basics exam 1 rvw for final Flashcards
What type of things should be included in the pre-op evaluation? (in general not a black or white question)
medications taken by patient.
all pertinent drug and contact allergies.
responses and reactions to previous anesthetics.
Head to toe assessment or focused assessment.
Labs that are pertinent.
What are the classes for UBLT? (give me the details of each class)
class 1 - able to bring lower teeth to the boarder of the upper lip. class 2 - can bring lower teeth into middle of upper lip class 3 - lower teeth can NOT reach the upper lip at all.
What are the classes for mellampati Test? (details please)
class 1 - you can see pillars and everything class 2 - fauces and all of uvula visible class 3 - soft palate and base of uvula class 4 - hard palate only
Of the following, which is not the responsibility of the CRNA? suction replacement airway surgical incision positioning
surgical incision
What is the first thing you do when you take a patient into the OR?
Put the pulse ox on them, you are getting a HR and oxygen level.
What is the contraindication on extubating an obese patient who was a difficult intubation?
Deep extubation, (if anyone is difficult to intubate you will more than likely want to extubate them awake.)
A spinal is given and the patient has upper extremity weakness, numbness, hypotension, mydriasis, etc. An astute SRNA student would be prepared to? (and why?)
Prepare to intubate bc you have just administered a high spinal.
Conservative measures regarding treatment of a post dural puncture headache would include the following: (choose two (exam question))
fluids and 500mg caffeine
How do you treat post dural puncture headache?
give fluids, bedrest, analgesics, and caffeine. (more aggressive treatment would be a blood patch)
Where is the subarachnoid space located?
spinal space
The structure after supraspinous ligamentum ?
Intraspinous ligamentum
Factors affecting spinal anesthesia, and which one is the most influential factor affecting the level of spinal anesthesia (test question previously)?
type of needle, site of injection, direction of needle, dosage amount, amount of CSF, etc…
most influential from the prev. exam was dosage amount.
Bupivacaine 0.75% plain length of duration is?
120 minutes
Ester action is prolonged in patients with atypical pseudocholinesterase and may cause hypersensitivity due to the metabolic end product of ester called Para-aminobenzoic; CHOOSE TWO.
(the answer is going to be any of the ester LA, but on the exam it was the two below)
procaine and chloroprocaine
NPO time for infant formula?
6 hours
The utility of a test depends on its sensitivity and specificity: CHOOSE TWO (from exam)
Specific tests have a low rate of false-positive results , and Rarely identify an abnormality when one is not present.
Which nerves are the parasympathetic nerves?
III, VII, IX, X (3,7,9,10)
How to check for laryngeal edema in PACU?
Suction the oral pharynx and deflate the ETT cuff to evaluate the ability to breathe around the ETT
Medication for post op shivering?
Meperidine 12.5mg IV
Which of the following is not an endogenous catecholamine? epi norepi dobutamine dopamine
dobutamine
Multimodal approach to perioperative therapy includes all of the following EXCEPT:
Enhance the perioperative stress response.
Drugs that DO NOT cause cardiac dysrhythmias?
anticholinergic
hypothermia
pain
cholinergic
cholinergic drugs DO NOT cause cardiac dysrhythmias
Which of the following does not cause CNS depression/toxicity?
Glycopyrrolate (Robinol)
Which of the following is at most risk of Post Op N/V? (EXAM question)
less than 50 years old
Thyromental distance?
Greater than or equal to 3 fingerbreadths from the mentum to the upper thyroid (thus a non reassuring finding would be less than 3)
which patient is most at risk for post op delirium (EXAM question)
17 year old deaf male
35 year old with A1C of 11.5 and has missed her doctor’s appointment last week. Presents to the hospital experiencing malaise, fatigue, fever. What should a vigilant SRNA do?
Cancel the case after consulting with surgeon (this is an elective surgery)
What are some common cardiac issues that may cause post-op complications? (choose 2, EXAM question)
Cr > 2.0
DM with insulin dependence
What kind of patients are at risk for pulmonary complications?
ASA class III or higher
What kind of patients are at risk for respiratory issues post-op? (choose 3 EXAM question)
Alcohol consumption
Smoking
High BMI
name some things that are system specific parts of the preop assessment?
cardiopulumonary assessment
renal function
35 year old female coming in for breast augmentation with A1C of 11.5 and has missed her doctor’s appointment last week. Presents to the hospital experiencing malaise, fatigue, fever. What should a vigilant SRNA do?
Cancel the case after consulting with surgeon (bc she is obviously a diabetic but is unaware of this diagnosis, also this is an elective surgery)
A 35 year old female informs you that she has a pseudocholinesterase deficiency. What medication should you take out of your anesthetic plan?
succinylcholine
After a failed attempt at laryngoscopy, what should you do next according to the difficult airway algorithm?
Provide bag mask ventilation
The rate of emergence from anesthesia is directly proportional to ——–and inversely proportional to ——–. (exam question)
alveolar ventilation
blood solubility
The larynx has how many cartilages? Name them.
9 (three paired and three unpaired).
thyroid, crycroid, epiglottis, corniculate in pair, cuneiform in pair, and arytnoid in pair
You are preparing to do a cricothyrotomy, the SRNA would describe the Superior thyroid artery to be found?
along the lateral edge of the cricothyroid membrane. Crossing the upper cricothyroid membrane.
The patient presents with unilateral recurrent laryngeal damage, this would display as?
paralysis of the ipsilateral vocal cord, causing deterioration in voice quality.
Have a patient with deteriorating voice and difficulty breathing, O2 sat is dropping and is currently 90%, what two things may be the problem?
Bilateral recurrent laryngeal nerve damage or
Hypocalcemia
What antisialogogue does not cause CNS toxicity?
Robinol
What med has the greatest antisialogogue effects?
Scopolamine
What are some possible reasons for why the HR of the patient would increase during anesthesia?
depth of anesthesia is not adequate.
surgical stimulation
Spinal cord ends in adults at?
L1-L2
46 year old transgender (origanlly male) what diagnostics may he need done with no other information given (EXAM question)
EKG
Adult larynx is located where?
C3-6
Patient comes in with a1c 11 and had a preop blood sugar of 190, what will you do in regards to the surgery?
Proceed with surgery.
preop blood sugar is below 200 which is adequate, already known to be a diabetic so an A1C of 11 is ok in this situation.
What nerves are responsible for laryngospasm?
innervation of the sensory nerve of SLN (internal SLN)
ASA 1
normal healthy patient, non smoking
ASA 2
Pt with mild systemic dz without functional limitations.
Can include smoker, mild lung dz, pregnant, well controlled DM/ HTN, obesity BMI greater than 30 or less than 40.
ASA 3
pt with sever systemic dz, substantial functional limitation.
can include poorly controlled DM/HTN, COPD, morbid obesity (BMI equal to or greater than 40), ETOH dependence or abuse, active hepatitis, implanted pacemaker, moderate decrease in EF, ESRD with reg dialysis, history of (greater than 3 months) MI, CVA, TIA, or CAD with stents.
ASA 4
Severe systemic dz that is a constant threat to life.
can include recent (less than 3 months) CVA, TIA, MI, CAD with stents, ongoing cardiac ischemia, sever valve dysfunction, severely decreased EF, sepsis, DIC, ARDS, ESRD not on regular dialysis.
ASA 5
Moribund patient, not expected to survive without operation.
Can include ruptured AAA, massive trauma, IC bleed with mass shift, ischemic bowel with significant cardiac pathology or multiple organ/ system dysfunction.
ASA 6
Declared brain dead, whose organs are being harvested for donor purposes.
What does an “E” in front of an ASA mean?
surgery is emergent, delay of treatment would lead to significant increase in threat to life or limb.
What kind of labs would you want to get with a diabetic patient, dialysis patient, and patient who was going to receive contrast dye?
glucose the day of surgery
potassium level
creatnine level
NPO guidelines for the following clear liquids breast milk infant milk nonhuman milk light meal (bread like toast) full mean (fatty food, ETOH)
2 hour 4 hour 6 hour 6 hour 6 hour 8 hour
grades of view?
grade 1 - visualization of the entire laryngeal aperture
grade 2 - just part of the larynx can be seen
grade 3 - only the epiglottis
grade 4 - only the soft palate (nothing)
Tell me how you apply cricoid pressure correctly?
Cricoid pressure is provided by exerting downward pressure with the thumb and index finger on the cricoid cartilage (apprx. 5-kg pressure) so that the CARTILAGINOUS CRICOTHYROID RING IS DISPLACED POSTERIORLY AND THE ESOPHAGUS IS THUS COMPRESSED (OCCLUDED) AGAINST THE UNDERLYING CERVICAL VERTEBRAE.
LMA size according to weight?
1= less than 5 kg 1.5 = 5-10 kg 2 = 10-20 kg 2.5 = 20-30 kg 3 = 30-50 kg 4 = 50-70 kg 5 = 70-100 kg 6 = greater than 100 kg
3 nerves provide sensation to the tongue. You have the nerve farthest back providing a small area, the middle of the tongue with a middle amount of area, and the front large area of the tongue.
in the very back it is the Internal branch of the SLN.
Middle is the glossopharyngeal nerve
the front (tip) of the tongue is the lingual nerve.
lingual nerve and glossopharyngeal nerve provide general sensation where?
anterior two thirds and posterior one third of the tongue, respectively.
mucus membranes of the nose are innervated by?
the ophthalmic division (V1) of the trigeminal nerve anteriorly (anterior ethmoidal nerve) and by the maxillary division (V2) posteriorly (sphenopalatine nerves).
what three divisions of the vagus nerve exist in relation to the throat?
SLN=Internal and External
RL
The vagus nerve is which cranial nerve and where does it provide sensation?
tenth cranial nerve, provides sensation to the airway BELOW THE EPIGLOTTIS
superior laryngeal branch of the vagus divides into?
external = motor internal = sensory
RLN a branch of the vagus nerve innervates?
the larynx BELOW the vocal cords and the trachea
Sensory innervation from the mucosal lining of the larynx ABOVE the vocal folds is done by?
Internal laryngeal branch of the SLN which is a branch of the vagus nerve.
who innervates above the larynx and vocal folds and who innervates below?
above = Internal SLN below = RLN
Who is the MAJOR motor nerve of the larynx? why?
RLN bc it supplies all intrinsic muscles of the larynx EXCEPT the cricothyroid.
who supplies motor innervation to the cricothyroid muscle?
External branch of the SLN
who innervates the VOCAL CORDS?
Internal branch of the SLN
supplies the vocal cords and above
posterior cricoarytenoids function?
abduct vocal cords (dilates cords)
lateral cricoarytenoids function?
adduct vocal cords
just think lateral adds together
cricothyroids function?
increase vocal cord tension (tenses the cords)
think cord tension in CricoThyroid
Thyroarytenoids function?
ruduce cord tension (relaxes the cords)
think relax thyRoarytenoids
if the cricothyroid tenses the cords, if their is damage to the cricothyroid what will occur?
cricothyroid muscle is supplied by the External branch of the SLN (motor). If damage occurs here you will hear WEAKNESS and HUSKINESS of voice.
cricothyroid muscle is paralyzed.
Unilateral Right Recurrent Laryngeal damage will show up how?
HOARSENESS
paralyzed cord assuming intermediate position
Most common injury after subtotal thyroidectomy?
Unilateral right RLN damage.
Bilateral RLN damage shows up how? What does it matter if someone has this?
APHONIA, paralyzed cords.
both cords assume an intermediate position, they can flop together and cause airway obstruction during inspiration. INTUBATION IS REQUIRED! RARE
HOARSENESS after subtotal thyroidectomy indicates? (two possibilities)
Unilateral recurrent nerve damage (common) or SLN damage (rare)
Aphonia after subtotal thyroidectomy would mean?
Bilateral RLN damage
Stridor after thyroidectomy can be what two things?
HYPOCALCEMIA (tetany causing cords to tense)
bilateral damage to RLN (floppy cords)
Tell me about the blood supply of the larynx? (just have to memorize this shit bc it does not really make sense to me)
The blood supply of the larynx is derived from branches of the thyroid arteries.
The cricothyroid artery arises from the superior thyroid artery itself, the first branch off the external carotid artery), and crosses the upper cricothyroid membrane, which extends from the cricoid cartilage to the thyroid cartilage.
The superior thyroid artery is found along the lateral edge of the cricothyroid membrane.
what incisor distance in an adult is desirable?
3cm or greater (thus less than 3cm is not assuring sign)
when you apply cricoid pressure what are you trying to compress posteriorly?
You are trying to compress the esophagus towards the back of neck in order to block it off and keep gastric contents from coming up.
Positive-pressure ventilation using a mask should normally be limited to WHAT to avoid stomach inflation.
20 cm of H20
Formula for ETT size of a child?
will be in mm
age / 4 then + 4
cut length formula for ETT size of a child?
will be in cm
age / 2 then + 14
cut length for adult male and female?
24 cm
size ETT typically for male and female?
female = 7.0-7.5 mm male = 7.5-9.0 mm
Full term infant ETT size and cut length?
3.5mm
12cm
UNCUFFED ONLY ETT size for infants and children?
(age + 16) / 4 = ETT size
what types of cuffs do we typically use bc of lower incidence of mucosal damage?
low - pressure cuffs
MAC blade goes where and Miller blade goes where?
MAC = Vallecula Miller = Epiglottis
Over inflation of the bulb on the ETT may inhibit capillar blood flow injuring the trachea, what should you not inflate the bulb past?
do not inflate beyond 30 mm Hg (thus 30 would technically be ok, but not advisable)
earliest evidence of bronchial intubation?
increased peak inspiratory pressure
Best confirmation / definitive test of tracheal placement of TT?
persistent detection of CO2 by capnograph
what measurement on the Vent do you look at to know that you are good to extubate?
Tidal volumes!
extubating during a light plane of anesthesia, what is considered light?and you risk causing what?
light would be in between deep and awake.
you are more likely to cause laryngospasm
how do you distinguish between light or deep anesthesia?
apparent during pharyngeal suctioning, they will breath hold and cough thus signaling a light plane.
what blunts the likelihood of laryngospasm while extubating?
lidocaine (1.5mg/kg IV 1-2 min before suctioning and extubation)
suction before you remove the ETT, then while you are pulling the tube out in one fluid motion you do what?
squeeze the ambu bag, this keeps junk in their throat and mouth that would normally come out during exhale and helps reduce spasm
Treatment of laryngospasm?
First choice is providing gentle positive-pressure ventilation with an anesthesia bag and mask using 100% oxygen. This will typically break it.
If it will not break you can give sux, propofol in addition if needed, lidocaine.
superior nerve spasm is also known as?
laryngospasm
laryngospasm could cause what?
negative pressure pulmonary edema
Who most commonly has bronchospasms? what can bronchospasm clue you into?
most common in asthmatic patients.
can sometimes be a clue to bronchial intubation.
