<\/p>\n
<\/p>\n
Additional Information on Airways<\/p>\n
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Recognition of difficult airway and preoperative evaluation: divided into 11 steps; clinician\u0092s eyes must first focus on teeth, then mouth, oropharyngeal space, mandibular space, and neck; follows line of sight needed when placing laryngoscope blade<\/p>\n
1) determine whether maxillary teeth (in involuntary state) lie anterior to mandibular teeth (ie, maxillary teeth \u0093buck\u0094 on mandibular teeth); forces laryngoscope blade to enter mouth in more cephalad direction than normal; requires seeing around greater radius of curvature;<\/p>\n
2) note length of upper incisors (long upper incisors force laryngoscope blade to enter mouth in more cephalad direction than normal, increasing size of curve);<\/p>\n
3) determine whether (in voluntary state) patient can bring mandibular teeth anterior to maxillary teeth (ie, able to prognath); indicates temporomandibular joint not frozen and jaw able to move forward, moving tongue into position to be moved aside during intubation;<\/p>\n
4) determine inter-incisor distance (greater than or equal to 3 cm required to get laryngoscope blade into mouth without hitting teeth) Pharyngeal structures:<\/p>\n
5) ability to visualize uvula and tonsillar pillars indicates tongue small relative to size of pharyngeal cavity (therefore relatively easy to move tongue out of line of sight during laryngoscopy; does not necessarily indicate easy intubation); large tongue obscures pharyngeal structures;<\/p>\n
6) determine height and narrowness of palate (highly arched and narrow palate can cause intubation difficulty due to smaller oropharyngeal volume)<\/p>\n
7) determine thyromental distance (ie, distance between inside of mandible and thyroid notch); index of degree vocal cords anterior or posterior relative to other upper airway structures (vocal cords lie directly under midpoint of thyroid cartilage); if thyroid notch very posterior, indicates vocal cords under midpoint lie relatively posterior and relatively straight line from incisors to cords; greater than or equal to 3 fingerbreadths (ie, 6 cm) between inside of mandible and thyroid notch indicates vocal cords posterior, and line of sight relatively straight;<\/p>\n
8) determine compliance and distensibility of submandibular space; laryngoscopy retracts tongue into mandibular space; mandibular space made noncompliant by, eg, inflammation, fibrosis, radiation, infection, cancer, edema<\/p>\n
9) qualitative determination; short neck causes intubation difficulty (vocal cords ride relatively high in neck; sharp radius of curvature; lining up angles more difficult); many short-neck syndromes (eg, Klippel-Feil syndrome)<\/p>\n
10) qualitative determination; thick neck decreases ability to align upper airway planes<\/p>\n
11) of head and neck; determine whether patient can assume sniffing position (involves 35\u00b0 flexion of neck on chest; head severely extended (approximately 90\u00b0) on neck at atlanto-occipital joint)<\/p>\n
20 to 30 sec required for thorough and complete preoperative evaluation; necessary to have \u0093prepared and educated mind\u0094<\/p>\n
<\/p>\n
The 6-D method of airway assessment*<\/a>Sign of difficulty Description Quantitative or qualitative findings reported to be associated with difficulty Acceptable findings not usually associated with difficulty 1. Disproportion \u0097Increased size of tongue in relation to pharyngeal size \u0097Mallampati class III or IV \u0097Mallampati class I or II \u00a0 \u0097Airway swelling \u0097Possibly difficult to assess \u00a0 \u00a0 \u0097Airway trauma (blunt or penetrating) \u0097Blunt or penetrating airway trauma \u0097Midline trachea \u00a0 \u0097Tissue consolidation (e.g., secondary to radiation) \u0097Tracheal deviation \u0097No contractures of the neck \u00a0 \u00a0 \u0097Neck asymmetry \u0097No surgical airway scar 2. Distortion \u0097Neck mass \u0097Voice changes \u0097Mobile laryngeal anatomy \u00a0 \u0097Neck hematoma \u0097Subcutaneous emphysema (crepitus) \u0097Easily palpated thyroid cartilage \u00a0 \u0097Neck abscess \u0097Laryngeal immobility \u0097Easily palpated cricoid cartilage \u00a0 \u0097Arthritic changes in the neck joints \u0097Nonpalpable thyroid cartilage \u00a0 \u00a0 \u0097Previous surgical airway \u0097Nonpalpable cricoid cartilage \u00a0 3. Decreased thyromental distance \u0097Anterior larynx and decreased mandibular space \u0097Thyromental distance >7 cm (\u00983 finger breadths) measured from the superior aspect of the thyroid cartilage to the tip of the chin \u0097Thyromental distance \u22657 cm (-3 finger breadths) \u00a0 \u00a0 \u0097Receding chin \u0097No receding chin 4. Decreased interincisor gap \u0097Reduced mouth opening \u0097Distance between upper and lower incisors (i.e., interincisor gap) <4 cm (<2 finger breadths) \u0097Interincisor gap <4 cm (-2 finger breadths) \u00a0 \u00a0 \u0097Mandibular condyle fracture \u00a0 \u00a0 \u00a0 \u0097Rigid cervical spine collar \u00a0 5. Decreased range of motion in any or all of the joints of the airway (i.e., atlanto-occipital joint, temporomandibular joints, cervical spine); atlantooccipital range of motion is critical for assuming the sniffing position \u0097Limited head extension secondary to arthritis, diabetes, or other diseases \u0097Head extension <35\u00b0 \u0097Head extension \u226535\u00b0 of atlanto-occipital extension \u00a0 \u0097Previous neck radiation and\/or radical surgery \u0097Neck flexion <35\u00b0 \u0097Cervical spine flexion \u226535\u00b0 \u00a0 \u0097Neck contractures secondary to burns or trauma \u0097Short, thick neck \u0097Long, thin neck \u00a0 \u00a0 \u0097Cervical spine collar or cervical spine immobilization \u0097No cervical spine collar or cervical spine immobilization 6. Dental overbite \u0097Large angled teeth disrupting the alignment of the airway axes and possibly decreasing the interincisor gap \u0097Dental overbite \u0097No dental overbite<\/p>\n *Based on references 16<\/a>\u009618<\/a>, 21<\/a>. The 6-D method of airway assessment helps practitioners remember to assess for each of the six signs that can be associated with a difficult intubation. Each sign begins with the letter D like the word difficult<\/em>. The potential for difficult intubation is generally proportional to the number of signs observed. (Baylor Proceedings)<\/p>\n have patient bite their upper lip (Khan ZH, Gharabaghian M, Ferozeh N, Ghiamat M, Mohammadi M. Easy endotracheal intubation of a patient suffering from both Cushing’s and Nelson’s Syndromes predicted by the upper lip bite test despite a Mallampati class 4 airway. Anesth Analg 2007;105:786\u00967)<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 In children less than 10 years old to prevent Sux induced Bradycardia<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 In adults and kids>10 y\/o, who receive repeat Sux, for the same reason<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 As an antisalagogue if using Ketamine (can also use glycopyrolate 0.2 mg)<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 0.02 mg\/kg<\/p>\n Can J Anaesth. 1998 Jun;45(6):521-5. Rocuronium is the best non-depolarizing relaxant to prevent succinylcholine fasciculations and myalgia. double blind randomized study, 120 female patients CONCLUSION: Among the pretreatments tested, 0.06 mg.kg-1 rocuronium was the best to prevent muscular fasciculations following succinylcholine injection. In the population studied, pretreatment did not prevent postoperative myalgia. Succinylcholine 1.5 mg.kg-1 was more effective without a non-depolarizing pretreatment.<\/p>\n <\/p>\n A randomized, double-blind comparison of rocuronium, d-tubocurarine, and “mini-dose” succinylcholine for preventing succinylcholine-induced muscle fasciculations. (Anesth Analg. 1998 Sep;87(3):719-22.)<\/p><\/blockquote>\n<\/blockquote>\n <\/p>\n <\/p>\n <\/p>\n |\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |<\/p>\n","protected":false},"excerpt":{"rendered":" Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[35],"tags":[],"yoast_head":"\n\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Atropine (No longer recommended)<\/h4>\n
\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Defasiculating Dose of Paralytic (No longer recommended)<\/h4>\n
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