Boot Camp Week 2 Flashcards
Cross-sensitivity to latex is highest with which allergies?
Avocado
Kiwi
Banana and lots of other plants
But NOT shrimp or shellfish
What factors are associated with airway fires?
First case on a monday
Sevo
Radial nerve injury is usually caused by:
external pressure at the spiral groove
BY
Surgical retractor or IV pole
Ulnar nerve injury is usually caused by:
external pressure at the post-condylar groove
2/2 pronation
In breast cancer patients, the #1 site of metastasis is:
bone, leading to hypercalcemia
What are the MRI zones?
Nitrous tank pressure =
745
What are absolute contraindications to ECT?
What is the maximum dose of tumescent lidocaine?
55mg/kg
What is ideal BP management with a ruptured cerebral AVM?
Deliberate Hypotension
At what length does the swan enter the RV?
25-30
At what length does the swan enter the PA?
30-45
At what length is the PA usually positioned appropriately?
40-50
INCREASED pseudocholinesterase activity is associated with:
obesity
ETOH
Hyperthyroidism (severe)
DECREASED pseudocholinesterase activity is associated with:
Burns
Liver Disease
Malnutrition
Neoplasm
Pregnancy
Neonates
What are some disadvantages of tramadol?
Seizures
N/V
Less effective when given with zofran
What genetic diseases cause obesity?
Prader Willi
Bardet-Biedl
Adipose becomes pathologic when:
it releases excess fatty acids and cytokines
Class I Obesity BMI
30-34.9
Class II Obesity BMI
35-39.9
Class III Obesity BMI
> 40
Obesity definition in children
95th-98th percentile
Severe obesity definition in children
99th percentile
What are the ventilatory changes in obesity
FRC decreases (ERV decreases and RV remains the same)
Closing volume increases
VC decreases
How does obesity impact O2 consumption?
Fat is metabolically active, so VO2 is increased and so is CO2 production
Does morbid obesity mandate an RSI?
No, not unless there’s something else going on
Since Succ is water soluble, why do we dose it based on actual body weight?
Because obesity causes increased pseudocholinesterase activity, so a higher dose is required
What cardiac parameters are altered in obesity?
Intravascular volume is increased
CO is increased
HR is unchanged
How is cardiac output impacted by fat?
It increases by 100ml/min for every 1kg of extra fat
Does obesity lead to diastolic or systolic heart failure?
Diastolic initially
The Vd of which drugs is increased in obesity?
BOTH
Lipo: more fat
Hydro: larger muscle mass and blood volume
Lipo»_space;> Hydro, but both increase
How do you calculate LBW?
IBW x 1.3
Vd in obese patients is altered by 4 things:
- Increased blood volume
- Increased CO
- Altered plasma protein binding
- Large fat mass
LBW is used to calculate which induction doses?
Prop
Roc/Vec
Remifentanil
Which loading doses are calculated using TBW?
Succ
Cis/Atracurium
Fentanyl
Sufentanil
Midazolam
Propofol infusions are dosed based on:
TBW
Fentanyl infusions are dosed based on:
IBW
In obese patients epidural doses should be:
reduced by 75%
What is the most sensitive sign of an anastomotic leak following gastric surgery?
Unexplained tachycardia
Followed by fever then abdominal pain
What cell signaling pathway do opioids use?
Decreases Adenylate cyclase -> decreased cAMP -> increased potassium conduction
What are the endogenous ligands for the opioid receptors?
Mu: Endorphins
Delta: Enkephalins
Kappa: Dynorphins
Which opioid receptor is responsible for bradycardia?
Mu
Which opioid receptors cause miosis?
Mu and Kappa
Which opioid receptors cause diuresis? Which cause retention?
Diuresis: Kappa
Retention: Mu and Delta
Which receptor is responsible for GI upset?
Mu
What are the mu 1 effects?
Supraspinal and spinal analgesia
Bradycardia
Euphoria
Low abuse potential
Miosis
Hypothermia
Urine retention
What are the Mu 2 effects?
SPINAL analgesia (the spine is the second part of the CNS)
Bradycardia
Respiratory depression (2 lungs)
Constipation
Physical dependence
What are the Mu 3 effects?
Immune suppression
What are the CNS effects of Mu receptors?
Sedation
Euphoria
Prolactin
Mild Hypothermia
What are the CNS effects of delta receptors?
None
What are the CNS effects of kappa receptors?
Sedation
Dysphoria
Hallucinations
Delirium
Which opioid receptor causes pruritis?
mu
The only opioid that doesn’t reduce heart rate is:
meperidine, because of its atropine-like ring
Do opioids impair the baroreceptor reflex?
no
What is the mechanism by which opioids cause nausea?
CRTZ
Vestibular apparatus
Sphincter of oddi pressure can be reduced by:
glucagon and naloxone
Which opioids promote histamine release?
Meperidine
Morphine
Codeine
Which opioid causes the LEAST oddi contraction?
Meperidine
In women, morphine is associated with:
greater potency
Slower onset
longer duration
lower postop consumption
Name two phenanthrene derivatives
morphine and codeine
Which narcotic is a thebaine derivative?
Oxycodone
Which narcotic is a piperidine?
Meperidine
Which narcotic is a phenylpiperidine?
All of the fentanyls
Which narcotic is a diphenylpiperidine?
Methadone
Rank the fentanyls in order of potency
Sufentanil (10mcg)
Remi/Fent (100mcg)
Alfentanil (1000mcg)
When does fentanyl withdrawal peak?
6-12 hours
When does heroin withdrawal peak?
Onset 6-18 hrs
Peak 36-72 hrs
When does methadone withdrawal peak?
3 - 21 days
Remifentanil is always dosed at:
LBW
What are four unique side effects of meperidien?
- Giving it with MAOs can cause serotonin syndrome
- Causes atropine-like effects (dry mouth, tachycardia etc)
- Only opioid with antishivering effect
- Histamine release
What’s special about Alfentanil?
Rapid onset because of a pKa that’s below physiologic pH
Which fentanyl should never be used neuraxially?
Remi
It has glycine in the mixture
Methadone has three MOAs:
- Mu Agonism
- NMDA antagonism
- MAOI
What is methadone’s active metabolite?
It doesn’t have one
What is the MOA of butorphanol?
Mu antagonism (weak)
Kappa agonism
What is the MOA of buprenorphine?
Partial Mu agonist
What is the MOA of nalbuphine?
Mu Antagonism
Kappa Agonism
Which partial agonist has an extremely high affinity for for mu receptor, making it hard to reverse?
Buprenorphine
Which partial agonist is helpful with postop shivering?
Butorphanol
Which antagonist does not cross the BBB?
Methylnaltrexone
Which antagonist is useful in alcohol withdrawal?
Naltrexone
What is the presentation of an ulnar nerve injury?
acute: inability to abduct 5th finger
chronic: claw hand
What are risk factors for ulnar injury?
Male
Pre-existing
Extreme habitus
Prolonged stay
cardiac surgery
Which nerve is most likely to be injured during an AC IV insertion?
median
Etiologies of median nerve injury include:
Elbow hyperextension
carpal tunnel syndrome
AC IV
The median nerve runs next to which veins?
Basilic and median cubital
What is the presentation of a median nerve injury?
Palmar surface of thumb
Inability to oppose thumb
Hand of benediction
(inability to clench fist)
Which nerve passes through the spiral groove?
Radial
Radial nerve can be injured by:
external compression by an IV pole
excessive BP cycling
UE tourniquet
tucking too tight
Which nerve innervates serratus anterior?
SALT:
Serratus anterior long thoracic
Damage to the long thoracic manifests as:
scapular winging
Damage to the suprascapular nerve manifests as:
dull shoulder pain
Damage to the suprascapular nerve is usually caused by:
ventral circumduction (rolling onto the dependent arm in lateral position)
Obturator injury manifests as:
inability to ADDUCT the leg
Obturator injury is usually caused by:
flexion of thigh toward groin
Excessive traction during abdominal surgery
forceps delivery
Femoral nerve injury manifests as:
impaired knee and hip extension
Lost sensation over anteromedial surface of leg
Femoral nerve injury is usually caused by:
excessive traction during abdominal surgery
Saphenous nerve injury manifests as:
reduced sensation of anteromedial leg
Saphenous nerve injury is usually caused by:
external pressure to medial leg
common peroneal injury manifest as:
foot drop and inability to evert
common peroneal injury is usually caused by:
external pressure at fibular head (lithotomy)
Fibula = Peroneal
Tibial = Saphenous
Sciatic nerve injury is usually caused by:
excessive flexion and abduction in lithotomy
sciatic nerve injury manifests as:
foot drop
Pudendal nerve injury is usually caused by:
compression against a perineal post on a fracture table
pudendal nerve injury presents as:
loss of penile sensation
Leaving the legs crossed leads to injury in which nerves?
sural (top leg)
superficial peroneal (bottom leg)
sitting with legs straight can injure which nerve?
Sciatic
compartment syndrome is most common in which position?
lithotomy
what causes midcervical tetraplegia?
hyperflexion of the neck
AND tracheal resection
What is the BEST positioning device in prone?
Jackson table is better than wilson or chest rolls
When intubating someone with an anterior mediastinal mass you should do two things:
maintain spontaneous ventilation
use a reinforced ETT
which body part should be placed over the kidney rest?
iliac crest
The saphenous is injured:
when the MEDIAL leg is contacted
The common peroneal is injured when:
the LATERAL leg is contacted
