12. Question listed under Other Flashcards
Causes of microcytic hypochromic anaemia
Macrocytic
Nornoctyic
The patient illustrated has an microcytic hypochromic anaemia. Causes include
iron deficiency
and thalasaemia.
A macrocytic anaemia may be caused by
folate deficiency,
B12 deficiency and
alcoholism,
normocytic normochromic anaemia may be caused by acute blood loss,
haemolytic anaemia,
chronic disorders and
leucoerythroblastic anaemias.
CPR
what is the sequence
how long can stop compression
tracheal admin drugs?
chest compressions while defib charging/
During cardiopulmonary resuscitation it is recommended giving 30 chest compressions at the rate of 100-120/minute and to a depth of 5-6 cm before giving two ventilations.
Chest compressions should not be interrupted for more than 10 seconds and should not be interrupted when an endotracheal tube is in place.
Chest compressions are now continued while a defibrillator is charged - this will minimise the pre-shock pause.
Tracheal administration of drugs is no longer recommended.
Diamorhpine elixir
seadation?
admin
cocaine effects?
side effect
dependence?
Im dose via PO
Diamorphine elixir is used for analgesia in terminal care patients.
The sedation that occurs in the first few days typically wears off, leaving the patient alert. It is very lipid soluble and can be adminstered via mucous membranes (intranasally or buccally)
Cocaine is a topical local anaesthetic agent which does not enhance the analgesic effect of diamorphine but gives the patient unwanted hallucinations.
Constipation is a common side effect of opioids and an aperient should always be added to the treatment regime.
Addiction or drug dependence is not usually a problem in terminal care. Tolerance is a slow process results from liver enzyme induction.
An intramuscular dose of diamorphine is three times more effective than the same oral dose.
PReop assesment given suggestion of anaphkaxis
As part of a preoperative assessment process, a thorough review a patients case notes and any previous anaesthetic records is mandatory.
Explanation
The patient gives a past history that suggests that she may have had an anaphylactic reaction during a previous anaesthetic. Her past notes would have to be reviewed to establish what course of events took place and if any investigations were performed. If the patient had been appropriately managed and investigated then a possible cause of her anaphylactic reaction would be known and a suitable anaesthetic management plan formulated. If not, then the patient should be referred to an allergy specialist for skin testing for the agents used at the time of her emergency appendicectomy.
Without further investigation it would be unsafe to proceed. It would be difficult to proceed with this laparoscopic surgery under regional anaesthesia.
White coat in an otherwise healthy patient
In conjunction with British Hypertension Society, the AAGBI has published guidelines for the measurement of adult blood pressure and management of hypertension before elective surgery.
The key objective is to ensure that patients that are admitted for elective surgery are known to have a systolic blood pressure below 160 mmHg and diastolic blood pressures below 100 mmHg. The onus is on the primary health care teams to ensure that, if possible, evidence to the pre-assessment clinic staff or on admission, that this is the case.
A secondary objective is to avoid cancellation on the day of surgery because of spurious (“white coat”) hypertension. There are also guidelines on how to accurately measure blood pressure.
The primary recommendation is that patients who present to pre-operative assessment clinics without documented evidence of primary care blood pressures should proceed to elective surgery provided the clinic blood pressures are below 180 mmHg systolic and 110 mmHg diastolic.
This is the case in the clinical vignette and is supported by the fact that there does not appear to be obvious end-organ damage. There is no indication for further investigation for secondary causes of hypertension or an echocardiogram at this point. The patient will not require further review and treatment at this point.
In the interim, it would be prudent to write to the patient’s GP and encourage serial blood pressure measurements in the primary health care/community setting.
Cricoid cartilage
is it the narrowest part of an adult airway
what about peads
whats the sellick manouevure
What pressure is recomended for crioid pressure
In adults the narrowest part of the airway is at the vocal cords, and in children it is at the level of the cricoid cartilage. The upper border of the cricoid cartilage is attached to the thyroid cartilage (not hyoid bone) and the lower border is attached to the first tracheal ring.
The application of cricoid pressure to control regurgitation (or reduce the risk of aspiration) of gastric contents during the induction of anaesthesia, was described by Sellick in 1961.There have been reports of pulmonary aspiration despite what was thought to be effective cricoid pressure. One possible reason is that the oesophagus is not exactly posterior to the cricoid and the manoeuvre might not necessarily in produce midline esophageal compression.
Based on studies of cricoid force to prevent material from reaching the pharynx, 40 N (10 N = 1.0 kg) was recommended.
What helps relieve px oes spasm w/ tumour
What inhibit ostelcastic bone resportion and help rx bone px
What helps ibs px
what helsp CNS tumour px
what help bladder spasm
Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal tumours and could be used to relieve his odynophagia.
Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and the associated hypercalcaemia.
Pinaverium is used to reduce the pain duration associated with irritable bowel syndrome (IBS).
Corticosteroids are used to treat pain from central nervous system tumours and painful bladder spasm may be relieved by oxybutynin.
PALS algorithim
Paediatric life support is different to adult life support; the primary cause for deterioration is hypoxia.
Current advanced paediatric life support (APLS) guidelines stipulate that after checking for danger, a gentle stimulus should be applied (such as holding the head and shaking the arm) and asking the child “Are you alright?”. This is often remembered as Safety, Stimulate, Shout. These actions should precede any airway assessment.
Although five rescue breaths are included in the algorithm, these are performed after the airway assessment.
Asking parents to leave is not suggested unless they are obstructing the resuscitation. A dedicated member of the team should be with them at all times to explain what is happening and answer any questions.
CPR should not be commenced before appropriately assessing the child and delivering rescue breaths.
DAS algorithim
Always call for help early. This patient is at risk of gastro-oesophageal reflux, the reason a rapid sequence induction has been opted for in the first place. The patient is not pregnant and the urgency of surgery is not immediate.
The plan A is to perform a rapid sequence induction under optimal conditions and successfully secure the airway with a tracheal tube.
Whilst no more that three attempts with direct laryngoscope (+ 1 attempt with videolaryngoscope) should be made to intubate the trachea the fact that the suxamethonium is wearing off should be borne in mind. One step is to ensure adequate neuromuscular blockade at this stage, this might include the administration of a non-depolarising relaxant if oxygenation can be maintained by bag-mask ventilation. As the surgery is not immediate there should be a low threshold to abandon attempts at intubation and resort to plan B.
An alternative strategy can then be planned.
The most important initial plan of action is to announce a “failed intubation” as this will stop you from persisting to intubate and alert your assistant that plan A has failed. Maintaining oxygenation and anaesthesia is also important prior to instituting plan B.
Do not give another dose of suxamethonium. Insert a supraglottic airway if there is failure of oxygenation and inability to maintain adequate ventilation
Plan D follows the declaration of a CICO
Sacral hiatus
borders sup and lat
what level does cord term in kids
what level does the cauda term
What level does Dura extend to
what are complications
are they common
Failure of fusion of the laminae of the fifth sacral segment results in the formation of the sacral hiatus.
The sacral cornua form the lateral border and the spinous process of the fourth sacral segment forms the superior border.
The sacrococcygeal membrane forms the roof of the sacral hiatus (posterior sacrococcygeal ligament).
The spinal cord terminates at L1/2.
The cauda equina (lumbar and sacral nerve roots), which is covered by the dura, terminates at S2.
Hence, the dura extends to the lower border of S2 (not L4). The filum terminale terminates at the coccyx.
The complications associated with caudal anaesthesia have a low incidence and are certainly not common. However, an intraosseous injection of local anaesthetic can produce results similar to an intravascular injection, causing profound hypotension or cardiac arrest.
Other complications, which are also not commonly encountered include:
Urinary retention
Lower limb blockade
Dural puncture
Hypotension.
Oxygen therapy
benefit in MI?
what level
CO
how benefit supplement oxygen
Physiological studies have made clear that there are potential adverse effects of oxygen therapy, and randomized trials have not demonstrated any significant benefits in terms of myocardial infarct size, patient haemodynamics, or patient symptoms. Some trials have identified a trigger for extended myocardial injury during uncomplicated acute myocardial infarction. There is strong evidence to avoid supplemental oxygen therapy in patients with uncomplicated acute myocardial infarction if the peripheral oxygen saturation is 93% breathing air.
Carbon monoxide (CO) has approximately 230 times the affinity for haemoglobin compared with oxygen. Once bound to haemoglobin oxygen itself is prevented from binding. This causes a shift of the oxygen-haemoglobin dissociation curve to the left resulting in a combination of anaemic and an element of histotoxic hypoxia. The latter is caused by the inhibition of cytochrome A3 by CO. The half-life of CO breathing air is 320 minutes. Breathing 100% oxygen reduces the half-life to 80 minutes and is the treatment of choice until the CO levels normalise (<10%). Hyperbaric oxygen therapy (2.5 bar) further reduces the half-life of CO to 23 minutes.
Supplemental oxygen therapy is appropriate in patients presenting with histotoxic hypoxia or a sickling crisis.
Prior to availability of blood gases, a 24% Venturi mask at 2-3 L/min or 28% Venturi mask at 4 L/min or nasal cannulae at 1-2 L/min should be used and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia (e.g. COPD) but no prior history of respiratory acidosis.
CV response to high cord trauma
Initial - sympathtic point of view
heart rate
blood volumes
what stag does autonomic hyperreflexia appear
The initial cardiovascular response to high cord trauma is a short-lived acute pressor response, due to massive sympathetic discharge, which can cause arrhythmias and myocardial dysfunction.
The loss of sympathetic tone causes a reduction in systemic vascular resistance (SVR), hypotension and venous pooling of blood.
The loss of sympathetic control to the myocardium (T2 - 5) results in bradycardia and an inability to increase contractility.
The onset of spinal shock with the risk of precipitating pulmonary oedema, demands the careful titration of intravenous fluids titrated against the central venous pressure or pulmonary artery occlusion pressure.
The presence of hypertension and arrhythmias in response to sometimes minor stimulation suggest the development of autonomic hyperreflexia. This may become apparent after 4-6 weeks when the spinal shock phase has receded.
Magnesium
What type of ion
where is it mainly
what are its action
use in pet?
effects uterus?
side effects what level
how is it monitor clinic
Magnesium is largely an intracellular cation present mainly in bone and skeletal muscle.
Only 1% is in the extracellular fluid and normal plasma levels are 0.75 - 1.05 mmol/l.
Its effect can be described as antagonising the actions of calcium.
Magnesium sulphate is used in pre-eclampsia as an anticonvulsant but it also relaxes vascular smooth muscle, causing vasodilatation thus lowering the mean arterial blood pressure.
It is also an effective tocolytic drug helping to decrease uterine contractions. It acts at the neuromuscular junction decreasing acetylcholine release thus neuromuscular function is weakened.
Therapeutic plasma levels of magnesium are 2.0 - 3.5 mmol/l, but side effects may occur above 4.0 mmol/l.
Increasing plasma levels of magnesium cause deep tendon reflexes to be diminished gradually until they become absent. Thus tendon reflexes are frequently used as a bedside measurement of hypermagnesaemia.
Cat sections
whent o act
Once a decision is made to deliver a baby by caesarean section, it should be carried out with an urgency that is appropriate to the risk to the baby and the safety of the mother.
The urgency of caesarean section has four categories:
Category 1 - A threat to maternal or fetal life
Category 2 - Maternal or fetal compromise that is not immediately life threatening
Category 3 - Requires early delivery, but not maternal or fetal compromise
Category 4 - Elective delivery, at a time convenient to mother and maternity staff.
Category 1 and 2 caesarean sections should be performed as quickly as possible after making the decision, particularly for category 1. A decision to delivery time of 30 minutes is currently being used for category 1 caesarean sections.
Category 2 caesarean sections should be performed in most situations within 75 minutes of making the decision.
The decisions taken for rapid delivery should take into account the condition of the woman and the unborn baby as may be detrimental in certain circumstances.
In the example above there is no evidence of fetal compromise yet (early fetal pulse decelerations and a pH of less than 7.25). Early fetal pulse decelerations are most likely to be due to compression of the fetal head by the uterus. These are not harmful to the fetus. Whenever possible a spinal anaesthetic is preferable to a general anaesthetic.
If the fetal scalp blood pH is more than 7.25, it might be prudent to repeat later and look for any deterioration. With fetal decelerations the mother should be given oxygen, maintained in a left lateral position and maintain adequate hydration and raise the possibility of a caesarean section.
Thyroid disease
Causes prim hypoothyorid
hashimoto?
TSH In prim and secondary
Clin featurs
CVs ft
what can precip my coma
Hypothyroidism can be primary or secondary to hypothalamic or pituitary disorders.
The causes of primary hypothyroidism can be classified as follows
Impaired synthesis or release of thyroid hormones
Resistance to thyroid hormones
Destruction of the endocrine gland (surgery, radioactive iodine)
Autoimmune disease.
Hashimoto’s disease is an autoimmune disorder that causes primary hypothyroidism (not hypoparathyroidism).
The thyroid stimulating hormone (TSH) level is elevated in all cases of primary hypothyroidism (not reduced) and can be normal or low in secondary hypothyroidism.
The clinical features of hypothyroidism usually have an insidious onset, with females being more commonly affected than males.
The cardiovascular features include
Pericardial effusions
Bradycardia and
Electrocardiograph abnormalities (inversion or flattening of the T waves and low voltage complexes).
Myxoedema coma may be precipitated by anaesthetic agents, opiates, cold and infection, and may be the presenting feature of hypothyroidism.
Profound bradycardia, bradypnoea and hypothermia are common, which require urgent treatment with thyroxine.
Thyroxine can cause angina pectoris in patients with ischaemic heart disease or heart failure.
Childs weight formula
Weight = (Age + 4) × 2
Childs weight formula
Weight = (Age + 4) × 2
PDPH mx
This patient is likely to have a post dural puncture headache (PDPH).
Conservative measures for the first 24 to 48 hours are considered the most appropriate initial management strategy. This is because more than 85% of PDPH resolve with conservative treatment.
Conservative measures include bed rest, intravenous hydration, caffeine supplementation, and analgesic medication. Obviously, bed rest in the supine position may improve the symptoms of PDPH, although there is no evidence for prevention or faster recovery. There is also no evidence to support the common practice of aggressive rehydration or epidural crystalloid infusions to prevent PDPH.
Patients who do not respond to conservative treatment within 24-48 hours require more aggressive interventions. An epidural blood patch is considered the most effective treatment for moderate and severe PDPH, with success rates of 61-98%.
DVT - what signs
RFactors
what type of techniwur has been shown to recude indicdence dvtg
Patients with deep venous thrombosis (DVT) usually present with physical signs that are unreliable or non-specific, and frequently require investigation to confirm the diagnosis. Some calf vein thromboses can be asymptomatic.
Risk factors associated with DVT and pulmonary embolism (PE) include hypercoagulable states such as deficiencies of:
protein C
protein S
antithrombin III, and
plasminogen.
Other risk factors are:
malignancy prolonged immobility the oral contraceptive pill pregnancy obesity previous DVT varicose veins polycythaemia myocardial infarction cardiac failure, and
connective tissue diseases.
Lumbar (not thoracic) epidurals and spinals have been associated with a reduced incidence of DVT. This has been attributed to the increased blood flow to the lower limbs, reduced venous stasis and reduced blood viscosity (from intravenous fluid
Caudal block in kids
The most important safety aspect in performing a caudal block is choosing an appropriate volume, and therefore dose, of local anaesthetic to minimise the chance of local anaesthetic toxicity.
Performing a caudal in a child “awake” is not a viable option. It would have to be inserted following induction of anaesthesia having first placed the patient in the lateral position. The sacral hiatus is identified and, under strict asepsis, a needle is advanced at an angle of approximately 55-65° to the coronal plane at the apex of the sacrococcygeal membrane where loss of resistance is a reliable endpoint.
The needle can be adjusted to an angle of 10-20° and advanced a small distance (3-4 mm); there should be no resistance to its passage. The most common needle used is a 21-23FG. Before injecting local anaesthetic, the needle must be aspirated first because there is a small risk (1 in 2000) of perforating the dura or vascular puncture.
The alternative is to use a 22-gauge plastic cannula with removal of the stilette following perforation of the sacrococcygeal membrane and advancing only the blunter plastic cannula; this lessens the risk of intravascular perforation.
Stimulating the caudal and epidural spaces and eliciting an appropriate end motor response at an appropriate current strength helps in improving the safety efficacy of neural blockade. A 22G insulated needle is placed in the caudal canal, instead of a 22-G hypodermic needle, until a “pop” is felt. An electrical stimulation of 1-10 mA is applied. The correct needle placement elicits anal sphincter contractions (S2 to S4).
One advance in paediatric regional anaesthesia is the application of ultrasonography in identification of the caudal epidural space. It has been shown that application of ultrasound guidance increases the safety and efficacy of the block in children, preventing inadvertent dural puncture.
In acute pulmonary embolism:
Embolectoym used?
when thrombolyiss
- does this have to be central
Heparin effect thrombolytic?
Embolectomies are rarely done nowadays due to the excellent results with thrombolysis.
Thrombolytic therapy is reserved for those with severely compromised circulation rather than hypoxaemia. It is equally effective when administered through either a peripheral vein or a pulmonary artery catheter.
Heparin reduces risk of further embolism (anticoagulant not a thrombolytic) and reduces pulmonary vasoconstriction.
A normal ECG does not exclude the diagnosis.
Paeds
Tracheal bifurc angle
vs adults
tissues
type of blade
Anatomical differences between adults and children must be considered during intubation.
For instance the angle of tracheal bifurcation is greater and the main bronchi come off at the same angle in children, whereas in adults the right main bronchus is more vertical and therefore more prone to inadvertent intubation.
However, children have comparatively larger soft tissues, including a floppy epiglottis.
In paediatric intubation a straight bladed laryngoscope (that is, Wisconsin, Magill or Miller) is placed behind the epiglottis holding it in position, so that it may be lifted to expose the slightly more antero-caudal placed cords.
In adults a curved Macintosh blade, with the tip in the vallecula anterior to the epiglottis, is used.
Complications of blood transfusions
omplications following blood transfusions can be early or late and may be classified as follows:
Immunological Infective Metabolic, or Volume effects. Haemolytic reactions may be early or late, for example, ABO incompatibility.
Haemosiderosis is a complication of iron overload secondary to chronic blood transfusions.
Consumption or dilution of clotting factors and platelets and disseminated intravascular coagulation (DIC) are also recognised complications.
An alkalosis may follow the metabolism of citrate (found in stored blood) to bicarbonate, but an acidosis is uncommon.
Hypocalcaemia (not hypercalcaemia) can be seen with rapid blood transfusions which may require intravenous calcium therapy.
Awareness management steps by nap5
Following the 5th National Audit Project of the Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland (NAP5) on Anaesthetic Awareness under General Anaesthesia (AAGA) in 2014 a support pack was produced for guidance.
The NAP5 Awareness Support Pathway for AAGA has 3 stages:
Stage 1
The patient should be met as soon as possible, preferably with a more senior colleague. The patient’s account should be listened carefully and accept that the story is genuine. The interview should be conducted empathically and at some stage regret should be expressed. At this early stage, it might be prudent to refer the patient to a local clinical psychologist.
Stage 2
A possible cause of awareness should be sought using the NAP5 process. Bearing in mind the patient’s account the details on the anaesthetic and recovery charts should be reviewed along with the accounts of attendant staff. An independent review by a suitably experienced group would be appropriate at this point to provide an unbiased view.
Stage 3
Detecting the psychological impact in the first 24-hours and active follow-up at 2-weeks. If psychological impact persists at this stage a formal referral to the psychiatric services is recommended.
