Anaesthetics

Question 1

What are the maximum doses for local anaesthesia

Answer 1

Question 2

What is the problem using sux with muscular dystrophy

Answer 2

sux induced hyperkalaemia

Question 3

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

Answer 3

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

Question 4

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

Answer 4

Question 4

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

Answer 4

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

Question 5

What are the steps in a CICO anyone over 12

Answer 5

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

Question 6

How can fire caused impaired oxygenation?

Answer 6

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

Question 7

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

Answer 7

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

Question 8

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

Answer 8

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

Question 9

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

Answer 9

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

Question 10

What equipment should you have prior to extubation

Answer 10

suction
o2 mask and o2
intubation drugs
airway equipment

Question 11

What are the steps in performing femoral nerve block?

Answer 11

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

Question 12

What should tidal volume be set at?

Answer 12

6ml/kg

Question 13

What are some causes of high airway pressures?

Answer 13

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

Question 14

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

Answer 14

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

Question 15

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

Answer 15

Question 16

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

Answer 16

deeper sedation and parylytic

Question 17

What are some causes of hypotension in tubed patient?

Answer 17

anaphylaxis
tension
cardiac arrthymias
oversedation
hypovoleamia

Question 18

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

Answer 18

• 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

Question 19

What are the normal ventilator settings

Answer 19

Question 20

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

Answer 20

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

Question 21

What is the level of monitoring needed for procedural sedation?

Answer 21

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

Question 22

Ketamine:
Onset
Dose
Duration
Side effects
IM V IV

Answer 22

Question 23

what factors may predict difficult BVM?

Answer 23

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

Question 24

what factors may predict difficult larynscopy?

Answer 24

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

Question 25

if BVM is unsuccessful what are the next steps?

Answer 25

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

Question 26

What are the steps in dealing with a blocked trachy?

Answer 26

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

Question 27

What can cause a bleeding trachy?

Answer 27

* tracheo-arterial fistula * infection * granuloma

Question 28

How do you deal with bleeding trachy fro fistula?

Answer 28

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

Question 29

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

Answer 29

Question 30

What are the principles for intubating severe asthma

Answer 30

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

Question 31

list some complications and management of extubation in ED

Answer 31

* 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

Question 32

list 5 diffences between adults and paeds airways

Answer 32

* 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

Question 33

How would you prepare to secure airway in stridoring patient

Answer 33

* 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

Question 34

During intubation why does severe AS cause cardiovascular collapse?

Answer 34

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

Question 35

1. why does severe metabolic acidosis cause cardiovascular collapse at intubation 2.how do you counteract this?

Answer 35

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

Question 36

why does cardiovascular collapse occur when tubing severe asthmatic?

Answer 36

* 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

Question 37

What are the best drugs for neuro protective intubation?

Answer 37

**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

Question 38

How does obesity affect assessment and management of airway?

Answer 38

**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

Question 39

How does obesity affect pharmacokinetics

Answer 39

**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

Question 40

how big should BP cuff be in obese patients

Answer 40

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

Question 41

List four early and four late complications of central line?

Answer 41

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

Question 42

eldely, T2DM, acidotic, vomiting, hypotensive, reduced GCS. What is the plan for intuabtion including ventilation strategy

Answer 42

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

Question 43

what are the steps in a cricothyroidotomy via seldinger

Answer 43

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

Question 44

how do you work out ET tube size for a child

Answer 44

uncuffed - age/4 +4 Cuffed - age/4 + 3

Question 45

when chest tube is used for tension pneunothorax

Answer 45

32 fr

Question 46

what are the causes of high ventilator pressures post intubaiton

Answer 46

* inadequately drained / recurrent tension pneumothorax * blocked ETT * ETT in right main bronchus / malpositioned tube * pt‐ventilator dysynchrony * ‐ bronchospasm (asthma / anaphylaxis / aspiration) * “over‐ventilation” / dynamic hyper‐inflation

Question 47

what are the indications for intubation in the ED?

Answer 47

* Airway protection/maintenance * Ventilation support * Oxygenation support * Neuroprotection * Control of the combative patient * Facilitate safe transfer of a patient * humane measures

Question 48

post trauma what are the featurs of laryngeal injury

Answer 48

* Hoarse voice / change in voice * stridor * Pain on swallowing * Haemoptysis * Subcutaneous emphysema

Question 49

why would laryngeal injury make intubation hard? What modifications would you do?

Answer 49

* loss of landmarks and changes to anatomy * inability to pass tube * c -spine fracture * haemodynamic instablity Modifications * Pre-oxygenate sitting up * Have surgical airway kit ready * Have a dedicated person for surgical airway eg surgeon * Use of video laryngoscope * Would accept avoidance of paralysis as well

Question 50

list indications for immediate airway management in ED

Answer 50

arrest hypoxia tiring loss of consciousness

Question 51

methods plus advantages and disadvantages for closing wound

Answer 51

Question 52

trauma key feature

Answer 52

* Significant bruising/abrasions to anterior aspect of neck and upper sternum. * Assymetrical swelling/fullness of R side of neck

Question 53

Mmenomic for difficult BVM

Answer 53

Question 54

mmenomic for difficult intubatiob

Answer 54