Otterbein/Grant CRNA Basics Midterm Review Pre-OP And Airway

Elective surgeries are typically cancelled for BP greater than or equal to 180/110 mmHg.

Pursuing an emergency surgical airway is the correct answer because the patient is unable to be intubated or ventilated, and the administration of Pancuronium, a paralytic agent with a long duration of action, further complicates the situation. An emergency surgical airway, such as a cricothyroidotomy or tracheostomy, may be necessary to establish a patent airway and ensure the patient's oxygenation and ventilation. Calling an attorney, administering more sedation, or waiting for the Pancuronium to wear off are not appropriate actions in this critical scenario.

The correct answer is to immediately remove the airway and discontinue O2. This action is necessary to prevent further injury to the patient and to extinguish the flames. Continuing to administer oxygen would only fuel the fire and increase the risk of harm. Removing the airway allows for the patient to breathe without the burning tube obstructing their airway.

The proper sequence of Rapid Sequence Intubation (RSI) is to first preoxygenate the patient without positive pressure ventilation, then administer drugs, apply cricoid pressure, and finally achieve successful intubation. This sequence ensures that the patient is adequately oxygenated before the administration of drugs, which can cause respiratory depression. Cricoid pressure is applied to prevent aspiration during intubation. Successful intubation is the final step in securing the patient's airway.

A contraindication to nasal intubation means a condition or factor that would make nasal intubation unsafe or not recommended. In this case, the correct answer is "A 20 year old patient undergoing jaw surgery." This is because undergoing jaw surgery does not pose a risk or contraindication to nasal intubation. The other options, such as a basilar skull fracture, active profuse epistaxis, and taking Coumadin with a high INR, all have potential complications or risks that would make nasal intubation unsafe or contraindicated.

A wide palate is not an indicator of a difficult airway because it allows for more space and easier passage of air. On the other hand, a large tongue, high-arched narrow palate, and large teeth can all contribute to a difficult airway by obstructing the air passage or making it harder to insert an airway device.

All of the given options are indications for awake intubation. History of difficult intubation suggests that the patient may have anatomical or physiological factors that make intubation challenging under general anesthesia. A neck mass can obstruct the airway and make intubation difficult, requiring awake intubation. High aspiration risk indicates that the patient is at a higher risk of regurgitation and aspiration during intubation, making awake intubation a safer option. Lastly, a cervical collar in place suggests that the patient may have a cervical spine injury, which requires caution during intubation and may necessitate awake intubation.

Based on the given information, the patient is a healthy 28-year-old smoker. ASA classification is a system used to assess the overall health of a patient before anesthesia. ASA 1 represents a healthy patient with no systemic diseases, ASA 2 represents a patient with mild systemic disease, ASA 3 represents a patient with severe systemic disease, and ASA 1E represents a patient who is brain-dead but whose organs are being used for transplantation. Since the patient is a smoker, they have a mild systemic disease, which corresponds to ASA 2 classification.

High risk of aspiration.

The glossopharyngeal nerve is responsible for providing sensation to the posterior 1/3 of the tongue, the roof of the pharynx, tonsils, and the undersurface of the soft palate. It also plays a role in the afferent signal of the gag reflex. This nerve is therefore the correct answer because it is the one that provides sensation to these specific areas and is involved in the gag reflex.

A pre-operative chest x-ray is typically done to evaluate the condition of the lungs and thoracic cavity before surgery. It helps to identify any abnormalities or conditions that may affect the safety or success of the procedure. In this case, a history of well-controlled asthma is not an indicator for a pre-operative chest x-ray. Asthma is a chronic respiratory condition, but if it is well-controlled and not causing any acute symptoms or complications, it does not necessarily require a chest x-ray before surgery.

A fire in the operating room (OR) requires three elements known as the fire triangle: a source of ignition, a flammable agent, and a gas that supports combustion. The use of high FGF (fresh gas flow) refers to the amount of gas delivered to the patient during anesthesia, which can contribute to the flammability of the atmosphere in the OR. Therefore, the use of high FGF is necessary for a fire to occur in the OR, making it the exception among the given options.

A Bovie is a device used in surgery that emits electrical current to cut or coagulate tissue. The electrical current from a Bovie can interfere with the function of an automatic implantable cardioverter-defibrillator (AICD), which is a device implanted in the chest to monitor and regulate the heart's rhythm. Therefore, it is necessary to deactivate the AICD when a surgeon plans on using a Bovie to prevent any potential interference or harm to the patient.

Continuous etCO2 monitoring of 40 for >3-5 breaths is the most reliable indicator of successful ETT placement because it confirms proper ventilation and end-tidal carbon dioxide levels. This indicates that the endotracheal tube is correctly positioned in the trachea, allowing for effective exchange of gases. O2 saturation and tube condensation can provide some information about ETT placement, but they are not as accurate or reliable as continuous etCO2 monitoring. The initial color change on a CO2 detector may indicate ETT placement, but it does not provide ongoing confirmation of proper ventilation.

The correct answer is 0800. Anesthesia is generally recommended to be performed on a fasting patient to reduce the risk of aspiration. For infants, it is recommended to fast for at least 4 hours for breast milk. Since the child last breastfed at 0400, the earliest safe time to induce the child would be 0800, which allows for a 4-hour fasting period.

Increased bleeding.

The cricoid cartilage is the only option in the list that is not paired. The arytenoid cartilages, corniculate cartilages, and cuneiform cartilages are all paired structures in the larynx. The cricoid cartilage, on the other hand, is a single, unpaired cartilage that forms a ring-shaped structure in the lower part of the larynx. It connects the thyroid cartilage above and the trachea below, providing support and maintaining the shape of the larynx.

Severe aortic stenosis poses the greatest risk for patients undergoing anesthesia and is associated with a 14-fold increase risk of perioperative sudden death. Aortic stenosis is a condition where the aortic valve becomes narrowed, leading to restricted blood flow from the heart to the rest of the body. Severe aortic stenosis can cause significant strain on the heart and can lead to complications during anesthesia, such as decreased cardiac output and sudden cardiac events. Therefore, patients with severe aortic stenosis require careful monitoring and management during anesthesia to minimize the risk of adverse events.

In this scenario, the correct next intervention would be to attempt ventilation with an LMA or combitube that is kept in the backstand. This is because the initial attempts at intubation were unsuccessful and the patient is now experiencing desaturation. Using an LMA or combitube can provide a temporary airway and ensure adequate ventilation while further interventions are planned. Administering more sedation/paralytic and reattempting intubation may not be effective in this situation and placing a surgical airway would be a more invasive and last resort option.

Patients with Type 1 diabetes mellitus should take 1/3-1/2 of their intermediate to long acting insulin dose on the morning of surgery. This is because they will be NPO (nothing by mouth) and not eating on the day of surgery, which can lead to hypoglycemia if they take their full dose of insulin. Taking a reduced dose helps to prevent hypoglycemia while still providing some insulin coverage to maintain blood glucose levels.

When utilizing transtracheal JET ventilation, it is important to remember that expiration is passive and requires a normal airway. Ignoring this fact could result in air trapping/barotrauma. This means that during transtracheal JET ventilation, the air naturally flows out of the lungs without any active effort, and this process relies on a normal airway. If this is not taken into consideration, it can lead to the accumulation of air in the lungs, causing air trapping and potentially damaging the lung tissues.

Patients with COPD are not at risk for delayed gastric emptying. Delayed gastric emptying, also known as gastroparesis, is a condition where the stomach takes longer than normal to empty its contents into the small intestine. It is commonly seen in patients with obesity and diabetes mellitus due to various factors such as nerve damage and hormonal imbalances. However, a gunshot wound to the leg or COPD does not directly affect gastric emptying.

Performing a needle-puncture cricothyrotomy involves creating an emergency airway by puncturing the cricothyroid membrane. This procedure is typically done in situations where traditional methods of intubation are not feasible or have failed. The necessary supplies for this procedure include a 14g IV catheter to puncture the membrane, the barrel of a 3 mL syringe to provide a stable handle for the catheter, and an oxygen supply to ensure the patient receives adequate oxygenation. Ultrasound guidance is not typically used for needle-puncture cricothyrotomy, as it is a relatively simple and quick procedure that does not require visualization with ultrasound.

The correct answer is "Glossopharyngeal" because the given description states that the block is placed at the posterior of the lower palate at the gutter of the floor of the mouth, affecting the lingual branch of the glossopharyngeal nerve. The glossopharyngeal nerve innervates the base of the tongue, the epiglottis, and part of the posterior pharynx.

A short thyromental distance refers to a distance that is less than 6 cm or 3 ordinary fingerbreadths. This measurement is considered ideal for intubation because it indicates that the anterior larynx is at a more acute angle and there is less space for the tongue to be compressed during laryngoscopy. Additionally, a short thyromental distance is also an indicator of a difficult airway, suggesting that intubation may be more challenging in such cases.

When a patient experiences acute respiratory distress with loud stridor after extubation, it suggests damage to the bilateral recurrent laryngeal nerve. The recurrent laryngeal nerve innervates the muscles responsible for vocal cord movement, and its damage can lead to vocal cord paralysis. Bilateral damage to this nerve can cause both vocal cords to be paralyzed and lead to severe respiratory distress and stridor.

Pediatric OR's are typically kept at 75F (24C) while adults are 68-72F.

Left is most common

4/4 twitched w/no fade.

The recurrent laryngeal nerve is the correct answer because it provides sensory innervation below the vocal cords and motor control to all intrinsic muscles of the larynx except the cricothyroid muscle. The other options do not fit this description. The spinal accessory nerve is not involved in innervating the larynx, and the superior laryngeal nerve, both internal and external branches, do not provide motor control to the intrinsic muscles of the larynx.

Convection is the correct answer because it involves the transfer of heat through the movement of air currents around the body. In the operating room, where there may be various equipment and people moving, air currents can carry away heat from the body, resulting in heat loss. This process is considered the second largest source of heat loss in the operating room, making convection the most appropriate answer.

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The correct answer is retrograde intubation. Retrograde intubation is a procedure where a guide wire is passed through the cricothyroid membrane and directed cephalad, then a catheter is inserted through the membrane and the guide wire is passed through it to the nose/mouth. This technique allows for intubation in cases where traditional methods are difficult or impossible, such as in patients with difficult airways or upper airway obstruction.

The LMA does not provide a protected airway.

Radiation is the type of heat loss that has the greatest effect on a patient's temperature in the operating room. Radiation occurs when heat is transferred through electromagnetic waves, such as infrared radiation. In the OR, patients may lose heat to the surrounding environment through radiation, as the body's heat is emitted as infrared radiation. This can be exacerbated by factors such as cool room temperatures and exposed surfaces. Convection, conduction, and evaporation also contribute to heat loss in the OR, but radiation is the most significant factor.

Fiberoptic intubations are contraindicated in cases of epiglottitis. This is because epiglottitis is an inflammation of the epiglottis, which can cause swelling and obstruction of the airway. Performing a fiberoptic intubation in such cases can worsen the condition and lead to further airway obstruction. Therefore, it is important to avoid fiberoptic intubations in patients with epiglottitis and consider alternative methods for securing the airway.

The lateral cricoarytenoid is the intrinsic muscle of the larynx that adducts the vocal cords. Adduction refers to the movement of bringing the vocal cords together, which is necessary for phonation or producing sound. The posterior cricoarytenoid muscle is responsible for abduction, or moving the vocal cords apart, while the thyroarytenoid and arytenoid muscles have different functions in controlling tension and position of the vocal cords.

Cocaine is the correct answer because it is a topical anesthetic that causes local anesthesia and vasoconstriction. However, it should be used with extreme caution in patients with known coronary artery disease, hypertension (HTN), pseudocholinesterase deficiency, preeclampsia, and hyperthyroidism. The maximum dose of cocaine is 200 mg or 1 mg/kg.

The correct answer is Spenopalatine because the given explanation states that the nerve block requires an angled needle to be inserted into the greater palatine foramen of the upper posterior palate. This block affects the greater and lesser palatine nerves, which provide sensation to nasal turbinates and the posterior 2/3 of the septum. Therefore, the spenopalatine nerve block is the most suitable option for this scenario.

The correct answer is 20% because ANSI/ASHRAE/ASHE standard 170 reduced the required humidity percentage in the operating room to 20%. This means that the operating room must maintain a humidity level of 20% in order to comply with the standard.

The correct answer is 6 mL. When intubating a patient, it is important to inflate the cuff of the endotracheal tube to ensure a proper seal. The recommended amount of air to inject into the cuff is usually around 6 mL. This amount is typically sufficient to create a seal without overinflating the cuff, which can lead to complications such as tracheal damage or pressure necrosis. It is important to check the cuff pressure regularly and adjust the volume as needed to maintain an appropriate seal.

To decrease carboxyhemoglobin levels, a smoker should refrain from smoking for 48 hours. Carboxyhemoglobin is formed when carbon monoxide binds to hemoglobin in the blood, reducing its ability to carry oxygen. By abstaining from smoking for 48 hours, the smoker allows their body to eliminate the carbon monoxide and restore normal oxygen-carrying capacity in the blood.

The maximum amount of electrical leakage in the operating room (OR) is 10 mA. This means that any electrical equipment or devices in the OR should not exceed this limit to ensure the safety of patients and medical staff. Maintaining a low electrical leakage is crucial to prevent electrical shocks or accidents during surgical procedures.

The greatest risk factor for post-operative pulmonary complications is surgical incision location. This is because the location of the incision can affect the respiratory system, leading to complications such as pneumonia or atelectasis. Obesity, a history of smoking, and a history of asthma are also risk factors for post-operative pulmonary complications, but they are not considered to be the greatest risk factor in comparison to surgical incision location.

Prolonging the pre-op NPO (nothing by mouth) period will not reduce the risk of aspiration during intubation. Aspiration occurs when stomach contents, including gastric acid and bacteria, enter the lungs. RSI (rapid sequence intubation) is a technique used to secure the airway quickly and minimize the risk of aspiration. Metoclopramide is a gastrokinetic agent that increases gastric emptying and reduces the risk of aspiration. Ranitidine is an H2 receptor antagonist that decreases gastric acid production and also helps reduce the risk of aspiration. Therefore, prolonging the pre-op NPO period does not have any direct effect on reducing the risk of aspiration during intubation.

A tracheotomy is a surgical procedure in which an incision is made in the trachea to create an opening for breathing. The trachea is made up of several rings of cartilage, and the level at which the tracheotomy is performed is important for proper placement of the incision. In this case, the tracheotomy is performed below the isthmus of the thyroid, which is located between the 4th and 6th tracheal rings. Therefore, the correct answer is 4th and 6th.

Patients are most likely to reinfarct in the 30 days following the acute event, typically occurs post-operatively.

The patient undergoing major surgery must have their history and physical and lab draws completed within 1 month or 4 weeks prior to the date of surgery. This ensures that the necessary tests and evaluations are up to date and accurate before the surgery takes place.

The external branch of the superior laryngeal nerve is responsible for providing motor control to the cricothyroid muscle. This muscle is important for vocalization as it tenses the vocal cords, allowing for changes in pitch and voice production. The recurrent laryngeal nerve is responsible for innervating the intrinsic muscles of the larynx, while the glossopharyngeal nerve is involved in taste sensation and swallowing. The internal branch of the superior laryngeal nerve is responsible for providing sensory innervation to the larynx.

This describes the superior laryngeal nerve block