1 Flashcards
3 scoring systems SAH severity
Hunt & Hess Grading of SAH (clinical)
World Federation of Neurosurgeons grading of SAH (clinical)
Fishers Grade (radiological)
Types of abnormal placental invasion
Placenta accreta (most common)
Placenta increta (into myometrium)
Placenta percreta surrounding organs (least common)
Grades of placenta praevia
1 - low-lying (near os)
2 - marginal (at margin of os)
3 - partial (partially covers os)
4 - complete (os totally covered)
Lees revised cardiac risk index
IHD
Congesitve cardiac failure
Cerebrovascular disease
High risk surgery
DM on insulin
Creat >170
0.4 / 0.9 / 6.6 / 11
STOPBANG
snoring
tiredness daytime
Observed apnoeas
Pressure – HTN
BMI >35
Age >50
Neck >40cm
Gender male
3-4 intermediate risk
5+ high risk
Never events
Surgical
1. Wrong site surgery
2. Wrong implant/prosthesis
3. Retained foreign object post procedure (inc throat pack)
Medication
4. Mis-selection of a strong potassium solution
5. Administration of medication by the wrong route
6. Overdose of insulin due to abbreviations or
7. Overdose of methotrexate for non-cancer
8. Mis-selection of high strength midazolam during sedation
Mental health
9. Failure to install functional collapsible shower or
General
10. Falls from poorly restricted windows
11. Chest or neck entrapment in bed rails
12. Transfusion or transplantation of ABO-incompatible blood components or
organs
13. Misplaced naso- or oro-gastric tubes
14. Scalding of patients
15. Unintentional connection of a patient requiring oxygen to an air flowmeter
NAP 5 AAGA incidences
Total:
NMBA:
No NMBA:
C/S
Cardiothoracic
Total - 1:19,000
NMBA - 1:8,000
No NMBA - 1:136,000
C/S - 1:670
Cardiothoracics - 1:8,600
Needlestick transmission rates
Hep B
Hep C
HIV
Hep B 1:3
Hep C 1:30
HIV 1:300
Burns appearance
Superficial - red, painful, dry
Partial - red, painful, blistered, oedematous
Full thickness - white, painless, no bleeding
Burns referral
All burns ≥2% TBSA in children or ≥3% in adults
All full thickness burns
All circumferential burns
Any burn not healed in 2 weeks
Any burn with suspicion of non-accidental injury should be referred to a Burn Unit/Centre for expert
assessment within 24 hours
All burns to hands, feet, face, perineum or genitalia
Any chemical, electrical or friction burn
Any cold injury
Any unwell/febrile child with a burn
Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn
MACOCHA score for difficult airway in critically ill patients
Mallampati 3/4 - 5 points
OSA - 2 points
C-spine movement limited - 1 point
Opening of mouth reduced <3cm - 1 point
Coma - 1 point
Hypoxia (SpO2 <80) - 1 point
Non-anaesthetist - 1 point
> 3 predicts difficulty
Define serotonin syndrome and outline 3 main features
Potentially life-threatening condition associated with increased serotonergic activity in CNS
- Change in mental state/cognition (agitation/delirium)
- Autonomic dysfunction (HTN, fever, sweating)
- Neuromuscular excitability (myoclonus, tremor)
What is the Sternbach diagnostic criteria for serotonin syndrome
Major (need all 3)
- Recent initiation/increase in serotonergic agent
- No recent addition/increase of neuroleptic agent
- No other possible aetiology
Minor (need 3+)
- Mental status change
- Agitation
- Sweating
- Shivering
- Diarrhoea
- Fever
- Myoclonus
- Tremor
- Incoordination
- Hyperreflexia
What are the 5 levels of evidence
1 - RCTs or systematic reviews of RCTs
2 - cohort studies
3 - case-control studies
4 - case series
5 - case report / expert opinion
Symptoms acoustic neuroma (4)
Unilateral sensorineural hearing loss
Unilateral tinnitus
Vertigo
Trigeminal nerve palsies
Asthma life-threatening & near-fatal features
Life-threatening features
- PEF <33% of best or predicted
- SpO2 <92%
- Silent chest, cyanosis, or poor respiratory effort
- Arrhythmia or hypotension
- Exhaustion, altered consciousness
- ‘Normal’ (4.6–6 kPa, 35–45 mmHg) PaCO2
- Severe hypoxia: PaO2 <8 kPa (60mmHg) irrespective of treatment with oxygen
- A low pH
Near-fatal asthma
- Raised PaCO2
- Requiring mechanical ventilation with raised inflation pressures.
Asthma indications for I&V
(4 absolute, 4 relative)
Absolute indications
- coma
- respiratory arrest
- cardiac arrest
- severe refractory hypoxaemia.
Relative indications
- an adverse trajectory of response to initial management
- fatigue and somnolence
- cardiovascular compromise
- development of a pneumothorax
Sickle cell disease:
Tests: (3)
Inheritance/abnormality:
Pathophys consequences (2)
Clinical manifestations (11)
Tests:
- Haemoglobinopathy screen (electrophoresis)
- Sickledex
- Peripheral blood film
Inheritance:
- Autosomal recessive
- Valine instead of Glutamic acid substitution at position 6 of B globin chain, Chromosome 11
Pathophys:
- microvascular occlusion
- reduced RBC lifespane
Clinical:
i acute chest syndrome
ii splenic infarction
iii acute splenic sequestration
iv stroke
v haemolytic anaemia
vi occlusive crises
vii priapism
vii avascular necrosis
viii sickle retinopathy
viii chronic renal failure
ix pulmonary HTN
x CHF
xi Adenotonsillar hypertrophy
Carotid endartarectomy
- Indication/timing?
-Regional techniques?
- Cerebral hyperperfusion syndrome
50-99% stenosis within 2 weeks of TIA
Superficial/deep cervical plexus or LA infiltration
Cerebral hyperperfusion syndrome (usually resulting from >100% increase in cerebral blood flow compared with baseline) which causes headaches, seizures, and focal neurological deficits. If untreated, cerebral hyperperfusion can lead to intracerebral haemorrhage and oedema
Myaesthenia gravis:
Sx? (7)
Signs? (3)
Path: (Ig / receptors (2))
Rx? (3)
Crisis Sx: (4)
Sx: Diplopia / dysphagia / dysarthria / limb weakness / unable to smile / difficulty chewing / dyspnoea
Signs: Ptosis / squint / fatigable weakness
Path: IgG to nACHr & MuSK (muscle-specific kinase)
Rx: anticholinesterases / immunosuppression / IV Ig / Plasma exchange
Crisis: Unable to support head, no cough, no gag, resp distress
Pul HTN:
Diagnosis:
Classes:
Sx:
Signs:
ECG RVH:
ICU Rx:
mean PA pressure >25mmHg at rest
1 – pulmonary artery hypertension
2 – left ventricular disease
3 – pulmonary disease (COPD)
4 – chronic VTE
5 – multifactorial / unclear mech (sarcoid)
Exertional dyspnoea / pre-syncope
Raised JVP / peripheral oedema / hepatomegaly / RV heave / pansystolic murmur tricuspid / irregular pulse
RAD / RBBB / P pulmonale (peaked P wave) / ST dep or TWI right precordial leads
Rx underlying cause (e.g. Abx)
Optimise RV preload (IVI or diuretics)
Reduce RV afterload (PDE5 inhib / avoid hypoxia hypercapnia)
Improve RV contractility (dobutamine)
Maintain perfusion pressure (pressor for SVR)
Define a hypertensive emergency
Define malignant hypertension
hypertensive crisis is a situation in which a severe, abrupt increase in arterial blood pressure is associated with impending or progressive hypertension-mediated organ damage (HMOD). A hypertensive emergency is defined by the presence of acute HMOD, which is absent in hypertensive urgencies
malignant hypertension refers to hypertension, which may or may not be severe, complicated by hypertensive microangiopathy (hypertensive retinopathy or thrombotic microangiopathy)
Paracetamol OD
Mechanism:
Activated charcoal?
Prediction model for transplant
Metabolised in liver, NAPQI (N-acetyl-p-benzoquinone imine) is a toxic metabolite, usually conjugated by glutathione which gets depleted in OD
> 150mk/kg or ingestion <1h ago
Kings criteria:
- pH<7.25
OR all of
- PT >100 s
- Creat >300 μ mol/L
- Encephalopathy grade 3/4
Kinds non paracetamol:
- PT >100 secs
OR 3 of
- Age <10 / >40
- seronegative or drug induced ALF
- Jaundice to encephalopathy > 7 days
- PT > 50 secs
- Bilirubin >300 μ mol/L
Define GBS
Clinical features
Rx
Ventilatory indicators:
Poor prognosis:
Acute immune mediated demyelinating polyneuropathy
Motor: progressive ascending muscle weakness
Cranial nerves: facial weakness, bulbar weakness
Eyes: ptosis, diplopia
Sensory: paraesthesia’s, glove & stocking sensory loss
Resp: hypoventilation/resp failure
Reflexes: Areflexia
Autonomic dysfunction: labile BP, arrhythmia, retention
Rx: IV Ig / plasma exchange
Vent:
Vital capacity <20mL/kg
Maximum insp. pressure <30cmH2O
Maximum exp. pressure <40cmH2O
Bulbar involvement
Raised PaCO2
Significant autonomic instability
Prog:
Old age
Campylobacter inf.
Ventilated
Upper limb involvement
Child-pugh score
Variables? (5)
Peri-op mortality A/B/C?
Ascites
Encephalopathy grade
Bilirubin
Albumin
Prothrombin time
(each scores 1, 2 or 3)
A (5-6) - 5-10% peri-op mortality
B (7-9) - 20-30% peri-op mortality
C (9+) - >50% mortality
MOA/stop pre-SAB/start post-SAB:
Warfarin
Dabigatran
Rivaroxaban
Apixaban
Heparin
LMWH
Aspirin
Prasugrel
Alteplase
Dabigatran reversal agent
Warfarin: Vitamin K reductase antagonist/INR<1.5/immediately
Dabigatran: Direct thrombin inhibitor/48-96hGFR/6h
Rivaroxaban: Direct Xa inhibitor/24-48h/6h
Apixaban: Direct Xa inhibitor/48h/6h
Heparin: increases anti-thrombin activity/4h-4h/1h-4h
LMWH: increases anti-thrombin activity/12h-24h/4h-4h
Aspirin: COX-1 inhibitor/cont/cont
Prasugrel: P2Y12 receptor antagonist/7 days/6h
Alteplase: tissue plasminogen activator /10days/10days
Dabi rev: PCC/dialysis/indarucizumab
Types of US artefact
Acoustic
- enhancement (more US energy passes through fluid filled structures enhancing structures behind)
- shadowing (structures behind highly reflective structures appear darker)
- Reverberation (US images bounce between 2 reflective surfaces)
- Refraction (change of direction as cross tissue interface)
Anatomic artefact (tissue structures that resemble nerves)
Optical illusion
Electrical noise
PPM letter meaning 1-5
ICD letter meaning 1-4
PPM:
1 - Pacing chamber (O/A/V/D)
2 - Sensing chamber(O/A/V/D)
3 - Response to sensing (O/I/T/D)
4 - Programmability (rate response) (O/R)
5 - multisite (O/A/V/D)
ICD:
1 - Chamber shocked
2 - Chamber paced in tachy
3 - Method of tachy detection
4 - Chamber paced in brady
Scoring systems pancreatitis (2)
Glasgow OR Ranson’s
Common features of both:
Age>55
PaO2 <8kPa
WCC
Calcium (low)
Urea
LDH
Labour pains:
Somatic:
Visceral:
Somatic:
- pelvic floor, perineal stretch
- A-delta fibres
- Pudendal nerves
- S2-S4
Visceral:
- uterine contractions / cervical stretch
- unmyelinated C fibres
- with sympathetic nerves
- T10-L1
Volume of oxygen cylinders?
CD
E
F
CD - 460L
E - 680L
F - 1360L
Heperin dose and ACT target on-pump and off pump cardiac surgery
Off -pump:
100-200iu/kg
ACT 250-300 seconds
On-pump:
300-400iu/kg
ACT >480 seconds
Nof delay reasons
&
Echo pre-op?
Chest infection with sepsis
Acute LVF
Correctable arrhythmia >120bpm
Uncontrolled diabetes
Hb <8g/dL
Correctable coagulopathy
Na <120 / >150
K <2.8 / >6.0
New systolic murmer + syncope/exertiontal dyspnoea or angina
LVH but no HTN PMH
Diagnostic criteria for infective endocarditis
Common organisms
Dukes criteria
2 major or 1 major + 3 minor or 5 minor
Major: 2x positive blood cultures
Echo findings - new veg/valve issue
Minor: Risk factor (heart issue/IVDU)
Fever
Vascular phenomenon (splinter, stroke,)
Immune phenomenon (glomerulonephritis,
RF, Oslers nodes)
Mirco evidence (Bld Cult not meeting major)
Streptococci
Staph aureus
Coagulase negative staphylococci
Lumbosacral plexus
T12-L1 - Iliohypogastric
L1 - Ilioinguinal
L1-L2 - Genitofemoral
L2-L3 - Lateral cutaneous nerve of thigh
L2-L4 - Femoral
L2-L4 - Obturator
L4-S1 - Superior gluteal
L5-S2 - Inferior gluteal
L4-S3 - Sciatic
S1-S3 - Posterior femoral cutaneous
S2-S4 - Pudendal
Chromosome abs
11 Sickle (Valine for glutamic acid pos 6 on globin)
13 Patau
18 Edwards
19 MH (RYR1) & Myotonic dystrophy
21 Downs
Non-technical skills
Call for help early (1)
Anticipate and plan (1)
Know the environment (1)
Use all available information (1)
Allocate attention wisely (1)
Mobilise resources (1)
Use cognitive aids (1)
Communication (1)
Distribute workload (1)
Establish roles
Designate leadership
Cervical plexus nerve roots
Cervical fascia layers
Cervical plexus branches
C1-C4
Superficial
Deep - investing, pretracheal, prevertebral, carotid sheath
Superficial - great auricular, lesser occipital, transverse cervical, supraclavicular (sensory)
Deep - motor branches to neck muscles
Thoracic aneurysm/dissection classification
Indications for surgery
Crawford for aneurysms - 1, 2, 3, 4 types
De Bakey (dissection) - 1, 2 or 3 types
Stanford (dissection) A or B
> 6.5cm (6cm if CT disorder)
Grown >1cm/yr
Symptomatic due to compression surrounding structures
Acute rupture/dissection
Brachial plexus nerve roots
Musculocutaneous - C5 - C7
Axillary - C5 - C6
Median - C6 - T1
Radial C5-T1
Ulnar C8-T1
CPET:
3x main variables
Absolute CI
Relative CI
Anaerobic threshold (>11ml/kg/min)
Peak VO2 (>15ml/kg/min)
Ventilatory efficiency at AT (VE/VCO2) >41
Absolute CIs:
- Acute MI (3-5 days)
- Unstable angina
- Uncontrolled arrhythmia with hypotension
- Syncope
- Active endocarditis
- Acute myo-/peri-carditis
- Symptomatic severe AS
- Uncontrolled heart failure
- Acute PE
- LL thrombosis
- Dissecting aneurysm
- Uncontrolled asthma
Relative CIs:
- LAD stenosis
- Moderate stenotic valvular disease
- Untreated severe HTN
- Tachy-/brady-arrhythmia
- Hypertrophic cardiomyopathy
- Signif pul. HTN
- Advanced pregnancy
- Electrolyte derangement
Define delirium
Acute disorder of attention and awareness, with disturbance in cognition and consciousness
ICU Delirium Ax tools
- Confusion Assessment Method for ICU (CAM-ICU)
- Intensive Care Delirium Screening Checklist
- Prediction of Delirium ICU (PRE-DELIRIC)
ICP waveform
P1 - percussion wave from systole
P2 - tidal wave from intracranial compliance
P3 - dicrotic wave - AV closure
Invasive ICP monitoring
TBI + GCS <8 + abnormal CTH
Severe TBI + normal CTH +
Age >40
SBP<90
Motor posturing
Day case spinals:
Drug - dose - duration
2% prilocaine - 40-60mg - up to 90 mins (20mg saddle block / 60mg in >T10)
1% 2-chloroprocaine - 40-50mg - up to 40 mins
Tumour lysis syndrome:
Definition
Sx
Signs
Risk factors
Bloods
Rx
Def: Oncological emergency due to high turnover of tumour cells causing severe metabolic derangement
Sx: - GI upset, fluid overload/oedema, haematuria, arrythmia, weakness, paraesthesia, tetany, renal failure
RF: 12-72h post-chemo, large tumour, lymphoma, AML, CML, ALL
Bloods:
- hyperkalaemia
- hyperphosphataemia
- hyperuraemia
- Hypocalcaemia
- High LDH
- Metabolic acidosis
- Raised urea & creat
Rx:
Prophylaxis - Allopurinol and hydration in high risk
Acute:
- general - hydration, metabolic correct, renal support (RRT)
- allopurinal (xanthine oxidase inhibitor - prevents urate formation)
- rasburicase (catalyses oxidation of urate)
- hyperkalaemia Rx
Splenectomy vaccinations
2x viral
3x bacterial
timing
Flu, covid
Pneumococcal, Meningitis B, Meningitis ACWY
2 weeks pre-splenectomy (2 weeks post- in emergency)
Remote site working
Facilities - guidelines, pt records, PAR
Staff - ODP availability with IR exp, supervising consultant, back-up distant if issue
Equipment - need all standard kit inc warming, Tx, machine
Environment - access to pt, line site/length, circuit length, light levels
Medications - full range of drugs inc emergency
Processes - labelling, pre-procedure checks, checklists, stock levels
Sedation scoring systems x3
Society of Anaesthesiologists Continuum of Sedation
Modified Observers Assessment of Alertness Scale
Modified Ramsay Sedation Scale
