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Where is the upper esophageal sphincter??? What is its job??
at the lower edge of the hypopharynx
acts as barrier to regurgitation
What is CN 7 and what does it innervate??
innervates taste on the anterior 2/3 of the tongue
What is CN 9? What does it innervate??
- -sensory and taste to the posterior 1/3 of tongue & pharynx
- -sensory to tonsils, pillars, oropharyngeal mucosa
- -Gag reflex
What is CN 10?? It divides into two parts.. what are they??
divides into superior laryngeal nerve and recurrent laryngeal nerve
What does the superior laryngeal nerve innervate??
internal division --- sensory info above the vocal cords
external division --- cricothyroid muscles
What does the recurrent laryngeal nerve innervate?
- sensory below vocal cords &
- all musculature of larynx except above the cicrothyroid
What is CN 12?? and what does it innervate?
motor function of tongue
Together what do CN 9, 10 and 11 do...
innervate all the muscles of the pharynx, larynx and soft palate
Unilateral injury to the recurrent laryngeal nerves causes what??
Bilateral injury to the recurrent laryngeal nerve causes what??
stridor, resp. distress from unopposed adduction and tension of the cricothyroid muscles-- (Come together and you can't get them apart)
The larynx extends from _____ to _____.
epiglottis to cricoid cartlidge
What are the 3 single and paired cartilages of the larynx??
- 3 single --- cricoid, thyroid, epiglottic
- 3 paired --- arytenoids, corniculate, cuneiform
What are the only cartilages that are completely circular??? What are the rest of the cartilages shaped like??
What is the carina???
the point at which the left and right main stem bronchi divide
Where does the trachea begin and end?
at the cricoid cartilage and ends at the carina
What kind of cartilage is the trachea composed of??
c-shaped cartilage anteriorly
What is the angle of the right mainstem??? left mainstem???
What are the Han's Mask Ventilation classifications???
- 0 = ventilation by mask not attempted
- 1 = ventilated by mask
- 2 = ventilated by mask with oral airway or other adjuvant
- 3 = difficult mask ventilation (inadequate, unstable or requiring two people)
- 4 = unable to mask ventilate
Name some predictors of a DIFFICULT MASK ventilation...
- NG tube
- facial hair
- edentulous (no teeth)
- OSA (obstructive sleep apnea)
- abnormal anatomy (tonsils, tumors, radiation)
Easy--- soft palate, fauces, uvula, and anterior and posterior tonsilar pillars seen
Possibly difficult --- tonsillary pillars hidden by tongue
Probably difficult --- only base of uvula seen
Very difficult --- even uvula not visualized
If you can not ventilate a patient, you can not ____ a patient.
When you intubate a patient you want them to be in the _____ position.
head flex to 35 degrees, extended to 80 degrees
What are some signs you will notice if you patient is not receiving adequate ventilation??
air leaking, cyanosis, decreased O2 sat, absent breath sounds, gastric distension (blowing air into belly)
How would you define a difficult intubation??
- 1. best attempt by a reasonably experienced anesthetist fails
- 2. usually 3 attempts at this
- 3. greater than 10 mins of struggle
If you expect a patient to be a difficult intubation it is most important to remember that your.....
1st shot is the best shot!!!
What is cricoid pressure?
increased pressure placed in the cricoid area to prevent regurg... this doesn't help you see things just prevents aspiration
If cords are not in view what should you aim for??
bubbles -- lets you know this is where the opening is
What is OELM? What does it mean??
optimal esophageal laryngeal manipulation
- posterior, cephalad pressure on the larynx
- can improve visualization by a whole grade
means you're doing external manipulation to make the vocal cords bubble
What is BURP??? what does it mean???
Backwards, upwards, rightwards pressure
means -- to get things more into a view where you can see!
What are some AIRWAY characteristics of a difficult intubation???
- decreased mouth opening
- short thyromental distance
- poor visualization of hypopharynx
- limited neck extension
Remember... GOOD ASSESSMENT LEADS TO GREATER PREDICTABILITY. GREATER PREDICTABILITY LEADS TO A BETTER OUTCOME!!
You want the mouth opening to be > than???
2 cm or 3 fingerbreadths
What should the thyromental distance be??
>6cm or 3 fingerbreadths
Name some techniques you should think about when you know a patient will be difficult to ventilate...
- 1. oral/nasal adjuncts (think about this first)
- 2. two person mask
- 3. laryngeal mask
- 4. combitube
- 5. rigid ventilating bronchoscope
- 6. transtracheal jet ventilation (using 100% o2, trying to oxygenate not ventilate)
- 7. invasive airway access (trach)
What are some things you can do when you need to intubate someone who you know will be difficult....
- 1. use alternative laryngoscope blades
- 2. use fiberoptic intubation
- 3. blind intubations (patient must be spontaneously breathing)
- 4. LMA conduit
- 5. light wand
- 6. retrograde wire
- 7. invasive airway access
LMAs do not protect the patient from....
aspiration and regurg
Where should the tip of your LMA sit??
tip of cuff rests in inferior recess of hypopharynx above esophageal sphincter
sides of cuff face into pyriform fossae
upper borders of lma rest against the base of the tongue
What are 3 keys to success with LMA placement??
- 1. get the tongue out of the way (give them a big dose of diprivan)
- 2. lubricate LMA (NO LIDOCAINE)
- 3. put pressure on hard palate to help slide LMA in
What are 3 limitations of using an LMA??
- 1. it is temporary
- 2. does not protect against regurg and aspiration
- 3. long term use can lead to supraglottic swelling
What is the kink test??
bending of the LMA to make sure the tube doesn't collapse when it is inserted
this is only used for classic and unique LMAs
Peirre Robin Syndrome
- severe micrognathia- bird mouth
- cleft palate
- gossoptosis- tongue pulled into mouth
Treacher Collins syndrome
- -choanal atresia
- patient missing bones in face
- problem with nasal overgrowth of bone, often die at birth if noes is completely occluded.
- non-cancerous lymphatic tumors
- Enlarged tongue
- palatal deformity
- anterior airway
*Difficult even if airway has been repaired, people with high palates also may be diff intubation b/c nothing to anchor onto
- large tongue
- large head
- instable spines, hard to get into good sniffing position.
Frontonasal auricular deformity
trached at birth
- soft tissue overgrowth of tongue, pharynx
- polypoid masses
- large lower mandible (difficult mask fits)** may want to mask
- airway emergency
- -diffuse supraglottic swelling
- distorted anatomy
* not as common anymore b/c of vaccinations
- aorta arch anomalies
- tracheal-esophageal fistulas
- mechanical ventilation
- Most common cause of stridor in babies
- -usually in NM disease
When testing cuff inflation sizes on LMA how much air should you put in cuff?
50% more than you normally inflate cuff
- size 1=6 cc (4 normal)
- size 2=15 cc (10 normal)
- size 3=30 cc (20 normal)
- size 4= 45cc (30 normal)
- size 5= 60 cc (40 normal)
- size 6= 75 cc (50 normal)
- designed for positive ventilation pressure up to 30 cm H20
- -gastric drain tube
- -built in bite block
-used for NG tube
LMA fast trach
Intubating LMA- look for 15 cm depth marker, lift handle 2-5 cm as ETT is advanced
handle- single handed insertion from any position
- Reinforced tube
- epiglottic elevating bar
- wider- accepts #8 cuffed ETT
- no fingers in airway
What is recommended when doing an intubation through a fasttrach LMA
fiber optic always recommended