2 Flashcards
supraclavicular blocks what part of BP
trunks and divisiojns
infraclavicular blocks what part of BP
cords
what part of arm does infraclav block
upper arm, elbow, forearm, wrist, hand
what block is best for copd
infra > supra
or ax if limited mobility
landmarks for infraclavicular
clavicle and coracoid process
complications of infraclavicular
chylothorax
this block has highest risk of vascular injection!! and patient discomfort (piercing pec muscles)
axillary block tagets what part of BP
terminal branches
where does axillary miss
medial upper arm- axillary and deltoid
what nerve is often missed with the axillary block
musculocutaneous- lateral foreram- 2nd injection needed
complications for axillary block
median nerve injury
hematoma and last also
phrenic n injury and pneumothorax not common
forearm blocks: radial, median, ulnar
radial- proximal to radial styloid- field block as many branchs of radial n.
median- between flexor carpi radialis and flexor palmaris longus
ulnar- between ulnar styloid and flexor carpi ulnaris
what is important to know abut digital nerve blocks
no epi!! ischemia
what type of procedures should bier block be used for
minimal operative pain procedures: carpel tunel release, dupuytren’s contraction
what cannot be used in bier block
no epi or bupivicaine in bier block
when does pain begin with bier block
25-60 mins
what nerve helps tolerate touorniquet pain but often needs to be blocked seperate
T2- intercostobrachial n
what does femoral n do
hip flexion and knee extension
sciatic n
hip extension and knee flexion
what controls toe extension/ flexion, abduction and adduction
tibial
what controls ankle eversion
superficial peroneal
what controls ankle dorsiflexion and inversion
deep peroneal
excess pain response to stimuli
hyperalgesia- remi
pain from nonpainful stimuli
allodynia- fibromyalgia
pain localized to peripheral nerve
neuralgia- herpes zoster
abnormal sensation occuring spontaneously
paresthesia
what appears anechoic on US
vessel, cyst (black)
all post ganglionic sympathetic nerve fibers are
c fibers; unmyelinated
which ankle nerve block requires 2 shots
common peroneal
a femoral knee block is great for
knee
pressure against the distal lateral humerus can cuase injury to what nerve
radial
lipid solubility of a LA is an indicator of
potency
what part of LA structure interfers solubility
benzene ring
what block is best for forearm/ wrist surgery
axillary
dermatome for c section
t6
what nerve trunk is most commonly missed with ISB HOT SPOT
ulnear n c8-t1
what nerve must be blocked for awake nasal intubation
infraorbital v2 maxillary trigeminal
landmarks for caudal (multi select)
superior posteior iliac spine
sacral cornu
sacrococcugeal ligament
sacral hiatus
what is c/i in bier block
epi and bupivicaine
what are intracellular ions
k, mag, phosphate
extracell
na, ca, cl, hco3
normal plasma osmolarity
280-290
what is the dominant extracellular ion
Na
increase na by no more than ___
2 meq/hr
a na < __ is very bad
<115 seziures coma cerebral edema
a na > __ = hyperreflexia; > __ = seizures coma
> 401-430 hyperreflexia, muscle twitches; >431 seizures coma
normal ionized ca
2.2-2.6
what phase of cardiac cell ap is ca involved in
ii
role of pth
raises serum ca
calcitonin role
lowers serum ca
acidosis means __ ionized ca
increased
alkalosis = decreased ionizedd ca
hyperventilation= high or low ca
low ca
hypocalcemia s/s
tetany, laryngospasm, seizures, chvostek (eye twitch), cramps, trousseaus (wrist), qt prolongation
tx for hypocalcemia
calcium and vit d
hyperca s/s
abd pain, htn, psychosis, seizures, qt shortening
hyperca tx
0.9% nacl; furosemide (loop)
hypomag symptoms
sizures, tetanty, dysryhythmias, long QT
hypermag s/s
diminished dtr, lethargy, hotn, resp depression, coma, ht block, can potentiate sux and ndmr (lower dose if emergent c section)
tx of hyper mag
ca gluconae or ca cl
hyperventilation causes
hypok, hypoca, inc cerebral blood flow
acute resp acidosis every __ inc in paco2 ph changes by
every 10 mmhg inc paco2; ph decreases by 0.08
practice fluid
what forms clot
fibrinogen (1)-> fibrin-> clot
what busts clot
plasminogen -> plasmin -> fibrinolysis
von willebrand factor (vwf)
plt adhesion
vwd tx
1- vwf / vii
2 desmopressin
3 cryp
4 ffp
intrinsic pathway is activated by
factor 12 hageman factor
what pathway is the longer one
intrinsic 6 minutes
intrinsic pathway factors
12, 11, 9, 8
what measures intrinsic pathway
aptt, act - inhibited by heparin
what activates extrinsic pathway
tissue factor iii
what masures extrinisc pathway
pt and inr- inhibited by warfarin
what factors are included in extrinsic pathway
3 and 7
how long is extrinsic pathway
15 seconds- shorter
what is the final common pathway
prothrombin (2) - acitvates thrombin 2a
thrombin 2a converts fibrinogen 1 to fibrin
activated fibrin stabilizing factor 13 crosslinks fibrin
normal act
90-120 sec
normal aptt
25-32 sec
normal pt
12-14
warfarin works on
pt/ inr- extrinsic pathway
normal inr
1 sec
bleeding time looks at
plt function and aspirin
2-10 minutes
d dimer
< 500 - measures fibrinolysis -> if elevted fibrinolysis is occuring
when should you stop clopidogrel
5-7 days before
what drug class is clopidogrel
adp receptor inhibitors
what type of drug is abciximab
gpiib/ gpiiia receptor antagonists
how long to stop abciximab
3 d
how long to stop asa/ nsaids
7 days
what class is asa/ nsaidss
cox inhibitors
how long to stop celecoxib/ rofecoxib
none
what drug class is celecoxib/ rofecoxib
cox 2 inhibitors
how long to stop unfractionated heparin
6 hrs
how long to stop lmwh/ enoxaparin
1-2 d
how long to stop argatroban, bivalirudin
2-6 hrs
what drug class is argatroban/ bivalirudin
thromnin inhibitors
what drug class is fondaparinux
factor 10 inhibitors
how long to stop fondaparinux
4 days
how long to stop warfarin
2-4 days
what type of drug is warfarin
vit k antagonist
what type of drug is tpa
plasminogen activator
how long to stop tpa
1 hr
how long to stop stroptokinase
3 hrs
what type of drug is streptokinase
plasminogen activator
phospholipids produce ___ which acitvates platelets
thromboxane a2
what causes plt acitvation and aggregation
adp
what does serotonin do for plt
activates neaby plt
what helps with plt aggregation
txa2 and adp
what is the universal donor and recpient with plasma
universal donor- AB+
universal recipient- O-
when should mom get rhogam
28 weeks for 2nd pregnancy
what is the risk with rh incompatability
next rh+ fetus- reythroblastosis fetalis
role of citrate
anticoagulant- binds ca (factor 4) - hypocalcemia and hyperkalemia
what is hct in prbc
70%
what is number 1 infectious complications of transfusions
cmv
cmv > hep b > hep c > hiv
what is leukoreduction
removes wbc from prbcs and plt-> decreases risk of hla sensitization, transfusion rx, cmv
what is washing
removes remaining plasma and antigens from donor rbcs- decreases anaphylaxis in igA deficient patients
what is irradication
destroys donor leukocytes- dec risk of graft vs host disease in immunocompromised
pt has fever chills n/v after transfusion
fever non hemolytic rxn
just give tylenol
pt has urticaria and facial swelling after transfusio
allergic transfusion rxn- need antihistamines
pt has non cardiogenic plm edema after transfiion
1 mortality- frm hla and neutrophil antibodies
biggest risk with ffp and plt!!!!
transfuion overload after transfusion
taco
hemoglobinuria, hotn, flushing after trasnsfurion
stop it, uop > 75 ,ml/ hr with bolus, mannitol 12.5-25 g, furosemide 40 mg, alkalize urine
benefits of intraop blood salvage
inc o2 carrying capacity, inc 2,3 dpg and atp, better able to keep shape
estimated blood volume
premie 100
neonate 90
infant 80
women 65
man 70
all ml/kg
citrate metabolizes to ->
hco3 in the liver
what are the consequences of mass transfusion
alkalosis- r/t citrate
hypothermia- cold blood
hyperglycemia- from dextrose
hypocalcemia- citrate binds to ca
hyperkalemia- old lysed blood- prbcs < 7 d old should be used
trauma triad
HAC
hypothermia, acidosis, coagulopathy
what is ffp used for
acute warfarin reversal, coagulopathy (pt or aptt > 1.5), antithrombin def, dic, c1 esterase deficiency (hereditary angioedema)
factor 7 (shortest half life)
what is cyro used for
fibrinogen (1), factor 8, factor 13, vwf
hypofibrinogenemia <80, vwd, hemophelia
gap acidosis
inc h+ ions- lactate, dka, renal failure
non gap acidosis
low hco3 or inc cl (diarrhea, renal tubular necrosis, high na admin)
what works on pct
carbonic anhydrase inhibitors- acetazolamide
osmotic diuretics- mannitol
what works on thick ascending loop
loop diuretics- furosemide, bumetanide
what works on dct
hctz- thiazide diuretic
spirnolactone- aldosterone antagonist
eplerone (or collecting duct?)
blood supply vs oxygen for hepaic v and a
hepatic v- 75% blood; 50% oxygen
hepatic a. - 25% blood; 50% oxygen
what is graves
hyperthryoid
what is hashimotos
hypothyroid
how does calcitonin lower calcium
inhibits osteoclast activity and dec kidney reabsorption
is pth high or low with hyperparathyroid
high pth-> inc ca retention-> hypercalcemia
blocks ca absorption in intestines-> dec renal ca excretion-> inc ca reabsorption by kidneys-> inc osteoclast activity-> inc serum ca
mineralcorticoid potency
aldosterone 3000
fludorocortisone 250
cortisol 1
prednisone 0.8
methylprednisone 0.5
what drugs have no mineralcorticoid effects
decadron, betamethasone, triamcinolone
what is reduced from anterior pituitary
flat peg
fsh, lh, acth, tsh, prolactin, edorphins, growth hormone
somatostatin inhibits what in posterior pituitary
growth hormone, tsh, insulin
