sim lab test 4

4 vasoconstrictors

1% phenylephrine afrin/ oxymetazoline 4%cocaine epi pledget

what are the steps for a jet ventilation

1. induce- and maintain as a TIVA 2. place lma to confirm ventilation and prepare for procedure 3. coordinate with pulm for removal of lma and insertion of bronchoscope 4. after scope insertion hook up jet to adapter 5. squeeze jet handle 6. oxygenation well tolerated 7. ventilation is adequate 8. maintain paralysis 9. reinsert lma 10. confirm spont vent 11. wakeup as normal

process for nasal intubation 11 steps

1. pre warm nasal rae in 500 ml of warmed saline 2. gather equipment 3. determine which nare is more patent 4. vasoconstrict both nares proir to going back to the or 5. educate pt ahead of time about the possiblilty of nose bleeds 6. take pt to or and prep for induction 7. vasoconstrict once more 8. induce 9. sequentially dilate the nares starting with 28 working up to 34 10. lubricate rae ands insert along the floor of the nasal passage 11. advance until rae in inlarynx and perform dl

steps for foi nasal

1. premedicate with antisalagogue 2. preoxygenate with nasal cannula or facemask 3. nebulize lido to anesthetize the airway 4. vasoconstrict and localize the nares 5. tape tube onto bronchoscope 6. insert scope into nare 7. insert to the level of the pharynx and identify and known landmark 8. advance through the glottic opening to near the carina 9. advance ett to appropriate depth and retract scope 10. connect and confirm co2 and induce (propofol very quick induction)

oral foi intubation

1. premedicate with antisalagogue 2. preoxygenate with nasal cannula or facemask 3. nebulize lidocaine to anesthetize airway 4. incrementally spray lido into airway and occasionally check anesthesia by touching the back of the pharynx 5. tape tube onto bronchoscope 6. insert into mouth 7. insert to the level of the pharynx and identify and known landmark 8. advance through the glottic opening to near the carina 9. advance ett to appropriate depth and retract scope 10. connect and confirm co2 and induce (propofol very quick induction)

Red Robinson nasal rae method 7 steps

1. take pt to or and prep for induction 2. vasoconstrict once more prior to intubation 3. induction 4. place cath over murphys eye of ett 5. lube catheter and insert into the patients nare, once seen in oropharynx pull catheter out through the mouth and removed red robinson 6. retract ett into back of the pharynx 7. perform dl and if needed use magills to direct ett into the glottic opening

how many breaths should be given in a minute to an adult?

10 (1 breath every 6 seconds)

what should our respiratory rate be during olv?

12-16 or maybe higher

at what pressure should we keep our jet vent under ideally

15-20, but may need 25-50 to get adequate chest rise

cpr to breath rate for children/ infants in a 2 rescuer scenario

15:2

how much oxygen is delivered in rescue breathing vs if they were to breathe on their own?

17% vs 21%

how many breaths should be given per minute to a child/infant

20-30 (1 breath every 2-3 seconds )

equipment needed for nasal intubation

28-34 nasal trumpet lube magils laryngoscope vasoconstrictor

cpr to breath rate for children/ infants in a 1 rescuer scenario

30:2

what is the compression rate: to breath for adult cpr

30:2

what are the sizes of left dlts?

35-41 only in odds, 35 can have trouble with the scope passing, and 41 is very large.

compression depth for infants? and what is finger placement?

4 cm or 1/3 the depth; just below the nipple line

what should our tidal volume be during olv?

4-6 ml/kg

what is the depth of compression for aldults and children?

5 cm or in kids 1/3 the depth of the chest

what is the smalled recommended ett size with an arndt?

5 fr with a 4.5 ett 7 with a 7 ett 9 with an 8 ett

what should our peep be during olv?

5-10 cmH20

what is the smalled recommended ett size with a ez blocker?

7 ett

what is the smalled recommended ett size with a fuji uniblocker?

8 ett

what is the smalled recommended ett size with a cohen?

8.0 ett

how many time a minute should the jet ventilation handle be squeezed

8/min lasting less than 1 second

6 Hs and 5 Ts of Arrest

Hypothermia Trauma Hypovolemia Toxin Hyper/hpyokalemia Thrombosis Hypoxia Tamponade Hydrogen Ion (acidosis) Tension Pneumothorax Hyper/hypoglycemia

What is hypoxic pulmonary vasoconstriction?

a response where the pulmonary arterioles bringing blood detect hypoxia and respond accordingly with vasoconstriction

each rescue breath must be delivered over: a. 1 second b. 2 seconds c. 3 seconds b. 4 second

a. 1 seconds

what is the position for placement of child aed pads? a. anterolateral b. anteroposterior c. posterolateral d. mediolateral

a. anterolateral

who should perform hands only cpr? a. untrained observers for adults b. untrained observers for children c. trained observers for adults d. trained observers for children

a. untrained observers for adults

which of the following rhythms can be shocked by an automated extenal defibrilator? a. v fib b. a fib c. asystole d. pulseless electrical activity

a. v fib

Relative Contraindications

active profuse bleeding active vomiting uncooperative patient if awake

4 limitations to retrograde intubation

airway polution/ smoke inhalation lack of etco2 measurement bc its not a closed loop possible loss of airway takes one hand to continuously ventilate

indications for foi- adam

anticipate a difficult tracheal intubation anticipate a difficult mask ventilation small mouth opening unstable c spine upper airway trauma (possible false passage) tube placement verification

which blocker uses a wire loop to hold the bronchoscope

arndt

what is the prefered method of foi deep sedation or awake and why?

awake, protects airway reflexes and maintains ventilation

which of the following indicates mild choking a. high pitched noise b. continuous cough c. inability to cy d. cyanosis

b. continuous cough

how many back blows must alternate with chest or abdominal thrusts for choking relief? a. four b. five c. six d. three

b. five

if too much air is delivered to the lung during rescue breathing what is the most likely complication? a. lung collapse b. gastric inflation c. pneumothorax d. brain injury

b. gastric inflation

which of the following is not an immediate life threatening event? a. cardiac arrest b. heart attack c. respiratory arrest d. airway obstruction

b. heart attack

which of the following is an antidote for opioids? a. pethidine b. naloxone c. oxycodone d. felypressin

b. naloxone

how frequently must the aed rhythms must be reassessed? a. one minute b. two minutes c. five minutes d. seven minutes

b. two minutes

when should a recruitment maneuever be performed?

before lung isolation and throughout as needed

what color is the bronchial lumen?

blue

how many chest compressions must be delivered per minute a. 60 b. 80 c. 100 d. 140

c. 100

after how many minute of hands only cpr must rescue breathing be started, if only a single rescuer is present? a. 9 minutes b. 11 minutes c. 13 minutes d. 15 minutes

c. 13 minutes

what is the ideal depth of compression for infants? a. 2 cm b. 3 cm c. 4 cm d. 5 cm

c. 4 cm

what is the minimum depth of chest compressions? a. 2 cm b. 4 cm c. 5 cm d. 6 cm

c. 5 cm

what is the ideal time window for defibrillation to be provided? a. 5 minutes b. 6 minutes c. 8 minutes d. 10 minutes

c. 8 minutes

which of the following organs is irreversibly affected if cpr is delayed beyond three minutes? a. kidney b. liver c. brain d. lungs

c. brain

if a c spine injury is suspected which of the following maneuvers can be used? a. head tilt b. chin lift c. jaw thrust d. roll over

c. jaw thrust

if the patient has and implantable pacemaker, which of the following is the most appropriate action? a. do not use the aed b. place the aed directly on the pacemaker c. place the aed pads away from the pacemaker d. use a magnet to divert energy from the pacemaker

c. place the pads away from the pacemaker

why is recoil necessary between each compression? a. to give rest to the rescuer b. to prevent injury to the patient c. to allow the heart to fill with blood d. to allow blood delivery to the brain

c. to allow the heart to fill with blood

which of the following protocols uses a compression ventilation ratio of 15:2? a. single rescuer for adults b. two rescuer for adults c. two rescuer for children d. single rescuer for children

c. two rescuer for children

which blocker uses a wheel to deflect the tip

cohen

what membrane is pierced in a retrograde intubation

cricothyroid membrane

which of the following groups of individuals can administer bls? a. physician b. emergency medical responders c. trained observers d. all of the above

d. all of the above

hemlich maneuver is not suitable for: a. adults b. pregnant women c. children d. infants

d. infants

which cpr technique is best for infants? a. one handed b. two handed c. two finger d. two thumb encircling hands

d. two thumb encircling hands

which of the following is not a sign of poor perfusion? a. weak pulse b. cyanosis c. pale skin d. warm extremities

d. warm extremities

what is the gold standard for bronchial blocker/ dlt placement

direct visualization via thoracotomy

equipment needs for dlt

dlt tube clamp bronchoscope adapters/ defog stethescope tube holder y piece to connect to our circuit

during dlt what should our fio2 be?

during induction and early maintenance 1.0 if we can reduce it we should

other measures to help with hypoxemia

ensure co is optimal ensure >1 mac to optimize hypoxic pulm vasoconstriction and V/Q mismatch venovenous ecmo

complications of nasal intubation (5)

epistaxis fractured turbinates avulsed nasal polyps septal abcess avulsed adenoids

which blocker is shaped like a crows foot and is set right over the carina and inflated

ez blocker

which blocker has a pre shaped tip?

fuji uniblocker

what and when should our antisalagogue be administered?

glyco or atropine 0.2 mg 15-20 min

contraindications to nasal intubation (6)

hx of new or old basal skull fracture pituitary tumor meningiomas chordomas trigeminal nueralgia surgery nuero procedures invoving the skull base

indications for dlt

infection bleeding bronchopulmonary fistula cyst hypoxia due to unilateral lung process

what is an alternative use for the suction port

insufflating o2 to blow secretions out of the way

what equipment is needed for a jet ventilation

jet vent good o2 check with surgical team that rigid bronchoscope is ready and all pieces are accounted for

which way do we turn the scope to go left vs right

l- counterclockwise r- clockwise

What are absolute contraindications to foi?

lack of time laryngeal trauma (cricothyroid seperation)

what is a potentially fatal complication following ENT surgeries if the jaw is wired shut?

leaving a throat pack in

which bronchus is longer and comes off at more of an angle?

left at around 5cm

bronchial blockers are preferred for lung or lobe isolation?

lobe

what is something we need to be mindful of with foi

local amounts, as we could quickly reach toxicity

extra indications for foi- book

micrognathia, mandibular fracture, papilloma, supraglotitis, hx of head and neck radiation, trismus, craniofacial abnormality

4 issues with prolonged nasal intubation

nasal damage local abcess otitis media sinusitis

indications for nasal intubation

oral route not possible, (jaw wired shut, severe swelling in oral cavity) impedance: dental surgery and omfs

what groups are at risk for lung injury during OLV?

preexisting lung disease, pneumonectomy, lung transplant

what vent mode should be used on patients who are at risk for lung injury?

pressure control

what must we do prior to retrograde intubation

proper mask ventilation and good pre oxygenation

3 indications for retrograde intubation

removal of lesion eval of airway dynamics removal of foreign bodies

what is used for a supraglottic jet vent

rigid bronchoscope accessory port

what right dlt has the oblique style vs the murpheys eye and what is one difficulty with the right sided tube

sheridan- murphy mallikroft, portex, rusch all the oblique style have to be placed perfectly otherwise we might go past the rul

how is subglottic jet ventilation completed?

small cath introduced through glottis or transtracheal through cricothyroid membrane

what are the 4 channels on the end of a bronchoscope

suction, channel outlet, light guide, objective lens

2 types of jet ventilation

supraglottic subglottic

management of hypoxemia is the surgical lung

surgical lung- 1-2 l/min via a suction catheter after a partial recruitment measure (followed by cpap 1-2 cm H2O) intermittent positive pressure vent oxygen insufflation with bronchoscope selective lobar collapse using a bronchial blocker small tidal volumes mechanical restriction of blood flow (clamp pulm art)

what is a recruitment maneuver

sustained peep used to pop open collapsed airways

where is the mercedes sign and what is it an indication of?

that you are in the right lobe, as you can see the rul, rml, and rll

what can affect how many ports we have on our bronchoscope?

the diameter, as the scope gets smaller we lose ports

whats our goal for Pco2 during onlv

there will be hypercapnia, we just need to keep our ph above 7.2

procedures that require dlt

thoracic aortic anuerism lung resection thoroscopy esophageal surgery single side pulm transplant rib fixation- 4,5,6 ribs thoracic spine surg, ant approach

what muscle identifies the posterior side of the pharynx

trachealis- longitudinal fibers

management of hypoxemia in the ventilated lung

vent- 1.0 fio2 confirm position of dlt recruitment maneuever apply peep (except in those with hx of emphysema)

if the jaw is wired shut what should always go with the patient to pacu?

wire cutters