Current Reviews for Nurse Anesthetists

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2 Current Reviews for Nurse Anesthetists Publisher And Editor-in-Chief FRANK MOYA, MD Coral Gables, Florida Editorial Board Advisory Board CHUCK BIDDLE, CRNA Ph.D Richmond, Virginia MONTE LICHTIGER, MD Coral Gables, Florida CHARLES BARTON, MSN, M.Ed. FRANK T. MAZIARSKI, CRNA Akron, Ohio Seattle, Washington LINDA CALLAHAN,CRNA,Ph.D MARY JEANETTE MANNINO, Klamath Falls, OR CRNA, JD Laguna Niguel, California CAROL G. ELLIOTT,CRNA, MPA, PhD Kansas City, Kansas CHARLES MOSS, CRNA,MS Larkspur, CO NANCY GASKEY-SPEARS CRNA, Ph.D Gastonbury, Ct JOSEPH A. JOYCE, CRNA, BS Winston-Salem, North Carolina MARIA GARCIA-OTERO, CRNA, Ph.D Coral Gables,Florida SANDRA OUELLETTE,CRNA, Med, FAAN Winston-Salem, North Carolina LINDA J. KOVITCH, CRNA, MSN Bedford, Massachusetts EULA M. WALTERS,CRNA JD San Francisco, California LAURA WILD-MCINTOSH, CRNA, MSN Hillsboro, NJ Associate Publishers Joan McNulty Elizabeth Moya, J.D. Assistant Editor Linda G. Williams Assistant Publisher Barbara McNulty Donna Scott Circulation Assistants Carrie Scott Tiffany Lazarich Myriam Montes Sponsor Frank Moya Continuing Education Programs, LLC Subscription Office - Editorial Office Current Reviews Frank Moya, M.D S.E. First Avenue 1450 Madruga Ave Ft. Lauderdale, FL Suite 207 Coral Gables, FL Phone: (954) Fax: (800) Accreditation This program has been prior approved by the American Association of Nurse Anesthetists for 26 CE credits; Code Number 32615; Expiration Date July 31, Approved by Frank Moya Continuing Education Programs,LLC. Provider approved by the California Board of Registered Nursing, Provider Number CEP 1754, for 26 contact hours; and Florida Board of Nursing, Provider Number FBN 2210 for 26 contact hours. In Accordance with AANA directives, you must get 80% of the answers correct to receive one credit for each lesson, and if there is a failure, there is no retaking. Disclosure Policy Frank Moya Continuing Education Programs, LLC, in accordance with the Accreditation Council for the Continuing Medical Education s ( ACCME ) Standards for Commercial Support, will disclose the existence of any relevant financial relationship a faculty member, the sponsor or anyone else who may be in a position to control the content of this Activity has with any commercial interest. BEFORE STARTING, PLEASE SEE LAST PAGE TO READ WHETHER THERE ARE ANY RELEVANT RELATIONSHIPS TO DISCLOSE AND, IF SO, THE DETAILS OF THOSE RELATIONSHIPS. Current Reviews is intended to provide its subscribers with information that is relevant to anesthesia providers. However, the information published herein reflects the opinions of its authors and does not represent the views of Current Reviews in Clinical Anesthesia, Current Reviews for Nurse Anesthetists, or Frank Moya Continuing Education Program, LLC. Anesthesia practitioners must utilize their knowledge, training and experience in their clinical practice of anesthesiology. No single publication should be relied upon as the proper way to care for patients. The information presented herein does not guarantee competency or proficiency in the performance of procedures discussed. Copyright 2013 by Current Reviews Reproduction in whole or in part prohibited except by written permission. All rights reserved. Information has been obtained from sources believed to be reliable, but its accuracy and completeness, and that of the opinions based thereon, are not guaranteed. Printed in U.S.A. Current Reviews is published biweekly by Current Reviews, 1828 S.E. First Avenue, Ft. Lauderdale, FL POSTMASTER: Send address changes to Current Reviews, 1828 S.E. First Avenue, Ft. Lauderdale, FL

3 Upper Airway Trauma and Obstruction: Diagnosis and Treatment Anthony L Kovac, MD Kasumi Arakawa Professor of Anesthesiology University of Kansas Medical Center Kansas City, Kansas LESSON OBJECTIVES Upon completion of this lesson, the reader should be able to: 1. List the common causes of airway obstruction in normal and trauma patients and the role airway obstruction plays in accidental deaths due to trauma. 2. Discuss the evaluation and examination of patients with maxillofacial trauma. 3. Describe the approach for triage and management of the patient with airway trauma. 4. Describe the three types of Lefort fractures regarding their etiology and considerations for endotracheal intubation. 5. Plan the use of non-surgical airway devices that can be used for management of patients with airway trauma. 6. List the advantages and disadvantages of techniques for blind nasotracheal intubation, blind digital orotracheal intubation and retrograde intubation. 7. Discuss the nerves involved and types of regional nerve blocks that are useful to anesthetize the airway. 8. Discuss the methods and drugs that are useful to anesthetize the airway for a sedated awake fiberoptic intubation. 9. List the advantages and disadvantages of transtracheal jet ventilation. 10. Describe the use of the laryngeal mask airway (LMA) as an airway rescue option in the ASA Difficult Airway Algorithm. Current Reviews for Nurse Anesthetists designates this lesson for 1 CE contact hour in pharmacology/therapeutics. Introduction Multi-trauma can be life-threatening and is one of the main causes of morbidity and mortality among individuals less than 30 years of age. Problems related to airway obstruction and respiratory compromise are major factors in many accidental deaths due to trauma. Maintenance of the airway with breathing, hemorrhage control and prevention of neurologic sequelae are among the highest resuscitation priorities. Anesthesia providers must have a high index of suspicion regarding the possibility of airway obstruction when evaluating the trauma patient. By proper detection and intervention, morbidity and mortality related to airway obstruction can be prevented. Causes of Airway Trauma and Obstruction Early deaths following trauma may be due to airway misdiagnosis and mismanagement. Since multiple signs and symptoms can occur, the anesthesia provider may be overwhelmed and not recognize the signs of airway obstruction, or may use faulty judgment in the proper use of airway rescue methods. Penetrating or blunt trauma to the maxilla and mandible may cause airway obstruction resulting from edema, fractures, or simply the tongue falling back onto the posterior pharynx. Foreign bodies can also cause direct airway obstruction. Congenital anomalies, neoplasms, inflammatory diseases, allergic reactions, burns and vascular neck injuries cause Curr Rev Nurs Anesth 36(14): ,

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7 deceleration above the clavicle or a head injury resulting in unconsciousness should raise suspicion that a C-spine or spinal cord injury may have occurred. Evaluation of Patients with Laryngeal Injury Patients with minor laryngeal injury present differently than those with major injury. They may have hoarseness without stridor and moderate pain when speaking or swallowing. Major laryngeal injury may occur following contusions, open lacerations and subcutaneous emphysema, resulting in loss of voice, abnormal laryngeal contour, and progressive airway obstruction. In evaluating the patient for laryngotracheal trauma, attention should be paid to any change in the size of airway anatomical landmarks, such as the prominentia laryngea (Adam's apple), which is more prominent in men compared to women. Supraglottic and glottic injury occurs more often in tall people with long necks, and is often associated with fractures of the hyoid bone or thyroid cartilage. With supraglottic and glottic injury, signs of early onset airway obstruction are wheezing, dyspnea, hoarseness, subcutaneous emphysema, or a marked difficulty in swallowing. Loss of the normal thyroid contour may occur. A LeFort II fracture involves the bony and cartilaginous components of the nasal septum, extending from the midface and base of the skull. Infraglottic and glottic injury are more common in short individuals with short necks, and these patients often present with thyroid or cricoid cartilage fractures. While breathing may be normal initially, several hours later more difficult breathing may occur when subglottic edema narrows the airway. Early swallowing difficulty may or may not be present. Common features of infraglottic and glottic trauma are paroxysmal cough, progressive subcutaneous emphysema, hemoptysis and increasing respiratory distress. Infraglottic injury and fractures of the cricoid cartilage may be associated with trauma to the trachea. Cervical neck subcutaneous emphysema, laryngotracheal disruption or separation between the upper tracheal cartilage and larynx may also occur. Burn and Inhalation Injury Burn patients should be initially evaluated and observed for signs of airway obstruction with pulmonary involvement. Burn patients may initially present with few signs of airway distress as the larynx helps protect the subglottic airway from direct thermal injury. The upper airway may become obstructed due to exposure to super-heated air and subsequent upper airway edema. Clinical signs of inhalation injury include facial burns, (especially eyebrows and nasal hair) carbonaceous sputum, carbon deposits and acute inflammatory changes in the oropharynx. Management of Airway Trauma Initial Action The initial approach for patient management of airway trauma involves determining the severity of injury and the priority for establishing an airway. One should determine if airway management is urgent (immediate), emergent (within minutes) or elective. Basic objectives are to: 1) maintain an intact airway, 2) protect the airway, 3) provide an airway if one is not available, and 4) rule out potential C-spine injury. A LeFort type III fracture is a very serious major fracture involving the temporal bone, zygomatic arch, fronto-zygomatic suture, orbit and nose. Cervical Spine Injury C-spine injury should be suspected in all multitrauma patients with an altered level of consciousness or blunt injury above the clavicle. CT or MRI are the primary diagnostic imaging methods to evaluate C-spine injury. Prevention of secondary injury and permanent C-spine disability are of the highest priority and are initially achieved by utilization of a rigid C-collar to minimize undesirable C-spine movement. Patients with high C-spine (C-1,2) injury require early intubation because of their inability to spontaneously ventilate and control the airway. Most multi-trauma patients require general anesthesia for surgical intervention and stabilization of their injuries. Use of a flexible fiberoptic or videolaryngoscope with manual in-line stabilization (MILS) has been shown to be beneficial to prevent secondary C-spine injury during intubation, and can be accomplished with minimal C-spine movement. In a patient with a C-collar in place, ET intubation usually will be more difficult using direct laryngoscopy with a standard Macintosh or Miller laryngoscope than with a videolaryngoscope such as the C- Mac or Glide Scope. Use of MILS does not appear to cause significant undesirable or unstable C-spine movement. However, the effect of MILS may be counterproductive during ET intubation with a Macintosh or Miller laryngoscope because glottic visualization usually requires an increased upward force during direct laryngoscopy, increasing the chance to cause cranio-cervical neck movement and Curr Rev Nurs Anesth 36(14): ,

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12 when ventilation is initiated. In addition, if the cricothyroid cartilage and membrane are extensively damaged due to trauma, a cricothyrotomy may be impossible. A disadvantage of PTTJV is kinking of the catheter in patients with thick, short necks. A dilator introducer (Cook Critical Care, Bloomington IN) is used to allow passage of a larger catheter that resists kinking. A variety of methods have been described to connect the catheter to an oxygen source. It is most important for all these methods to have a luer-lock connection to prevent a disconnect when 50 psi high pressure oxygen ventilation is initiated. Ventilating the patient approximately times per minute with PTTJV can help maintain normal oxygenation and normocarbia, allowing time to re-evaluate and develop an alternate plan to establish the airway. When TTJV is used, there is always the possibility of barotrauma and lung or airway rupture. The airway must be open cephalad to (above) the site where the catheter has been placed. As air enters the airway via a cricothyrotomy catheter, expired air must have a point of exit. The best way for air to exit is through an open airway above the site where the catheter has been placed. If no exit exists and no air is exhaled, an increase in lung volume and pressure can result in barotrauma and/or a tension pneumothorax. Summary Unanticipated difficult airway anatomy is a major factor in failed intubations. The chance for intubation success usually decreases after more than three intubations have been attempted. Improved outcomes to decrease the incidence of a failed intubation have occurred using alternative techniques and devices such as digital intubation, PTTJV, retrograde intubation, cricothyrotomy and videolaryngoscopes. Prolonged attempts at intubation using less effective techniques were found to prolong the time to cricothyrotomy. While trauma directly to the airway itself is an uncommon event, airway obstruction as a consequence of trauma is more common. Anesthesia providers and rescue personnel need to be aware of the various presentations of airway trauma and obstruction in order to evaluate, position, and provide an airway for these patients. By proper diagnosis, treatment and use of alternate airway techniques and devices, deaths associated with airway trauma and obstruction can be prevented. Knowledge of the ASA difficult airway algorithm is mandatory. Anthony L Kovac, MD, Kasumi Arakawa Professor of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas. akovac@kumc.edu References Benumof JL, Management of the difficult adult airway with special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: (Excellent review) Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71: Cogbill TH, Cothren CC, Ahearn MK, et al. Management of maxillofacial injuries with severe oronasal hemorrhage: a multicenter perspective. J Trauma 2008; 65: (Proposed algorithm for the management of maxillofacial injuries) Dupanovic M, Fox H, Kovac A. Management of the airway in multitrauma. Curr Opin Anaesthesiol 2010; 23: (Review article) Kovac AL. Upper airway trauma and obstruction: a review of causes, evaluation and management. Respir Care 1993; 38: (Review article) LeFort R. Etude experimental sur les fracturer de la machoire superieure. Parts I, II, III. Rev Chir Paris 1901; 23:201. (Landmark historical study) Practice Guidelines for Management of the Difficult Airway. An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: (Definitive landmark reference) Seshul MB, Sinn DP, Gerlock AJ. The Andy Gump fracture of the mandible: a cause of respiratory obstruction or distress. J Trauma 1978; 18(8): (Case report) Sise MJ, Shackford SR, Sise CB, et al. Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients. J Trauma 2009; 66: (Well done retrospective review evaluating intubation rates, indications and outcomes) 176 Current Reviews for Nurse Anesthetists

13 Tips for your Clinical Practice: Key Points # The possibility of a basal skull fracture in cranio-facial trauma must be considered, since a nasal endotracheal tube or NG tube may pass into the cranium. # Bimandibular fractures (Andy Gump fractures) can produce complete airway obstruction. # LeFort I fractures extend above the teeth and displace the mandible; nasal or oral intubation usually is possible. LeFort II fractures typically involve the zygomatic or maxillary part of the nose. Nasal intubation is contraindicated. LeFort III fractures completely separate the face from the cranial skeleton; these patients often require cricothyrotomy or tracheotomy. # Whiplash injuries result from hyper-extension and flexion of the C-spine from high-speed deceleration. # The entire airway can be anesthetized with a combination of superior laryngeal nerve block, transtracheal block, and local anesthetic spray into the nose and mouth. # Tracheostomy in maxillofacial trauma is indicated by inability to intubate, unrelieved airway obstruction, LeFort II and III fractures, and basal skull fracture. # TTJV may result in lung or airway rupture. The airway must be open cephalad of the cricothyroidotomy catheter so that expired air has an exit pathway. Robert R. Kirby, M.D. Professor Emeritus of Anesthesiology University of Florida, College of Medicine FRANK MOYA CONTINUING EDUCATION PROGRAMS, INC. & FACULTY DISCLOSURE THIS AUTHOR S AND FMCEP S SPECIFIC DISCLOSURES: The author / faculty, Anthony L. Kovac, has indicated that there is a relevant financial interest or relationship with Baxter, Helsin and Merck. The type of relationship is as follows: speaker honoraria. The author / faculty has indicated that, as appropriate, he/she has disclosed that a product is not labeled for the use under discussion, or is still under investigation. As a matter of policy, FMCEP does not have any relevant financial interest or relationship with any commercial interest. In addition, all members of the staff, Governing Board, Editorial Board and CME Committee who may have a role in planning this activity have indicated that there is no relevant financial interest or relationship with any commercial interest. Current Reviews is intended to provide its subscribers with information that is relevant to anesthesia providers. However, the information published herein reflects the opinions of its authors. Anesthesia practitioners must utilize their knowledge, training and experience in their clinical practice of anesthesiology. No single publication should be relied upon as the proper way to care for patients. DESIGNATON OF SPECIFIC CONTENT AREAS: Current Reviews for Nurse Anesthetists (CRNA) is designed to meet the standards and criteria of the American Association of Nurse Anesthetists (AANA) for the prior-approved continuing medical education activity, Provider-Directed Independent Study, also known as home study. CRNA is an approved program provider. CRNA has designated the lessons which meet specific content areas such as pharmacology, HIV/AIDS, etc. However, only the Board of Nursing of an individual State is the final authority in the determination of whether or not these lessons meet the State s licensure requirements. Curr Rev Nurs Anesth 36(14): ,

14 Mark Your Calendar! Caribbean Seminar in Anesthesiology January 19 24, 2014 Frenchman's Reef & Morningstar Resort, St Thomas USVI 40th Annual Virginia Apgar Seminar March 14-16, 2014 at the Hilton Resort in Lake Buena Vista, FL Call or write to: Frank Moya Continuing Education Programs 1828 SE First Ave Ft. Lauderdale, FL Phone: Fax: or Visit our website: Scan for more information

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16 MARK ONLY THE ONE BEST ANSWER PER QUESTION ON YOUR ANSWER CARD. MARK THIS PAGE AND KEEP FOR YOUR RECORDS. 14 In accordance with AANA directives, you must get 80% of the answers correct to receive one credit for each lesson, and if there is a failure, there is no retaking. POST-STUDY QUESTIONS 1. Airway obstruction from trauma may be due to all of the following EXCEPT: G A. Blunt trauma to head, face or neck. G B. Foreign bodies causing direct obstruction. G C. Lefort III fractures. G D. Tongue raising anteriorly onto the anterior teeth. 2. Regarding severe midface trauma: G A. The facial skeleton is divided into fifths. G B. One must always consider the possibility of a fracture at the base of the skull. G C. Anesthesia management and treatment does not need to be chosen carefully. G D. A blow to the midface usually does not affect either the facial or cranial skeleton. 3. The mandible: G A. Is square-shaped. G B. Is most vulnerable to trauma in the area of the first and second upper incisors. G C. Has a thin bony cortex at the anterioinferior margin that is the weakest and most vulnerable to fracture. G D. Has the highest incidence of fracture where the cortex is thinner at the angle and ramus. 4. Regarding the temporomandibular joint (TMJ): G A. A fracture at the zygomatic arch of the temporal bone does not limit TMJ mobility. G B. The mandible and TMJ have a simple function. G C. Movement of the TMJ is independent of the mandible. G D. With a coronoid process fracture, limitation of TMJ function can occur. 5. Regarding the mandible, all of the following are correct EXCEPT: G A. Elderly edentulous patients who do not wear their dentures may have mandible decalcification. G B. A bi-mandibular fracture has the appearance of a hyperplastic elongated upper mandible. G C. A bi-mandibular fracture has a foreshortened appearance called an Andy Gump fracture. G D. A bi-mandibular fracture is an airway emergency. 6. The correct statement regarding Lefort fractures is: G A. Lefort III is a very serious fracture involving the zygomatic arch of the temporal bone, the frontozygomatic suture, orbit and nose. G B. Lefort I fracture involves the bony and cartilaginous components of the nasal septum, with fracture of midface structures and the base of the skull. G C. First described by Sir Ivan Lefort of Germany in G D. Cerebrospinal fluid (CSF) rhinorrhea and circumorbital ecchymosis occur with Lefort I fractures. 7. In the evaluation of patients with maxillofacial trauma: G A. Supraglottic injury secondary to blunt trauma occurs more often in people with short necks without fractures of the hyoid bone or thyroid cartilage. G B. Infraglottic injury is most common in patients with long necks. G C. Common features of infraglottic and glottic trauma are paroxysmal coughing, hemotypsis, progressive subcutaneous emphysema and increasing respiratory distress. G D. Snoring sounds or inspiratory stridor are present with complete airway obstruction. 8. Regarding non-surgical airway management: G A. Blind digital oral endotracheal intubation is not a useful technique. G B. Videolaryngoscopy is associated with higher success rates and longer times to intubate when compared with conventional laryngoscopy. G C. Nasal intubation can be easily and safely accomplished if a basal skull fracture is present. G D. The LMA has limitations for patients with nasal, pharyngeal or upper airway bleeding due to the possibility of aspiration of blood and supraglottic obstruction. 9. Regarding the superior laryngeal nerve: G A. Is a branch of the phrenic nerve. G B. An internal sensory branch penetrates the thyrohyoid membrane providing sensory innervation from the base of the tongue to the vocal cords. G C. Has five branches at the level of the larynx. G D. The internal sensory branch innervates the cricothyroid muscle which relaxes the vocal cords. 10. Regarding percutaneous transtracheal jet ventilation (PTTJV): G A. It s always useful and necessary if complete airway obstruction is present. G B. Has no possibility of lung or airway rupture during ventilation. G C. Is used with a 20-gauge catheter so kinking will not occur. G D. The airway must be open above (cephalad) to the site where the catheter has been placed to allow for air to exit.