A&E Flashcards
Identify the 6 Main ASA classifications?
ASA I - A normal healthy patient
ASA II - A patient with mild systemic disease
ASA III - A patient with severe systemic disease
ASA IV - A patient with severe systemic disease that is a constant threat to life
ASA V - A moribund patient who is not expected to survive without the operation
ASA VI - A declared brain-dead patient whose organs are being removed for donor purposes
What are the main characteristics of ASA 2?
Mild diseases only without substantive functional limitations.
E.g. current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes/Hypertension, mild lung disease
What are the main characteristics of ASA 3?
Substantive functional limitations; One or more moderate to severe diseases.
E.g. poorly controlled Diabetes/HTN, COPD, Morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRF undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA
What are the main characteristics of ASA 4?
E.g.: Recent (< 3 months) of MI, CVA, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRF not undergoing regularly scheduled dialysis
Name some conditions that would classify into ASA 5?
AAA, Ischaemic bowel, intra-cranial bleed with mass effect , Ruptured aneurysm, Massive trauma.
What are the main complications of poorly managed diabetes during surgery?
UNDETECTED HYPOGLYCAEMIA under GA
Increased risk of wound + Resp infections
Increased hospital stay
Increased risk of post-op AKI
When should patients stop taking?
A - Food/non-clear liquids
B - Clear Fluids
A - At least 6 hours before surgery.
B - At least 2 hours before surgery.
What factors are considered when deciding to investigate heart before surgery?
Learning point: Anaesthesia puts stress on the CVS, reduce lung function
Urgency of surgery - Emergency/Urgent/Elective
Severity of surgery - Minor, Intermediate, Major
Patient Comorbidities
Patient exercise capacity- I.e How many flights of stairs/Distance of walking flat before SOB/CP?
Difference between Crystalloid and Colloid?
Crystalloid = Solution containing small molecules - e.g. Nacl
Colloid = Solution containing larger molecules. e.g. Albumin
Fluid Resuscitaion Approach
4 - Steps
- Identify cause of fluid deficit and respond
- Fluid bolus of 500mL crystalloid over <15min (Fluid challgenge)
- Reassess using ABCDE Approach
- Further fluid boluses (up to 2000mL) may be needed
Clinical Observations that Indications fluid resuscitation may be needed?
Systolic BP <100mmHg Heart rate >90bpm Capillary refill >2s Cool peripheries Respiratory rate >20bpm NEWS ≥5 Dry mucous membranes
Emergency Treatment for:
- TCA Overdose
- Organophosphate poisoning (pesticides, nerve gases, etc..)
- Benzodiazepine OD
- Opioid OD
- Sodium Bicarbonate (due to metabolic acidosis) or Activated charcoal (2-4hrs of OD)
- Atropine
- Flumazenil (Can precipitate seizures)
- Naloxone
Type of receptors these medicines act on?
A - Baclofen B - Hyoscine butylbromide C - Ondansetron D - Cyclizine E - Prochlorperazine
A - GABA-B RECEPTOR AGONIST
B - MUSCARINIC ANTAGONIST (Decrease pain, nausea + secretions
C - 5HT3 Receptor antagonist (Centrally + also acts on chemoreceptors in the gut)
D - Histamine H1 Receptor antagonist (Avoid HF)
E - Dopamine D2 Receptor antagonist (Risk of extrapyramidal side effects)
Post-Op N+V
5 Common causes?
Management?
Causes- Infection, Hypovolaemia, Pain, Paralytic ileus, Drugs
Management: Non-pharmacological
Minimize patient movement, Analgesia, IV fluids if dehydrated.
Pharmacological:
Ondansetron - first line. Risk of QT prolongation and constipation
Cyclizine.
Prochlorperazine
Epidural Anaesthesia
- Location of injection
- Risks + Monitoring requirements
- Epidural space (L2-L3 or L3-4 vertebral level)
- Hypotension (reduced sympathetic tone + unopposed parasymp. activity), severe postural headache (dural puncture), epidural haematoma
Monitoring - Once the epidural has taken effect, continuous CTG monitoring of the foetus is recommended.
Describe Perioperative management of anaemia?
- . Causes of anaemia [7 Marks]
- Pre-operative Rx [5 Marks]
- Post Op Rx [3 Marks]
- Iron deficiency, Vit B12/Folate deficiency, renal failure, malignancy, menorrhagia, Anaemia of CD, Drugs (chemotherapy agents)
- Oral iron if >6 weeks until planned surgery
IV iron if <6 weeks until planned surgery
B12/folate replacement
Erythropoiesis‐stimulating agent (ESA) therapy
Transfusion if profound anaemia and surgery cannot be delayed - Transfusion, IV iron, Oral iron
When should sliding scales be considered in diabetic patients?
Sliding Scales AKA - Variable rate insulin infusions (VRIII)
When tight glycaemic control will be difficult.
Patients with poor diabetic control at baseline, or patients due to have long operations where they will miss multiple meals.
Main considerations for perioperative management of diabetic patients?
[7 Marks]
Insulin-dependent or non-insulin dependent
Non-Insulin Dependent
- Hold all oral diabetic medication on the morning of the procedure.
- If the patient is on insulin then switch to sliding scale infusion (restart when they can eat).
- Restart all oral medication the morning after surgery.
Insulin Dependent
- Put the patient as early on the theatre list as possible minimising the amount of time the patient is nil by mouth.
- Stop any other insulin and begin sliding scale insulin infusion from when the patient is placed nil by mouth.
- Continue infusion until patient is able to eat post-operatively.
- Switch to normal insulin regimen around their first meal.
Drug Reversal for Rocuronium?
What type of Anaesthetic is Roc?
Suggamadex
Non-depolarising muscle blocker
What is a good drug for operative hypotension?
Metaraminol - Alpha Agonist
How much would you increase the breakthrough dose and total dose for a patient struggling to control his pain?
Breakthrough dose - Increase by 1/3
Total dose - Increase by 1/6
When should the following drugs be stopped before surgery?
A- Asprin & Clopidgrel
B- Contraceptive pill
C- Patients with drug eluting stents
D - Ramipril
A - 7 Days
B- 4 weeks before surgery, Can restart 2 weeks after surgery once mobile
C - Speak to cardiology first
D - Day of surgery to prevent AKI
What is used in the managment for malignant hyperthermaia following RSI using Suxamethonium?
IV Dantrolene (Ryanodine recptor antagonist) Restoring Normothermia
Suxamethonium can cause rhabdomyolysis which would cause brown/tea-coloured urine to pass following induction.
What should never been done in a trauma patient at risk of a c-spine injury?
Head tilt chin lift as it make damage worse
What is the appropriate anaesthetic induction method for a patient with a history of hiatus hernia?
RSI because of high risk aspiration during induction (Quickest method is needed)
Burns Assessment and Management ?
Assessment of airway for smoke inhalation - Early airway inutabation (secured airway)
Assessment of size and depth of burn v.important
Analgesia + Fluids
Fluids Resus Requiremnet (Parkland Formula)
4 x weight (kg) x %burn = ml/24h
Burns unit referral - Full-thickness burn >5% body surface area, Partial-thickness burns >10%, and if patient is very young or elderly
Causes for Post-Operative Fever
4 W’s?
Wind - Pneumonia, aspiration, PE (D1,2)
Water - UTI (D3-5)
Wound - Infection at the surgical site/abscess formation (D5-7)
Walking - DVT/PE (D5+)
Drugs, transfusion reactions, sepsis, line contamination
What chemical complications may be caused as a result of Excess IV Fluids?
Fluid Overload
Hyperchloraemiac acidosis - Dilution of the body’s bicarb. Causing an imbalance (>-ve charge by CL)
Hartmans preferred over saline as lactate is metabolised into bicarb, so don’t get acidosis.
Where should you avoid cannulation in a diabetic patient?
Feet - As they could have peripheral neuropathy + could lead to a diabetic ulcer.
How long can a cannula be left in a patient ?
24hrs - Diabetic patients [Review]
3 Days most people
