below), and is able to fit 2 finger breadths between the hyoid bone and the thyroid cartilage (see

thyrohyoid distance in
the second image below).
Hyomental distance (3 finger breadths).
Thyrohyoid distance (2 finger breadths).
M: Mallampati classification
The Mallampati assessment is ideally performed when the patient is seated with the mouth open and the tongue
protruding without phonating. In many patients intubated for emergent indications, this type of assessment is not
possible. A crude assessment can be performed with the patient in the supine position to gain an appreciation of the
size of the mouth opening and the likelihood that the tongue and oropharynx may be factors in successful intubation
(see image below).
O: Obstruction
Obstruction of the upper airway is a marker for a difficult airway. Three signs of upper airway obstruction are difficulty
swallowing secretions (secondary to pain or obstruction), stridor (an ominous sign which occurs when < 10% of
normal caliber of airway circumference is clear), and a muffled (hot-potato) voice.
N: Neck mobility
The inability to move the neck affects optimal visualization of the glottis during direct laryngoscopy. Cervical spine
immobilization in trauma (with a C-collar) can compromise normal mobility, as can intrinsic cervical spine immobility
due to medical conditions such as ankylosing spondylitis or rheumatoid arthritis.
1. Grade I: full view of the cords
2. Grade II: partial view of the cords
3. Grade III: view of the epiglottis
4. Grade IV: No view of the cords or epiglottis
PREOPERATIVE MEDICATION
A. The student shall demonstrate knowledge of the objectives of effective pre-anesthesia medication by naming and
discussing drugs used for:
1. Relief of anxiety
2. Sedation
3. Reduction of gastric acidity and volume
B. The student shall demonstrate knowledge of the basic pharmacology and pharmacokinetics of the following
premedication agents, including dosage schedules and relative and absolute contraindications:
1. Fentanyl
2. Midazolam
3. Pepcid (Famotidine)
4. Bicitra (Citric Acid/Sodium Citrate)
POST-OPERATIVE MANAGEMENT
1. Be aware of the more common causes of the following in the early post-operative period:
a. Respiratory: Airway obstruction, hypoventilation, hypoxaemia
b. Cardiovascular: Hypotension, hypertension
c. Neurological: Somnolence, muscle relaxant problems
2. Be able to describe the correct positioning of the unconscious patient
3. Pain
Acute Pain Management
1. Be aware of current theory of the mechanism of pain, and the physiological effects of pain and the
modalities of treatment of acute post-operative pain.
2. Know (in general terms) the proposed mechanism of the analgesic effect of NSAIDs; know the major side
effects and contraindications; know the available routes of administration.
3. Know the current theory of the mechanism of action of narcotics. Know the available routes of
administration. Know the major side effects, contraindications to their use and basic management of a
narcotic overdose.
4. Be aware of PCA and epidural analgesia.
5. Understand the role of an Acute Pain Service.
Acute Pain Management
1. What are the common sources and key features of acute pain?
2. Describe the methods of assessment of acute pain
3. Describe the hormonal and physiologic stress response to acute surgical pain
4. Describe the role of opioids in acute pain management, acute and chronic physiologic effects of opioids
including tolerance, and features of commonly used opioids in acute surgical pain management
5. Describe the features of intravenous opioid patient controlled analgesia, including benefits, contraindications
and how PCA relates to the concept of the "Minimal Effective Analgesic Concentration"
6. Describe the features of analgesic adjuncts to opioids such as NSAIDs, ketamine, Alpha-2 agonists and
gabapentin, and their role in acute surgical pain management
7. Describe the role of neuraxial analgesia in acute surgical pain management, including mechanism of action,
benefits, side-effects, and contraindications