Acute Care Flashcards by Emma Godson

Why is rheumatoid arthritis relevant info for anaesthetistS?

Risk of atlantoaxial joint dislocation on intubation (over-extension)

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What is the Mal-Pate score?

Grades of intubation

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Why might TMJ dysfunction not be as bad as thought?

More pain than mechanical - so when sedated easier to manipulate

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Why/when is aspirin and clopidogrel stopped for surgery?

Only for 'microcirculation' procedures/high-risk bleeding eg some neurosurgeons
7 days (platelet production) - all irreversible inhibition

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What bridging therapy used for patients on warfarin?

Stop warfarin 5 days prior.
3 days prior started on dalteparin (LMWH) injections.
Omitted morning of surgery.

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What kind of pain is cancer pain?

Mixed (nociceptive/neuropathic)

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Causes of neuropathies?

Diabetic
Peripheral
Chemotherapy/azathioprine

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New name for gate control theory re: pain?

Modulation

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Mechanism of action of clonidine?

alpha2 receptor agonist -> decreases systemic peripheral resistance -> lowers BP
Also used in ADHD, withdrawl, personality disorders, pain, etc etc.

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Most likely MoA of acupuncture?

Endogenous opioid production stimulation

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Emergency reversal of rivaroxaban?

andexanet alfa

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Mechanism of action prochlorperazine?

D2 receptors in CTZ

Anticholinergic action too - M3 receptors

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Mechanism of action haloperidol?

Central D2 antagonism

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Mechanism of action metoclopramide?

Dopamine2, H1 and 5-HT3 antagonism

Increases gastric emptying

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Mechanism of action cyclizine?

Antagonism of H1 central receptor
Anticholinergic
Cause tachycardia if IV

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Mechanism of action ondansetron?

5-HT3 anatagonists

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Mechanism of action lorazepam?

Gaba agonist

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Mechanism of action cannabinoids?

CB1 receptors in CNS, lung, liver and kidney

Naturally occuring delta-9-tetrahydrocannibol

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Mechanism of action of atropine/hyoscine?

Cross BBB (non-polar)
Act on muscarinic receptors in vomiting centre and GI tract, reducing GI tract and salivary secretions and intestinal tone. 
Good for motion sickness and opiate-induced nausea

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4 areas for risk factors for PONV?

Patient,
Anaesthetic,
Surgery,
Medical

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Patient risk factors for PONV?

Female > Male (2.5:1)
Anxiety
Personal hx of PONV
Motion sickness
Non-smoker
Pain
Gastric contents (unfasted)

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Anaesthetic risk factors for PONV?

Volatile agents
Nos
Opioids
Neostigimine
IV anaesthetics - ketamine and etomidate
Stomach insufflation
Spinal anaesthetic (w/ hypotentsion)

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Surgical risk factors for PONV?

ENT - esp middle ear, adenoids and tonsilectomy
Squint surgery
Gynaecological surgery
GI surgery
Laprascopic procedures
Intestinal obstruction

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Medical risk factors for PONV?

Hypoxia
Uraemia
Metabolic disorders eg hypoglycaemia, hypercalcaemia

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Nonpharmacological treatment?

Peri-op fluids Acupuncture Ginger Hypnosis

What precedes vomiting?

Increased sympathetic activity | Increase in intra-abdo pressure

4 stages of poisoning and when we can intervene?

Contact -> ingestion -> metabolism -> elimination | Decontamination, antidotes, aid excretion

Antidote for benzos?

Flumazenil

Antidote for paracetamol?

N-acetyl Cysteine or Methionine

Antidote for local anaesthetic toxicity?

Intra-lipid emulsion

Antidote for atropine?

Beta-blockers or glucagon

Antidote for TCAs?

Sodium bicarb

Antidote for iron salts?

Desferrioximine

Antidote for organophosphates?

atropine, pralidoxamine

Antidote for Ethylene Glycol, Methanol?

ethanol

Options for gut decontamination?

Rarely used Activated charcoal/whole bowel irrigation Boundary for activated charcoal: 1 hour after ingestion Not suitable for alcohols or metal salts

Three main options to aid elimination?

Urinary alkalinisation Haemodialysis Haemofiltration

What is urinary alkalinisation used for?

Salicylates/volatile oils

What is haemodialysis used for?

salicylates, alcohols, phenobarbitol, lithium and sodium valproate

What is haemofiltration used for?

Theophylline, barbiturates, chloral hydrate

If transient narrowing of QRS complexes when sodium bicarb given for suspected TCA overdose? Dx? Further tx? Why?

Diagnoses most likely TCA culprit Requires infusion after bolus For sodium channel blockade not to narrow QRS

What electrolyte abnormality are burns patients predisposed to?

Hyperkalaemia

Head injury in kids - likely to vomit?

Yes very, allowed two before more concerned

Important basic measure for head injury?

Sit them up

Most important component of GCS?

Fixed pupil - be aware of the...

False eye!

Which antiemetics mostly avoided in concussion?

Metoclopramide/cyclizine

What does pneumocephalus predispose to?

CNS infection

Safe paracetamol dose/day? | What if a high risk group?

150mg/kg/day | 75mg/kg/day

Toxic metabolite of paracetamol?

N-acetyl-p-benzoquinone imine | NAPQI

What can happen with first parvalex infusion?

Anaphylactoid reaction

Cut-off for more vs less effective for starting parvalex?

Around 8 hours

What is parvalex?

Glutathione

When might toxicity risk be increased?

Any drugs acting on P450 system: rifampicin, phenobarbital, phenytoin, carbamazepine and alcohol Low glutathione levels (malnourished, HIV+ve, alcohol)

Why is flumazenil often not used unless iatrogenic cause of benzo overdose?

Street valium Even if reported/prescribed mixed in with other medication, can muddy water (irreversibly binds and has a long half life)

When is a paracetamol level not reliable?

After 16 hours or if below 5 may read undetectable so err on side of caution

If paracetamol overdose ingestion time is staggered - tx?

Start parvalex in case

If paracetamol OD time is all within 1 hour?

Activated charcoal? | paracetamol levels at 1 hour

Treatment of betablocker OD? | When given?

Glucagon - vomit often | In elderly mixed OD

Ace inhibitor overdose?

Insulin (1mg/hour) and dextrose

Anaphylaxis drug doses?

500mcg adrenaline (0.5ml of 1:10000) 10mg chlorphenamine 200mg Hydrocortisone

How long should warfarin be stopped prior to elective surgery?

5 days

Mechanism of action morphine?

Mu receptor agonist NB also - causes histamine release One of metabolites more potent than morphone

Define base excess? | Normal values?

A measure of how much base must be removed or added to the system to correct the pH in standard conditions -3-+3 or 2

Naloxone given in practice?

40 mcg to ensure RR comes up but ? stay asleep

Patients with diabetes - elective surgery?

1st on list Fast for 6 hours IV insulin with IV dextrose and potassium Monitor glucose