Assessments Unit 2 Flashcards
How much do you want the mouth to be able to open for intubation?
At least 6 cm
If you can’t see the airways, what paired structures hint that the vocal cords would be right above them?
The arytenoids
What drug can cause angioedema? Treatment?
ACE inhibitors, and tx = steroids, FFP and TXA
What would your primary concern be if the patient had no teeth?
Loss of structure - easier for the airway to collapse and harder to ventilate the patient. May require on oral airway.
What is the preferred pathway for passage of nasal airway devices?
The inferior meatus (between the inferior turbinate and the floor of the nasal cavity)
What is the primary cause of upper airway obstruction during anesthesia? What maneuver would you use to overcome this and how does it work?
Loss of pharyngeal muscle tone. Chin thrust - it increases longitudinal tension in the pharyngeal muscles countering the tendency of the pharyngeal airway to collapse
What does the larynx encompass?
The epiglottis to the lower end of cricoid cartilage (C6)
What provides the most structural support to the soft tissues of the larynx?
The thyroid cartilage
What do the true vocal cords attach to?
The arytenoids and the thyroid notch
List the paired and un-paired cartilage of the larynx
Unpaired = thyroid, cricoid and epiglottis
Paired = arytenoid, corniculate and cuneiform
What is the most predictive factor of difficult intubation?
A history of past difficult intubation
What anatomical feature is more predictive than BMI at predicting a difficult airway?
A thick neck of greater than 43 cm
What tooth is most frequently injured during intubation? Why?
Left incisor - this is where we put the laryngoscope in
What are you trying to align by getting a patient into the sniffing position?
To get the oral, pharyngeal and laryngeal axis’ to align (specifically, get the LA and the PA to align and have the OA bisect the now LA/PA line)
What is the goal strenomental distance?
Greater than 12.5 cm
Describe testing for prognathic ability
Bulldog test - have them stick their lower jaw out and see how far it goes, then see if the patient can bite their upper lip
Describe the basics of Mallampati I - IV
I = fauces, pillars, entire uvula and soft palate visible
II = fauces, portion of the uvula and soft palate visible
III = base of the uvula and soft palate visible
IV = hard palate only
What are two acronyms to help guide laryngeal manipulation?
BURP (backwards, upwards and rightwards pressure)
OELM (optimal external laryngeal manipulation)
Describe grades I - IV of Cormack-Lehane classification
I = entire glottis
II = only the posterior portion of the glottis
III = on the epiglottis is visible
IV = epiglottis cannot be seen
When does a Cormack-Lehane classification not apply?
When using fiber optic or glidescope to intubate
What basic factors can help you decide between an awake or post-induction airway strategy?
Suspected difficult laryngoscopy, suspect difficult ventilation, significant risk of aspiration, increased risk of rapid desaturation, suspect difficult emergency invasive airway (if even one of these is relevant to the patient, it may be enough to warrant an awake intubation)
On the difficult airway algorithm, there are 4 points that are highlighted as critical to accomplish, what are they?
Optimize oxygenation throughout, limit attempts (consider calling for help), consider awakening the patient after attempts, and be aware of the passage of time/call for help/help for invasive access
What 3 scenarios in lecture were presented as examples of when to intubate early?
Neck trauma, anaphylaxis/angioedema and burn injuries.
What are some conditions that could necessitate early intubation not listed in lecture?
Airway concerns - infection, tumors, bleeds, foreign bodies
Breathing - failure to oxygenate or ventilate
Circulation - impaired oxygen delivery by unloading the muscles of respiration (think sepsis)
Disability - CNS catastrophes or CNS depression, seizures
Feral - need for prompt, aggressive sedation to protect patient and others
Describe the awake technique of intubation including drugs
Start with glyco or atropine 15 min prior, then suction/dry the mouth, administer nebulized lidocaine (give atomized into the oropharynx if unable to give via nebulizer. Viscous lidocaine also an option), preoxygenate/position, lightly sedate with versed 2 - 4 mg and/or ketamine 20 mg, then intubate awake
What is the most important factor to keep in mind with a difficult airway?
Time elapsed - your pace on each step is critical, minimize time attempting intubation.
Outline the basic steps of laryngoscopy to intubation
1) ensure all equipment is ready and pt is positioned, 2) instrument airway and identify epiglottis 3) optimize head (sniff and head tilt), 4) set blade in vallecula or on the epiglottis and lift, 5) optimize the larynx and intubate
What does the black stripe on the bougie indicate?
25 cm
What are 2 good drugs to use for intubation in a patient with suspected CV problems?
Ketamine and etomidate
What are some contraindications for Sux (there are a ton, try to hit the highlights)?
Suspected Rhabdo, hyperkalemia, neuromuscular disorder(s), burns, muscular dystrophies, patients at risk to fasciculate, MH history
What are the “big 3” that kill during intubation?
Hypoxia, hypotension and acidosis
What dosing ranges have greater than 50% excellent intubating conditions with Roc?
1.2 mg/kg or greater
Roc vs Sux wear off times?
Sux = 5-10 minutes
Roc = 30-90 minutes
Goal SBP for intubation?
SBP of 140 or greater
What are the 2 drugs of choice in intubation in shock?
Ketamine and Roc
What are 2 ways you can provide PEEP to a non-intubated patient?
Peep valve on a BVM, the APL valve on the anesthesia machine
What is delayed sequence intubation? What population is it used for?
Uncooperative/combative patient. Give 1 mg/kg IV ketamine -> preoxygenate -> paralyze -> once apneic, intubate
Why does giving bicarb not truly fix the problem in acidosis? How could it make it worse?
Because it doesn’t address the underlying cause. The issue with bicarbonate is that it eventually gets turned into CO2 making the acidosis problem worse (of note, no controlled studies have shown improved hemodynamics due to Na bicarb infusion)
In what condition does Reglan not work to improve motility? What would you give instead?
Scleroderma and Somatostatin analogues (Octreotide)
What can too much oxygenation cause?
Vasoconstriction
What complication tends to kill DMD (Duchenne’s) patients?
Weakness/failure of the diaphragm leading to pulmonary complications
What disease commonly presents with ptosis?
Myasthenia Gravis
ACh-esterase inhibitor of choice in MG?
Pyridostigmine
Which condition is resistant to sux?
Myasthenia Gravis
What condition has Heberden nodes?
Osteoarthritis
What condition are we worried about atlanto-occipital instability?
RA
Easy way to distinguish OA from RA?
OA = distal phalanges are the problem (swollen, nodes)
RA = proximal phalanges are the problem (swollen, nodes)
What condition has cricoarytenoid arthritis and atlantoaxial subluxation?
RA
In what condition is the arthritis symmetric?
Lupus
What is vanishing lung syndrome?
There is a mediastinal shift to the affected lung and the diaphragm curves towards it due to a lower lung volume (the opposite movement occurs in a pneumo, mediastinum shifts away from the affected lung and diaphragm drops)
What condition can have vanishing lung?
Lupus
What condition is more prone to thrombo-embolic events?
Lupus
What conditions can have cricoarytenoid arthritis?
Lupus and RA
What 2 medications can be given to treat MH?
Dantrolene and Ryanodex
What can cause MH?
Volatiles (sevo, iso, des) and Sux
What drug can cause masseter spasms?
Etomidate
Dose range for dantrolene?
2.5 mg/kg 10 mg/kg max
2 issues with cooling a patients during/after MH?
Shivering and e-lyte disturbances
What drugs could help with shivering?
Demerol, propofol, A2 agonists (clonidine, precedex) NMBDs (not sux) such as cisatracurium
What are the 3 hallmarks of scleroderma?
Auto-immune mediated vasculitis, fibrosis of skin and internal organs via collagen deposits, and microvascular changes causing fibrosis and sclerosis
Define CREST and what disease process does it help identify?
Scleroderma
C = calcinosis
R = Raynauds
E = esophageal dysfunction
S = Sclerodactyly (thick/tight skin on hands)
T = Telangiectasias (dilation of capillaries causing red marks)
What is the only drug that has been shown to slow the progression of renal disease in scleroderma?
ACE inhibitors
What is the cause of DMD?
Mutation of the dystrophin gene
What drugs do you need to avoid giving to DMD patients?
Sux is the big one, but technically all NMBDs
What anesthesia is preferable for DMD patients?
Regional over GA
What are some unique processes to DMD?
Kyphoscoliosis, serum CK 20 - 100x normal, waddling gait
What is the hallmark pathology of MG?
Lose and decreased function of post-synaptic ACh receptors
Rapid exhaustion of voluntary muscles with repetitive use that partially recovers at rest would make you suspect what condition?
MG
List the types of MG
I = only ocular muscles affected
IIa = slowly progressive and mild, spares respiratory muscles (responds well to drug therapy)
IIb = rapidly progressive more severe form that can involve respiratory muscles (does not respond well to drug therapy)
III = Acute onset and rapid deterioration within 6 months (high mortality)
IV = Severe form of weakness, progression from types I or II
What would an edrophonium/tensilon test do if you were in a myasthenic crisis vs cholinergic crisis?
MC = improves s/sx
CC = makes s/sx worse
Myasthenic crisis vs cholinergic crisis?
MC = severe muscle weakness and respiratory failure
CC = SLUDGE-M, profound muscle weakness, bradycardia, diarrhea abd pain
What procedure is commonly done to help improve s/sx and reduce need for immunosuppression in MG?
A thymectomy - full benefits do take time to manifest
Why are MG patients notorious for being resistant to sux?
They have very few ACh receptors left so there are far less receptors for sux to bind to
Assuming you give a large enough dose to produce an effect, why is sux’s effect profoundly longer in MG patients?
They are common on pyridostigmine which inhibits plasma cholinesterase, meaning there are less esterases around to break down sux/force it to leave the receptor
Why are MG patients extremely sensitive to non-depolarizing muscle relaxers?
Because they have so few ACh receptors it doesn’t take much drug to block them
What treatment is recommended and what should you avoid in OA treatment?
PT and exercise, avoid corticosteroids (may improve s/sx but the further degrade the joint)
What joints are typically spared in RA?
The thoracic and lumbar spine
Why are we concerned about atlantoaxial subluxation?
Because the odontoid process can press on the spinal cord, or cause a stroke by occluding the vertebral arteries
What drugs could help with RA?
Cox 1/2, corticosteroids, DMARDS (methotrexate), TNF and IL-1 inhibitors
What is advantageous about TNF (tumor necrosis factor) drugs over DMARDs in RA?
TNF has a faster onset
Why do you commonly need to use fiber optics to intubate RA patients?
Due to TMJ limitation, direct laryngoscopy is almost impossible
What drugs can induce lupus?
Procainamide and hydralazine
What condition commonly has avascular necrosis of the femoral head?
Lupus
What GI/liver issues are common with lupus?
pancreatitis and elevated liver enzymes
What condition can anti-malarial agents help treat?
Lupus
What is the root cause of MH?
Genetic mutation of the ryanodine receptor
What is a massester spasm? What causes it? Why is it important?
Jaws of steel (jaws rigid, won’t open)! Sux administration. It can be an early indicator of MH
What are are some early signs of MH? Is hyperthermia an early or late sign?
ETCO2 increase, tachycardia, muscular rigidity, acidosis. Hyperthermia is a late sign
Describe basic treatment for MH
Stop all triggering drugs/gasses, hyperventilate at 100%, change breathing circuit, try to cool the patient and give dantrolene
Where is the cervical plexus?
In the prevertebral layer of cervical fascia of C1-C4
Why would you block the stellate ganglion?
To block sympathetic impulses
What causes Horner’s syndrome?
Phrenic nerve blockade, which is blockaded by the stellate ganglion
At what levels could you do an interscalene block?
C5-7
What levels would you find the brachial plexus?
C5-T1
What nerve innervates the shoulder?
Supraclavicular (C3-C4)
What nerve innervates the deltoid muscles?
The axillary nerve C5/6
What nerve gives rise to the upper lateral cutaneous nerve?
The axillary nerve
What innervates the lateral aspects of the forearm?
Musculocutaneous nerve C5-7
What innervates the anterior compart of the forearm?
The median nerve C6-T1
What innervates the posterior forearm, lateral dorsum of the hand and the dorsal surface of the lateral three and a half digits?
The radial nerve C5-T1
What innervates the medial one and a half fingers and the palm?
Ulnar nerve C8-T1
Where is the lumbar plexus?
L1-L4
Pneumonic to remember the nerves of the lumbar plexus?
I I Get Leftovers On Fridays
Iliohypogastric,Ilioinguinal,Genitofemoral,Lateral cutaneousnerve of the thigh,ObturatorandFemoral
What nerves make up the brachial plexus?
Musculocutaneous, axillary, median, ulnar, radial, medial antebrachial cutaneous, medial brachial cutaneous
What does the iliohypogastic innervate?
The internal oblique and transverus abdominus L1 (some of it does branch down from T12). Does provide sensory for the gluteal and pubic regions
What does the lateral femoral cutaneous innervate?
The anterior and lateral thigh down to the level of the knee, L2/3. All sensory, no motor function
What does the obturator innervate?
the muscles and skin of the medial thigh L2-4. Both sensory and motor.
What does the femoral nerve innervate?
The muscles of the anterior thigh and the skin of the anterior thigh and medial leg. Motor and sensory. L2-4
Where would you find the sacral plexus?
S1-4, though it does receive contributions from L4-5
What does the sciatic nerve innervate?
Directly innervates muscles of the posterior thigh and indirectly innervates all muscles of the leg/foot. No directly sensory function though does have indirect sensory function of the lateral leg, heel and foot
How do you treat an amniotic fluid embolus?
Left side down, feet in the air, LIJ central insertion, aspirate it out. Meds = zofran and toradol.
Common spontaneous pneumo patients?
Skinny male smoker and Marfan’s syndrome patients
Most common gallbladder patient?
FFF - fat fertile female. A pregnant woman is the most common gallbladder patient.
Treatment for Prinzmetal angina?
CCB -> Verapamil
2 most important risk factors for IHD (ischemic heart disease)?
Male and age
How much of an occlusion does stable angina indicate?
70%
What condition is the most common cause of impaired coronary flow resulting in angina pectoris?
Atherosclerosis
Angina can radiate through what dermatomes?
C8-T4
Stable vs unstable angina?
C - CP that does not change over 2 months
U - angina at rest lasting longer than 10 minutes
Describe the acute and long term trends of a troponin level
Acute: remains elevated for 3-4 hours
Long term: elevated ~2 weeks
Is a stress test or nuclear stress imaging more sensitive for detection of IHD?
Nuclear stress imaging
Tracers that are used in nuclear stress imaging?
Thallium, atropine, dobutamine, pacing, adenosine and dipyridamole
What does coronary angiography NOT tell us about IHD? What could provide a hint?
The stability of the plaque (old vs new). Presence of collateral circulation
What anti-platelet is a prodrug?
Plavix
What anti-platelets are sensitive to hypo/hyper responsive metabolism?
Plavix and ASA
What drugs are nitrates synergistic?
BBs and CCBs
What conditions are nitrates contra-indicated?
AS and hypertrophic cardiomyopathy
Only drug that prolongs life in CAD?
BBs
Which BBs have bronchospasm concerns?
Propranolol and Nadolol
Advantage of being on an ACE? Cons?
A = prevent remodeling and stabilize electrical activity, reduce myocardial workload/oxygen demand
C = loss of RAAS means they don’t handle hypotension as well
When is revascularization indicated in L main, all other coronaries and EF changes?
L main = 50% occlusion
Other coronaries = 70% occlusion
EF: less than 40%
What coronary occlusions is a CABG generally preferred over PCI?
L main disease, triple vessel disease or a patient with DM with 2 or more vessel disease
How would you differentiate unstable angina vs a N/STEMI?
12-lead and troponins. 12-lead is +/- with + troponin = N/STEMI
negative 12-lead with negative troponin = unstable angina
What is the criteria to diagnose an MI?
+ troponin, s/sx of ischemia, ECG changes, pathologic Q waves, imaging evidence (wall motion abnormality) or direct identification via angiography
What is the relationship of depth of ST changes to likelihood of ACS?
The greater the degree of depression = the higher chance of significant coronary disease
If an EKG suggests an MI, is an echo required?
No. It can be helpful if they have a BBB or if AMI is uncertain such as suspected aortic dissection.
Contraindications to starting a BB?
Heart failure, low CO state and not at risk of cardiogenic shock
When should thrombolytics be given? Cutoff time?
Within 30 - 60 minutes, and no later than 12 hours
Timeframe to start angioplasty?
Within 90 minutes and within 12 hours of symptom onset
When is PCI preferred over thrombolytics?
Heart failure, pulmonary edema, symptoms present for at least 2-3 hours or when the clot becomes more mature
Treatment for unstable angina?
Bed rest, oxygen, analgesia and BBs. Nitro and CCBs can help if ischemia persists.
Other helpful agents: ASA, plavix, heparin
Thrombolytics = contraindicated
How long is a patient at risk for thrombosis after balloon angioplasty, bare metal/drug eluding stent placement?
BA = 2-3 weeks
Bare stent = 12 weeks minimum (longer preferred)
Drug stent = a full year
What are our 2 major concerns with a stent placement?
Thrombosis and increased risk of bleeding
Downside of ASA/Plavix relative to heparin?
No reversal agent, all you can do is give platelets
How long should a patient wait for surgery after angioplasty, bare metal stent, CABG and drug eluding stent placement?
Angio = 2 -4 weeks
Bare = 4 - 12 weeks
CABG = 6 - 12 weeks
Drug = 6 - 12 months
When do you stop an ACE?
24 hours
What is the preferred agent to treat bradycardia in the OR?
Glyco > atropine
Goal for METs?
Greater than 4, which is climbing a flight of stairs or better
Ideal time to wait for surgery after an MI?
Generally greater than 60 days
Hard cardiac stops to the administration of anesthesia?
Unstable angina, decompensated HF, severe valve disease, significant dysrhythmias
Most important goal to achieve if a patient has heart disease when going to the OR? Other factors to try and control?
Must avoid tachycardia. Other goals = prevent HTN, SNS stimulation, arterial hypoxemia and hypotension
What anesthetics are good to use to prevent tachycardia?
Sux, Vec, Roc, cisatracurium, lidocaine, esmolol, fentanyl, remifentanil and Dex
With severely impaired LV function, what would be a good choice of anesthesia for induction?
High dose opioid only
Assuming appropriate anesthetic depth, good drug of choice to treat tachycardia? Brady?
T = esmolol
B = Glyco > atropine
II, III and AVF changes indicate what kind of occlusion?
RCA occlusion
I, AVL indicate changes indicate what kind of occlusion?
Circumflex occlusion
V3-5 indicate changes indicate what kind of occlusion?
LAD occlusion
