Airway Scenario: IVD Setting: Weekday morning where you are providing “hands-on” anesthesia in the OR suite. The expected equipment and personnel are available. Patient: 63 y/o woman for a subtotal thyroidectomy. History & PE: NPO: 14 hours PMH: HTN, depression PSH: TAH w/o anesthetic complications Meds: atenolol, Zoloft Allergies: PCN - hives SocHx: quit smoking 15 yrs ago – 25 p-y; 1 drink/day ROS: Active. No chest pains or SOB. PE: 64”, 60 kg; BP 156/98, HR 64, RR 14, T 36.3 A/W: Large thyroid deviating trachea to right. MP I, full CROM, interincisor dist 4 cm., Cor: RRR Lungs: clear bilat Associated Information: Following placement of routine monitors and preoxygenation, the patient was induced using propofol 150 mg with lidocaine 30 mg, and succinycholine 120 mg. You now find yourself faced with--- Equipment Available:
- Macintosh/Miller blades- Fiberoptic Bronchoscope
- LMA/ Fastrack LMA- Esophageal-tracheal Combitube
Instructors Guidelines Section: Instructor Guidelines for Scenario IVD: Title: Unanticipated difficult airway secondary to thyroid enlargement. Author: Randolph B Wood, MD Date last revised: Sept 2007 General type of case: Cannot intubate, Cannot ventilate, 5 min. desaturation. LMA and Combitube work. Simulator Setup: Standard prep, hand jet vent. flow control turned off (the trainee should be expected to check this). SimMan Scenario Name: Overview: The patient is a general healthy woman who after induction of anesthesia is impossible to intubate or ventilate. The scenario starts just after induction with the patient unconscious. She will die within 5 minutes if an airway is not obtained. The scenario is geared towards obtaining an emergency airway. Given the large goiter, attempt at a surgical airway puts the patient at high risk, and is unnecessary in this scenario. Scenario Objectives:
1) Appropriately recognize that this scenario immediately leads to the
2) Call for appropriate help and equipment. 3) Identify the appropriate options for emergency non-surgical airway
4) Demonstrate effective psychomotor skill sets applying these options. General Guidelines for Airway Scenario IVD:
1) Lay out the “Equipment Available.” 2) Make sure that hand jet ventilator pressure regulator is turned off.
Unless trainee is familiar with device, they will think it does notwork.
3) The patient will not return to spontaneous ventilation or wake up. The
only options that will successfully save the patient are LMA orCombitube within 5 min. of apnea. 4) The Trainee’s 5 minutes to complete the scenario starts with administration of induction .
5) Use the “ASA Difficult Airway Algorithm” performance checklist to
6) Use the “ASA Difficult Airway Algorithm” poster as a teaching aide. 7) Review & offer correction of either psychomotor skill sets or
knowledge/judgment errors. Let the trainee practice a skill set tillsuccessful.
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No fundo, todos nós, gays (e não gays) alimentamos em nossa imaginação um tipo ideal do homem que gostaríamos de amar e ter do lado. E que nem sempre é igual à nossa paixão atual. O ideal pode ser alto e branco, o real, baixo e preto. No meu caso, para dizer a verdade, se pudesse escolher livremente, o que eu queria mesmo não era um "homem" e sim um meninão. Um "efebo" do