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