Intro to the OR, anesthesia set up, crisis management, airway management

Questions and Answers

What level of amperage can cause fatal fibrillation?

1 mA

10 mA

100 mA (correct)

200 mA

What does the oLIM predict regarding current flow?

It predicts potential current flow and when current exceed 2-5 milliAmps and sets an alarm. (correct)

It stops current flow when it exceeds a certain amperage

It predicts current flow is always safe under 2 milliAmps.

It does not monitor current flow.

What should you do if an airway fire occurs?

Stop the flow of O2

Remove the airway

Put out the fire

All of the above prioritizing stopping the flow of O2 (correct)

What conditions increase the risk of intraoperative fire? (Select all that apply)

Open oxygen Signup and view all the answers

What are the preferred fire extinguishers used in the Operating Room (OR)?

CO2 extinguishers Signup and view all the answers

Which of the following items is part of the mandatory airway setup? (Select all that apply)

2 Laryngoscopes Signup and view all the answers

match the drug to the proper syringe size

phenylephrine, succs = 10 cc rocuronium, ephedrine, lidocaine, succs = 5 cc propofol = 20 cc atropine, versed, glycopyrrolate, fentanyl = 3 cc Signup and view all the answers

What percentage deviation from baseline typically indicates hypotension or hypertension?

20% Signup and view all the answers

What is the first sign of hypotension?

Low ETCO2 Signup and view all the answers

Why does bradycardia occur during hypertension?

Increased baroreceptor sensitivity Signup and view all the answers

What types of beta-blockers should be administered to treat intraoperative hypertension?

Short-acting (e.g. esmolol) Signup and view all the answers

When should you treat bradycardia with atropine instead of glycopyrrolate?

Atropine is preferred in cases of acute bradycardia due to vagal stimulation. Signup and view all the answers

If anticholinergics are ineffective at treating bradycardia, what is the next medication to be used?

Epinephrine Signup and view all the answers

You've administered a sedative to a patient prior to laryngoscopy and cannot ventilate. What should you do next?

Attempt airway repositioning Signup and view all the answers

After repositioning the head, if you still can't ventilate, what should you do next?

Insert an airway adjunct Signup and view all the answers

After placing an airway adjunct, and you still can't ventilate, what should you do next?

Initiate a 2-person ventilation technique Signup and view all the answers

If you still cannot ventilate the patient using a two-person technique, what should you do next?

Insert a supraglottic airway (SGA) Signup and view all the answers

What are the treatments for laryngospasm? (Select all that apply)

Positive pressure ventilation up to 60 cmH2O Signup and view all the answers

How can laryngospasm be prevented?

All of the above Signup and view all the answers

ETCO2 may be gone in severe bronchospasm

True Signup and view all the answers

Which of the following are treatments for severe bronchospasm? (Select all that apply)

Albuterol Signup and view all the answers

What are the implications of hypothermia? (Select all that apply)

Increased cardiac strain Signup and view all the answers

What is the initial sign of malignant hyperthermia?

elevated ETCO2 Signup and view all the answers

What effects do increased PEEP and PIP have on blood pressure?

Decrease blood pressure due to increased intrathoracic pressure Signup and view all the answers

What is the typical hemodynamic consequence of stimulation of the carina and bladder distension?

Hypertension Signup and view all the answers

What is the hemodynamic consequence of prolonged tourniquet time?

Hypertension due to accumulation of metabolic waste Signup and view all the answers

Which of the following is commonly seen during intubation and emergence from general anesthesia?

Hypertension Signup and view all the answers

In cases of mild to moderate bronchospasm, how should the anesthetic be titrated to alleviate symptoms?

Deepen anesthetic Signup and view all the answers

If difficulties are anticipated in managing the airway after induction, what type of airway management technique should be performed if no other contraindications exist?

Awake intubation Signup and view all the answers

What is the common cause of an unanticipated difficult airway?

Lingual tonsil hyperplasia Signup and view all the answers

LEMON = Look, Evaluate 3-3-2, Mallampati, Obstruction, Neck Mobility

True Signup and view all the answers

If an invasive airway approach fails in a Can't Intubate, Can't Ventilate (CICV) situation, what is an alternative intervention?

Extracorporeal membrane oxygenation (ECMO) Signup and view all the answers

You've induced a patient and are unable to ventilate after placing an SGA. What intervention should you prepare to perform while pursuing alternative intubation approaches?

Prepare for a cricothyrotomy Signup and view all the answers

What are the disadvantages of awake intubation? Select all that apply.

Increased risk of bronchospasm Signup and view all the answers

In awake intubation, spontaneous ventilation is maintained

True Signup and view all the answers

Patient cooperation is essential to perform an awake intubation.

True Signup and view all the answers

What types of medications are commonly used in awake intubation? (Select all that apply)

Local anesthetics Signup and view all the answers

What is a complication of benzocaine use?

Methemoglobinemia Signup and view all the answers

Lidocaine and mepivacaine are noted for having a ___ onset of action.

rapid Signup and view all the answers

Which local anesthetic is noted for its longer duration of action?

Bupivacaine Signup and view all the answers

Which local anesthetic is noted for its rapid onset and can be used in all areas of the tracheobronchial tree?

Lidocaine Signup and view all the answers

Which anticholinergic drug does not cross the blood-brain barrier or placenta and is noted to have a longer duration of action?

Glycopyrrolate Signup and view all the answers

Which anticholinergic is noted to cause less tachycardia but can cause sedation, amnesia, and euphoria?

Scopolamine Signup and view all the answers

What are the three anatomical areas where local anesthetic (LA) should be placed for awake intubation?

Nasopharynx, Pharynx/Base of Tongue, Larynx/Trachea Signup and view all the answers

From which cranial nerve do the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN) arise?

Cranial Nerve X (Vagus) Signup and view all the answers

What nerve provides sensory information from the area above the vocal cords?

Internal branch of the SLN Signup and view all the answers

What nerve provides sensory information from the area below the vocal cords?

Recurrent laryngeal nerve Signup and view all the answers

Which muscle does the external branch of the superior laryngeal nerve (SLN) innervate?

Cricothyroid Signup and view all the answers

What is the motor innervation of the recurrent laryngeal nerve (RLN)?

Laryngeal muscles except the cricothyroid muscle Signup and view all the answers

At what stage of general anesthesia is laryngospasm most likely to occur?

Stage 2: Excitement/Delirium Signup and view all the answers

What is the sensory innervation of the glossopharyngeal nerve in relation to the airway?

Posterior 1/3 of tongue, rostral epiglottis, pharynx Signup and view all the answers

Which nerve provides sensory information about the larynx?

Recurrent Laryngeal Nerve (RLN) Signup and view all the answers

Which nerve provides sensory information about the vocal cords and dorsal epiglottis?

Internal Branch of the Superior Laryngeal Nerve Signup and view all the answers

Which of the following correctly describes the Greater and Lesser Palatine Nerves? (select 2)

They are branches of the Trigeminal Nerve. Signup and view all the answers

What areas does the Anterior Ethmoidal Nerve innervate and what cranial nerve is it a branch of?

Nares and anterior 1/3 of nasal septum Signup and view all the answers

What nerves must be anesthetized to target the pharynx and base of the tongue?

Glossopharyngeal and Superior Laryngeal Nerve Signup and view all the answers

Which artery should CRNAs be cautious of when performing an invasive oral approach to anesthetizing the nasopharynx?

Sphenopalatine artery Signup and view all the answers

Where is local anesthesia placed to anesthetize the pharynx and base of the tongue?

Palatoglossal arch Signup and view all the answers

What is the landmark used in placing a SLN block?

Greater cornu of the hyoid bone Signup and view all the answers

How should the hyoid be displaced when placing a superior laryngeal nerve (SLN) block?

Medially Signup and view all the answers

Which ligament is the target in a superior laryngeal nerve (SLN) block?

Thyrohyoid ligament Signup and view all the answers

What nerve is anesthetized when placing a local anesthetic in the translaryngeal space?

Recurrent laryngeal nerve (RLN) Signup and view all the answers

Air should be aspirated before injecting LA when anesthetizing the RLN

True Signup and view all the answers

What is a disadvantage of using local anesthesia (LA) through a fiberoptic scope to anesthetize the larynx and trachea?

LA can obscure the lens of the scope Signup and view all the answers

A patient has an anticipated difficult airway but is at a massive risk of aspiration. Is an awake technique appropriate?

True Signup and view all the answers

What should be considered when an awake intubation fails and the patient is hemodynamically stable (non-emergent)?

Regional anesthesia techniques Signup and view all the answers

What are the contraindications for regional anesthesia in patients with difficult airways? (Select all that apply)

Poor airway access Signup and view all the answers

What is a disadvantage of percutaneous cricothyroidotomy?

Exhalation is passive and not able to be controlled Signup and view all the answers

What is a disadvantage of a tracheostomy?

It is not appropriate for emergent situations due to the length of the procedure. Signup and view all the answers

The upper airway must be ____ for percutaneous jet ventilation.

patent Signup and view all the answers

When is retrograde intubation indicated?

Cannot intubate, can ventilate Signup and view all the answers

In which of the following situations is retrograde intubation indicated? (Select all that apply)

Impaired visualization Signup and view all the answers

Which device is best used to assist in the extubation of a difficult airway?

Airway exchange catheter Signup and view all the answers

Which of the following medications should be included in the emergence and recovery plan of a difficult airway? (Select all that apply)

Anti-inflammatory agents Signup and view all the answers

Which of the following is NOT one of the emergence criteria for anesthesia? (Select one)

Increased heart rate Signup and view all the answers

Patients must be breathing spontaneously before extubation

True Signup and view all the answers

What is the recommended pressure to be generated during positive pressure ventilation (PPV)?

<20 - 25 cmH2O Signup and view all the answers

What is the BURP maneuver used for?

To improve the laryngoscopic view by displacing the thyroid cartilage. Signup and view all the answers

What is the maximum amount of pressure used in the Sellick maneuver during RSI?

30 mmHg Signup and view all the answers

What is an alternate form of preoxygenation in the crashing patient?

8 vital capacity breaths over 60 seconds Signup and view all the answers

Patients on ACE inhibitors or ARBs are most likely to present with which intraoperative complication?

Hypotension Signup and view all the answers

Neuraxial anesthesia is most likely to result in which intraoperative complication?

Hypotension Signup and view all the answers

What is an appropriate intervention in the event of an airway obstruction?

Rigid bronchoscopy Signup and view all the answers

What are characteristics of effective teams? (Select all that apply)

Respect Signup and view all the answers

Match the appropriate ASA

ASA 1 = healthy ASA 2 = mild systemic disease ASA 3 = severe disease that is not life-threatenind ASA 4 = severe disease that is life-threatening Signup and view all the answers

What describes a patient that is ASA 5?

A patient who is not expected to survive without surgery Signup and view all the answers

How can an ASA 6 patient be described?

A patient who is declared brain dead and whose organs are being removed for donor purposes Signup and view all the answers

What is a McGrath?

A type of video laryngoscope used for intubation. Signup and view all the answers

Which video laryngoscope has an external monitor separate from the laryngoscope?

Glidescope Signup and view all the answers

What is the target site for anesthetizing the recurrent laryngeal nerve (RLN)?

Cricothyroid membrane Signup and view all the answers

What are the contraindications for an awake intubation? (Select all that apply)

Patient refusal Signup and view all the answers

Which surgical airway technique is recommended for use in pediatric populations (less than 6 years old)?

Percutaneous jet ventilation Signup and view all the answers

What are the advantages of an awake intubation? (Select all that apply)

Decreased risk of aspiration due to airway reflexes being intact Signup and view all the answers

What are the options for extubation of difficult airways? (Select all that apply)

Awake extubation Signup and view all the answers

Study Notes

Electrical Safety in Anesthesia

Amperage levels above 100 mA can cause fatal fibrillation.
oLIM predicts the potential risk of current flow in medical devices.

Fire Safety

If an airway fire occurs, immediately remove the airway device and extinguish the flames.
Conditions that increase the risk of intraoperative fire include the presence of ignition sources, flammable substances, and patient’s body type (obesity).
Preferred fire extinguishers in the Operating Room include Class B and Class C extinguishers.
Mandatory airway setup items include an endotracheal tube, laryngoscope, and suction.

Hemodynamics and Pharmacology

A deviation of 20% from baseline typically indicates hypotension or hypertension.
The first sign of hypotension is often tachycardia.
Bradycardia during hypertension can occur due to baroreceptor reflexes.
Beta-blockers such as metoprolol or labetalol are used to treat intraoperative hypertension.
Atropine should be used to treat bradycardia if heart rate is below 40 bpm or there are signs of hemodynamic instability, rather than glycopyrrolate.

Airway Management in Emergencies

If unable to ventilate after administering sedatives, reposition the airway and reattempt ventilation.
If still unsuccessful, use airway adjuncts before considering alternative ventilation techniques or intubation.
Treatments for laryngospasm include positive pressure ventilation, administering anesthetics, or succinylcholine.
Preventive measures against laryngospasm include ensuring adequate depth of anesthesia and avoiding airway irritation.

Bronchospasm Management

Treatments for severe bronchospasm include bronchodilators like albuterol and corticosteroids.
Hypothermia implications include delayed drug metabolism, increased bleeding risk, and impaired immune response.
Initial sign of malignant hyperthermia is an unexplained rise in end-tidal CO2.

Intubation Techniques and Complications

Increased PEEP and PIP can lead to decreased blood pressure.
Difficult airway management techniques should include preparation for potential hyperextension or use of alternative devices.
If an invasive airway approach fails in a Can't Intubate, Can't Ventilate (CICV) scenario, consider emergency surgical airway techniques.
Patient cooperation is crucial for effective awake intubation, which maintains spontaneous ventilation.

Local Anesthetic Administration

Benzocaine may cause methemoglobinemia as a complication.
Lidocaine and mepivacaine are known for rapid onset of action; bupivacaine has a longer duration.
External branch of the superior laryngeal nerve innervates the cricothyroid muscle.
Structures above the vocal cords are innervated by the internal branch of the superior laryngeal nerve.

Surgical Aspects of Airway Management

Local anesthetics target specific areas for awake intubation: glossopharyngeal nerve, superior laryngeal nerve, and recurrent laryngeal nerve.
The hyoid bone should be displaced posteriorly during an SLN block.
Contraindications for regional anesthesia in difficult airways include patient refusal or uncooperative demeanor.

Recovery Strategies

Patients must be spontaneously breathing prior to extubation; pressure during positive pressure ventilation should be controlled.
The BURP maneuver is used during intubation to manipulate the trachea for better visualization.
Recommended preoxygenation techniques include using high-flow nasal cannula or non-invasive ventilation in crashing patients.

Management of Intraoperative Complications

Patients on ACE inhibitors or ARBs may present with hypotension intra-operatively.
Interventions during airway obstruction may include repositioning the head and utilizing back pressure.

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Description

This exam covers intro the OR and anesthesia set up, basic anesthesia crisis management, and airway management