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Anaesthetics and A&E Flashcards

1
Q

Initial management of acute patient

A

ABCDE

Airway
- Secure airway (Guedel, NP airway, LMA (i-gel), ET tube

Breathing

  • Check RR
  • O2, neb salbutamol/Ipratropium bromide

Circulation

  • BP, HR, Cap refill, urine output
  • Fluid resus, vasopressors, cathertirisation

Disability

  • Do GCS, AVPU, cap glucose,
  • CT, IV glucose if needed

Exposure
- Rashes, burns etc

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2
Q

What scoring system used to determine CT post neck injury

A

Canadian C spine score

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3
Q

Canadian C-spine indicators for Radiography

A 
Age over 65
Dangerous mechanism
Parasthesia 
Immediate pain, C-spine tenderness
Unable to rotate 45 degrees L and R
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4
Q

AVPU

- What does this assess

A

Patient response:

Awake
to Voice
to Pain
Unresponsive

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5
Q

Burns:

  • Who are high risk
  • Initial assessment
A

Under 5 and over 75 yrs

ABCDE (prevent hypothermia) ± need for fluid resus

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6
Q

Burns rule of 9s

A 
Head 9%
Each arm 9%
Torso front 18%
Torsa back 18%
Each leg 9%
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7
Q

Hand as % body surface area

A

1%

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8
Q

5 Burn thickness

A

1) Epidermal (superficial partial thickness)
2) Superficial dermal
3) Deep dermal
4) Full-Thickness (third degree)
5) Fourth degree

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9
Q

Superficial epidermal/dermal features

A

Pain, red, no/small blistering, brisk cap refill,

Healing 1-3 week, minimal scarring

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10
Q

Full thickness burn features

A

White/black, dry, no blistering, no cap refill, no sensation/pain

Tx: requires surgical excision and graft.

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11
Q

What is fourth degree burn?

A

Includes sub cut fat/muscle/bone.

May need Reconstruction/amputation

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12
Q

What is the problem with burns assessment

A

They are DYNAMIC. Need reassessment in 24-72hrs

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13
Q

Ix in burns

A

Bloods: Serum glucose, Crossmatch, U&E

CXR: Dysrhythmia and electrolyte disturbance

Circulation: BP may be low, monitor urine

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14
Q

Burn management

A

Stop burning (remove stimulus, chemical/clothing etc) and cool site

Minor burns - Dress, analgesia, ABX (fluclox) if infected

Major: ABC

  • A: look for inhalation injury, May need ET intubation (stridor due to airway oedema in inhalation inj)
  • Breathing for inhalation, CO poisoning. COHb levels
  • C: Fluid loss (vasodilation = inc cap permeability)). Fluid replace 15% Body SA burns adults and 10% in children
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15
Q

Parkland formula for fluids in burns

A

4ml/kg/% body area

Hartmann’s

50% first 8 hours
50% second 16 hours

Children then also get 4/2/1 maintenance per hour

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16
Q

Burns when to refer

A

Under 5 or Over 60yrs

Site: Face, hands, perineum (risk forneirs), flexure, circumferential

Inhalaiton injury

Over 5% child under 16
Over 10% in someone over 16

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17
Q

Flail Chest

  • Mech
  • what is seen
  • Assoc with
A

3+ ribs broken in 2 + places due to trauma and detached from rest of the chest

Paradoxical breathing - in-drawing on inspiration

Pulmonary contusions - haemothorax
Punctured lung - pneumothorax

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18
Q

Flail chest management

A

Positive pressure ventilation (note intubation may worsen tension pneumothorax)

Pain control - intercostal blocks

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19
Q

Reversible causes of cardiac arrest (5H’s, 4T’s)

A 
Hypoxia
Hypovolaemia
Hypo/Hyperkaaemia
Hypothermia
H+ (acidosis)

Thrombosis (coronary/pulmonary)
Tamponade
Toxins
Tension Pneumothorax

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20
Q

Major haemorrhage Lethal triad (similar to what kills you in shock)

A

Hypothermia

Acidosis

Coagulopathy of trauma

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21
Q

What kills you in shock?

A

Hypothermia

Acidosis

Coagulopathy (e.g. DIC)

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22
Q

Major haemorrhage management

A

Stop bleeding:
- splint, pressure, haemostat agent (tranexamic acid IV), REBOA (aortic occlusion balloon)

Replace fluids lost:
- Fluids + Blood + Blood products (FFP, cryoprecipitate)

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23
Q

Major haemorrhage protocol:

A

RBC 4 units

FFP 4 units

Platelets 1 unit

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24
Q

GCS

  • Three categories
  • How many points per
A

Eye opening response (4)

Verbal response (5)

Motor response (6)

Max score: 15
Min score: 3

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25
GCS - Eye opening
Spontaneously To verbal command To pain None
26
GCS - Verbal response
``` Oriented Confused conversation Inappropriate words Sounds None ```
27
GCS - Motor
``` Obeys command Moves toward pain Withdraws from pain Spastic flexion Extensor response No motor ```
28
BUFALO
``` Bloods Urine (vol and culture) Fluids Abx Lactate Oxygen ```
29
``` Status epileptics: Drug: - No IV access - IV access - If not effective ```
Buccal Midaz Lorazepam Phenytoin
30
Wernickes (reversible)
Ophthalmoplegia Encephalopathy Ataxia
31
Korsakoffs | non-reversible
Aterograde/Retrograde amnesia | Confabulation
32
What to give in Alcoholic presenting to A&E
PAbrinex: prevent Wernickes/Korsakoffs
33
Delerium tremens
Coarse tremor Confusion Visual hallucinations (Lilliputian), formication Seizures
34
Anaphylaxis - Type of reaction - Mech
Type 1 Antigen binds to IgE on mast cells of sensitised individuals Mast cell degranulation (histamine, thromboxjnes PG, Leukotrienes, Pt activators - bradykinins) Vasodilation & Inc permeability Bronchospasm
35
Anaphylaxis features
Respiratory - swollen lips, tongue, pharynx, epiglottis Lower - wheeze, chest tightness, dyspnoea Skin - pruritus, erythema, urticarial rash, angio-oedema CVS - increased permeability leading to hypotension —> anaphylactic shock GI - N&V, diarrhoea, cramps
36
5 Step anaphylaxis Tx
1) Remove offending agent (e.g. if infusion) 2) IV adrenaline (500micrograms = 0.5ml 1 in 1000 ) 3) Establish airway, give O2, consider Salbutamol 4) IV fluid challenge to correct hypotension (up to 2L) 5) Chloramphenamine and hydrocortisone can reduce symptom severity and duration
37
Fluid maintenance: - Adult - Paeds
25-30 ml/kg/day of water and. approximately 1 mmol/kg/day of potassium, sodium and chloride. Fluid resus: 500ml crystaloid in 15 min
38
Fluid maintenance: - Adult - Paeds
25-30 ml/kg/day of water and. approximately 1 mmol/kg/day of potassium, sodium and chloride. Fluid resus: 500ml crystaloid in 15 min Paeds hourly = 0-10kg 4 ml per kg, 10-20 2ml/kg/hr after that its 1ml/kg/hour
39
Drugs to stop Pre-op
ACEi/ARB: Anaesthetic will drop BP so stop 24 hr before Warfarin: if Af use LMWH bridging protocol Clopidogrel: stop 5d before
40
For Insulin dependant diabetics pre-surgery
Don't starve | Give variable rate insulin infusion
41
What makes up a difficult airway
Anatomically: small mouth, small chin, big neck, beard Mechanical: mouth opening, neck mobility Dentition: dentures
42
Pre-op prediction of difficult airway
Mallampati Thyromental distance (under 6.5cm = difficult) Upper cervical spine extension
43
The anaesthetic triad
Unconsciousness Analgesia (local or systemic) Muscle relaxation
44
3 Phases of anaesthesia
Induction (normally IV) Maintenance (IV e.g. propofol and remifentanil infusion or inhaled e.g. volatiles) Reversal
45
Opioids used in anaesthesia
Remifentanil Alfentanyl Fentanyl Morphine (nausea) All risk respiratory depression
46
What GCs needs airway control
8
47
Airway manoeuvres Airways
Head tilt, Chin lift, Jaw thrust Guedel (Oropharyngeal), Nasopharyngeal (Beware skull base fracture), Supraglottic (LMA), ET tube
48
When is Muscle relaxant needed
Intubation: relax tracheal opening Relax skeletal muscles for surgery
49
Local anaesthetic action
Unionised LA enters cell LA becomes ionised and blocks Na channel
50
Types of use for NA
Local wound/area Peripheral nerve block Plexus block Spidural/Spinal block
51
Lidocaine Vs Bupivocaine Onset Duration Use
Onset: L - immediate B - 10 mins Duration: L - 15 mins B - 12 hrs analgesia Use: L - small procedures, lacerations, chest drain B - Regional blocks
52
Advantages of regional anaesthesia
Avoid GA Can stake awake Avoid airway issues Less N&V
53
Spinal Vs Epidural
Spinal through ligaments and dura. Local anaesthetic bolus lasts 2 hours Epidural - through ligaments, sit on top of dura. Catheter and infusion of LA Both block from below highest nerve root affected
54
Types of muscle relaxants
Depolarising - Suxamethonium (depolarises and blocks depolarisation) Non-depolarising - Atracruium, rocurnium - Competitive inhibition of ACh at nicotinic receptors
55
Reversal of muscle relaxants
Neostigmine (inc Each by blocking ACh esterase)
56
BP formula
CO X systemic vascular resistance CO = HR X SV
57
Why older have faster HR
Lower vagal tone. | Vagus is PSNS
58
Drugs to inc HR in surgery
Block ACh (Atropine) Stimulate Beta-adrenoreceptors (Dobutamine) = inc HR and contractility
59
Drugs to give if BP too low
Stim alpha adrenoreceptors | Ephidrine and adrenaline - added befit of also inc HR Alpha nd beta stimulation
60
WHO pain ladder - Step 1 - Step 2 - Step 3
1) aspirin, para, NSAIDs 2) Codeine ±non-opioid 3) Morphine ± non-opioid
61
Paracetamol caution and reversal
Liver failure in OD (Glutathione depletion) N-acetyl-cysteine
62
NSAIDs mechanism
COX inhibitors (irreversible) COX usually converts Arachidonic acid into PGs = inflammation, rubor, dolor
63
SE of NSAIDs
Peptic ulcers (prostaglandins key in mucus secretion) AKI: Pre-renal and infrarenal (nephrotoxic) Bleeding
64
Opioids SE
CNS: sedation, Miosis (constriction) CVS: Bradycardia, Hypotension Resp: Bradypnoea, apnoea GI: N&V, constipation Urinary retention
65
Opioids mechanism
Pre and post synaptic modulation via MU receptors
66
Weak opioid and strong opioid examples
Weak: - Codeine (PO/IM) = prodrug connected to morphine - Tramadol Strong: - Morphine, oxycodone, Methadone, Buprenorphine
67
Calories per Kg needed
20
68
Crystaloids Vs colloids
Crystaloids have ions or small molecules which dissolve in water Colloids have large insoluble molecules retained within plasma. Can be natural (blood albumin) or synthetic (starch, gelatin)
69
O2 sats aims
94-98% If T2RF 88-92% (don't want to remove hypoxic drive)
70
E.G of non-invasive ventilation
CPAP (T1RF) BiPAP (T2RF - keeps airways open on expiration to allow CO2 clearance) Venturi mask
71
Invasive ventilation E.G
ET tube, Tracheostomy
72
Complications invasive ventilation
Ventilator assoc pneumonia Vent assoc lung injury Oxygen toxicity
73
Indications for intubation
Paralysis Long surgery Surgery with: Lung disease, Obese Low GCS

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