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Head, Neck, MaxFax & Dental - Coggle Diagram

- - - - Comfortable breathing position
      - 15L NRB
      - Check for obstruction (blood/teeth/bone - if posterior midface displacement then pull it forwards)
      - ?Intubation - stridor, drooling, voice change, dyspnoea
      - C-spine immobilisation (if compliant)
    - - Associated injuries
    - - Large bore access
      - IVF/blood if hypovolaemia
    - - GCS & lateralising signs
    - - Other injuries
  - - - Preferred if not co-operative or full stomach
      - Videolaryngoscope + difficult airway trolley
        
        B - SGA, C - cricothyroidotomy
      - Pros
        
        Rapidly secured airway
        
        Minimal pt co-op required
        
        Max protection from aspiration
      - Cons
        
        Potentially difficult intubation & ?prolonged apnoea
    - - Pros
        
        Maintains spont ventilation
        
        Useful in distorted anatomy
      - Cons
        
        Skill requirement
        
        No airway contamination protection
        
        Requires full co-operation
        
        ? Requires transfer to theatre
        
        ? Difficult if active airway bleeding
    - - Pros
        
        Avoids potentially difficult airway
      - Cons
        
        Skilled surgeon
        
        Co-operation
        
        Skilled anaesthetist
  - - - Lack of co-operation
      - Change of facial shape - poor mask fit
      - Pain
      - ?HFNO
    - - Bloods
      - Anatomical distortion
      - ?Neck immobilisation
    - - Used uncut tube
- - - - ? Difficult airway due to tumour + radiotherapy
      - ? AFOI or awake tracheostomy
      - Extubation plan - trache?ITU?
      - Flexnasal endoscopy! - Give up to date info on airway
      - Statergy should be safest option with pt acceptance
    - - Smoker ?lung disease
      - Smoking increase risk of flap failure
    - - Smoker ?IHD
      - ?PVD
      - ETOH ?arrhythmia/cardiomyopathy
      - Chemotherapy ?CVS effects
      - Access issues (and donor site)
    - - ?Risk of ETOH withdrawal while inpatient
    - - Poor nutrition - worse wound healing and increased flap failure rate
    - - ETOH/malnourished/chemo - poor wound healing
    - - Increased infection risk
    - - PPP
    - - Life changing operation
- - - - Radius
        
        Normothermia
        
        Core:Peripheral <1 degree
        
        Anaglesia - reduce catecholamines
        
        Flow directed fluid Mx
        
        Pressure gradient of vessels
        
        Maintain MAP
        
        Avoid external arterial pressure (compression/oedema)
        
        Avoid poor venous drainage (compression/oedema)
      - Flap Oedema
        
        Minimise handling & ischaemic time
        
        Avoid excessive IVF
      - Poor wound healing
        
        Glucose control if diabetic
        
        Smoking cessation
        
        Mx malnutrion
      - Poor oxygen delivery
        
        Hb & Hct
      - Anastamosis failure
        
        Good surgical technique
        
        Avoid BP surges (coughing/straining)
        
        Antiemetics
      - Blood flow:
  - - - Better healing & vascularisation than graft
      - Better coverage of deep wound than graft
      - Lack of donor sites for pedicle flap
      - Better function result than graft
      - Better cosmetic result than graft
    - - Pedicle flap
      - Local flap
      - Graft (skin & SC)
    - - Feeding artery and draining vein still respond to stimuli
      - No lymphatic drainage so increase risk of interstitial oedema
      - Loss of intrinsic sympathetic tone
      - Denervated tissue
    - - US doppler
      - Ensure adequate flow/pressure
      - Clinical obs - skin colour/temp/CR
      - Early surgical exploration if concerns
  - - - High CO, low SVR - CO monitor, HCt 30%, catheter
    - - Harvesting/anastamosis
        
        Normal/slightly raised MAP to ensure perfusion pressure, catecholamines, fluid replacement
      - Dissection
        
        Controlled hypotension, positioning (drainage), LA infiltration
- - - - Failure of haemostasis -> haematoma
        
        Risk of airway compression - remove clips on ward and back to theatre
        
        Oesophageal discomfort (difficult swallow/drooling)
        
        Unusual behaviour/agitation
        
        Hoarseness or voice changes
        
        Tachypnoea or DiB
        
        Swelling of neck of stridor
        
        Treat -> cut steristrips, cut sutures, open skin, open muscles, pack over wound
      - Tracheomalacia
        
        Rare
        
        Immediate reintubation
      - Recurrent laryngeal nerve palsy
        
        Bilateral - Stridor,DiB
        
        Unilateral - hoarse voice, difficulty phonating
      - Laryngeal oedema
      - Hypocalcaemia
        
        Trauma/removal of parathyroids
        
        Chvostek's (facial twitch with tapping & Trousseau (carpopedal spasm with inflation of cuff)
      - Pneumothorax
        
        If retrosternal goitre dissection
  - - - Bloods
        
        TFTs - confirm euthyroid
        
        FBC - carbimazole & propylthiouracil can cause agranulocytosis
        
        G&S x 2 for blood loss
        
        Ca2+ - pre-op as post op can drop due to loss of parathyroid glands
      - ECG
        
        Rate
        
        Normal if euthyroid
        
        Brady - ?B blocker
      - Fibreoptic Nasendoscopy
        
        If airway concerns overall view of larynx
      - CXR or lateral thoracic inlet film
        
        ?Tracheal deviation or narrowing
      - CT
        
        Assess goitre & tracheal compression
    - - Sx of thyrotoxicosis
      - Change in voice/positional dyspnoea/exertional dyspnoea
  - - - Possible tracheal compression from goitre when flat
        
        Head up tilt
        
        ? Small diameter ETT
      - Slow intubation
        
        Good pre-oxygenation
        
        ?HFNO/THRIVE
      - Robust airway plan - agreed with surgeon
        
        Difficult airway trolley to hand
      - Shared airway
        
        Armoured tube
      - CICO
        
        Obstruction likely below cricothyroid due to goitre
        
        ENT ready for rigid bronch
      - Thyroid tube
        
        Similar to reinforced
        
        Silver electrodes which sit between VC
        
        Electrodes sense movements of cords
        
        Allows surgeons to test to find RLN during dissection
    - - Shared airway & head distant
        
        Pad eyes
        
        Tape tube
        
        Alert to airway dislodgement or compression
        
        Airway and IV extensions
      - Drugs
        
        IV or INH maintanence
        
        Remifentanil
        
        Reduce NMB (?none if thyroid tube) and allows hypotension
        
        Vasopressors at end to achieve normotension for haemostasis
        
        Antiemetics as high risk PONV
        
        Post op analgesia as BP control important
        
        ?superficial cervical plexus block
      - Warming
    - - Surgical assessment of tracheomalacia/recurrent laryngeal nerve palsy (via fibre scope)
        
        If present defer extubation
      - Failure of homeostasis
        
        Aim smooth extubation (cont remi)
      - Risk of laryngeal oedema if problems at extubation
        
        Dexamethasone intraop
        
        Pt sat up
        
        Pt awake
        
        Pt fully reversed
        
        Pt pain free
      - With SGA in - gentle and allows VC assessment
- - - - <3 excludes
      - 3-4 intermediate risk
      - 5-8 high risk
  - - - Compliant with CPAP 3months
      - Weight loss
      - Smoking cessation
      - Robust airway plan
      - ?Regional
      - Avoid sedation pre-meds
    - - GA - normal O2 and CO2
      - Short acting agents
      - Reverse NMB
      - Extubate awake
      - Multimodal analgesia
    - - CPAP available
      - Prolonged PACU stay
      - Suitable ward for monitoring
      - Supplemental O2
      - Sats monitoring
  - - - ETCO2
      - Oesophageal pressure
      - Airflow sensors
      - Chest & abdominal movement
      - EOG (ocular)
      - Pulse oximetry
      - EEG
      - ECG
    - - Apnoea = cessation of airflow for at least 10s
      - Hypoapnoea = 30% reduction in airflow for at least 10s with decreased O2 sats
      - AHI
        
        Normal AHI <5
        
        Mild OSA AHI 5-14
        
        Moderate AHI 15-30
        
        Severe OSA AHI >30
        
        AHI = number of events/hours of sleep
- - - - Prolonged PR
      - TWI or flattening
      - Short QT
      - Severe
        
        VT
- - - - General
        
        Advance, rotate and step back mandible/maxilla
        
        Osteotomy and repositioning of the mandible
        
        Orthognathic surgery
      - Indications
        
        Function/cosmetic correction of dental malocclusions
        
        Functional/cosmetic correction of congenital head and mouth issues
      - Patients
        
        Usually fit and well
        
        Occasionally have a syndrome
      - Anaesthetic concerns
        
        Anaesthetist needs detailed understanding of surgical plan
        
        Effective antiemetics (swallow blood)
        
        Needs good communication with surgical team
        
        Vigilance for post op airway complicaitons
        
        Shared airway (nasal)
        
        Techniques to assist surgical haemostasis
        
        Extubation
        
        Normotension
        
        Remove throat pack
        
        Suction under direct vision
        
        Options
        
        Deep - use nasal as NPA or switch for SGA
        
        Awake - avoid pressure from FM
      - Postop
        
        Multimodal analgesia
        
        Surgical nerve blocks
        
        Steroids (inflamm and PONV prevention)
        
        Risk of airway oedema, bleeding, PONV
        
        If they need IMF (wiring) then only once awake in recovery