocker, metoclopramide (.15 mg/kg), and a nonparticulate antacid, ie. Sodium citrate (30cc) preoperatively
c. Pretreat with lidocaine (1-1.5 mg/kg IV), narcotic (fentanyl 2 ug/kg or sufentanil .1 mg/kg), labetalol or esmolol.
d. Rapid sequence induction: d-tubocurarine .05 mg/kg, sux 1.5 mg/kg, thiopental 4-6 mg/kg, propofol 1.5 mg/kg
e. Consider a modified rapid sequence induction with rocuronium .6-1.2 mg/kg. Guard against intubating too early thus causing coughing, bucking, and increased IOP.
f. Maintenance: ensure adequate depth of anesthesia. Carefully monitor neuromuscular block.
g. Emergence: ensure that airway reflexes and spontaneous ventilation are present. Consider lidocaine 1.5 mg/kg 5 minutes before emergence to decrease coughing.
h. Bottom line: protect the patient from aspiration. Do a RSI with sux if indicated. Focus on a smooth intubation with minimal sympathetic stimulation.

Front 40

Strabismus surgery (amblyopia)

Back 40

a. Early surgical intervention (4 months of age) is needed to allow stereoscope visual development to proceed.
b. May be associated with underlying myopathies which can be related to an increased risk of malignant hyperthermia and/or masseter muscle spasm.
c. Employ usual monitors and heighten your vigilance level to the early signs of malignant hyperthermia.
d. Incidence of postoperative nausea and vomiting (PONV) varies from 48-85%. Caused by eye muscle manipulation and vagal stimulation.
i. Consider ondansetron .15 mg/kg
ii. Propofol infusion (if <3 years of age)
iii. Decreased narcotic use or avoidance.
iv. Oral gastric tube, IV hydration

Front 41

Oculocardiac reflex (OCR)

Back 41

1. Caused by eyeball traction, eyeball pressure, eye pain, or orbital hematoma.
2. It is a trigeminovagal reflex
a. Ectopic beats, nodal rhythms common.
b. Bradycardia progressing to asystole.
c. Ventricular fibrillation
3. Incidence of OCR varies, 32-90%.
4. Hypoventilation and increased PaCO2 can significantly increase the incidence of bradycardia.
5. Treatment:
a. Stop stimulation
b. If needed, give atropine .007mg/kg IV (007-for your eyes only) or glycopyrrolate (.005-.01 mg/kg)
c. Ensure adequate depth of anesthesia and normocarbia.

Front 42

____ and ____ are most susceptible to the systemic effects of these medications.

Back 42

Infants and elderly

Front 43

Phenylephrine: sympathomimetic mydriatic (dilation)

S/A's [3]

Back 43

a. Increased blood pressure, can be severe.
b. Headache
c. Myocardial ischemia

Front 44

Epinephrine: sympathomimetic

s/a's [4]

Back 44

a. Decreases aqueous humor formation
b. Tachyarrhythmias
c. Premature ventricular complexes
d. Angina and myocardial ischemia

Front 45

Timolol: beta adrenergic receptor blocker

s/a's [4]

Back 45

a. Glaucoma treatment to decrease aqueous formation and IOP
b. Decreases heart rate and blood pressure
c. Exacerbates obstructive lung disease
d. Congestive heart failure in susceptible patients.

Front 46

5. Echothiopate: miotic (constricting)

s/a's [2]

Back 46

a. Decreased plasma cholinesterase levels for 4-6 weeks after cessation of the drug
b. Prolonged response to sux, mivacurium, and ester local anesthetics.

Front 47

Acetylcholine: miotic

s/a's [3]

Back 47

a. Used after cataract surgery
b. Decreases heart rate and blood pressure
c. Bronchospasm and increased salivation are possible

Front 48

Pilocarpine: miotic

s/a's

Back 48

a. Causes transient fall in blood pressure then possible severe increases due to excitation of the muscarinic receptors on sympathetic ganglion cells.
b. Bronchospasm

Front 49

Scopolamine/atropine: mydriatic

s/a's [3]

Back 49

a. Disorientation/hallucinations
b. Increased IOP
c. Anticholinergic symptoms

Front 50

9. Cocaine: sympathomimetic, local anesthetic

s/a's [2]

Back 50

a. Ocular use can cause severe bradycardia
b. Used for dacryocystorhinostomy as a topical anesthetic and vasoconstrictor.

Front 51

Patients undergoing head and neck surgery frequently have significant coexisting diseases. [5]

Back 51

1. Emphysema
2. Heart disease
3. Alcohol related disorders
4. Potential or actual airway management problems
5. Hypothyroid or hyperthyroid symptoms

Front 52

Anesthetic techniques for head and neck cases [3]

Back 52

1. Tracheostomy under local may be the first procedure followed by the main dissection.
2. General anesthesia with inhaled anesthetics/narcotics.
3. Discuss the use of neuromuscular blockers with the surgeons preoperatively.

Front 53

Hemodynamic changes during radical neck dissection are caused by __________. Bradycardia, hypotension, and cardiac arrest can result.

Back 53

by manipulation of the carotid sinus

Front 54

Trauma to the right stellate ganglion and cervical autonomic nervous system during the neck dissection may cause: [4]

Back 54

1. Prolonged Q-T interval
2. Decreased ventricular fibrillation threshold
3. Tachyarrhythmias
4. Cardiac arrest

Front 55

Venous air embolism

Back 55

1. Incidence is low. Watch for decreases in end tidal carbon dioxide readings.
2. Hypotension and arrhythmias are late signs.
3. Treat with positive pressure, 100% oxygen, jugular vein compression, head down tilt, left lateral positioning, and aspiration of a right arterial catheter.

Front 56

Trauma to the neck and larynx

Back 56

a. Internal damage may be extensive with minimal external damage.
b. Stridor and cyanosis may be present.
c. Signs of airway problems include:
1. Wheezing and coughing
2. Changes in voice
3. Hemoptysis
4. Subcutaneous emphysema
d. Always assume that a C-spine fracture exists until proven otherwise.
e. Decompensation may be rapid. Do not leave the patient unattended.
f. Stabilize the neck by holding it in a neutral position and intubate the patient orally. Do not apply traction.
g. Tracheostomy under local is a frequent intervention

Front 57

Foreign body in the airway.

Back 57

a. Very common cause of acute onset respiratory distress in young children.
b. Any intervention by you must not convert a partial obstruction into a total obstruction. Techniques include:
1. Awake fiberoptic exam.
2. Awake direct laryngoscopy.
c. Use extreme caution with sedation.
d. Maintain spontaneous ventilation
e. Do not induce anesthesia until the ENT surgeon is scrubbed in and the tracheostomy set is in the room and opened.

Front 58

Microlaryngoscopy

Back 58

a. Anesthetic goals
1. Provide surgeon with a clear view, immobile field, and adequate room to work.
2. Protect the trachea, ensure adequate ventilation and oxygenation, minimize secretions, and provide rapid awakening with return of protective airway reflexes.
b. Preoperative glycopyrrolate and midazolam will dry secretions and decrease anxiety.
c. Communication with the surgeon is imperative. Find out the location and size of the area in question. Discuss the surgical technique and expected duration of the procedure.
d. Ensure that you understand the sequence of the procedure.
e. Check that all adapters/special equipment is available and functioning before the patient arrives in the OR suite.
f. Most microsurgical procedures on the larynx can be accomplished around a small (6mm) endotracheal tube.
g. TIVA
1. Adequate muscle relaxation is a must
i. Sux drip, 1-2 mg/kg then 30-150 ug/kg/min
ii. Mivacurium infusion
h. Ensure adequate depth of anesthesia
1. IV: Midazolam 1-4 mg, propofol 2 mg/kg for induction, then 150 ug/kg/min with Fentanyl 1-2 ug/kg
2. Consider topical lidocaine in the airway (LTA)
3. Beta-adrenergic blocking medications for heart rate control.

Front 59

Laser surgery in the airway

Back 59

a. Fire in the airway
1. Can involve subglottic, epiglottic, and oropharyngeal areas.
2. Inhalation of smoke produces bronchospasm and edema.
b. Reduce the incidence of fire by:
1. Maintaining high vigilance and an increased index of suspicion during the case.
2. Keep FIO2 <30% by using air or helium with oxygen.
3. Use laser endotracheal tubes.
4. Only water soluble lubricants on the endotracheal tube.
5. Keep paper drapes away from operative field.
6. Fill cuff of OETT with saline, tint with methylene blue
c. Treating an airway fire
1. Disconnect circuit
2. Remove OETT
3. Reintubate trachea
4. Flush trachea with cold saline
5. Use humidified oxygen
6. Rigid bronchoscopy to check airway for damage and residual endotracheal tube.
7. Consider steroids, mechanical ventilation, and ICU observation.

Front 60

Tonsillectomy Anesthetic goals [3]

Back 60

1. Provide deep general anesthesia to prevent HTN, tachycardia, and arrhythmias.
2. Provide adequate muscle relaxation for mouth gag placement.
3. Rapid recovery with return of protective airway reflexes. (Extubate when awake)

Front 61

Tonsillectomy Preoperative

Back 61

1. Check for loose teeth.
2. Observe size of tonsils.
3. Check for presence of an upper respiratory infection.
4. Ask about aspirin and nonsteroidal anti-inflammatory use.
5. Consider PO/intranasal midazolam premedication for pediatric patients. PO dose .5 mg/kg, Intranasal .2-.3 mg/kg for children > 1year of age.

Front 62

Tonsillectomy Anesthetic technique

Back 62

1. Mask induction with Sevoflurane for children too young for an awake IV start (<12).
2. Follow with an IV after asleep, then intubate either deep using inhalation agent or by using a neuromuscular blocker.
3. Remember to hold the endotracheal tube while the bed is turned 90 degrees and while the surgeon places mouth gag. Chance of extubation is very high at this time. Remember to check breath sounds after the surgeon secures the mouth gag.
4. Maintenance with N2O, narcotic, short acting paralytic, gas.
5. Hydrate with a crystalloid
6. Remember: blood loss can be hard to estimate, may total 5% of total blood volume. Blood loss is much less as more ENT surgeons use the suction bovie technique for tonsillectomy vs. a tonsil snare forceps technique.
7. Extubate in OR when awake and airway reflexes present. Lidocaine at 1-1.5mg/kg can decrease post extubation laryngospasm incidence

Front 63

Tonsillectomy Transport to the PACU

Back 63

1. Tonsil position (side, slight head down)
2. 100% O2 mist

Front 64

tonsillectomy PONV management (can be as high as 70%) [5]

Back 64

1. Suction stomach for blood at the conclusion of the case.
2. Use propofol when possible.
3. Administer prophylactic antiemetic.
4. Appropriate IV hydration.
5. Do not force PO fluids or food.

Front 65

Peritonsillar abscess

Back 65

1. Abscess can cause severe pain, trismus, dysphagia, and respiratory obstruction
2. Surgeon may needle aspirate abscess prior to general anesthesia.
3. Expect difficult intubation due to:
i. Distorted anatomy
ii. Edema
iii. Trismus
4. Airway options if obstruction is expected include:
i. Awake intubation (FOB)
ii. Tracheostomy, especially if stridor is present at rest.

Front 66

Microlaryngoscopy Anesthetic goals [2]

Back 66

1. Provide surgeon with a clear view, immobile field, and adequate room to work.
2. Protect the trachea, ensure adequate ventilation and oxygenation, minimize secretions, and provide rapid awakening with return of protective airway reflexes.

Front 67

Most microsurgical procedures on the larynx can be accomplished around a small ______ endotracheal tube.

Back 67

(6mm)

Front 68

Reduce the incidence of fire in the airway by: [6]

Back 68

1. Maintaining high vigilance and an increased index of suspicion during the case.
2. Keep FIO2 <30% by using air or helium with oxygen.
3. Use laser endotracheal tubes.
4. Only water soluble lubricants on the endotracheal tube.
5. Keep paper drapes away from operative field.
6. Fill cuff of OETT with saline, tint with methylene blue

Front 69

Treating an airway fire [7]

Back 69

1. Disconnect circuit
2. Remove OETT
3. Reintubate trachea
4. Flush trachea with cold saline
5. Use humidified oxygen
6. Rigid bronchoscopy to check airway for damage and residual endotracheal tube.
7. Consider steroids, mechanical ventilation, and ICU observation.

Front 70

Uvulopalatopharyngoplasty (UPPP)
Definition
indications
sleep apnea types

Back 70

a. Definition: tonsillectomy, adenoidectomy, uvulectomy, resection of redundant tissue of soft palate and oral pharynx.
b. Indications:
1. Snoring
2. Sleep apnea (60-70% effective)
c. Sleep apnea types:
1. Central: cessation of air flow and respiratory effort due to decreased neural output
2. Obstructive: cessation of air flow due to upper respiratory obstruction
3. Mixed

Front 71

Uvulopalatopharyngoplasty (UPPP)

Preoperative assessment [4]

Back 71

1. Examine sleep studies, ABG’s
2. Consult cardiology for evaluation of right ventricular hypertrophy/performance
3. Patients are frequently obese so apply the usual aspiration prophylaxis
4. Thorough airway exam. Counsel patient for an awake intubation and possible arterial line.

Front 72

Uvulopalatopharyngoplasty (UPPP)

Intraoperative management

Back 72

1. Do not hesitate to do an awake intubation if questions exist regarding the ability to do a safe asleep induction.
2. Consider the use of an arterial line.
3. Many similarities to the anesthetic management for the tonsillectomy patient.

Front 73

Uvulopalatopharyngoplasty (UPPP)

Postoperative care

Back 73

1. Extubate when awake with intact airway reflexes
2. Overnight stay is a must with the documented sleep apnea patient.

Front 74

______ % of patients have the recurrent laryngeal nerve running through the thyroid fascia or between the arterial branches that supply the thyroid

Back 74

25%

Front 75

An enlarged thyroid gland extends ________. Displacement or impairment of the recurrent laryngeal nerve can occur. The thyroid can also cause deviation and/or compression of the trachea.

Back 75

retro-sternally.

Front 76

___________ places the hyperthyroid patient at increased risk for corneal abrasions. Also, congenital hypothyroidism patients have large tongues causing problems for the anesthetist during mask ventilation and making direct laryngoscopy more difficult.

Back 76

Exophthalmos

Front 77

Do not hesitate to employ invasive blood pressure monitoring if the thyroid gland is large requiring dissection close to the ________ arteries.

Back 77

carotid

Front 78

Usually thyroidectomy cases are ______ in blood loss with virtually no third space fluid losses.

Back 78

low

Front 79

Airway management difficulties are common in patient’s with large goiters. Physical exam, CT scan, or MRI scans should be employed to evaluate the degree of displacement or impingement of the trachea.

Back 79

xxxxxx

Front 80

Evaluate possible preoperative impairment of the vocal cords due to recurrent laryngeal nerve compression. Techniques include indirect mirror exam or direct exam by fiberoptic instruments.

Vocal cord paralysis is caused by bilateral nerve damage and usually produces respiratory compromise.

Back 80

xxxxxxx

Front 81

Nitrous oxide is _____ times more soluble in blood than nitrogen

Back 81

34

Front 82

Middle ear pressure can reach ______mmH20 within 50 minutes of using N2O.

Back 82

375

Front 83

__________ will usually vent the middle ear. Surgery, disease, and edema will decrease tube function.

Back 83

Eustachian tube

Front 84

Once N2O is stopped, a negative middle ear pressure can occur from the gas leaving the middle ear. If used, maintain at <50%.

Back 84

E. Turn off at least 15 minutes prior to closure of the middle ear.

Front 85

Potent inhaled anesthetics at proper MAC provide anesthesia, amnesia, analgesia, and muscle relaxation adequate for surgery of this type. Consider avoiding N2O completely unless the case is a BMT (bilateral myringotomy tubes).

Back 85

xxxxx

Front 86

Control of bleeding during ear surgery...[3]

Back 86

1. Surgical area injected with epinephrine containing local anesthetic solutions.
2. Slight head up position to improve venous drainage can be helpful.
3. Deliberate hypotension (MAP between 60-70 torr).

Front 87

Deliberate hypotension is frequently employed to lower EBL and facilitate surgery. (MAP 55-60 torr) by....

Back 87

i. Volatile inhaled agent.
ii. Head up position to provide better venous drainage
iii. Labetalol boluses and/or esmolol

Consider placing an arterial line to monitor hct., acid/base balance, and blood pressure. Especially indicated for cases greater than 4 hours when using deliberate hypotension.

Front 88

Elective orthognatic surgery

Back 88

a. Patients are generally young and healthy
b. Used to treat dental malocclusion and balance facial proportions.
c. Most common procedure is a sagittal split osteotomy of the mandible (BSSO).
d. LeFort I osteotomies move the maxilla forward or backwards. A combined LeFort/BSSO can be a 5-6 hour surgery.
e. Intubate nasally with a nasal RAE tube to facilitate surgical access. Be sure to avoid pressure of the tip of the nose through out the case.
f. EBL ranges from 300cc to 2,000cc for a LeFort osteotomy. Greatest blood loss is during the down fracture of the maxilla. Autologous blood donation is common.
. Surgeons can easily damage and/or cut the endotracheal tube during the operation. Be vigilant, watch airway pressures, tidal volume, ventilator bellows and expired carbon dioxide measurements. Listen to your precordial stethoscope. Have a back up plan.
j. Insert an NG in the other nare at the beginning of the case to aspirate blood from the stomach.
k. A throat pack is always inserted at the beginning of the case. Document on the patient’s chart. A retained throat pack will cause airway problems after extubation.
l. Monitor the endotracheal cuff pressures throughout the case. This can be accomplished by routinely checking the pilot balloon.
m. Steroids (decadron) may be given for swelling.

Front 89

Extubation after oral surgery

Back 89

a. Patient must be awake, able to swallow, and follow commands. All other extubation criteria must be met as well.
b. If surgery has been >8 hours, deflate cuff, occlude the endotracheal tube, and have the patient breathe around the tube. This allows you to assess for airway edema.
c. Remember, most patients will be in intermandibular fixation, ie. Jaws wired shut with wires or elastic bands. Make sure wire cutters are at the bedside or on the patients chart.

Front 90

Management of facial trauma

Active management of the airway is a must.

Back 90

1. Institute in-line neck stabilization. Do not apply traction.
2. Suction the oral pharynx of blood, dirt, teeth, etc.
3. Oxygenate
4. Attempt oral intubation initially.
5. Do not nasally intubate patients if a cerebrospinal leak is present or if the nasal passages are severely disrupted.
6. Severe facial derangement may mean an emergency tracheotomy.
7. Do not disregard the possibility of a C-spine or intracranial injury. The forces necessary to cause facial trauma usually result in associate injuries.
8. Exercise caution when applying cricoid pressure. The downward pressure can cause flexion on an unstable C-spine.

Front 91

If there is any doubt about the ability to intubate the patient with facial trauma, consider: [5]

Back 91

1. Awake FOB intubation
2. Awake blind technique (oral)
3. Retrograde wire technique
4. Needle cricothyroidotomy with jet ventilation
5. Tracheostomy under local anesthesia

Front 92

Procedures of the nose [7]

Back 92

a. Oral tube, ORAE is a good choice
b. Be sure to use oral suction before extubation
c. Surgeon will usually place splints before he is done.
d. Sometimes nasal packing/ointment is used
e. Protect self/others from the patient coughing up blood
f. Won’t be able to breathe through their nose
g. Surgeon will usually localize first to help decrease bleeding