DAANCE 2023 Questions Answered 100% Correct

DAANCE 2023 Questions Answered 100% Correct MODULE V: OFFICE ANESTHESIA EMERGENCIES ... Hypoxia deficiency in the amount of oxygen reaching the tissues hypoxia results cardiac dysrhythmias, cardiac arrest, neurologic or brain damage, and ultimately death hypoxia adverse effects - more rapidly in children, elderly and those w diminished respiratory reserve; systemic ailments like cardiac, pulmonary, sickle cell anemia or sezieures - aid with pre-oxygenation period prior to anesthesia airway maintenance -evaluation of the patients anatomy: neck, mandible, tongue and body obesity - short thick neck with poor flexibility is more difficult ------ Class II or higher Mallampati classification airway obstruction a. head position and the tongue b. foreign body cause of airway obstruction- head position and the tongue -most often posterior positioning of the tongue in the oropharynx -poor headpositioning -loss of tone of pharyngeal muscles secondary to deep anesthesia or sedation prevention of airway obstruction- head position and the tongue correct positioning of the patients head and mandible in head tilt-chin lift position signs of airway obstruction Choking, gagging, substernal notch retraction, labored breathing, rapid pulse initially, then decreased pulse, respiratory arrest, and cardiac arrest early treatment of airway obstruction-head position and the tongue a. 100% (O2) via nasal mask b. place the patient in a Trendelenburg position and pack off the surgical site c. digital traction of the tongue with gauze, tongue forceps, a hemostat ortongue suture d. suction oropharynx continued treatment of airway obstruction- head position and the tongue a. a nasopharyngeal airway can be utilized in a conscious or semiconscious patient b. in an unconscious patient an oropharyngeal airway can be used c. consider using an LMA, igel or other supraglottic (above level of vocal cords) airway d. endotracheal intubation Cricothyrotomy- airway obstruction- head position and the tongue - if an airway obstruction persists after all conventional methods for establishing an airway have failed - quickest and easiest - making an opening through the thin ciricothyroid membrane between the ciricoid and thyroid cartilages of the larynx treatment by ciricothyrotomy - activate EMS 1. cleanse the overlying skin 2. locate the ciricothyroid membrane by palpation 3. utilize the emergency ciricothyrotomy needle/cannula kit or a large gauge to enter the trachea beneath the vocal cords through the ciricothyroid membrane 4. attach the tube of the ciricothyrotomy device to an oxygen source such as an anesthesia machine or Ambu bag and ventilate with 100% oxygen cause of airway obstruction- foreign bodies partial dentures, surgical packs or partitions and teeth prevention of airway obstruction- foreign bodies preoperative removal of foreign bodies(dentures, partials, tongue piercings etc.), effective placement of packs or partitions, adequate suctioning and assistance an good visualization of the field treatment of airway obstruction- foreign bodies 1. digital removal of the foreign body only if it can be well- visualized- do not attempt blind finger sweeps that may push the foreign body farther down into the airway 2. chest compressions if no airflow during ventilation with the patient in s supine position. Use Heimlich maneuver is Patient is upright —— preferred over abdominal thrusts: more pressure develop in chest, lower chance of puncture of organ 3. Direct laryngoscopy(removal of foreign object utilizing a laryngoscopes) for visualization and retrieval of the foreign body with forceps and/or suction 4. If cannot be removed and severe obstruction persists, a ciricothyrotomy may be necessary laryngospasm A protective reflex of the vocal cords that attempt to prevent passage of foreign matter, such as blood or excessive secretions into the larynx, trachea, and lungs Signs of laryngospasm Partial- crowing sounds and labored respiratory efforts Complete- cessation of crowing sounds, suprasternal retraction, paradoxical chest movements(rocking pattern of the chest and abdomen) Prevention of laryngospasm Proper pack placement or throat partition, changing packs and partitions when necessary, adequate suctioning, control of secretions and adequate anesthesia levels Treatment of laryngospasm Closely observe the ventilatory status with pretracheal stethoscope, pulse oximetry and capnography 1. Administer 100% oxygen via nasal hood 2. Establish proper head position to maintain/establish airway 3. Pack off surgical site 4. Suction of oral cavity and oropharynx with tonsil suction tip 5. Positive pressure, 100% oxygen via a bag/mask system 6. Administer Succinylcholine(anectine) 10-20mg IV Support ventilation manually until effects of drug have dissipated and strong spontaneous respiration has resumed - occasionally a light anesthesia plane will help trigger the reflex that causes condition. Deepening the level of anesthesia may be carefully utilized Side effects of Succinylcholine (anectine) -May precipitate malignant hyperthermia in susceptible individual - Can lead to bradycardia in pediatric patients and in adults when multiple doses are administered ——— atropine should be administered concomitantly in children Bronchospasm Generalized contraction of the smooth muscles of the small bronchi and bronchioles in the lungs, resulting in a restriction of the flow of air to and from the lungs Signs of bronchospasm -patient has more difficulty with expiration than with inspiration - Patient will exhibit wheezing and often slow labored breathing -diminishing respiratory status - cyanosis or decreased ventilation patterns on the capnograph -patients with allergies, asthma, COPD, or bronchitis are more susceptible Treatment of bronchospasm Closely observe the ventilatory status with pretracheal stethoscope, pulse oximetry and capnography 1. 100% oxygen via bag/mask 2. Albuterol inhalation(Beta-2 agonist) 4-8 puffs via inhaler every 20 minutes for up to 4 hours, then every 1-4 hours as needed 3. Ipratropium bromide (atrovent) 2 puffs stat; repeat every 4 hours 4. Epinephrine injection (alpha and beta agonist) — a. 0.5ml of 1:1000 solution intramuscularly or sublingual if anaphylaxis is suspected and/or hypotension present — b. IV epinephrine: 3-5 ml of 1:10,000 solution slowly in small increments(reserved for severe bronchospasm only in patient with hypotension present) 5. Intubation/ventilation (endnote ache all tube, LMA or igel) 6. Steroid injection such as dexamethasone(decadron) 4-6mg IV or hydrocortisone (Solu-Cortef) 100mg IV 7. Diphenhydramine (Benadryl) 50mg IV 8. Aminophylline is no longer considered a first-time drug for management of bronchospasm 9. If bronchospasm has not completely responded to steps 1-6, EMS should be activated and transport the patient to an acute care facility Emesis with aspiration When the contents of the stomach enter the lungs secondary to emesis(vomiting or passive regurgitation) or when a foreign body or fluid inadvertently enters the lungs from the oral pharyngeal cavity through the larynx - may cause blockage of air exchange within the pulmonary tree - acidic gastric contents cause severe reaction within the lungs that results in damage to the endothelial lining of the lungs (pneumonitis), rales, dyspenea and tachycardia. Prevention of emesis with aspiration - Solid foods should not be eaten for 6 hours before surgery - Clear liquids may be consumed up to two hours before surgery - normal gastric emptying time is in range of 30 to 90 minutes —— apprehension, pain, opiate analgesics and sedatives may prolong gastric emptying time significantly -closure of the trachea at the level of the vocal cords, vigorous coughing are protective reflexes —— anesthesia may obtund these reflexes Treatment of Emesis with Aspiration Closely observe the ventilatory status with pretracheal stethoscope, pulse oximetry and capnography 1. Activate EMS, protect the integrity of the IV catheter 2. 100% oxygen via bag/mask 3. Turn patient on his/her right side with head down (tredelenburg position) 4. Tonsil suction of oral cavity/oropharynx 5. Removal of visible foreign bodies with a laryngoscopes and Magill forceps 6. Intubation (ETT-preferred, LMA or igel) with suction via suction catheter 7. Transport to an acute care facility Hyperventilation When the Patient is breathing at a rate faster than his/her normal breathing pattern or breathing more deeply than the body requires - triggered by change in body's natural balance of oxygen and carbon dioxide - results in patient exhaling too much carbon dioxide - patient feels anxious and lightheaded causing to hyperventilate more Causes of hyperventilation Anxiety, apprehension, fear, pain, overdosing of certain medications (aspirin, asthma medications, cocaine, methamphetamines) Early treatment of hyperventilation 1. Terminate treatment and remove foreign bodies form mouth and surgical instruments from pt view. 2. Maintain the airway. 3. Verbally try to calm the pt. 4. Monitor vital signs. 5. Do NOT give oxygen. 6. Have pt breathe into a bag to recapture exhaled CO2. Advanced treatment of hyperventilation 1. If non-sedated pt fails to respond, can try IV midazolam, diazepam, propofol, etc. 2. Continue to monitor vital signs. 3. Discontinue rebreathing bag as breathing returns to normal. 4. Activate EMS if condition deteriorates. Respiratory depression and apnea Can be the result of many different causes and can result in increased heart rate and the development of hypoxia and cyanosis. Causes of respiratory depression and apnea -Many of the drugs administered for sedation can depress or stop the patient's ability to breathe. - mechanical hyperventilation lowers the patients CO2 levels which can diminish respiratory drive and cause transient apnea - overdose or relative overdose of a narcotic or benzodiazepine Treatment of respiratory depression and apnea - if caused by anesthetic drug that cannot be reversed (propofol, Succinylcholine(anectine)) respiration must be supported by ventilation with positive pressure oxygen utilizing a bag-valve-mask - Mechanical hyperventilation is usually self reversing when it mechanical hyperventilation has stopped - overdose can be treated with reversal agents of naloxone(narcan) for narcotics or flumazenil (romazicon) for benzodiazepines —- effects of overdose drug can outlast reversal agent, patient should be monitored for several hours Acute Coronary Syndrome- angina - damage to the myocardium from diminished blood flow through the coronary arteries - caused by spasm in the coronary arteries that supply blood to the heart muscle and is indicative of the diminished blood flow of ischemic heart disease Acute Coronary Syndrome- myocardial infarction -represents death of myocardial tissue when the coronary arteries become totally occluded - an acute medical emergency precipitated by decreased oxygenation of the heart muscle with severe occlusion or complete blockage of blood flow in the coronary arteries, resulting in necrosis or death of heart muscle. signs of Acute Coronary Syndrome- angina pectoris pain that begins in the center of the chest and may radiate to any area above the diaphragm(arm, shoulder, neck, mandible, teeth etc. ) - primary symptom of coronary artery disease and deteriorating cardiac condition - know when, how frequent, and with increasing or decreasing frequency of past angina attacks - know what exercise level precipitates the attack ——- angina at rest is atypical/unstable and particularly ominous Treatment of Acute Coronary Syndrome- angina increase the coronary artery blood flow by dilating the coronary arteries - Nitrates (nitroglycerin) under the tongue - calcium channel blockers(verapamil (Calan), diltiazem (Cardizem)) - beta-adrenergic blockers (propranolol (Inderal), atenolol (Tenormin) 1. Terminate surgery 2. Give one dose of nitroglycerin sublingual 3. Administer 100% oxygen through mask 4. Place patient in comfortable position 5. Loosen all tight clothing 6. Attach monitors 7. If no relief within 5 minutes of nitroglycerin then may administer 2nd and third dose in 5 minute intervals 8. If after third dose there is no relieve then it is assumed patient is having myocardial infarction(heart attack) Signs of Acute Coronary Syndrome- myocardial infarction - history of angina and/or other cardiovascular complaints - symptoms may develop immediately after physical, pharmacologic or psychological stress, or they may develop during rest - chest pain, anxiety, weakness, sweating, cardiac dysrythmia (palpitations, irregular or skipped beats) and a drop in blood pressure Treatment of Acute Coronary Syndrome- myocardial infarction - surgery should be stopped, mouth cleared of any foreign material 1. Activate EMS, closely observe vital signs 2. 100% oxygen administered 3. Make patient comfortable/reassure 4. Attach AED or defibrillator 5. Aspirin 325mg 6. Establish IV access with normal saline slow drip 7. Morphine sulfate for pain 2-4mg IV push. Repeat every 5-10 minutes as needed MONA -Morphine(4) -Oxygen(1) - Nitroglycerin(2) -Aspirin(3) Treatment of Supraventricular dysrhythmias- symptomatic bradycardia 1. Terminate procedure 2. 100% oxygen 3. Establish IV ( if not already in place) 4. Atropine 0.5mg IV; may repeat to total dose of 3mg 5. The patient may need to be transported to the ER for transcutaneous pacing Treatment of Supraventricular dysrhythmias- supraventricular tachycardia (SVT) 1. Place patient in supine position 2. Adenosine 6mg rapid IV push over 1-3 seconds and follow with immediate flush of 20cc saline. Following administration of adenosine there may be a period of astyole, which is usually only about 6-12 seconds in length but can last up to 30 seconds 3. After 1-2 minutes, Adenosine 12mg. Rapidly flush as before 4. A third dose may be given in 1-2 minutes if needed Treatment of Ventricular dysrhythmias- premature ventricular contractions (PVCs) 1. Try to determine the cause of the PVCs (ex. hypoxia) and correct 2. Lidocaine 0.5-1.5 mg/kg IV; repeat 0.5-0.75mg/kg every 5-10 minutes up to 3mg/kg Treatment of Ventricular dysrhythmias- ventricular tachycardia (V. Tach) 1. 100% oxygen 2. Amiodarone 150mg IV over 10 minutes. Maximum dose 2.2g in 24 hrs 3. Prepare for synchronous cardioversion - if displayed but no pulse then treat as ventricular fibrillation Treatment of Ventricular dysrhythmias- ventricular fibrillation (V. Fib) - high quality CPR delivered in sequences of 2 minutes with 5 cycles of chest compressions and breaths given in a ratio of 30:2 - during treatment, Attempt should be made to determine cause and treat if possible 1. Check lead placement and if V. Fib. Confirmed, call 911 2. First sequence: begin CPR, without discontinuation of CPR attach AED or defibrillator and deliver a shock if indicated at the end of the sequence 3. Second sequence: continue CPR, during this sequence establish IV access and prepare to give epinephrine. Deliver a shock if indicated at the end of the sequence 4. Third sequence: continue CPR, during this sequence give epinephrine 1mg IV and prepare amiodarone for administration during the next sequence. Deliver shock, if indicated at the end of the sequence 5. Fourth sequence: continue CPR, during this sequence give amiodarone 300mg IV and prepare epinephrine for administration during the next sequence. Deliver shock, if indicated, at the end of the sequence 6. Fifth sequence: continue CPR and during this sequence give epinephrine 1mg IV. (First 2 doses of epinephrine can be replaced with vasopressin) 7. Sixth sequence: continue CPR, during this sequence give amiodarone 150mg IV and prepare epinephrine for administration during the next sequence. Deliver shock, if indicated, at the end of the sequence. 8. The fifth and sixth sequences can be repeated until help arrives.