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Phase 3b > Anaesthetics + emergency med > Flashcards

Anaesthetics + emergency med Flashcards

1
Q

Summarise the purpose of the ASA classification system

A
  1. Stratifies the overall risk of a patient prior to surgery + predict short and long term outcomes
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2
Q

Define the ASA classification system

A
  1. Grade 1
    • Normal healthy patient
    • Non-smoker
    • No/minimal alcohol intake
  2. Grade 2
    • Mild systemic disease
      • Well controlled T2DM or HT
    • Current smoker
    • Obese (BMI >30)
    • Mild lung disease
  3. Grade 3
    • Severe systemic disease (poorly controlled chronic conditions)
    • Morbidly obese (BMI>40)
    • History of ACS/Stroke/TIA >3m ago
  4. Grade 4
    • Severe systemic disease that is a constant threat to life
      • MI/stroke/TIA within 3m
      • Severe valve dysfunction
      • Sepsis
  5. Grade 5
    • Moribund patients; not expected to survive the operation
      • Ruptured abdo aortic aneurysm
      • ICH
  6. Grade 6
    • Pt declared brain dead whose organs are being removed for donation
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3
Q

State some common causes of airway compromise

A
  1. Angioedema
  2. Anaphylaxis
  3. Thermal injury
  4. Neck haematoma
  5. Wheeze
  6. Surgical emphysema (presence of air in sc tissue due to escaped air from compromised lung)
  7. Reduced consciousness
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4
Q

State the simple airway manoeuvres

A
  1. Suction
    • If visible fluid or foreign object
  2. Recovery position if actively vomiting UNLESS c-spine injury)
  3. Head tilt/chin lift
  4. Jaw thrust
    • Hook fingers under angle of patient’s jaw and lift the mandible forwards
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5
Q

Summarise airway adjuncts

A
  1. Oropharyngeal airway (OPA)
    • Used when Pt unconscious
    • Rigid plastic tube
    • Measure from incisors to angle of the jaw
    • Insert upside down then rotate 180 to hold tongue away from posterior pharynx
    • For paeds, NO ROTATION, insert as it should sit in the oropharynx
  2. Nasopharynx airway (NPA)
    • Used with Pts in variable/semi-conscious state
    • Flexible rubber tube
    • No reliable sizing method, but tube should go in with MINIMAL resistance and exert NO pressure on surrounding tissue
    • Pass through one anterior nasal passage to sit inferior to the base of the tongue
    • Contraindicated in base of skull fracture (risk of entering cranial vault)
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6
Q

Summarise supraglottic airway

A

Laryngeal mask airway (LMA) or i-Gel
- Flexible plastic tube with inflatable cuff
- Sits over the top of the larynx
- Can be used with ventilation machine

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7
Q

Summarise endotracheal tube

A
  • Flexible plastic tube with inflatable cuff
  • Insert using laryngoscope
  • Prolonged mechanical ventilation
  • Protected (against aspiration) airway
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8
Q

Summarise surgical airway

A
  1. Tracheostomy
  2. Cricothyroidotomy
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9
Q

What is the handover acronym for major trauma?

A

ATMIST
A-GE
T-IME
M-ECHANISM
I-NJURIES
S-IGNS
T-REATMENT given

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10
Q

CACB

A
  1. Catastrophic haemorrhage
  2. Airway
  3. C-spine management
  4. Breathing
    5.
  5. Disability
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11
Q

State absolute indications for intubation

A
  1. Unable to maintain own airway
  2. Inability to oxygenate adequately
  3. Inability to maintain normocapnia
  4. Deteriorating conscious level
  5. Significant facial injury
  6. Seizure
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12
Q

Summarise the causes of breathing distress in major trauma

A

ATOM FC
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flaill chest
Cardiac tamponade

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13
Q

Signs and Sx of tension pneumothorax

A
  1. Consistent history (blunt force trauma)
  2. Air hunger/agitation
  3. Hypoxia
  4. Hypotension
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14
Q

Summarise open pneumothorax

A
  1. Chest wall defect allowing air to flow freely between pleural cavity and external environment
  2. Air inters pleural space on inspiration preventing lung expansion
  3. Sx include:
    • Whoosing sound on inspiration
    • Dyspnoea + tachypnoea
  4. Tx includes:
    • Apply sterile occlusive dressing taped 3 way to create one way valve
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15
Q

Summarise flail chest

A
  1. Fracture of 2 or more ribs in 2 or more places
  2. Floating section of ribs
  3. Moves paradoxically during resp
  4. Ventilatory failure
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16
Q

Most common causes of fatal bleeding

A

Blood on the floor and 4 more

  1. External haemorrhage
  2. Chest
  3. Abdo
  4. Pelvis
  5. Long bones
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17
Q

Sx of C-spine injury

A
  1. Neck pain
  2. Decreased range of motion in the neck
  3. Focal neuro deficit
    • Weakness/numbness of limbs
  4. Signs of spinal shock
    • Flaccid paralysis
    • Loss of bowel/bladder control
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18
Q

Summarise NEXUS criteria for C-spine injury

A
  1. Normal level of alertness
  2. No evidence of intoxication
  3. No painful distracting injury
  4. No focal neuro deficit
  5. Absence of midline cervical tenderness
    If all of the above met, no imaging needed
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19
Q

Tx of C-spine injury

A
  1. Airway management while maintaining full in-line stabilisation; jaw thrust rather than chin lift
  2. Immobilise C-spine with semi-rigid collar
  3. Secure head with blocks and tape
  4. Full in-line stabilisation
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20
Q

Summarise acute epiglottitis in adults

A
  1. Strep., S, Aureus, HiB, Pseudomonas
  2. Dx (gold standard)
    • Fibre-optic laryngoscopy; due to risk of airway obstruction this should be done where urgent intubation or tracheostomy is possible
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21
Q

Define compartment syndrome

A
  1. Inflammation of injured muscle causes increase in pressure within a fascial compartment
  2. As pressure increases, circulation decreases -> tissue ischaemia + necrosis
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22
Q

Ax of compartment syndrome

A
  1. Crush injuries
  2. Xs exercise
  3. Constrictive dressing or plaster casts
  4. Prolonged immobilisation
  5. Reperfusion of ischaemic limbs (due to reactive oxygen species exacerbating ischaemic damage)
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23
Q

Sx of compartment syndrome

A
  1. Severe pain disproportionate to initial injury
  2. Increased pain due to passive stretching of affected muscles
  3. Sequential compression of vein->nerves->arteries
    • Parasthesia
    • Pallor
    • Pulselessness
    • Paralysis
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24
Q

Ddx of compartment syndrome

A
  1. DVT
    • Affected area warm whereas cold with compartment syndrome
  2. Cellulitis
    • Same as DVT
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25
Ix for compartment syndrome
1. Clinical 2. DBP vs compartment pressure <30 mmHg suggests compartment syndrome 3. Bloods - CK elevated - U&E deranged due to rhabdomyolysis
26
Tx of compartment syndrome
1. Surgery; fasciotomies (within 1h of decision to operate) 2. Debridement of necrosed tissue 3. Management of renal failure secondary to rhabdomyolysis
27
State complication of central line insertion
1. Air embolism - Sudden onset dyspnoea, hypoxia, hypotension 2. Bleeding 3. Pneumothorax - Same as air embolism 4. Infection 5. Phrenic nerve palsy - Dyspnoea and elevated hemidiaphragm
28
Summarise the drugs to stop before surgery
1. Cardio drugs - Clopidogrel - 7d before - Warfarin - 5d before, place of LMWH until night before - ACEi - day before surgery 2. Diabetes drugs - Insulin - withhold day of - Sulfonylureas - withhold day of - Metformin - given as normal for short procedure where prescribed BD. Longer procedures -> withhold metformin and prescribe variable-rate insulin 3. COCP - 4-6w before - Restart at least 2w after surgery (once Pt is mobile). Reduce risk of DVT
29
Summarise epidural anaesthesia
1. Injection of local anaesthetic into epidural space around L3-4 or L4-5
30
Summarise fluid resuscitation
1. Fluid bolus of 500 mL crystalloid over <15m 2. Reassess using ABCDE 3. Further fluid boluses (up to 2000mL)
31
Summarise maintenance fluids
Normal requirement is: - 25-30mL/kg/day - 1mmol/kg/day Na - 1mmol/kg/day K - 1mmol/kg/day Cl - 500-100g/day glucose to limit ketosis
32
State difference between crystalloid vs colloid
1. Crystalloid - Solution containing small molecules 2. Colloid - Solution containing larger molecules (e.g. albumin)
33
Summarise the content of different types of fluids
1. Normal saline - 0.9% NaCl 2. Hartmann's - Na - K - Cl - HCO3 3. Saline + glucose 4. 5% dextrose
34
Define lactic acidosis
1. Metabolic acidosis 2. pH < 7.35 3. Lactate > 5mmol/L
35
Ax of lactic acidosis
1. Drugs & toxins - Cyanide - CO - Antiretroviral drugs - Metformin - Alcohol - Salbutamol 2. Hepatic failure - Ischaemic hepatitis 3. Cardiac arrest 4. Sepsis 5. Acute mesenteric ischaemia (sudden onset intestinal hypoperfusion) 6. Large tumour burden
36
Sx of lactic acidosis
1. Fatigue + weakness 2. Tachypnoea 3. N+V 4. Abdo pain 5. Altered mental status
37
Ix for lactic acidosis
1. ABG 2. FBC 3. LFT 4. RFT
38
Tx of lactic acidosis
1. Treat underlying cause 2. IV fluids 3. Haemodialysis in severe cases
39
Define local anaesthetic toxicity
1. Potentially life threatening 2. Systemic levels of local anaesthetic exceed maximum safe dose 3. Leads to blockade of Na channels
40
Sx of local anaesthetic toxicity
1. Parasthesia around the mouth 2. Restlessness + shivering 3. Tinnitus 4. Vertigo 5. Tachycardia
41
Ix for local anaesthetic toxicity
1. ECG 2. Bloods to monitor anaesthetic conc.
42
Tx of local anaesthetic toxicity
1. Stop admin of local anaesthetic 2. ABCDE 3. ECG 4. Lipid emulsion (20% intralipid) at 1mL/kg/3m
43
What are the 3 components of anaesthesia
1. Hypnosis 2. Muscle relaxation 3. Analgesia
44
What are the 3 levels of hypnosis
1. Awake 2. Sedated 3. Asleep
45
What are the 3 types of local anaesthesia techniques
1. Local - Small surgery 2. Regional - Target specific nerves - Usually for post-op pain relief 3. Neuraxial - Spinal - Epidural
46
Summarise difference between spinal and epidural
1. Spinal - Needle goes past ligament and dura into CSF - Single bolus - Anaesthetic - Injected at lumbar region below the level where spinal cord ends (L1-L2) 2. Epidural - Continuous infusion - Anaesthesia or analgesia (including labour) - Thoracic or lumbar
47
Summarise the local anaesthetic agents for spinal and epidural
1. Lidocaine - Immediate onset - 15m duration - Small procedures 2. Bupivicaine - Regional, spinal and epidural - 10m onset - 2h anaesthesia - 12-24h analgesia
48
What is meant by sedation?
1. Reduce anxiety 2. Reduce consciousness 3. Reduce irritability of the airway 4. Induce amnesia
49
Summarise sedative anaesthetic drugs
1. IV Midazolam - Endoscopy - Regional anaesthesia 2. Propofol +/-alfentanil - Intensive care - Intubate
50
Summarise inhalational hypnosis drugs
1. Isoflurane - Cheapest - Maintain sedation 2. Desflurane - Maintain sedation - Short half life 3. Sevoflurane - Induce and/or maintain anaesthesia
51
Summarise IV hypnosis drugs
1. Propofol - Quick onset 2. Thiopenthal - Emergency anaesthetics 3. Ketamine - CVS instability - Also analgesic
52
Summarise the two types of relaxants used for intubation
1. Non-depolarising - Routine anaesthesia - 120-180s onset - Atracurium - Rocunorium - Vecuronium - Work by blocking calcium channel ACh binding site at neuromuscular junction 2. Depolarising - Emergencies - 30s onset - Suxamethonium - 2x ACh molecules bonded together than bind to both ACh receptor sites in a calcium channel. Allows contraction but then keeps channel open preventing further contraction
53
Summarise how muscle contraction occurs
1. ACh releases into neuromuscular junction 2. Channel opens only when TWO Ach bind to either side of the channel 3. Passage of Ca2+ occurs causing muscle contraction
54
What are the 2 types of ventilation that can be achieved with invasive ventilation
1. Volume-control - Pressure increases - Target volume reached - Ventilator stops - Expiration occurs - Used primarily in theatre 2. Pressure-control - Pressure constant - Target time reached - Ventilator stops - Expiration occurs - Almost exclusively ITU - Protects lungs from too high a pressure
55
Summarise the mechanism of anticholinergics
1. Inhibit ACh which is the neurotransmitter for the vagus nerve 2. Vagus nerve = parasympathetic 3. Therefore sympathetic response increases - Increased HR - Increased RR - Pupil dilation
56
Summarise the mechanism of beta adrenoceptor agonists
1. Stimulate beta adrenoreceptors in the myocardial cells 2. Therefore they stimulate the myocardium 3. -> Increased HR and contractility
57
Summarise the types and uses of the anticholinergics and beta agonists
1. Anticholinergics - Atropine - Glycopyrrolate - Treat bradycardia - Common under anasthesia 2. Beta agonists - Dobutamine - ITU - Used in HF
58
Summarise the mechanism of alpha agonists
1. Stimulate alpha receptors found in peripheral vessels 2. Cause vasoconstriction 3. -> Increased BP due to systemic vascular resistance 4. Increase in BP may lead to reduced HR as body tries to self correct
59
Summarise the type and route of alpha agonist administration
1. Peripheral - Via cannula - Phenylephrine - Metaraminol 2. Central - Central line - Noradrenaline
60
Summarise management if both HR and BP are low
1. Combined alpha (BP) & beta (HR) agonist - Ephedrine 2. Adrenaline also has combined alpha and beta effect but v potent therefore only used in arrest/ITU
61
What is a vascath
1. Large bore catheter 2. Inserted in central vein 3. Used for blood filtration
62
State some conditions that are treated with fluid filtration
1. Fluid overload 2. Severe metabolic acidosis 3. Uraemia 4. Poisoning 5. Hyperkalaemia
63
Summarise the pain ladder
1. Mild - Paracetamol - NSAIDs 2. Moderate - Codeine - Tramadol 3. Severe - Morphine
64
Summarise the mechanism of action of NSAIDs
1. Phospholipase found in cell membranes 2. Converted to arachidonic acid 3. Which is converted by COX to PROSTOGLANDINS 4. Or convervted by LOX to LEUKOTRIENES (exacerbate asthma) 5. Prostoglandins invovled in peripheral inflammation Prostoglandins ALSO affect - Stomach acid (Peptic ulcers) - Renal blood flow (AKI) - Platelets (Blood thinning)
65
Summarise how aspirin achieves blood thinning
1. Inhibits thromboxane (prostoglandin) 2. Stops platelet aggregation
66
What are opioids
1. Drugs with morphine like qualities
67
State the side effects of opioids
1. CNS - Sedation - Miosis 2. CVS - Bradycardia - Hypotension 3. Respiratory - Bradypnoea - Apnoea 4. GI - N+V - Constipation 5. Urinary - Retention 6. Skin - Pruritis
68
State the opiods used pre-op
1. Weak - Codeine - Tramadol 2. Strong - Morphine - Oxycodone - Methadone - Buprenorphine 3. Modified release - Fentanyl patch - Morphine sulphate tablets - Oxycontin
69
State the opiods used intra-operatively
1. Fentanyl or alfentanil - fentanyl more potent - Alfentanil rapid onset/offset - Injections or infusions 2. Remifentanil - Ultrashort acting with rapid onset/offset - Metabolised differently to other opiods - Wide therapeutic range - Infusion only
70
State the opiods used post-operatively
1. Codeine - Prodrug (needs to be broken down into morphine) - Contraindicated in children - Oral or IM Only, NO IV (sudden, severe opioid side effect of cardio distress) 2. Tramadol - Acts on receptors: - Noradrenaline - Opioid - Serotonin - Oral or IV 3. Morphine - Morphine sulphate oral tablets
71
State the opioids used in critical care
1. Alfentanil - Best for low accumulation due to rapid onset/offset - Bolus injection and infusion 2. Morphine - Ongoing pain - Infusion will accumulate - Used in Patient Controlled Analgesia (PCA) system
72
State the receptors involved in N+V and their corresponding antiemetic
1. Serotonin - 5HT-3 - Ondasetron (PONV after cute opioid administration) 2. Dopamine - D2 - Domperidone - Premed for PONV risk pts - Metoclopromide - Long term opioid use as it has prokinetic effect to counter gastric stasis caused by opioids - Prochlorperazine (used in vertigo) 3. Histamine - H1 - Cyclizine - Used for travel sickness - Causes tachycardia if administered too quickly - PONV after acute opioid administration
73
Define AF
1. Irregular uncoordinated atrial contraction 2. Delay at AV node means only some atrial impulses conducted 3. Results in absent P waves and irregular QRS complex
74
Ax of AF
1. IHD 2. HYT 3. Valvular heart disease - Rheumatic heart disease 4. HF 5. Myo and pericarditis 6. Electrolyte imbalance (hypoK and hypo Mg) 7. PE 8. Sepsis 9. Lithium
75
State the classifications of AF
1. Paroxysmal - <7d and intermittent 2. Persistent - >7d 3. Permanent - >7d with no plans for further attempts to get back to sinus 4. Slow AF - Ventricular rate <60 bpm 5. Fast AF - >100 bpm
76
Sx of AF
1. Palpitations 2. Chest pain/ tightness 3. Dyspnoea 4. Syncope (transient loss of consciousness) 5. Irregularly irregular pulse
77
Tx of AF with adverse signs
1. A-E 2. Unstable if: - Shock (SBP <90) - Syncope - HF - MI 3. Conscious patient require GA before cardioversion 4. If 3 attempts at cardioversion unsuccessful: - 300mg IV amiodarone - Then another DC shock - 24h infusion of 900mg amiodarone
78
Tx of AF in stable pt within 48h on onset
1. Cardioversion under GA 2. Pharmacological cardioversion with flecainide (amiodarone for pts with structural or IHD)
79
Tx of AF in stable pt after 48h/unclear onset
1. After 48h risk of cardioversion may dislodge clots in left atria 2. Pts with rapid ventricular response should be rate controlled - beta-blocker - Rate limiting CCB (Diltiazem) 3. Target HR < 110bpm 4. Elective cardioversion after 4-6w anticoag or ECHO
80
Ongoing Tx of AF
1. DOAC 2. CHA2DS2VASc (stroke risk) and orbit (bleeding) score
81

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