BASICS Exam 2 Flashcards
what is normal daily fluid volume required to maintain total body water
25-35 ml/kg (2-3L)
how much weight does total body water make up in the body
60% (40L)
what is total body water volume
40L
what is the breakdown of total body water in intracellular fluid vs extrracellular fluid
intracellular= 25L (40% of total body weight)
extracellular= 15L (20% of body weight)
what is the breakdown of extracellular fluid volumes
interstitial fluid= 12L (80%)
plasma= 3L (20%)
what are the four transcapillary pressures (starling)
interstitial hydrostatic
plasma
interstitial osmotic
capillary hydrostatic
what is a problem with crystalloids
dont always stay in intravascular
Stay in intravascular space for roughly 30 min
what are the four groups of crystalloids
balanced
isotonic
hypertonic
hypotonic
what is a balanced crystalloid
LR
plasmalyte
normosol
what solution is nearly isotonic but slightly hypertonic
normal saline
why is NS slightly hypertonic
contains more chloride than extracellular fluid
what is a hypertonic crystolloid
3% saline
what is a hypotonic crystalloid
0.45% saline
d5w
how much of crystalloid remains intravascular and where does the other 2/3 go
1/3 intravascular- interstitial compartments (3rd space)
what is not an optimal choice if you need to replace a lot of volume
crystalloid
how much Na in 1L bag NS
9g per liter (0.9g per 100ml)
what can giving more than a couple of liters of ns lead to and why
acidosis
too much chloride
how long does it take a normal adult to excrete 2L NS
2-3 days
why is ns indicated as a replacement fluid in someone with renal failure
doesn’t have potassium like LR does
in what instances is NS preferred over LR
brain injury
hypochloremic metabolic alkalosis
hyponatremia
what solution is ideal to dilute RBCs
NS bc it is nearly isotonic
what solution can cause hemolysis at the point of injection
3% saline
which solution function as free water and why
D5W
dextrose is metabolized
which solution is iso-osmotic
D5W
which fluids are large molecular weight substances
colloids
when should you not give albumin and why
sepsis-
capillary membranes enlarge so large molecules go outside of vessel, creating osmotic pressure difference outside of vessel, so then albumin pulls water extra-vascular
under normal conditions, what fluid will not third space like ns does
albumin
what fluid should you not give in sepsis
albumin
what are two conditions to avoid giving propofol
aortic stenosis
sepsis
what is a condition to avoid giving ketamine
head injury
Ppt said ok just give small doses
what are the risks with dextran
anaphylaxis,
reactions with blood products
what is the Donnan effect
increased plasma osmolality and intravascular volume
what is the effect by which albumin works
Donnan effect
what can happen in you given propofol in an already intravascularly depleted patient
decreased bp
decreased perfusion of organs
what does propofol decrease in cardiovascular
decreases:
svr
cardiac contractility
preload
what does ketamine increase in cardiovascular
increases:
bp
hr
co
what anesthetic med stimulates sns and inhibits reuptake of norepinephrine
ketamine
what anesthetic med decreases svr and mildly depresses cardiac contractility and function
inhaled anesthetic
which anesthetic gas decreases svr the most/least
most= isoflurane
least=desflurane
what is go to anesthetic for sick patient
etomidate
what effect does positive pressure ventilation have on preload
decreases preload
how does positive pressure reduce preload
increases intrathoracic pressure which squeezes heart, has a tamponade effect
what is imperative when giving neuraxial anesthesia to a intravascular depleted patinet
fluid administration
does neuroaxial anesthesia block PNS or SNS fibers
SNS
what kind of muscle does neuraxial anesthesia affect in vasculature
smooth muscle
what does neuraxial anesthesia cause dealing with heart and vasculature
vasodilation,
decreased preload,
pooling of blood
does positive pressure increase or decrease preload
decreases preload
what needs to be taken into account when calculating fluid defecit
npo defecit (maintenance rate x fasting hours)
maintenance fluid
evaporative loss
blood loss
when do you add an additional 1L of fluid to fluid deficit calculation
colon prep
what are the ways to assess fluid status
vitals: bp/hr
urine output- not accurate
labs
cvp- only half are fluid responsivewhat
skin turgor
what labs monitor fluid status
HCT
BUN/creatinine
ABG
what is normal urine output
0.5ml/kg/hr
what effect can anesthesia have on urine output
decrease it
true/false: MAP is a reliable index of volume status
FALSE
what does the 4 in 4-2-1 stand for
0-10 kg: 4ml/kg/hr
what does 2 in 4-2-1 represent
11-20 kg: 4ml/kg/hr + 2ml/kg/hr (for every kg >10)
what does 1 in 4-2-1 represent
greater than 20kg: 4ml/kg/hr + 2ml/kg/hr (for every kg >10) + 1ml/kg/hr (for every kg > 20)
what is an easy way to calculate fluid requirement for weight >20kg
60ml + 1ml/kg/hr >20kg
what does 4-2-1 rule calculate
maintenance fluid required per hour
what calculating fluid replacement, what 4 areas should be considered
maintenance fluid (4-2-1)
fluid deficit (maintenance x fast hours)
evaporative (surgical) loss
blood loss
what is the calculation for estimated npo deficit
maintenance fluid x fasting hours
what is replacement for superficial trauma such as orofacial
1-2 ml/kg/hr
what is replacement for minimal trauma such as herniorraphy
2-4 ml/kg/hr
what is replacement for moderate trauma such as laparascopic abdominal surgery
4-6 ml/kg/hr
what is replacement for severe trauma such as major open abdominal surgery
6-8 ml/kg/hr
how much crystalloid should be given for blood loss
3 ml given for every 1ml blood loss
how much colloid or blood is given for blood loss
1ml for 1ml lost
what is maintenance fluid calculation
4-2-1
what is the breakdown for iv maintenance in first hour
1/2 NPO + hourly maintenance + estimated blood loss + evaporative loss
what is the breakdown for iv maintenance in second hour
1/4 NPO + hourly maintenance + estimated blood loss + evaporative loss
what is the breakdown for iv maintenance in third hour
1/4 NPO + hourly maintenance + estimated blood loss + evaporative loss
how long does it take to catch up with npo defecit
after 3rd hr is completed
a 65kg patient has been npo for 8 hours undergoing colon resection
ebl first hour= 50ml
ebl second hour = 75ml
ebl third hour= 100ml
Hourly maintenance= 60 + 1ml/kg/hr (45)= 105ml
NPO deficit= 105x8 (fasting hours)= 840ml
evaporative loss= major abdominal surgery= 8x65kg= 520
blood loss= 50x3 for 1st, 75x3 for 2nd, 100x3
1st hour= 420 (1/2 npo) + 105 (HM) + 150 (blood loss) + 520 (evap loss) = 1195ml
2nd hour= 210 (1/4 npo) + 225 (HM) + 225 (blood loss) + 520 (evap loss) = 1060ml
3rd hour= 210 (1/4 npo) + 300 (HM) + 300 (blood loss) + 520 (evap loss) = 1135 ml
what does evaporative loss depend on
type of surgery- more invasive surgery=more evaporative loss= more replacement fluid
what law states that as you stretch fibers of the heart you get a more forceful contraction
frank starling
what should be administered to determine preload dependance or independence
200-250ml of fluid
when giving small volumes of fluid to determine preload, what curve are you assessing the patient’s position on
frank starling curve
what happens when cardiac output and left ventricular end diastolic pressure get too high
pulmonary edema
which quadrant is the safe zone on the frank starling curve graph
upper left
what are the x and y axis of the frank starling graph
x= lvedp
y= cardiac output
what does the top right quadrant on frank starling curve graph represent
normal cardiac ouptut, raised left atrial pressure leading to pulmonary edema
which quadrant on frank starling curve graph represents shock
bottom left- low cardiac output, low lvedp
which quadrant on frank starling curge graph represents shock and pulmonary edema
bottom right- the most dangerous- low cardiac output but raised left ventricular end diastlopic pressure
how often should preload responsiveness and oxygen delivery be assessed in perioperative goal directed therapy
5-10 min
What is included in the eras fluid management protocol
clear liquids up to 2 hours before surgery
avoid bowel prep
avoid excess fluid admin during intraoperative phase
bolus 250-500 ml crysalloid/colloid or vasopressor
what can excessive fluid administration during intraoperative phase contribute to
edema of gut, prolonged ileus
what monitors should you look at for blood loss
bp,
hr,
urine output,
ekg,
o2,
abg,
pulse contour,
echo
what should you listen for blood loss
suction
surgeon
SpO2 alarm
what should you look for blood loss
suction
sponges
drapes
floor
surgeons gown
arterial spray
how many cc’s of fluid is in a 1/4 saturated dry lap
10cc
how many cc’s of fluid is in a 1/2 saturated dry lap
20cc
how many cc’s of fluid is in a 3/4 saturated dry lap
40cc
how many cc’s of fluid is in a full saturated dry lap
100cc
how many cc’s of fluid is in an over saturated dry lap
110 cc
how many cc’s of fluid is in a 1/2 saturated wet lap
10cc
how many cc’s of fluid is in a 3/4 saturated wet lap
30cc
how many cc’s of fluid is in a full saturated wet lap
40-50cc
how many cc’s of fluid is in an over saturated wet lap
60cc
how many cc’s of fluid is in a 3/4 saturated dry 4x4
5cc
how many cc’s of fluid is in a fully saturated dry 4x4
10cc
how many cc’s of fluid is in an oversaturated dry 4x4
10cc
how many cc’s of fluid is in a fully saturated wet 4x4
5cc
how many cc’s of fluid is in an oversaturated wet 4x4
5cc
s/s of 10% blood loss
thirst
vasoconstriction
s/s of 50% blood loss
coma
death
what fluid should blood loss be replaced with
crystalloid
colloid
what are the three things the decision to transfuse blood should be based on
monitor for blood loss
monitor for transfusion indicators
monitor for inadequate perfusion/oxygenation of vital organs
how long can you replace blood loss with crystalloid/colloid for
until danger of anemia or depletion of coagulation factors necessitates administration of blood products
why do you start with sweating in blood loss
trying to concentrate blood
what is blood volume of premature infant at birth
90-105ml/kg
what is blood volume of term newborn infant
80-90 ml/kg
what is blood volume of infant less than 3 months
70-75ml/kg
what is blood volume of child-adult male
70ml/kg
what is blood volume of child-adult female
65ml/kg
what is blood volume of obese
lean body weight plus 20%
what is the formula for lean body weight
bmi (using ibw) x ht (m2
Ideal body weight x 1/3
what is the formula for bmi
weight (kg) / height (m^2)
what is the formula for max allowable blood loss
estimated blood volume x (orginal hct- lowest acceptable hct/original hct)
in a healthy individual, what is the lowest acceptable hematocrit
21 (7hbg)
in a sick (asa 3-4) individual, what is the lowest acceptable hematocrit
30
what are some questions you could ask before deciding to transfuse
are they symptomatic,
are their vitals being affected,
do they have aortic stenosis or other pathology
an 80kg man with a preoperative hct of 40% could lose how much blood and still maintain a hematocrit of 30%
80x 70ml/kg= 5600 (40-30/40)= 1400ml
what is the universal PLASMA donor
AB pos
what is the universal red cell donor
o neg
what blood type has group a antigen on red cells and b antibody in plasma
group A
what blood type has group b antigen on red cells and a antibody in plasma
group B
what blood type has group a and b antigen on red cells and neither antibody in plasma
AB group
what blood type has group has neither a or b antigen on red cells and both a and b antibody in plasma
group O
what are agglutinins
Antibodies that will attack antigens on RBC’s of a different blood type
what blood type is the universal recipient
AB+
after how many units of blood should you start thinking about replacing clotting factors
2-3
what is an electrolyte that is lacking when you give several units of blood and why
calcium
citrate from blood
when are rh antibodies produced
2-4 months after first exposure to rh antigens
when does rh sensitization occur
rh positive blood in an rh- person
what is the preventative medication for mom for hemolytic disease of newborn
rho-gam (anti D, IgG)
when should rho gam be given
28 weeks of pregnancy and 72 hours after childbirth
what is hemolytic disease of the newborn
in rh- mom and rh+ baby, RHD enters mom and sensitizes mom to form rhd antibody.
In subsequent pregnancy, rhd antibody cross placenta and cause hemolysis of rh+ blood
what are the components of blood
RBCs
platelets
FFP
cryo
what blood product is used for anemia with surgical blood loss
PRBC
how much will 1 unit of prbc increase hct
3%
how much will 1 unit of prbc increase hgb
1g/dL
what is the major goal of prbc administration
increase o2 carrying capacity of blood
what ion imbalances can be caused by mtp
hyperkalemia-
hypocalcemia- from citrate
what factors are absent in rbc
Factor V
Factor VIII
is prbc acidic or alkalotic
acidic
after how many days of refrigerated storage are viable platelets no longer found in prbc
2 days
what is ratio for blood loss replacement with crystalloid vs blood (colloid)
crystalloid: 3:1
colloid: 1:1
what platelet count should you considered transfusion of platelets
less than 50,000 cells/mm
when would you give for platelet count higher than 50,000
use of perfusion pump, which uses all of platelets
how many cc’s are in prbc
250-300cc
what is blood product used for thrombocytopenia
platelets
what is not present in ffp
platelets
which coagulation factors are in ffp
all of them except platelets
when is the only time you should give ffp during surgery
when pt or ptt is at least 1.5 x greater than normal
what is a normal pt and ptt
PT: 11-16
PTT: 35-40
what blood product is given for hemophilia A
cryoprecipitate
what factors are in cryoprecipitate
1
8
13
vWF
Protein C
what blood product is given for hypofibrinogenemia
cryoprecipitate
what has more fibrinogen, cryo or ffp
cryo
on frank starling graph, what causes hypertensive pulmonary edema
high co and high ledvp
on frank starling graph, what causes low cardiac output pulmonary edema
decreased co, high ledvp
on frank starling graph, what causes low cardiac output
decreased co, low ledvp
what are most common complications of transfusions
bacterial contaminants,
transfusion related lung injury,
abo mismatch
what are two least common but most feared complications of transfusions
infectious disease transmission (hiv or hepatitis)
hemolytic transfusion reaction
what is TRALI
transfusion related acute lung injury
what is a respiratory distress syndrome occuring within 6 hours of transfusion of prbc or ffp
TRALI
signs and symptoms of TRALI
dyspnea
hypoxemia secondary to non cardiogenic pulmonary edema
how is a diagnosis of trali confirmed
pulmonary edema in absence of left atrial htn
pulmonary fluid is high in protein
what is the treatment for trali
stop transfusion
treat vitals
sample pulmonary edema and analyze for protein
cbc and chest xray
notify blood bank
what are the labs and imaging for trali
CBC
CXR
what is the single most common transfusion reaction
fever
what causes a transfusion reaction fever
interaction between patient antibodies and antigens on donor leukocytes/platelets
what is treatment for transfusion reaction fever
slow infusion,
give antipyretics,
possible d/c infusion
what are transfusion allergic reaction s/s
increased body temp,
urticaria,
pruritus
what is treatment for transfusion allergic reaction
antihistamines, d/c if necessary
what is treatment for hemolytic reaction in transfusion
immediate d/c
maintain urine output via crystalloid, mannitol, lasix
Alkalinize urine with sodium bicarb
Send urine/plasma hgb samples to lab
Check platelets, pt and fibrinogen
Send blood back to lab
Support hemodynamics
what blood type can ab- receive
o-,
b-,
a-
ab-
what blood type can a+ receive
o-,
o+,
a-,
a+
what blood type can a- receive
O-
A-
what blood type can b+ receive
O-
O+
B-
B+
what blood type can b- receive
O-
B-
what kind of blood type can O+ receive
O-
O+
what blood type can o- receive
O-
what are the three types of transfusion reactions
immune mediated (hemolytic)
fever (non-hemolytic)
allergic (non-hemolytic)
what reaction can occur when wrong blood type is given
hemolytic reaction
what does hemolytic reaction usually damage
kidney
what can mask immediate signs of hemolytic reaction
GA
what is evidence of hemolytic reaction
free HgB in plasma or urine
when can symptoms appear for hemolytic reaction
- trali
- hemolytic transfusion reaction
- transfusion associated sepsis
- taco
- babesiosis
how is acute renal failure manifested in the kidney in hemolytic reaction
hemolyzed rbc in distal tubule
what are symptoms of immune mediated transfusion reaction
shock,
chills,
fever,
sob,
renal failure,
dic,
trali
how long will a person live with complete unresolved renal shutdown
7-12 days
what are the 3 causes of a transfusion reaction causing kidney shutdown
- toxicity from hemolyzing blood causes renal vasoconstriction via hgb binding most nitric oxide
- loss of circulating rbc’s + toxins cause circulatory shock
- holes are made in rbc by antigen-antibody reaction, hgb leaks out of holes, too much hemoglobin for haptoglobin to break down leads to hgb in glomerular filtrate, when hbg builds up and h2o is reabsorbed, hgb blocks kidney tubules
what does haptoglobin do
finds free hemoglobin and binds to it in order to recycle it
what are some s/s of circulatory shock during transfusion reaction that can cause kidney shutdown
arterial bp/renal blood flow/urine output bottom out
what is the process for acute normovolemic hemodilution (autologous donation)
- pull of 1-2 units of blood
- replace blood with crystalloid and colloids
- reinfuse blood at end of surgery
what are the four strategies to conserve blood
intraoperative rbc salvage
rbc alternatives
preop preparation
preoperative autologus donation
when doing normovolemic hemodilution, what should hct stay above
27
when should you not used rbc salvage- 4 instances
cancer
sepsis
c-section (because of amniotic fluid)
any contaminated blood
what are the 3 basic mechanisms for stopping blood loss
vascular spasm/vasoconstriction
platelet plug formation
blood clotting (coagulation)
what is a fibrin thread formation made up of
fibrin molecules combine to form long threads to entangle platelets–building a spongy mass which gradually hardens to form clot
what is the average time for a clot retraction to happen
20-60 min
what are the 5 steps for clot formation
- severed vessel
- platelets agglutinate
- fibrin appears
- fibrin clot forms
- clot retraction occurs
what does platelet activation lead to
clot formation
what does platelet dysfunction lead to
bleeding problems
what three things does activation of platelets cause
release of clotting factors
release of inflammatory mediators
shape change that makes platelets stick to damaged site
how many days should plavix be d/c before surgery
7-10 days
when happens to platelet when it is activated
changes shape
where are platelets formed
bone marrow
normal platelet level
150,000-400,000 microliters
what helps platelets to become active
adp
thromboxane a2
type 4 collagen,
thrombin
what is megakarycocyte and platelet production regulated by
thrombopoietin- produced in liver and kidneys
where is thrombopoietin produced
liver and kidneys
another name for platelet
thrombocyte
where does a platelet come from
fragment of precursor megakaryocytes
where is the hormone produced that regulates megakarycotye and platelet production
liver and kidneys
where are platelets sequestered and how much
spleen- 30% by macrophages
what is the life span of a platelet
10 days
8-12 days
true or false: platelet has a nucleus
FALSE
how big is a platelet
2-4 micrometers
which one of fibrinogen and fibrin is soluble and which one is insoluble
fibrinogen-soluble
fibrin= insoluble
what are the three mechanisms of hemostasis
vascular spasm
platelet plug formation
blood clotting (coagulation)
what are the steps to platelet plug formation
- platelet adhesion
- platelet release reaction aka degranulation
- platelet aggregation
what are the two things that happen during platelet release reaction
change of shape
spill contents of granules (alpha and dense)
what is contained in alpha granules of platelet
platelet factor 4
transforming growth factor beta 1
platelet derived growth factor
fibronectin
b-thromboglobulin
vwf
fibrinogen
labile factor, antihemophilic factor
what activates factor 2 into factor 2a
factor 10a,
5a,
calcium
activate prothrombinase which acts with platelet phospholipids and calcium to turn 2 into 2a
what organizes strands of factor 1a
factor 13
what converts fibrinogen to fibrin
thrombin and Ca
what is contained in the dense granules of platelets
adp/atp
calcium
serotonin
what is also present during platelet release reaction that is not in alpha or dense granules
thromboxane
what is the extrinsic pathway initiated by
tissue factor from injured tissue
what is the intrinsic pathway stimulated by
contact with negatively charged surface (collagen)
what retracts clot to pull skin together
actin and myosin
what kind of feedback mechanism does clot formation operate under
positive feedback
what helps to dissolve clots
plasmin
True or false: plasminogen is circulating at all times
TRUE
What converts plasminogen to plasmin?
tissue plasminogen activator (tPA)
what prevents clots from spontaneously forming along epithelium
prostacyclin
what converts fibrinogen to fibrin
thrombin
what is the combination of phsopholipids and tissue factor
thromboplastin
in the extrinisic pathway, what factors activate factor 10
3 and 7a
in the intrinsic pathway, what factors activate factor 10
8a and 9a
what is factor 1 and 1a
fibrinogen-fibrin
what is factor 2 and 2a
prothrombin and thrombin
what is factor 3
tissue thromboplastin
aka tissue factor
what is factor 4
calcium
what is factor 5
labile factor- proacclerin
what is factor 7
stable factor
prothrombin conversion accelerator
what is factor 8
anti hemophilic factor
globulin or factor A
what is factor 9
christmas
plasma thromboplastin component
AHF B
what is factor 10
stuart factor
what is factor 11
plasma thromboplastin antecedent
what is factor 12
hageman factor
what is factor 13
fibrin stabilization factor
what is prekallikren
fletcher factor
what is high molecular weight kininogen
Fitzgerald factor
what is a major clotting factor without a name at the very end of the list
platelets
what converts protein c and thrombomodulin to active protein c
protein S
what do protein c and thrombomodulin make
active protein C
what is active protein c made of
protein C and thrombomodulin
what are the two places that active protein c works
inhibiting factor 8 to factor 8a
inhibiting factor 5 to factor 5a
what is the cell surface receptor for factor 7a in presence of calcium
tissue factor
under what condition do endothelia cells express tissue factor
exposure to inflammatory molecules such as tumor necrosis factor alpha
what three cells express tissue factor
endothelial cells
platelets
monocytes
what inflammatory molecule causes endothelia cells to express tissue factor
tumor necrosis factor alpha
what is necessary for the formation of tissue factor-factor 7 complex
calcium
what is necessary for the formation of factor 7a
factor 7
tissue factor
calcium
what converts factor 7 into factor 7a
tissue factor (3) which gets released through trauma
what is necessary for the formation of factor 10a in the extrinsic pathway
factor 7a and Ca
what is expressed by cells which are not normally exposed to flowing blood, when they are exposed to blood
tissue factor
what is an example of a endothelial cell that is not normally exposed to flowing blood
smooth muscle cells
fibroblasts
which two steps in the intrinsic pathway do not require calcium
12 converting to 12a
12a converting 11 to 11a
besides the first two steps in the intrinsic pathway, what is required to promote or accelerate all blood clotting reactions
Ca
what is total calcium range
8.5 to 10.2 mg/dl in plasma
which top has heparin to inactivate thrombin
green
which top has citrate to bind to calcium to inhibit clotting
blue
what is the speed of the extrinsic vs intrinsic pathway
extrinsic= 15 secs
intrinsic= 1-6 mins
which pathway generates a thrombin burst
extrinsic
how are simultaneous and congruent pathways created in clotting cascade
tissue damage= extrinsic
collagen contact with factor 12 platelets
-both happening at same time
what is clinical relevance of thrombocytopenia
increased risk of bleeding
which patient type has a higher incidence of coagulation prolongation
trauma patients
which unit has the most patients with prolonged pt or aptt
icu
trauma specifically
what patients are elevated fibrin split products often detectable in
sepsis
trauma
icu
what illness does elevated fibrin split products manifest in 99% of patients
sepsis
what is an example of a fibrin split product
d dimer
what are fibrin split products aka fibrin degradation products
left over protein after blood clot dissolves- indicate a thrombotic event such as DIC or thrombosis
what patients are low levels of coagulation inhibitors (antithrombin and protein c) found in
trauma and sepsis
name two coagulation inhibitors mentioned in the clotting cascade slides
protein C
antithrombin
what are two coagulation defects often seen in sepsis patients
elevated fibrin split products
low levels of coagulation inhibitors
what does elevated fdp indicate
thrombotic event
what does fdp stand for
fibrin degradation products (aka fibrin split products)
what two things are consumed during dic which cause bleeding
platelets and coagulation factors
what is caused by systemic intravascular activation of coagulation
DIC
what is formed and activated in dic
formed= microvascular thrombi
activated= inflammation
what can dic lead to
organ dysfunction
what five factors lead to dic
inflammatory cytokines
tissue factor expression
fibrinolysis suppression
intravasculars fibrin formation
platelet and coagulation factor consumption
what happens to fibrin, platelets, and coagulation during dic
fibrin, platelets, and coagulation factors are used intravascularly to make clots–>microvascular thrombosis and bleeding
what patient population is at risk for vitamin c deficiency
elderly and alcoholics
what deficiency is characterized by bleeding gums, nosebleeds, bruising easily
vitamin C
what vitamin deficiency causes weak blood vessel walls due to lack of stable collagen
vitamin C
what kind of organ failure leads to bleeding disorders
hepatic failure
what clotting factors need vitamin K
prothrombin,
7,
9,
10,
protein s, c, and z
what is released in massive amounts during DIC
thromboxane a2
what kind of malabsorption can cause vitamin k defiency
fat
what is a fat soluble vitamin
vitamin K
what factor is hemophilia a associated with
8
what factor is hemophilia b associated with
9
what does vWF bind
platelets
factor 8
what is platelet count in thrombocytopenia
less than 50,000 microliters
what is a test you should check before neuraxial anesthesia with thrombocytopenia and pregnancy
platelet level
what diseases does the body make antibodies against platelets
idiopathic thrombocytopenic purpura
lupus
rheumatoid arthritis
what diseases results from premature destruction of rbc which clog the kidneys and low platelet count
hemolytic uremic syndrome
what is the most common coagulation defect overall
vw disease
what anticoag is more predictable with fewer side effects
LMWH
what is an example of a direct thrombin inhibitor
dabigatran, argatroban, bivalirudin
what is white clot syndrome, when heparin stimulates formation of antibody to platelets
HIT
what medication depresses 2, 7, 9, 10
warfarin
what medication competes with vitamin k for binding sites
warfarin
how much clotting function remains after 12 hours of warfarin
50%,
20% after 24 hours
how many minutes can heparin increase clotting time
6-30 min
how long does heparin last for
1.5-4 hrs
what does heparin activate
antithrombin 3, which blocks thrombin
what blood test measures intrinsic and common pathways
partial thromboplastin time
what is normal ptt
25-39 sec
what blood test measures extrinsic pathway
PT/INR
what is normal pt/inr and inr on coumadin
pt= 10-16
inr= 0.8-1.2
therapeutic inr= 2-3
what is minimum safe act for ecmo or cp bypass
300sec
what is normal act
70-120sec
what test assess platelet function
bleeding time
what is normal bleeding time
1-6 min
what activates factor 10 into factor 10a on the intrinsic pathway
8a and 9a
what activates factor 10 into factor 10a in the extrinsic pathway
7a
Ca
when do endothelial cells express tissue factor
Trauma unless exposed to inflammatory factors
what is a segment of fdp that can indiciate dic
d dimer
what are some triggering factors of dic
sepsis
amniotic fluid embolus
what are there massive amounts of in blood during dic
thromboxane a2
what are some treatment meds for-amniotic-fluid-embolism
zofran
toradol
tylenol
what is a good blood product for hemophilia a
cryo
what is the primary cation and anion of ecv
cation= sodium
anion= chloride
what is the primary cation and anion of icv
cation= potassium
anion= phosphate
what is standard fluid intake for normal person
2-3 L
what is fluid exchange between extracellular compartments largely dependent on
starling forces
plasma concentration
na 142
k 4
cl 103
phos 1.4
mag 2
ca 5
ph 7.4
mosm 291
plasmalyte concentrations
na 140
k 5
cl 98
mag 3
acetate 27
gluconate 23
ph 7.4
mosm 294
LR concentration
na 130
k 4
cl 110
ca 3
lactate 28
ph 6.2
mosm 275
NS concentration
na 154
cl 154
ph 5.6
mosm 310
what kind of acidosis can NS lead to
hyperchloremic metabolic acidosis
what lab test can Na increase on ABG
base excess
what can high levels of chloride from ns admin lead to
decreased GFR
what patient would LR not be indicated for and why
diabetic- because byproduct of lactate metabolism is gluconeogenic
TBI- hypotonic may increase edema
Citrate containing products- risk of coagulation because LR has calcium
true or false: LR is mildly hypertonic
FALSE
hypotonic
t or f: plasmalyte, normosol, and isolyte can be used with blood
TRUE
do not have Ca
what conditions should albumin be avoided
sepsis
hyperglycemia
where are catecholamines released from
adrenal medulla
what 3 measurements are NOT accurate indicators of fluid volume status
MAP
CVP
urine output
what happens in-response-to left ventricular preload increasing and what describes it
increases myocardial contractility- frank starling mechanism
what are the goals of eras
-optimal fluid therapy
reduce stress response from surgery
non-opioid pain modalities
maintain baseline organ function post procedure
decrease complications and accelerate recovery
how can you improve optimization of colorectal surgery patient preoperatively according to eras
carbohydrate drink up to 2 hours prior to surgery
avoid mechanical bowel prep
what can excess fluid intraoperatively lead to
edema of gut wall and prolonged ileus
what is a serious risk with hyponatremia
cerebral edema
what is usually the cause of hypernatremia
inadequate water intake
what can using a cell saver for a lot of blood replacement lead to
thrombocytopenia- need to replace clotting factors
what blood product would you give for hypofrinogenemia
cryo
what blood product would you give for thrombocytopenia or platelet function defects
platelets
what blood product should be given for reverseal of anticoagulatn effects
FFP
what blood product would you give to reverse vitamin k deficiency or warfarin
FFP
what are s/s of delayed hemolytic reactions from blood transfusion
jaundice, hemoglobinuria, anemia
what are s/s of nonhemolytic transfusion reaction
fever
chills
urticaria
what are s/s of acute hemolytic reaction
hypotension
hemoglobinuria
hemorrhagic episode
what is most common cause of transfusion related deaths
trali- transfusion associated acute lung injury
what is key to address during golden hour of trauma
blood loss- need blood to pump o2 to damaged tissue
soft tissue injury- inflammation from trauma
what is leading cause of death before age 45
trauma
after how much blood loss will patient die/go into coma
50%
which survey is involved with assessing abcde
primary survey (resuscitation phase)
what is abcde in trauma
airway
breathing
circulation
disability
exposure
what is involved in secondary survey of trauma
after patient is stabilized:
-head to toe assessment
-internal injuries of chest/abdomen/musculoskeletal
-diagnostic studies
what test definitively rules out c spine injury
ct scan
what is involved in tertiary survey
avoiding missed injuries
occurs within 24 hours
another head to toe exam
identify every injury
what should be initially assumed in every trauma
cervical spine injury
what should be avoided with airway during c spine precautions
jaw thrust maneuver- neck hyperextension
in what kind of fracture should nasal intubation or ng tubes be avoided
basilar skull fracture
what are some ways to secure airway while in c psine
ett with in line stabilization during laryngoscopy
nasal intubation
fiberoptic in spontaneously breathing
trach
what are the three main ways of intubating during c spine preacuations
video laryngoscopy
awake or asleep fiber optic
light wand
what is an ion side effect of succinlycholine
hyperkalemia
why should you avoid succ in trauma patients after 24 hours through 1 year
Lethal increase potassium
where is a needle decompression performed
2nd intercostal space- 14 gauge
what is beck’s triad and what does it diagnose
JVD, muffled heart sounds, hypotension
diagnoses cardiac tamponade
what can flail chest cause in the heart
tamponade
what is cushings triad
hypertension,
bradycardia,
bradpynea
why does bp get high and hr get low in cushing’s triad
trying to perfuse brain-
so hering’s nerve stimulates brain for hr to get lower to compensate signaling via vagus nerve
what two nerves are associated with cushing’s triad responses
herings nerve
vagus nerve
what are the characteristics of stage 1 shock
15% blood loss- <750 ml
normal: pulse, bp, rr, pp, urine output
cns- slightly anxious
fluid replacement 3:1 crystalloid
what are the characteristics of stage 2 shock
15-30% blood loss (750-1500ml)
pulse 100-120
normal bp
pp decreased
rr 20-30
uop 20-30 ml/hr
cns- mild anxiety
fluid-crystalloid
what are the characteristics of stage 3 shock
30-40% blood loss (1500-2000ml)
pulse >120
decrease bp, pp
rr 30-40
uop 15-30
cns: anxious/confused
fluid= crytalloid + blood
what are the characteristics of stage 4 shock
> 40% blood loss (>2000ml)
pulse >140
decrease bp, pp
rr >40
uop negligible
cns: lethargic, confused
fluid: crystalloid and blood
what are some of the common pathologies of shock
hypoxia
anaerobic metabolism
organ dysfunction
organ failure
death
what ph imbalance can hypovolemia lead to and how does it do so
carotid body baroreceptors sense decreased o2 which stimulates increased respiratory drive which can lead to respiratory alkalosis
how much percentage of blood volume can normal person lose before they won’t compensate bp
30%
how can large amounts of crystalloid lead to ards/dic
break down soluble proteins in endothelial cells, which initiates inflammatory response which can trigger ards/dic
how do you treat ards
peep,
decrease vt,
increase rr
steroids,
paralyze
why is coronary blood flow not intially impacted by hypovolemia
autoregulation
what happens to myocardial oxygenation use as shock increase
increases use of O2
what happens to contractility of heart during hypovolemia
decreases
what does cardiac output rely on during hypovolemia
heart rate- stroke volume will be low
what does persistent shock shunt blood away from in kidney
from renal cortex to renal medulla
what can shunting of blood away from renal cortex to renal medulla result in during hypovolemia
no blood to nephrons in cortex = acute tubular necrosis
when will bun rise back to normal after trauma
24 hrs
what level of creatinine clearance level indicates acute renal failure in trauma
<15ml/hr in 2 and 6 hour test
what fluids should be given first for fluid resuscitation
albumin, lr, plasmalyte
what kind of blood is emergent blood
O-
which fluid class does not stay intravascular so large quantities are needed
crystalloid
what fluid can aggravate cerbral edema because it is slightly hypotonic
LR
which fluid is less likely to cause hyperchloremic acidosis than ns
LR
what can dextrose solutions exacerbate
cerebral ischemia
what is not a good fluid and med to give in head injury
ketamine and D5W
what do you look at on abg to determine fluid level
base deficit
what base deficit level indicates mild, moderate, severe shock
-2 - -5= mild
-6- -9 = moderate
>-10= severe
what vasopressor works the best in acidotic state
vasopressin
what does increase use of crystalloid to restore volume correlate with
ards
abdominal compartment syndrome
what can rapid bicarb admin cause with acidosis
bicarb draws out hydrogen ions and they go through carbonic acid cycle to become co2- which dilates the patient, potentially bottoming them out
what should you look at before pushing bicarb very fast
base deficit
what med can spike etco2 during acidotic state
bicarb
what fluid is best for restoring intravascular volume
colloid
what is best blood product for hemorrhagic replacement and what are the cons of use
whole blood
but t and cross take 45 mins, and they need more volume to raise hct
what is preferred emergency administration blood product and why
prbc
t and c takes 5-10 mins
less volume to raise hct
why are dextran or hextastarch not used anymore
coagulopathy concerns
what is the dose/volume per dose/expected response prbc
dose- 1 unit
volume- 250-325
response- 1g/dl increase in hgb
what is the dose/volume per dose/expected response of plasma
dose- 10-15ml/kg
volume- 200ml
response- correction of pt, ptt, inr
what is the dose/volume per dose/expected response of platelets
dose- 4-6 units from whole blood- 1 from apheresis
volume- 200-250ml
response- increase platelets by 30,000-60,000 mm3
what is the dose/volume per dose/expected response of cryo
dose- 10 pooled units
volume- 100 ml
response- increase fibrinogen, 8, 13, vwf
what is abbreviation for circulatory overload during transfusion
TACO
what is a new acute lung injury within 6 hours of transfusion
TRALI
what is a human leukocyte antigen or monocyte antibody reaction with wbc’s during transfusion
TRALI
what is the term for immunosuppression after transfusion
transfusion related immunomodulation
what are the ion imbalances created with transfusion
hypocalcemia,
hyperkalemia,
acidosis
what blood product has the most citrate
7x higher in platelets/plasma
t or f- it is appropriate to pressure bag blood
False technically
is rocuronium dose higher or lower for rsi vs general paralysis
higher
what paralytic should not be used 24 hours after trauma
succinylcholine
what sedative should be avoided in head injuries
ketamine
which has less vasodilatory affect, nitrous or isoflurane
nitrous
what anesthetic med should be avoided with potential closed air spaces such as pneumothorax, pneumocephalus, or obstructed bowel
N2O
what is only anesthetic gas that provides pain relief
N2O
what is placental abruption and when will it occur after trauma
premature separation of the placenta from the uterine wall- usually within 6 hours
what has more devastating effects- knife wound or gunshot wound
gunshot wound- more penetrating, more wound channels
what does etco2 look like from air embolism
gradually decreases- c-section it is common
what position should patient be in during air embolism
higher than level of heart
-left lateral trendelenburg to try to localize
what do hemopericardium and pneumopericardium require and how soon
immediate pericardiocentesis to relieve tamponade
what are eye opening response on gcs
4- spontaneous
3- to speech
2- to pain
1- none
what are motor responses on gcs
6- obeys verbal commands
5- localizes to pain
4- withdraws from pain
3- decorticate flexion
2- extensor response
1- none
what are verbal responses on gcs
5- oriented
4- confused
3- inappropriate words
2- incomprehensible sounds
1- none
how should you control icp with in brain injury/head and spinal cord trauma
mannitol 0.5 mg/kg,
restrict fluids,
avoid tachycardia and htn during intubation
how do you calculate cerebral perfusion pressure
map - icp
map - cvp
tbi classification
gcs 8 or less
pupillary dilation
hypotension
hypoxia
hypothermia
increased icp
what is the point where blood flows to in abdomen and what is it located between
morrison’s pouch- kidney and liver
what may be beneficial in preventing ischemia induced injury from head trauma
mild hypothermia
what kind of trauma should hyperglycemia be avoided in
head/spinal
how is pneumothorax differentiated from hemothorax
perussion dullness and silent lung fields
also morrison’s pouch with pocus
what type of ventilation is cautioned with hemothorax
jet ventilation- can cause crepitus- air embolisms
how is myocardial contusion diagnosed and what do they produce increased risk of
diagnosed: st elevations, enzymes, echo
-heart block, afib
what is the most accurate way to diagnose a pneumothorax
pocus- lung point
where is air in simple pneumothorax
between parietal and visceral pleura
s/s of simple pneumo
vq mismatch,
hypoxia,
decreased breath sounds,
hyperresonnant to percussion
what almost always happens with 100% long bone fracture
fat emboli
what can fat emboli cause
PETECHIAE,
pulmonary insufficiency,
dysrhytymias,
aloc in 1-3 days,
decreased etco2
what do most people die of from burns
sepsis
a burn of greater than how much of your body is considered major
20%
what affect can burn have on co and why
decreases within 30 mins as a response to vasoconstriction
t or f- fluid is encouraged in burns unlike trauma
true
which pneumothorax does air enter through a one way valve in lung or chest wall during inspiration and cannot get out during expiration
tension pneumothorax
what can tension pneumo do to trachea
shift mediastinum and trachea to other side
what is an indicator of tracheal shift
distended neck veins
what can a lung laceration from jagged rib fracture cause
arterial air embolism
what should a patient with multiples rib fractures tried to be treated with for anesthetics
regional anesthesia
what can an incision with abdominal trauma cause
profound hypotension due to lack of tamponade effect by blood
what should you try to do before making an incision in patient with abdominal trauma
rapid fluid/blood resuscitation before
what is damage control resuscitation
1:1:1 ratio of rbc, ffp, and platelets during trauma
what are two things to assume of all trauma patients
c spine injury
full stomach
which is greater risk for trauma patient taco or trali
TACO
what age groups are trauma a leading cause of death
under 20 over 70
what kind of tube is used during trauma that has a cuff inflate in the supraglottic airway and a tube that hopefully goes further down into trachea
king supralaryngeal device
in a trauma, what may abrupt cardiovascular collaps shortly after beginning mechanical ventilation indicate
pneumothorax- treat with thoracostomies second intercostal space, midclavicular line
what is the fast exam
focused assessment with sonography for trauma
how does trauma induced coagulopathy work on the clotting cascade
hypoperfusion causes thrombomodulin release which binds to thrombin and stops it from binding to factor 1 (fibrinogen).
Additionally, it also activates protein c which inhibits factors 5 and 8
also induces hyperfibrinolysis by indirectly increasing tissue plasminogen activator
what is a med that can be given to combat trauma induced coagulopathy
TXA (anti-fibrinolytics)
what blood type is usually given in a trauma
o negative
what happens when blood products are adminstered at a rate greater than patients cardiac output
transfusion associated circulatory overload
TACO
when is a taco most likely to occur
unrecognized control of the source of bleeding
what drug should be considered for induction of profoundly hemodynamically unstable patient
scopolamine 0.4 mg
t or f- all blood products can be warmed
false do not warm platelets
what is key to give to promote clotting during mtp
Ca
during trauma, why should vasopressors not be used if possible until source of bleeding is controlled
raising bp may disrupt fresh clots
what are the top two priorities during trauma resuscitation
surgical control of bleeding
dcr (blood admin)
what is any trauma patient with aloc assumed to have until proven otherwise
TBI
what is the most common brain injury requiring emergency surgery and has highest mortality
acute subdural hematoma
what are two keys in mitigating effects of tbi
avoid hypoxia and hypotension
when should you give fluids for second degree burn
greater than 20% tbsa involved
what is a major burn
> 20% tbsa, can be second or third degree
what fluid is preferred for burns
crystalloid
what is a common respiratory problem with burns
carbon monoxide poisoning
what does the temperautre of all burn care environments need to be
40 degree C
what is most difficult thing for burn patients to maintain
body temp- always cold
when should succ not be used after a significant burn and why
48hrs-2 years, life threatening hyperkalemia
what is the most important component of general anesthesia
amnesia- inability to recall events
define sensitivity
the percentage of people who test positive for a disease that have the disease
define specificity
the percentage of people without the disease who test negative for that disease
what can a high sensitivity test rule out
those who do not have the disease
highly sensitive test often used as screening tests
what can highly specific tests do
can help rule in those that have the disease
what are sensitive and specificity tests measured against
gold standard tests
ex: fine needle biopsies
formula for sensitivity
number of people who test positive (a) divided by the total number of people with the disease (a+c)
a / (a +c)
formula for specificity
the number of people who test negative (d) divided by the whole number of people without the disease ( b+d)
d / (b + d)
What does sensitivity of test tell you
Ability to rule out disease if test is negative
Few false negatives; think d dimer
What does specificity of test tell you
Ability to rule in a disease if test if positive
Few false positives
Think strep test
What’s normal serum osmolarity
275-290 mOsm/kg H2O
what is the most common electrolyte imbalance
hyponatremia
signs and symptoms of hyponatremia
headache
confusion
NV
SEVERE: vomiting, somnolence, seizures, card/resp distress, brain herniation
what should eval of hyponatremia include
serum osmo (rules out SIADH)
urine sodium (renal vs non renal)
clinical status (symptomatic?)
what does urine sodium >20 mEq/L suggest
renal salt wasting; problem with kidneys
what does urine sodium <10mEq/L suggest
renal retention of sodium to compensate for extrarenal fluid loss (problem other than kidneys)
what is isotonic hyponatremia
serum osmo 284-295 mosm/kg
occurs with extreme hyperlipidemia and hyperproteinemia
treatment cut down on fats
what is hypotonic hyponatremia
serum osmo <280; state of body water excess
diluting all body fluids
1. need to assess if patient is hypovolemic or hypervolemic
2. if hypovolemic, assess where hyponatremia is due to extrarenal salt losses or renal salt wasting
what is hypertonic hyponatremia
serum osmo >290
hyperglycemia: usually from HHNK
osmo high and Na is low (high tonicity)
what are the correction rates for hyponatremia
min Na 4-8 meq/L per day
max Na 8-10mEq/L per day
what is the number of photons in an xray called
kvp
what is the time for xray and what does it measure
mAs: amount of exposure
miliamp seconds
what is best view for x-ray because it provides more accurate dimensions
posterior anterior
the ______________ photons absorbed by the plate, the _____________ the image
less
brighter
what absorbs photons from least to most
air, fat, water/soft tissue., bone/metal
t or f- standing provides better views for chest x ray
true
what can help detect a pneumothorax on an x ray
expiration
what is a pneumomediastinum
air in the space between the lungs
do you want inhalation or exhalation during x ray
inhalation usually
true or false: apex of the lung should be above the clavicle on xray
true
what are the ways to make sure the patient posture is correct on xray
clavicle vs vertebral spinous processes
lung apex above clavicle
how do clavicles and spinous processes help ensure correct posture
clavicles should be equi-distant from spinous processes on both sides
what is the problem if your xray film is under exposed
KVP too low or mAs too short
what is the problem if your xray film is over exose
KVP too high
Mas too long
abcdefgh of xray
airway
bone
cardiac
diaphragm
effusions/extra-thoracic soft tissue
foreign bodies
gastric bubble
hila/mediastinum
what are two things to compare when evaluating x ray
compare to previous film and physician exam
what are the four indications for xray
support diagnosis
assess/monitor progress
monitor for complications
guide therapy like ventilations
how many ribs should see in patient with adequate lung volume on xray
10 ribs
what is indicative of a fully expanded lung on xray
thin white lines going out to peripheries
what is the bottom corner of the chest wall and diaphragm
costaphrenic angles
what is between the stomach and diphragm
gastric bubble
what is underneath diaphragm on right and left slide
right= liver
left= stomach
t or f- free air in the abdomen is called gastric bubble
False
what shows up in ap view xray that helps diagnose lobular pneumonia
horizontal fissure
why is taking lateral x ray beneficial when looking for pleural effusion
might be hiding in low lobe behind diaphragm in posterior costaphrenic angle
what is an increase in brightness of areas normal radiolucent (darker)
opacification
what is fluid or mucous buildup in passages around small airways
peribronchial filling
t or f- consolidation vs infiltrate generally means the same thing
True
what means too many lines
reticular
what means too many dots
nodular
what means too many lines and dots
reticulonodular
is left lower lobe anterior or posterior
posterior
what kind of pna hides left heart border
left upper lobe
what kind of pna hides left diaphragm
left lower lobe
what kind of pna hides right diaphragm
right lower lobe
what kind of pna hides right heart border
right middle lobe
what kind of pna hides ascending aorta
right upper lobe
what is the spine sine
decreased lucency/increased opacification on lateral view on spine as you go down the spine
what does a chest x ray look like in early ards (exudative)
bilateral diffuse infiltrates
starts peripheral and patchy
what does a chest x ray look like in proliferative ards
intense parynemal opacification (white out)
what does a chest x ray look like in fibrotic stage
residual fibrosis (reticular pattern)
t or f- ards usually respects lobular boundaries
f- opacities are everywhere
what is a common finding on x ray in ards
air bronchograp
what is an air bronchogram
air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white)
what is the deep sulcus sign and what does it help diagnose
affected side- costaphrenic angle is dark and deep
pneumothorax
what is a dependent opacity and why is it called that
pleural effusion- fluid moves with gravity- so standing it’s at base of lung
what can large pleural effusions cause
tracheal shift
what pathology causes blunting of the costophrenic angle (top of fluid border is u shape)
pleural effusion
what pathology cuases lateral sloping of meniscus shaped contour
pleural effusion
what ratio is indicative of cardiomegaly
> 50%
whats the cardiothoracic ratio
maximum horizontal cardiac width/maximum horizontal thoracic width
what view gives more accurate view of cardiomegaly
posterior anterior
besides cardiothoracic ratio, what else can signify cardiomegaly
-carina angle greater than 90 degrees
-double density of atria
what is left atrium usually parallel to on xray
right atrium- won’t be able to differentiate on normal x ray
where do you look for right ventricular enlargement
retrosternal space- lateral view
what are the pericardial effusion signs
water bottle- large silhouette with sagging margins (looks like water bottle top)
oreo cookie sign- hyperlucent layer between hypolucent layers
what kind of trauma does pneumopericardium happen
neck trauma
what is air around the heart
pneumopericardium
what is gold standard of aortic aneurysm detection
CT scan
t or f- constipation is an indication for x ray
false- only 50% sensitive
what is most sensitive to abdominal x ray
abdominal free air, foreign bodies
where is air trapped during abdominal free air
underneath diaphragm and above liver. look at right side as left side may be gastric bubble
what is a large floppy sigmoid colon that kinks itself off
volvulus- coffee bean sign
how should cvc line placement x-ray be filmed and positioned
ap view, semi fowlers
where should tip of cvc be placed for right sided cvc
at level of carina or slightly above
where should tip of cvc be placed for left sided cvc
a little lower in svc than right sided- tip should be verticle
where is svc in relation to carina
right lateral
how deep can hemodialysis catheters be placed
into right atrium
what are the three aspects of documenting normal x ray cvc findings
relationship to clavicle (with subclavian)
carina orientation within chest (vertical 1.5cm above carina)
s/s of pneumothorax or hemothorax
what is a consideration with a picc line
potentially have it at level of carina since it is more long term- want to avoid erosion of vessel wall-make sure it is verticle
what vertebrae is carina near
T5-T7
where should ett placement correspond to on spinal cord
T2-T4
what is ett position measurement dependent on
position of the head
flexed head ett position relative to carina
3 cm above carina
neutral head ett position relative to carina
5cm above carina
extended head ett position relative to carina
7cm above carina
children ett position relative to carina
1.5cm above carina
if you can’t see the carina on xray, where should ett be around
T2-T4
what can cervical accessory rib cause
thoracic outlet syndrome
what does T1 ariculate with
first rib
how do you count vertebrae to find t5 for carina level
find first rib, it should articulate with t1
what will you see near diaphragm in esophageal intubation
large air bubble
what should tip of feeding tube clearly be below
diaphragm
what should tip of feeding tube be 10cm beyond
gastroesophageal junction
Pt normals
11-13
Therapeutic 1.5-2reference
Tests extrinsic
INR
0.8-1.1 normal
Therapeutic 2-3
PTT
Normal 25-35 sec
Therapeutic 3x normal
ACT
Normal 70-120 sec
Therapeutic 160-600
Fibrinogen
Normal 200-400 g/Dl
Critical <100 g/dl
Fibrin degradation
Normal < 10 mcg/ml
Critical >40 mcg/ml
How much will 1 unit of platelet increase platelet count
5000-10000/mm3
What are the six things that have to be fixed immediately
Airway obstruction
Flail chest
Open pneumothorax
Massive hemothorax
Tension pneumothorax
Cardiac tamponade
What is increased potential for c spine injury
LOC at scene
Intoxication
Any neurological s/s
Neck pain
Severe distracting injury (ex:leg cut off)
Priorities to restore circulation
Stop bleeding
Replace volume
Fluid resuscitation points
Pressure bag
LR at 30ml/kg IBW
After 2-3L crystalloids go to PRBCs
AMPLE
Allergies
Medications
Past medical
Last meal
Events
Fat emboli points
Seen with pelvic/long bone fractures
Pulm insufficiency
Skin petechia
Dysthymias
Mental deterioration 24-72hr post event
First degree burn
Pain
Erythema
Second degree burn
Red
Blisters
Weeping
Painful
3rd degree burn
Painless
White
Leathery
Full thickness
Parkland formula
4ml x BSA x kg
1/2 in first 8 hrs
1/2 over next 16hrs
Time starts at the time of burn
When can you give succs in head/spinal trauma
Safe in the first 48 hrs
Dose of methylprednisolone in head/spinal trauma
30mg/kg
Then 5.4mg/kg/ hr for 23 hrs
Autonomic hyperreflexia
Lesions above T5
Txa dose
1g over 10 min
What’s the target fibrinogen level in mtp
> 150-200mg/dL
Can give cry or fibrinogen concentrate
Max allowable blood loss equation
MABL=EBV x (starting hgb - target hgb) / starting
What’s the target hct
24 usually
What products are highest risk for Trali
FFP and platelets
Treating hyponatremia too quickly is risk for
Central pontine myelinolysis
Treating hypernatremia too quickly may cause
Cerebral edema
mild K 5.5-6.5
peaked t waves
prolonged pr segment
moderate 6.5-8.0 K
loss of p wave
prolonged qrs complex
st segment elevation
ectopic beats and escape rhythms
severe >8.0 k level
progressive widening of QRS
sine wave
vfib
asystole
axis deviations
BBB
fasicular blocks
what drugs can cause hyperkalemia
succs (0.5 meq/l increase after admin)
ace
BB
spironolactone
NSAIDs
cyclosporin
does acidosis cause increase or decrease in K
increase
Anesthesia considerations for HYPERnatremia
increased MAC requirements
replace volume (replace with free water)
how to treat central DI
DDAVP 1-2 mcg IV BID
what are three major mechanisms for hypernatremia
increase renal water losses (DI, med, renal disease)
extrarenal water losses (sweating, fever, burns, GI loss)
excessive Na intake (bicarb)
Hyponatremia anesthesia considerations
decreases MAC requirements
decreased LOC
cerebral edema, central pontine myelinolysis
seizures
Right ventricular hypertrophy signs
Tall R in v1
RV strain in V1-V3
Prominent S wave in V5-V6
Total body water
60% weight
Intracellular fluid volume
40% body weight
Interstitial fluid volume
80% of extracellular volume
Extracellular fluid volume
20% body weight
Plasma volume
20% of extracellular volume
Lean body weight equation
Ideal body weight x 1/3
Ideal body weight male equation
Height (cm) - 100
Ideal body weight equation female
Height cm- 105
Burn % of adult
Face 9
Arms 9
Front 18
Back 18
Legs 18 each
Burn % of peds
Face 18
Front 18
Back 18
Arms 9 each
Legs 14 each
Peri area 1
what causes metabolic acidosis with anion gap
o Methanol
o Uremia
o DKA / Starvation Ketosis
o Pyroglutamic Acid
o INH (Isoniazid)
o Lactic Acidosis
o ETOH
o Renal Dysfunction
o Salicylates
what can cause non anion gap metabolic acidosis
o Renal Tubular Acidosis
o Diarrhea (loss of HCO3 through stool)
o Acetazolamide
o Excess Normal Saline administration
o Aldactone
what is another way to calculate anion gap
3 x albumin level
what is winters formula
(1.5 x HCO3) + 8 (+/- 2)
What is the shelf life for FFP
1 year at -18C
What is the shelf life of PRBCs
42 days at 1-6*C
What is the shelf life of platelets
5 days at 20-24*C
Valley 1-2 days
What is shelf life for Cryo
1 year at -18C
Pre renal disease diagnostics
bun: creat >10:1
Urine Na <20 mmol/dl
Spec grav > 1.015
Urine sed normal
FENA <1
Intra renal disease diagnostics
Bun:creat 10:1
Urine Na >40mmol/dl
Spec grav <1.015
Urine sed white casts
FENA 3
Post renal diagnostics
Bun: creat 10:1
Urine Na >40 mmol/dl
Spec grav <1.015
Urine sed normal
FENA >3
How often should Ca be given with PRBCs
1g Ca for every 3 PRBCs
Changes in banked blood
Depleted 2,3 DPG
Shifts oxy hemoglobin curve left
Decreased ATP
Decreased pH
Increased K
Impaired ability to change shape
Hemolysis
Increased pro inflammatory mediators
Leukoreduction
Removes WBCs from banked RBCs and platelets
Decrease HLA reactions
Washing
Prevents anaphylaxis in IgA deficient pts
Irradiation
Prevents graft host disease
Hypercalcemia ECG signs
Shortened QT
Hypocalcemia ECG signs
Prolonged QT segment
Hypokalemia ECG
Prominent U waves
Posterior MI
V1-V2
Posterior descending
Inferior wall MI
II, III, aVF
Right RCA
Anterior wall, septum MI
I, aVL, V1-V4
LAD
Lateral Wall MI
I aVL V5-V6
Left circumflex
What are the best leads to look at for ST segment depression or elevation
V3
V4
V5
III
aVF
What is lead II used to assess
Assessment of Narrow qrs complex rhythms
