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1. Fellowship - Written SAQ > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

What are the maximum doses for local anaesthesia

A
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2
Q

What is the problem using sux with muscular dystrophy

A

sux induced hyperkalaemia

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3
Q

What things would you tell a registrar to do if called in to intubate?

A
  1. establish and secureIV
  2. Prepare diffcult airway troller
  3. pre oxygenate with 15 NRM and 100% o2
  4. ensure BP over 100 eg fluid
  5. get then in position - sniffing morning air
  6. prepare drugs - give doses
  7. prepare adrenaline infusion at 10mcg/min
  8. other things related to specifics eg abx
  9. Tell ICU
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4
Q

Other than incorrect tube position name 4 reasons and fixes for poor oxygenation

A
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4
Q

What are the steps in a CICO for child under 12 situation?

A
  1. declare emergency and that CICO
  2. Cannula cricothyroidotomy - Extend the neck (shoulder roll) + Stabilise larynx with non-dominant hand + Access
    cricothyroid membrane with a dedicated 14/16 gauge cannula + Aim in caudal
    direction Confirm position by air aspiration using a syringe filled with saline
  3. Jet insufflation - connect to pressure limiting device and deliver lowest pressure to achieve rise and fall. flow l/min to childs age
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5
Q

What are the steps in a CICO anyone over 12

A
  1. declare emergency and that CICO
  2. Surgical airway - cannula cicothyroidotomy
  3. Ventilate
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6
Q

How can fire caused impaired oxygenation?

A
  • cellular hypoxia eg methamoglobulinemia, cyanide, CO
  • Bronchospasm secondary to fumes
  • Atalectasis and airway obstruction as smoke causes hypersecretion ad inflammation
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7
Q

Explain why partial/complete upper airway obstruction is a relative contraindication
to percutaneous transtracheal ventilation

A

much of expired air comes out air and mouth so with obstruction difficult to expire so can cause barotrauma and death

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8
Q

how would you connect bag valve to catheter used for cannula cricothyroidotomy?

A

via 10 ml syringe with no plunger
3mm ID ET tube connector to catheter
2.5 mm ID endotracheal tube connector attached to cut off IV tubing with Luer lock
end connected directly to the catheter

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9
Q

What are the clinical and non clinical criteria for extubation in ED

A

Clinical
* Resolution of underlying cause for intubation resolved
* spontaneously breathing
* can obey commands
* haemodynamically stable without support
* sedation and paralysis worn off
* not a difficult intubation
* Resp parameters: O2 sats > 95% on FiO2 < 40%, PEEP < 5, RR < 30, TV > 6mL/kg

Non Clinical
* Staff skilled in managing extubation
* staff who can reintubate if needed
* equipment there for reintubation
* department under control
* no space in ICU

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10
Q

What equipment should you have prior to extubation

A

suction
o2 mask and o2
intubation drugs
airway equipment

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11
Q

What are the steps in performing femoral nerve block?

A
  1. Consent - include alternatives and risks
  2. sterile technique including probe cover for US
  3. Prepare local eg bupi 2mg/kg or rop 3mg/kg and dilute to 20-30ml
  4. identify anatomy with US
  5. ir or out plane with needle and keep needle in vision
  6. aspirate every 3-5ml and try to surround nerve
  7. review signs of toxicity and monitor for 15 mins
  8. document procedure
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12
Q

What should tidal volume be set at?

A

6ml/kg

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13
Q

What are some causes of high airway pressures?

A
  • tension pneumothorax
  • blocked ETT
  • Aspiration lung injury
  • mispositioned ETT
  • Awake patient - ventilator mismatch
  • bronchospasm
  • ventilator malfunction
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14
Q

If you have high airway pressures what are the steps for assessing cause?

A

disconnect from source - remove machine ASAP
Examine for tension
CXR for tube position
Suction ETT
check sedation/paryltic

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15
Q

List three changes to ventilator settings that will affect oxygenation and their risks

A
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16
Q

What is different about ventilator settings in asthmatics?
What else can help ventilate asthmatics

A
deeper sedation and parylytic
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17
Q

What are some causes of hypotension in tubed patient?

A

anaphylaxis
tension
cardiac arrthymias
oversedation
hypovoleamia

18
Q

What are four problems associated with tubing obese patients and how can you mange these?

A
  • hypotension - optimise pre intubation eg fluid or pressors
  • hypoxia - optimise pre o2 eg nasal and bvm, bag through apnoea
  • difficulty intubating - position - ramp with pillow, have other airway equipment ready
  • difficulty ventilating - well sedated and paralysed once tubed, sitting up, adjucts, back up equipment
  • difficult BVM - adjuncts
19
Q

What are the normal ventilator settings

A
20
Q

What are the landmarks for posterior tibial nerve block.
What drug would you use?
how would you close foot wound?

A

posterior to medial malleolus and anterior to achillestendon. 0.5-1cm superior of posterior tibial artery
1%lidocaine or 0.25% bupicavaine max 5mg/kg
3.0 nylon interrupted

21
Q

What is the level of monitoring needed for procedural sedation?

A

continual pulse ox with end tidal
ECG
5 minute BP and interval pulse

22
Q

Ketamine:
Onset
Dose
Duration
Side effects
IM V IV

A
23
Q

what factors may predict difficult BVM?

A

obesity
over 55
asthma/COPD - chest stiffness
poor seal - beard
no teeth

24
Q

what factors may predict difficult larynscopy?

A

impaired neck mobility
upper airway obstruction
mallapatti score 3/4
332 rule

25
Q

if BVM is unsuccessful what are the next steps?

A

optimise position - elevate occiput , sniff morning air
two person technique for bag
airway adjunct
sedation eg for laryngospasm
ED tube if all fails

26
Q

What are the steps in dealing with a blocked trachy?

A
  1. fi02 100% to face and trachy
  2. remove inner cannula or speaking valve and attempt BVM
  3. if unsuccessful pass suction catheter and oxygenate via trachy
  4. if unsuccessful BVM around trachy
  5. if unsuccessful remove trachy and attempt replacement
  6. if unable then RSI or surgical airway
27
Q

What can cause a bleeding trachy?

A
  • tracheo-arterial fistula
  • infection
  • granuloma
28
Q

How do you deal with bleeding trachy fro fistula?

A
  1. notify ENT, anaesthetics and vascular for immediate surgical mangement
  2. TXA 1g or other reversals
  3. MTP and blood products
  4. slowly hyperinflate trachy cuff with 35-40ml air
  5. RSI oral route and attempt to compress fistula
29
Q

what are three equipement and three patient causes for high ventilator pressures and how will you manage?

A
30
Q

What are the principles for intubating severe asthma

A

LAST RESORT
I:E ratio <1:3
low RR approx 8
tolerate hypercapnia
avoid hypoxia - fio2 100%
TV 5-6 ml/kg
PEEP 0-2 to stop hyperinflation

31
Q

list some complications and management of extubation in ED

A
  • cough/sore throat - analgesia
  • incresse sympathetic response - analgesia, GTN, stop ionotropes
  • laryngospasm - jaw thrust, o2, sedate, prepare to retintubate
  • bronchospasm - bronchodilators
  • aspiration - abx, sit upright
  • resp failure - NIV/intubate
32
Q

list 5 diffences between adults and paeds airways

A
  • Smaller mandible
    • Larger head and occiput
    • Tongue is relatively larger
    • Epiglottis is longer and floppier * Larynx is higher and more anterior * Narrowest part is cricoid ring (until about 5 years)
    • Airway is shorter and narrower
33
Q

How would you prepare to secure airway in stridoring patient

A
  • Aim to manage airway in theatre with anaesthetics and ENT present.
  • Infant in position of comfort and preferred position, parents close
  • Minimise distress – avoid iv, avoid topical anaesthesia, avoid unnecessary transfer
  • Consider oral dexamethasone
  • ED airway only if resp arrest
  • Check and prepare for DL or VL
  • Anticipate difficult airway
  • Anticpate CICO prepare for FONA
34
Q

During intubation why does severe AS cause cardiovascular collapse?

A

AS causes LVH which is dependent on pre load for diastolic filling. if you drop the preload by vasodilaton you get poor stroke volume and cardiac output
also a tachycardia reduce diastolic filling - also bad in AF

35
Q
  1. why does severe metabolic acidosis cause cardiovascular collapse at intubation

2.how do you counteract this?

A
  1. Patients tend to have marked respiratory compensation so need to match their minute volume pre intubation or acidosis worsens causing poor cardiac contractility and diminished catecholamine response
  2. pre oxygenate with spontenous breathing or match RR on NIV, no apnoea, RSI, dont let ETc02 climb
36
Q

why does cardiovascular collapse occur when tubing severe asthmatic?

A
  • likely volume deplete from illness
  • have maximised endogenous sympathetic outflow which gets reduced at induction causing vasodilation
  • raised ITP from positve pressure ventilation without inadequate expiration
  • potential for pneumothorax
37
Q

What are the best drugs for neuro protective intubation?

A

Ketamine
1mg/kg
maintains BP but theoretical risk of high ICP

Fentanyl
high dose
blunts sympathetic response
hypotension

Thiopentone
3-5mg/kg
anticonvulsatn and neuroprotective
can cause hypotension

Plus paralytic - ROC

38
Q

How does obesity affect assessment and management of airway?

A

**Increased **
* upper airway tissue so difficult intubation
* PA occlusion pressure
* pulmonary artery pressure
* pleura; pressure and airway resistance
* upper airway resistance

**Decreased **
* hypercapnic ventilatory response
* respiratory system compliance
* TLC, VC, FRC

39
Q

How does obesity affect pharmacokinetics

A

Absorption
* Difficult IV access
* IM may fail if needles to short
* increased oral absorption and increased gastric emptying

Distribution
* if lipid soluble affected by increased lipid content
* increased volume of distribution of lipid soluble drugs but not water soluble
* may need increase of resus fluid drugs
* altered protein binding
* may need higher doses

Metabolism
* reduced hepatic flow
* increased cp450 activity
* more likely to have severe affects of drug interactions

Elimination
increased half life of lipid soluble drugs
may have increased egfrs if normal renal function
co-existing diease will effect eg diabetic nephropathy

40
Q

how big should BP cuff be in obese patients

A

bladder should be 80% of arm width and width 40%
midline of cuff should be in ACF over area of palpation of brachial artery with 2-3cm gap for stethoscope between acf and cuff

if arm circumference over 50cm then around forearm at heart level over radial

41
Q

List four early and four late complications of central line?

A

Early:
pneumothorax
cant locate vein
arterial puncture
haemothorax
haematoma
air emboli
arrhtymia
thoracic duct emboli

Late:
catheter fracture
infection
thrombosis
vessel stenosis
vascular erosion
clavicle osteomyelitis

42
Q

eldely, T2DM, acidotic, vomiting, hypotensive, reduced GCS.

What is the plan for intuabtion including ventilation strategy

A

prepare for arrest
most senior intubator
fluids and ionotropes
high ventilatory rate to blow off co2
drugs - ketamine and sux or roc

43
Q

what are the steps in a cricothyroidotomy via seldinger

A

locate CTM
insert needle until air aspirated
pass guidewire through needle
remove needle
incise skin
dilate tract
insert tube

1. Fellowship - Written SAQ (20 decks)

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