Assessments Unit 1 Flashcards
1
Q
What percentage of a diagnosis can be correctly determined from a patient history alone?
A
56%
2
Q
What constitutes a medical history exam?
A
Underlying condition requiring surgery, medical history/problems, previous surgeries/anesthetic history, anesthetic complications, ROS, current meds, allergies, tobacco/ETOH/illicit drug use, functional capacity
3
Q
What 4 things are BMI used to calculate (per powerpoint slide)?
A
1 - estimate/calculate drug dosages
2 - determine fluid volume requirement
3 - calculate acceptable blood loss
4 - adequacy of urine output
4
Q
What is important to establish from a focused physical exam?
A
The patients baseline (neuro, CV, respiratory etc) in all systems
5
Q
What acronym is used for an emergent physical exam? In an emergency if you can only pick 2, which do you pick?
A
A - allergies
M - medication
P - PMH
L - last meal
E - events leading up to surgery
Emergency pick 2 = allergies and PMH
6
Q
What accounts for almost half of perioperative mortalities?
A
Problems with the CV system
7
Q
What is a G6PD deficiency?
A
The body lacks that enzyme, which the lack of causes hemolytic anemia. RBCs break down faster than they are made in response to stress
8
Q
What court case established informed consent? Outcome of the surgery?
A
Salgo v Leland Stanford Jr. University Board of Trustees. An aortogram left the pt paralyzed
9
Q
What surgeries carry a high mortality risk (>5%)? Intermediate (1 - 5 %) or low (<1%)?
A
High = aortic and major vascular surgery
Intermediate = Intra-abdominal or intrathoracic surgery, carotid endarterectomy, head/neck surgery
Low = ambulatory, breast, endoscopic, cataract, skin, urologic, orthopedic
10
Q
What is the goal of METs?
A
greater than 4
11
Q
Define emergency, urgent and time-sensitive surgeries
A
Emergent = life or limb would be threatened if surgery did not proceed within 6 hours
Urgent = life or limb would be threatened if surgery did not proceed within 6 - 24 hours
Time-sensitive = delays exceeding 1 - 6 weeks would adversely affect patient outcomes
12
Q
Describe ASA physical status grading I - VI
A
I = healthy, non-smoking, minimal ETOH
II = Mild disease only w/o substantive functional limitations. Current smoker, social ETOH, pregnant, overweight, controlled DM/HTN
III = Severe systemic disease. Substantive functional limitation. One or more moderate/severe disease. Poor DM, COPD, HTN, obese, hepatitis, ESRD w/regular HD, moderately reduced EF
IV = Severe systemic disease that is a constant threat to life. MI, CVA, TIA, CAD/stents, severe valve dysfunction, severely reduced EF, DIC, ARDS, ESRD w/o regular HD
V = moribund pt who is not expected to survives w/o the operation. Ruptured aneurysm, massive trauma, ICH
VI = brain dead, organs being donated
12
Q
What are Saklad’s 5 degrees of ASA PS grading of operative risk?
A
1 - Pt’s physical state
2 - the surgical procedure
3 - the ability/skill of the surgeon
4 - attention to post-op care
5 - past experience of the anesthetist in similar circumstances
13
Q
Define: GA, IV/monitored sedation, Regional and Local anesthesia
A
GA = total LOC, ET or LMA, major surgeries
IV/Monitored = LOC ranges, drowsy to deep sleep. NC or face mask, requires vigilant observation
Regional = numbs a large part of the body using a local anesthetic (epidural or spinal), good for child birth or a hip replacement
Local = one-time injection that numbs a small area. Such as a biopsy
14
Q
What agents most commonly have side effects in anesthesia?
A
Neuromuscular blockers, latex, antibiotics, chlorhexidine and opioids
15
Q
What medications do you continue prior to surgery?
A
HTN meds (excepts ACEs and ARBs), BBs, anti-depressants, anxiolytics, TCAs (get an EKG), thyroid meds, oral contraceptives (unless they are at high risk of thrombosis, then dc 4 weeks prior), eye drops, Gerd, opioids, anti-convulsants, asthma, corticosteroids, statins, ASA (if they had prior PCI or high grade ischemic disease) COX and MAOIs (avoid demerol and ephedrine)
16
Q
What medications do you DC prior to surgery?
A
ASA, P2Y12 (plavix, prasugrel, ticlopidine), topical meds (day of) diuretics (except HCTZ), sildenafil, NSAIDs, Warfarin, post-menopausal HRT, non-insulin anti-diabetics (day of), short acting insulin (if insulin pump, keep it going), long acting insulin (type 1 = take 1/3 usual dose, type 2 = take none or up to half usual dose)
17
Q
Echinacea effects?
A
Activates immune system, may decrease effectiveness of immunosuppressants and allergy concerns. No data about need to DC prior to surgery
18
Q
Ephedra effects?
A
Increase HR/BP. Increase risk of stroke/tachycardia. Long term use can cause hemodynamic instability d/t decreased catecholamines. Stop 24 hours before
19
Q
Garlic/Ginseng/Ginger/Ginkgo/Green tea effects?
A
All have change coagulation. G for bleeding. No data for ginger. Stop garlic /ginseng 7 days before, stop ginkgo 36 hours
20
Q
Kava effects?
A
sedative, anxiolytic. Stop 24 hours before
21
Q
Saw Palmetto
A
May increase bleeding risk, no data on when to stop
22
Q
St Johns wort
A
Helps with depression. Linked with delayed emergence, stop 5 days before
23
Q
Valeria
A
Sedation, may increase anesthetic requirements. No data on when to stop
24
Goals of premedication aspiration prevention?
Less than 25 ml in the stomach and a pH greater than 2.5
25
What are the risk factors for PONV via the Apfel score? Koivuranta score?
Apfel = Female, hx of PONV, non-smoking status, post-op opioids,
Koi = Female, hx of PONV, non-smoking status, Age less than 50, duration of surgery
26
Meds that can help prevent PONV?
Scopolamine (watch for dry mouth), Lyrica (MOA unclear), Ondansetron (prevention, not treatment), Phenergan, Dexamethasone
27
Most common antibiotics and dosages?
Ancef (2 - 3 g, 30 mg/kg in peds, give q4h over 30 min)
Clindamycin (900 mg, 10 mg/kg in peds, give q6h over 30 - 60 min)
Vancomycin (15 mg/kg in adults/peds, infuse 15 mg/min
28
What should be conducted prior to administration of any mind-altering substance?
An anesthesia timeout, pt name, age, sex, hospital name, MRN, source of history and time of admission
29
What must be kept in mind regarding temperature in critically ill patients?
Core temperature will likely be different than a temporal/axillary temperature and can affect the temperature which can affect the QI measure
30
What is anthropometry?
The scientific study of the measurements and proportions of the human body
31
What areas can be used for a BP measurement?
Radial, PT/DP, brachial and popliteal. Any of these spots can be used for an arterial line too
32
What risks are involved with a rectal temperature?
Perforation, and avoid in uncooperative or immuno-suppressed patients
33
Define a pack year for a smoker
1 PPD x 365 days = 1 pack year. Anyone with 55 years or older with a 30+ PPD history = high risk lung cancer
34
What is the leading cause of beta blocker OD?
Accidental excess intake, particularly with the elderly
35
What is mediate or indirect percussion used to evaluate?
The abdomen and thorax
36
What is percussion used to evaluate for?
The presence of air or fluid in body tissues
37
What is immediate percussion used to evaluate?
The sinus or an infant thorax
38
What is fist percussion used to evaluate?
The back and kidney
39
What is circumferential cyanosis?
Blue-ish discoloration around the mouth and NOT on the lips. It is not harmful and should go away with gentle external warming
40
What are some common causes of jaundice?
Acute inflammation of the liver, inflammation or obstruction of the bile duct, hemolytic anemia, Cholestasis, and pseudo-jaundice (harmless, results from excess of beta-carotene - eating large amounts of carrot, pumpkin or melon)
41
What are some genetic causes of jaundice?
Crigler-Najjar syndrome - inherited condition that impairs an enzyme responsible for processing bilirubin
Gilberts syndrome - inherited condition that impairs the ability to excrete bile
Dubin-Johnson syndrome - inherited form of chronic jaundice that prevents conjugated bilirubin from being secreted from the cells of the liver
42
Describe the physiology of Vitiligo
An auto-immune issue where the melanocytes are attacked. Generally shows up after a triggering event like a cut, scrape or bruise
43
What are "raccoon eyes"?
Battles sign - symptom of a basilar skull fracture
44
Causes of petechiae?
Prolonged straining, medications, infectious disease, leukemia, thrombocytopenia
45
Suspect cause of unilateral edema? Bilateral?
Uni = think clot, parasite or injury
Bilat = suspect a central issue such as CHF or systemic infection
46
What is Koilonychia?
Spoon nails - sign of hypochromic anemia or iron-deficiency anemia. The nails are flat or even concave in shape.
47
What causes nail clubbing?
Generally a cardiovascular or pulmonary problem, such as lung cancer, ILD or cystic fibrosis.
48
What is Paronychia?
inflammation around the nail, usually due to a staph aureus infection or candida albicans
49
What do beau's lines indicate?
Can indicate a wide variety of issues, such as external injury, infection if its only on one nail.
Multiple nails = systemic illness (ARF, mumps, thyroid, syphilis, chemotherapy, endocarditis, melanoma, DM, pneumonia, scarlet fever, zinc deficiency)
50
What are some causes of hirsutism?
Polycystic ovary syndrome, cushing syndrome (high levels of cortisol, either an adrenal issue or too much prednisone over time), congenital adrenal hyperplasia, tumors, medications (hair growth medications, minoxidil, rogaine, androgel, testime)
51
What is ptosis?
Drooping of the eye lid
52
Ectropion vs entropion?
Ectropion = eversion, eye lid margin turned out
Entropion = inversion, lid margin turns inwards
53
What is horners syndrome?
When we paralyze a nerve supplying the eye causing miosis (pupil constriction) and a droopy eyelid (ptosis)
54
Snellen test? Random E test?
Snellen = this is the letter chart you use to assess vision
E = vision test, you use a capital E and rotate it and you have to visually identify it's position
55
Webers vs Rinnes test?
W = Tuning fork on the head and feel for vibrations
R = Tuning fork outside the ear or placed on the post-auricular bone
56
What does cherry lips, bright red skin and bright red blood indicate? Treatment?
Carbon monoxide poisoning. Tx = cyanokit
57
How to check biceps reflex?
Flex the elbow against resistance, bend arm at 90 degrees, strike the antecubital tendon and the arm should flex
58
How to check triceps reflex?
Flex the arm at the elbow, bring arm across the chest and strike the tendon behind the elbow, arm should extend
59
How to check patellar reflex?
Hammer test on the knee, make sure patient is sitting freely
60
How to check plantar relfex?
lie supine, feet relaxed and stroke the sole of their foot, the toes should flex
61
How to check gluteal reflex?
Side lying, spread the cheeks and stimulate the perineal area, sphincter should contract
62
Describe the romberg test
Checks proprioception, pt stands up, eyes closed, and see if they can maintain balance. + test = a proprioception issue
63
What 3 non-pharmacologic factors can affect a patient perception of pain?
Perceived effective communication, perceived responsiveness of the team, perceived empathy by the team
64
What is pain catastrophizing?
An exaggerative cognitive response to an anticipated or actual painful stimulus
65
What other conditions does pain catastrophizing share similarities?
Depression and anxiety
66
What are the 3 factors that make up catastrophizing?
Magnification: the response that symptoms can be or are greater than expected
Rumination: When an individual focuses repeatedly on attributes of an event that evoke a negative emotional response
Helplessness: The belief that there is nothing that anyone can do to improve a bad situation
67
What kinds of pain can differentiate the underlying etiology?
Nociceptive (result of direct tissue injury), inflammatory (result of inflammatory mediators) and neuropathic (injury of nerves leading to alteration in sensory transmission)
68
What are the 2 types of pain that differentiate anatomic location?
Somatic (skin or muscle) and visceral (deep organ)
69
What is temporal pain?
Acute vs chronic vs acute on chronic
70
What is inflammatory pain?
Pain that is the result of released inflammatory mediators that control nociceptive input, released at the site of tissue inflammation
71
What is neuropathic pain?
The result of injury to nerves leading to an alteration in sensory transmission. Can be central or peripheral in nature
72
What makes up OPQRST pain assessment?
O = onset
P = provocation/palliation
Q = quality
R = region/radiation
S = severity
T = timing
73
With the equi-analgesic chart, what is the general trend when converting PO to IV dosages?
Generally, the IV dosage is 1/3 to 1/4 the PO dose
74
What is the pediatric dose for Tylenol?
15 mg/kg q4-6 hours, max of 90 mg/kg/day
75
What is the procedural dose for ketamine in adults and kids?
Adult = 0.5 - 1 mg/kg
Ped = 1 - 2 mg/kg
76
What is the sub-dissociative analgesia dose for ketamine IV, IM and Inhalation?
IV = 0.1 - 0.3 mg/kg
IM and INH = 0.5 - 1 mg/kg
77
What are the concentrations of intranasal ketamine, fentanyl and versed?
Ketamine = 50 mg/ml
Fentanyl = 50 mcg/ml
Versed = 5 mg/ml
78
What is the advantage of intranasal administration?
Close to the CNS and lungs, so rapid distribution = rapid CSF levels
79
Describe the basic pharmacokinetics of ketamine
Blocks the N-methyl D-aspartate (NMDA) receptors, peripheral Na channels and u-opioid receptors = sedation, amnesia and analgesia.
High lipid solubility rapid crossing of the BBB and quick onset of action (1 minute) with rapid recovery to baseline
80
In general, what is the recommended dosing regimen (not numbers here) for using ketamine to treat pain?
A sub-anesthetic dose
81
What is a common failure in regards to pain management?
Timely reassessment or failure to reassess. Always reassess pain after an intervention.
82
What are 3 consequences of unrelieved acute pain?
Psychological impacts = PTSD, anxiety, catastrophizing and depression
Chronic pain syndromes can develop, can lead to spinal cord hyper-excitability
Increased mortality/morbidity
83
How does unrelieved pain impact mortality and morbidity?
Increased oxygen demand, increased metabolic rate, higher rates of cardiovascular/pulmonary complications and reduced immune function
84
What GA anesthetic sensitizes myocardium?
Halothane
85
What GA prolongs the QT during induction?
Desflurane
86
What GA can cause bradycardia in infants?
Sevoflurane
87
Why can some LA's be dangerous if given IV? Tx?
Severe bradycardia - treat with lipid rescue
88
Why are seizure medications a concern?
Because NMBDs lose efficacy if you are on anti-seizure medications
89
What are 2 hard stops for someone with CHF?
Active chest pain/unstable angina or decompensated heart failure
90
What is the big question you need to ask asthma patients?
Have you ever had to be put on a ventilator because of your asthma
91
Why can obese patients take longer to wake up?
Volatiles and injectable sedatives can accumulate in the fat
92
What are 3 benefits of pre-op evaluation?
Anesthesia is an added risk to surgery, pre-anesthetic evaluation of patients improve clinical safety and minimizes mobility
93
What are the metric/imperial BMI formulas?
Metric = weight (Kg) / height (meters squared)
Imperial = 703 x weight (lbs) / height (inches squared)
94
Define the 3 levels of DNR orders
FC
Limited resuscitation defined with regard to specific procedure (may refuse certain resuscitation procedures, make sure pt knows which ones are essential)(try to align with patient goals)
Full DNR
95
What does a cardiac index risk of 0 through 3 indicate?
0 = 0.4% of a major cardiac event
1 = 1.0%
2 = 2.4%
3 or more = 5.4%
96
What ABX have the most common causes of anaphylaxis?
Penicillins and cephalosporins
97
What is red man syndrome?
Histamine induced redness from Vancomycin
98
What causes the allergic reaction in ester anesthetics?
The preservative PABA - para-aminobenzoic acid
99
Why would a patient report chest pain as a side effect of lidocaine administration?
Lidocaine can have epinephrine in it
100
What NMBDs have the highest rate of allergy concerns?
Quaternary ammonium compounds - Sux. Possible cross-reactivity with allergy to neostigmine and morphine
101
What test do you need to order if a patient is on a TCA?
12-ECG to check QT interval
102
What is the primary concern if a patient is on an oral contraceptive?
Post-op venous thrombosis
103
When would you continue ASA?
Continue in patients with prior PCI, high grade ischemic disease or significant cardiovascular disease
104
When would you stop a Cox-2 inhibitor?
If there are concerns about bone healing
105
What adjustments would you make if the patient was on a MAOI?
Avoid Demerol and Ephedrine
106
What is concerning if the adrenal system isn't working?
Without the appropriate hormone response, the body can't respond to hypotension as well. Start pressors earlier, maybe give hydrocortisone to help overcome the lack of cortisol
107
What dose of hydrocortisone would you give for a superficial, minor, moderate and major surgery in someone with HPA suppression?
Superficial = usual daily dose pre/post op
Minor = Hydrocortisone 50 mg IV before incision, 25 mg IV q8h for 24h
Mod = Hydrocortisone 50 mg IV before incision, 25 mg IV q8h for 24h
Major = Hydrocortisone 100 mg IV before incision, continuous 200 mg of hydrocortisone over 24 hours or 50 mg IV q8h for 24h then taper dose by 50% per day until usual daily dose reached
108
What is Mendelson syndrome?
Pneumonitis in young/healthy people who aspirated under anesthesia. This helped create the standard of regional anesthesia for most laboring women.
109
How many preventative drugs would you give with 1-2 PONV risk factors, 3-4?
1-2 = prevention with 2 - 3 drugs from different classes
3-4 = avoid GA, use propofol, minimize opiates, prevention with 3 drugs from different classes
110
What is the risk of PONV from 0 - 4 risk factors?
0 = 10%
1 = 20%
2 = 40%
3 = 60%
4 = 80%
111
What are some medications you can give to help prevent PONV?
Scopolamine, lyrica, ondansetron, phenergan, dexamethasone
112
Adjunct options for analgesia control?
NSAIDs, gabapentin, lyrica, clonidine, acetaminophen
113
Pediatric dose of Ancef?
30 mg/kg q4h
114
Pediatric dose of Clindamycin?
10 mg/kg q6h
115
What non-CV/Pulm cause does nail clubbing indicate?
If it occurs together with joint effusions/pain, then it could indicate hypertrophic osteoarthropathy
116
What is the condition where you have little or no sweating? What type of anesthesia can cause it?
Anhidrosis, and spinal anesthesia could temporarily knock that out
117
What is the first ocular reflex to be lost and when do you lose it?
Eyelash reflex and stage 2
118
What is arcus senilis?
The deposition of phospholipids and cholesterol in the cornea creating a hazy white grey or blue opaque ring around the cornea. It is benign.
119
What is retinitis pigmentosa?
Eye strokes or occlusions
120
What is papilledema?
Compressed optic nerve causing damage
121
What is a sign of optic neuritis?
Pain with ocular movement
122
Other than CO poisoning, what can cause a bright red tongue?
Iron deficiency, B12 deficiency or niacin
123
What can cause a white coating of the tongue?
Dehydration
124
What is leukoplakia?
White pre-cancerous lesions in the mouth
125
Where do you find the apical pulse?
Find the 5th ICS left of the sternum and move just medial to the left-mid clavicular line
126
Lordosis vs kyphosis?
Lordosis (think lumbar) = lumbar spine sticks forward
Kyphosis = abnormal forward curvature (think old people curve)
127
What does a + pronator drift test indicate?
Disconnect or damage between the brain and nerves communicating to the arms
128
Signs of hyperkalemia on EKG?
Wide/flat P-waves, QRS widening, tall tented T-waves
129
Hypokalemia on EKG?
ST depression and flattening of the t-wave, negative T-waves, a U-wave (wave after the T-wave)
130
Where would you expect to find a U-wave?
After the T-wave
131
Hypercalcemia on EKG?
Broad tall peaking t-waves, very wide QRS, low R wave, no p-waves, tall peaking t-waves
132
Hypocalcemia on EKG?
Narrow QRS, reduced PR, T-wave flattening/inversion, prolonged QT, prominent U-wave, ST changes
133
What does a J-wave indicate? Where would you find it?
Hypothermia and hypercalcemia. It is at the J-point (right after the QRS) and a + deflection in the precordial and limb leads, - deflection in aVR and V1
134
What is the delta wave? What is it associated with?
A slurred upstroke of the QRS, commonly associated with WPW. It is related to pre-excitation of the ventricles.
135
Where do the V leads go?
V1 = 4th ICS right of the sternum
V2 = 4th ICS left of the sternum
V3 = Between V4 and V2 (kinda 5th ICS
V4 = 5th ICS left of the sternum
V5 = 5th ICS left of the sternum but left of V4
V6 = 5th IC left of sternum left of V5
136
What is the Q-wave?
First negative deflection after the P waves, meaning the Q-wave could technically be the bottom of the QRS if there is no positive deflection
137
What is the R wave?
First positive deflection after the P wave (again, you can have a R wave without a Q-wave and vice versa)
138
What would a QS wave look like?
A QRS that never goes above isoelectric baseline, making a QS wave
139
What is the S wave?
The negative deflection below baseline after an R or Q wave
140
What is RSR prime?
It is when the QRS complex goes above isoelectric baseline twice (think 2 mountains)
141
What does RSR prime indicate?
Class pattern for a right bundle branch block in lead MCL1
142
Which is the normal axis range?
0 - 90
143
What is the physiologic left axis range?
0 to -40
144
What is a pathologic left axis range?
-40 to -90
145
What is the right axis range?
90 - 180
146
What is the difference in a physiologic and pathologic left axis shift?
Phys = a normal variant in the obese or the athletic
Path = a disease process
147
What can cause a pathological left axis shift?
Anterior hemiblock
148
What can cause a right axis shift?
Posterior hemiblock
149
What is the origin of an extreme right axis shift?
Ventricles
150
What does the LAD innervate?
Anterior wall of LV, septal wall and bundle of HIS/BB
151
What does the circumflex innervate?
Lateral wall of LV, SA/AV nodes, posterior wall of LV
152
Chest pain on exertion indicates how much occlusion?
70 - 85%
153
Chest pain at rest indicates how much occlusion?
90%
154
Chest pain unrelieved by nitro indicates how much occlusion?
100%
155
How sensitive is an EKG to an MI? why?
46 - 50%, can miss the other half due to other MIs/NSTEMI
156
What are the 3 I's of infarction?
Ischemia, Infarction and Injury pattern
157
Why are we moving away from morphine in ACS? Good option for pain?
Because morphine releases histamine = BP drops. Fentanyl a good choice instead.
158
What does a pathologic Q-wave indicate?
Q-wave greater than 40 ms wide or 1/3 the depth of R-wave. Indicates death or necrosis of tissue.
159
What non-ischemia issues can cause ST changes?
Digoxin toxicity, hypokalemia
160
Where would an inferior MI show up? Reciprocal changes? Vessel?
II, III AVF. R = I and AVL and RCA
161
Where would a septal MI show? Reciprocal? Vessel?
V1 and V2. R = II, III and AVF and LAD
162
Where would an anterior MI show? Reciprocal? Vessel?
V3/V4, R = II, III and AVF and LAD
163
Where would a lateral MI show? Reciprocal? Vessel?
V5/V6, I AVL, R = II, III and AVF. Circumflex
164
Where would a posterior MI show? Reciprocal? Vessel?
V8/V9, R > S in V1. R = V1-4 with ST depression. RCA
165
Where would a right ventricular MI show? Reciprocal? Vessel?
V4R. No reciprocal. RCA
166
What is the most common MI seen?
Inferior MI, results from occlusion of the RCA
167
What is the most lethal MI?
Anterior Wall (fed by LAD)
168
What causes ST elevation in all leads?
Pericarditis
169
What patient population is far less likely to receive pain medication?
Physiologically unstable patients
170
What 4 factors can help classify pain?
Underlying etiology (source of the pain), anatomic location (the site of pain), temporal nature (duration of the pain) and intensity (degree or level of the pain experience)
171
What is nociceptive pain?
Pain as the result of direct tissue injury
172
Examples of nociceptive pain?
Bone fracture, surgical incision, acute burn
173
Examples of inflammatory pain?
Appendicitis, rheumatoid arthritis, inflammatory bowel disease, late stage burn healing
174
Examples of neuropathic pain?
Diabetic neuropathy, post-herpetic neuralgia, chemotherapy induced pain and radiculopathy (injury/damage to nerve roots as they leave the spine. Think pinched nerve)
175
Define acute on chronic pain
Refers to times of acute exacerbations of a chronic painful syndrome or new acute pain in a person suffering from a chronic condition (Ie, sickle cell)
176
Treatment for nociceptive pain?
Opiate/non-opiates
177
Treatment for inflammatory pain?
Anti-inflammatory agents
178
Treatment for neuropathic pain?
TCA, SNRIs, Gabapentinoids or anti-depressants
179
Treatment for somatic vs visceral pain?
Somatic = topicals, LA, opiates or non-opiates
Visceral = opiates
180
What is a reasonable goal for pain reduction per the literature?
33 - 50% reduction
181
Describe the basic treatment pathway for adult bradycardia
Stable vs unstable. Give atropine 1 mg, repeat q3-5 minutes up to 3 mg. If still bradycardic, start dopamine or epi, consider transcutaneous pacing
182
What are the monophasic/biphasic defibrillation values?
Mono = 360J
Bi = manufacturer recommendations, usually 120 - 200J
183
What is the dose of epi in ACLS?
1 mg q3-5 min
184
What is the dose of Amiodarone in ACLS?
First dose = 300mg, second dose = 150mg
185
What is the dose of lidocaine in ACLS?
First dose = 1 - 1.5 mg/kg, second dose = 0.5 - 0.75 mg/kg
186
In adult ACLS, which condition and when would you give amiodarone /lidocaine?
VF/VT. After epi
187
What are some of the H/T's for post arrest care?
Hypovolemia, hypoxia, hydrogen ions (acidosis), hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, pulmonary/coronary thrombosis
188
After ROSC is obtained, what do you start if the patient is not following commands?
TTM = targeted temperature management. Goal temp 0f 32 - 36 Celsius
189
What is the adenosine dosage trend?
6 mg rapid IVP followed by 12 mg if 2nd dose is required
190
Treatment for stable regular narrow tachycardia?
Vagal, adenosine, BB or CCB, expert consultation
191
Treatment for unstable regular narrow tachycardia?
Synchronized cardioversion
192
Treatment for stable wide QRS tachycardia?
Procainamide (20 - 50 mg/min), Amiodarone 150 mg bolus followed by standard infusion, Sotalol 100 mg or 1.5 mg/kg over 5 minutes (avoid in QTC prolongation)
193
What HR do you start giving EPI to a neonate?
HR less than 60
194
Normal fetal HR?
120 - 180, anything below 100 is inadequate
195
Neonate dose of epi?
0.01 mg/kg epi
196
Rescue breathing for pediatrics if you have a pulse?
1 breath every 2-3 seconds or 20-30 breaths/minute
197
At what HR do you start CPR in peds?
HR less than 60
198
CPR compression to breath ratio in single vs dual rescue peds CPR
Single = 30 compressions to 2 breaths
Dual = 15 compressions to 2 breaths
199
What is the atropine dose in pediatrics?
0.02 mg/kg, minimum dose 0.1 mg and maximum of 0.5 mg. May repeat once.
200
What synchronized cardioversion dose do you use in pediatrics?
0.5 - 1 J/kg, up to 2 if needed
201
Adenosine dose in pediatrics?
0.1 mg/kg (max of 6) up to 0.2 mg/kg (max 12)
202
Defibrillation dose in pediatrics?
First shock = 2 J/kg, 2nd = 4 J/kg, subsequent is greater than 4 with max of 10 J/kg or adult dose
203
Pediatric Amiodarone dose?
5 mg/kg bolus, repeat up to 3 times
204
Pediatric Lidocaine dose?
1 mg/kg loading dose
205
2 most common clotting disorders in pregnancy?
Factor-5-Leiden and GP6D
206
What is a SINE wave?
A wide stretched out QRS indicative of hyperkalemia
207
Per the book answer, what does a U-wave indicate?
Hypokalemia
208
What is a fast treatment for hyperkalemia?
Give them calcium
209
What is the most common cause of hemodynamic disturbance in anesthesia?
Endotracheal intubation
210
Butterfly rashes indicate what?
Lupus
211
Clubbing of finger can indicate what (pick 4)?
VSD, overriding aorta, pulmonary stenosis an RV hypertrophy
212
Pill rolling tremors are associated with what?
Parkinsons
213
What is Murphy's sign?
RUQ pain indicating cholecystitis
214
What vision change accompanies glaucoma and meds to avoid?
Tunnel vision and anti-cholinergics (atropine, sux)
215
What is Levine's sign?
Clutching of the chest in response to an MI
216
What is Leoning's face?
Leprosy
217
What is Ludwig's angina?
Infection of the neck tissue
218
What is chipmunk face associated with?
Bulimia Nervosa
219
What is spider angioma associated with?
Liver cirrhosis
220
Pyloric stenosis is associated with what shape of mass?
Olive
221
Hyperthyroidism is associated with what ocular change?
Exopthalmus
222
What physical feature is commonly associated with Cushing syndrome?
Buffalo hump
223
Rice water stool is commonly found with what illness?
Cholera -> NS invented to treat cholera
224
What is Cullen's sign?
Bluish periumbilical discoloration associated with appendicitis
225
What is McBurney's point?
The RLQ, and rebound tenderness (more pain when pressure is released off the abdomen) here is associated with appendicitis
226
Icteric sclera is associated with what?
Hepatitis (Icteric = jaundice)
227
Addison's disease or adrenal insufficiency is associated with what color skin?
Bronze
228
What condition results in wheezing on inspiration?
Asthma
229
MG results in what facial condition?
Ptosis
230
What are 2 common findings with hyper thyroidism?
Exophthalmos and tachycardia
231
What medication must be avoided in adrenal insuffiecency?
Etomidate
232
What is Kernig's sign?
Pain or resistance to pain during extension of the knee beyond 135 degrees, indicative of meningitis
233
What is Brudzinski's sign?
Reflexive flexion of the knees/hips following passive neck flexion, indicative of meningitis
234
What is Homan's sign?
Calf pain with dorsiflexion of the feet, indicates thrombosis
235
What is Trousseau's sign?
Carpopedal spasm of the hand/wrist during a BP measurement, indicative of hypocalcemia
236
What is Chvostek's sign?
Facial twitching, indicative of hypocalcemia
237
What is the recommended lead for cardioversion?
Lead II
238
Explain how a LBBB can be a bifascicular block
The left side has the left bundle branch and the posterior hemi-fascicle, if both get blocked you can have a bi-fascicular block
239
What is the progenitor for the anterior/posterior hemifascicle?
The left bundle branch
240
What fibers do Somatic and Visceral pain use?
S = A-delta fiber
V = C-fiber
241
What is the spinal level for the biceps reflex?
C5-C6
242
What is the spinal level for the brachio-radialis tendon reflex?
C5-C6
243
What is the spinal level for the triceps tendon reflex?
C7-C8
244
What is the spinal level for the patellar tendon?
L3-L4
245
What is the spinal level for the Tibialis tendon?
L4-L5
246
What is the spinal level for the achilles tendon?
S1-S2
247
What are some common causes of LV hypertrophy?
HTN, hypertrophic cardiomyopathy, extreme exercise and aortic disease.
248
What is a common cause of RV hypertrophy?
Severe lung disease, pulmonary embolus and pulmonary valve disease
249
A left/right axis deviation is associated with which hemiblocks?
L = anterior hemiblock
R = posterior hemiblock
250
Is a right axis deviation pathologic or physiologic?
Always pathologic
251
What does the RCA innervate?
Inferior/posterior wall of the LV, RV, posterior fascicle of LBB and SA/AV node
252
What is the triad to diagnose an MI?
History, physical exam and EKG, if all are +, it indicates treatment for an MI is necessary
253
What does 2 inverted T-waves indicate?
Ischemia if they are NOT in leads III and V1
254
What clinical signs suggest a RV MI?
Precipitous drop in BP following nitro administration (common to need fluids), hypotension, JVD, bradycardia, heart blocks are common, and clear lung sounds
255
Basic difference in treatment of an LV vs RV infarct
LV = nitrates and no fluid
RV = no nitrates and give fluid
256
Common s/sx of an LV infarct
VF/VT, CHB, hemiblocks
257
Why is an aortic dissection so dangerous?
It can mimic an MI and have ST elevation. This is dangerous because if you give heparin you can easily bleed out. Nitro could cause extra stress on the aorta.
