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Maxillo, Pain EYE & ENT DNB Q & A Dr. Azam’s Notes in Anesthesiology Postgraduates appearing 3rd Edition for MD, DNB & DA Exams Maxfax, Pain, Eye, ENT & Orthopedic Edited by: Dr. Azam Consultant Anesthesiologist & Critical Care Specialist www.drazam.com 2 Dr Azam’s Notes in Anesthesiology 2013 Dedication To Mohammed Shafiulla, my father, my oxygen, companion, and best friend; for being my major pillar of support and making this vision a reality. Thank you for your continual sacrifices with boundless love and limitless gratitude, for the sake of your children. I owe you a debt I can never repay. I also would like to thank my mom (Naaz Shafi), my wife (Roohi Azam), my two lovely kids (Falaq Zohaa & Mohammed Izaan), for their support, ideas, patience, and encouragement during the many hours of writing this book. Finally, I would like to thank my teachers (Dr.Manjunath Jajoor & team) & Dr T. A. Patil . The dream begins with a teacher who believes in you, who tugs and pushes and leads you to the next plateau, sometimes poking you with a sharp stick called "truth." 3 Dr Azam’s Notes in Anesthesiology 2013 Dr Azam’s Notes in Anesthesiology 2013 A NOTE TO THE READER Anesthesiology is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. However, in view of the possibility of human error or changes in medical sciences, neither the author nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the editor assumes any liability for any injury and/or damage to persons or property arising from this publication. Dr. Azam 4 Dr Azam’s Notes in Anesthesiology 2013 Contents Dr Azam’s Notes in Anesthesiology 2013 1. Maxillo-Facial Trauma & Anesthesia - 6 32.Anesthetic Management of Cleft Lip & Cleft Palate - 90 2. Anatomy of Nociception - 8 33.Polytrauma - 103 3. Pain Theories - 13 34.Tourniquet & Anesthesia - 122 4. Pain Clinic - 15 35.Tourniquet - 126 5. Patient controlled analgesia - 16 36.Grading of Nerve Injury - 128 6. Secondary Analgesia (Co-Analgesia) - 18 37.Spinal Surgery - 129 7. Adjuvant Analgesic Methods - 20 38.Total Hip Replacement - 130 8. Electrical Stimulation - 21 39.Total Knee Replacement. - 143 9. Cancer & Anesthesia - 22 40.Specific problems of Orthopedics - 145 10.Cancer Pain Management - 23 11.Neurolept Analgesia - 27 12.Post operative Management - 29 13.Complex Regional Pain Syndrome.(CPRS) - 42 14.Trigeminal Neuralgia - 45 15.Bromage Scale. (L1 - S2) - 47 16.Nitrous Oxide in Middle ear surgery - 48 17.Bleeding Tonsil - 49 18.Post tonsillectomy management - 51 19.Endoscopy & Anesthesia - 52 20.Bronchoscopy - 54 21.Fiber Optic Bronchoscopy - 55 22.Bronchography - 56 23.Foreign Body aspiration & Anesthesia - 57 24.Post extubation Stridor - 59 25.Anesthesia for Micro-laryngeal Surgery - 60 26.NO & ARDS - 66 27.Dental Anesthesia. - 67 28.Intraocular Pressure - 69 29.Keratoplasty - 71 30.Open Eye Surgery & Full Stomach - 72 31.Anesthetic for Opthalmic Surgeries - 74 5 Dr Azam’s Notes in Anesthesiology 2013 1. Maxillo-Facial Trauma & Anesthesia. Dr Azam’s Notes in Anesthesiology 2013 • Maxillofacial injuries are commonly seen in accident and Le Fort I: emergency department. • A horizontal fracture of the maxilla passing above the floor of the • These injuries can disturb patient ability to nose, involving the lower third of the septum. • Breath /See/Hear/Talk/Eat/Walk Anesthetic implication – • The major cause of death in facial trauma may be related to • Affords little difficulty to an anaesthesiologist. The patient may be airway obstruction. intubated orally or nasally and the airway usually is secured without • To attain patent and clear airway, the anaesthesiologists need to problem. recognize damages of soft tissue cartilaginous and bony Le Fort II: compartments in the face & skull area. • Fracture is pyramidal shaped. Facial skeleton can be divided into 3 broad compartments: • It begins at the junction of upper thick nasal bones with lower thinner 1. Lower third portion which form the upper margin of anterior nasal aperture. The • Mandible fracture crosses the medial wall of the orbit with lacrymal bone 2. Middle third passes beneath the zygomaticomaxillary suture. Crosses the lateral • Maxilla wall of antrum and traverses posteriorly through the pterygoid plates. • Zygomatic bone Anaesthetic implication: • Zygomatic process of temporal bones • Because this type of fracture involves nose, nasal intubation is • Frontal processes relatively contraindicated. One must always consider the possibility • Nasal bones and eye orbits of concomitant fracture of the base of the skull. 3. Upper third Le Fort III: • Frontal bone • The mid face is separated from the cranium. The fracture line • Fronto-zygomatic processes extends through the base of the nose and the ethmoid in its depth and through the orbital plates in proximity to cribriform plate which Mandibular fracture: may also be fractured. It crosses the lesser wing of sphenoid then Can be unilateral or bilateral seen following passes downwards to the pterigomaxillary fissure and • Road traffic accident sphenopalatine fossa. • Assassination attempt • Bimandibular “Andy Gump” fracture may cause life threatening airway occlusion or airway closure. Facial fracture: Rene Le Fort classified facial fracture into three categories: I. Le Fort I – Maxilla (low level) II. Le Fort II – Mid face (sub zygomatic) III. Le Fort III – Separation of mid face structure from cranium. 6 Dr Azam’s Notes in Anesthesiology 2013 Maxillo-Facial Trauma & Anesthesia.Continuation: Dr Azam’s Notes in Anesthesiology 2013 ! !"#$%&'(' !"#$%&'((' !"#$%&'(((' Rules for airway management: • Determine the absolute urgency of the situation • Consider the possibility of concurrent head injury • Consider the possibility of concurrent cervical injury • Consider the possibility of concurrent ocular injury • Remember full stomach consideration • Suspect airway obstruction by Foreign Body. Airway assessment and management: • Oxygenation by nasal prongs and face mask From the base of the inferior orbital fissure, it extends laterally and • Nasal and or oropharyngeal airway upwards towards frontozygomatic suture. • LMA • Awake intubation Anaesthetic implication: • Orotracheal • Base of the skull and cribriform plate are fractured. The • Blind nasotracheal intracranial subarachnoid space may be open and • Fiber optic oro / naso tracheal intubation communicating with nasal cavity. • Cricothyroid puncture • Attempted nasotracheal intubation – serious risk of tube entering • Minitracheostomy the skull and may damage brain and other intracranial structure • Tracheostomy and also pushing contaminated foreign bodies into the skull Post operative extubation: which may cause meningitis. • Depends upon development of airway edema Common concurrent surgical problems in facial injury patients: • Post operative mechanically ventilated patient should be sedated 1. Pelvic bone fracture and opioids should be given. 2. Ruptured intra abdominal viscera. ! Thoracic injury !- a. Pneumothorax b. - Flail chest c. - Cardiac tamponade d. - Cardiac hematoma 3. Cervical spine fracture 4. Ocular trauma !Intra cranial injury - a. Extradural hematoma b. Subdural hematoma c. Intracranial hemorrhage 5. Bleeding – may be life threatening 7 Dr Azam’s Notes in Anesthesiology 2013 2. Anatomy of Nociception. Dr Azam’s Notes in Anesthesiology 2013 Pain pathways: - First order Neuron: • Pain is conducted along three neuron pathways that transmit • Majority of 1st order neurons send proximal end of their axons into noxious stimuli from the periphery to cerebral cortex. the spinal cord via dorsal (sensory) spinal root at each cervical, • Primary afferent neurons are located in dorsal root ganglia lie in thoracic, lumbar and sacral level. vertebral foramina at each spinal cord level. • Some unmyelinated afferent (c) fibers → enter spinal cord →via • Each neuron has a single axon that bifurcates, sending one end ventral nerve (motor) root – accounting for observations that some to the peripheral tissues it innervates and other into the dorsal patients continue to feel pain even after transaction of the dorsal horn of the spinal cord. nerve root (rhizotomy) and report pain following ventral root • In the dorsal horn, primary afferent neurons synapses with a stimulation. second order neuron – axons cross the midline and ascend in • In dorsal horn, in addition to synapsing with 2nd order neurons the 1st contralateral spinothalamic tract to reach thalamus. order neurons may synapse with interneurons, sympathetic neurons • Second order neuron synapse in thalamic nuclei with third order and ventral horn motor neurons. neurons – which in turn sends projections through
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