Basic Airway Management

Head Positioning

• Head tilt-chin lift: Standard maneuver
• Jaw thrust: When cervical spine injury suspected
• Sniffing position: Optimal for intubation

Bag-Mask Ventilation

• Two-person technique: Often more effective
• Seal: C-E grip for mask seal
• Ventilation: Gentle, avoid gastric insufflation
• Adjuncts: Oropharyngeal/nasopharyngeal airways

Advanced Airway Management

Laryngeal Mask Airway (LMA)

• Indications: Bridge device, difficult intubation
• Insertion: Blind technique, high success rate
• Advantages: Easier than intubation, seals airway
• Limitations: Doesn't protect against aspiration

Endotracheal Intubation

• Gold standard: Definitive airway protection
• Technique: Direct laryngoscopy or video laryngoscopy
• Confirmation: Capnography, bilateral breath sounds
• Complications: Esophageal intubation, aspiration

Difficult Airway Algorithm

Prediction

• Mallampati score: Visibility of oral structures
• Neck mobility: Range of motion assessment
• Jaw opening: Interincisal distance
• History: Previous difficult intubation

Management Steps

1. Preparation: Equipment check, team briefing
2. Positioning: Optimize head/neck position
3. Pre-oxygenation: 100% oxygen for 3-5 minutes
4. Attempt: Limit to 3 attempts maximum
5. Fallback: LMA or emergency surgical airway

Dental/Oral/Upper Respiratory Tract Procedures: Antibiotic Prophylaxis Guidelines

Antibiotic prophylaxis is crucial for patients at risk of infective endocarditis or other infections during dental, oral, or upper respiratory tract procedures. The following guidelines outline the standard and alternate regimens for antibiotic prophylaxis based on the patient's allergy status and ability to take oral medications.

I. Standard Regimen in Patients at Risk

1. For Patients Allergic to Penicillin/Ampicillin/Amoxicillin:

   • Erythromycin:
     • Dosage: Erythromycin ethyl-succinate 800 mg or erythromycin stearate 1.0 gm orally.
     • Timing: Administer 2 hours before the procedure.
     • Follow-up Dose: One-half of the original dose (400 mg or 500 mg) 6 hours after the initial administration.
   • Clindamycin:
     • Dosage: Clindamycin 300 mg orally.
     • Timing: Administer 1 hour before the procedure.
     • Follow-up Dose: 150 mg 6 hours after the initial dose.

2. For Non-Allergic Patients:

   • Amoxicillin:
     • Dosage: Amoxicillin 3.0 gm orally.
     • Timing: Administer 1 hour before the procedure.
     • Follow-up Dose: 1.5 gm 6 hours after the initial dose.

II. Alternate Prophylactic Regimens in Patients at Risk

1. For Patients Who Cannot Take Oral Medications:

   • For Penicillin/Amoxicillin Allergic Patients:
     • Clindamycin:
       • Dosage: Clindamycin 300 mg IV.
       • Timing: Administer 30 minutes before the procedure.
       • Follow-up Dose: 150 mg IV (or orally) 6 hours after the initial dose.
   • For Non-Allergic Patients:
     • Ampicillin:
       • Dosage: Ampicillin 2.0 gm IV or IM.
       • Timing: Administer 30 minutes before the procedure.
       • Follow-up Dose: Ampicillin 1.0 gm IV (or IM) or amoxicillin 1.5 gm orally 6 hours after the initial dose.

2. For High-Risk Patients Who Are Not Candidates for the Standard Regimen:

   • For Penicillin/Amoxicillin Allergic Patients:
     • Vancomycin:
       • Dosage: Vancomycin 1.0 gm IV.
       • Timing: Administer over 1 hour, starting 1 hour before the procedure.
       • Follow-up Dose: No repeat dose is necessary.
   • For Non-Allergic Patients:
     • Ampicillin and Gentamicin:
       • Dosage: Ampicillin 2.0 gm IV (or IM) plus gentamicin 1.5 mg/kg IV (or IM) (not to exceed 80 mg).
       • Timing: Administer 30 minutes before the procedure.
       • Follow-up Dose: Amoxicillin 1.5 gm orally 6 hours after the initial dose. Alternatively, the parenteral regimen may be repeated 8 hours after the initial dose.

USP Classification

• Ranges: 11-0 (finest) to #5 (heaviest)
• Common oral surgery sizes:
  • 6-0, 5-0: Delicate procedures, facial surgery
  • 4-0, 3-0: General oral surgery, soft tissue closure
  • 2-0: Heavy tissue, areas requiring strong closure

Selection Criteria

• Tissue type: Delicate tissues require finer sutures
• Healing time: Longer healing requires stronger/slower-absorbing sutures
• Location: Visible areas need finer sutures for better cosmesis
• Patient factors: Age, healing capacity, immune status

Sedan Classification (3 Grades)

Classic classification based on functional and anatomical severity:

Grade I: Neurapraxia

• Definition: Temporary loss of nerve function without structural damage
• Pathophysiology: Local demyelination, nerve conduction block
• Recovery: Complete, spontaneous recovery in weeks to months
• Prognosis: Excellent (100% recovery expected)
• Example: Temporary numbness after local anesthesia

Grade II: Axonotmesis

• Definition: Axonal damage with intact nerve sheath (endoneurium preserved)
• Pathophysiology: Axonal disruption, Wallerian degeneration distal to injury
• Recovery: Spontaneous regeneration possible, slower process
• Rate: ~1mm/day axonal regrowth
• Prognosis: Good to fair, may have incomplete recovery
• Timeline: Months to 1-2 years

Grade III: Neurotmesis

• Definition: Complete nerve transection with disruption of all structures
• Pathophysiology: Complete anatomical and functional discontinuity
• Recovery: No spontaneous recovery without surgical intervention
• Prognosis: Poor without repair, depends on surgical reconstruction
• Treatment: Requires surgical repair or grafting

• Abbe flap: Used for lip reconstruction.
• Protein requirement (critically ill): 1.5 – 2 g/day.
• Alkali burns: Cause more tissue damage than acid burns.
• Fluid resuscitation (hypernatremia): Prefer 5% dextrose in water (D5W) over Ringer’s lactate.
• Torque testing: Checks osseointegration during implant uncovering.