Clinical prep Flashcards
1
Q
Ventilator vt formula for mask ventilation
A
4-6 ml/kg
2
Q
NPO calculation formula
A
4,2,1
4mlx 1st 10 kg = 40ml
2ml x 2nd 10 kg = 20 ml
1 ml x Every KG > 60 mmhg = x
40+20+ x = ml/ hr to replace
3
Q
VT formula for ventilator
A
6-8 ml/kg of IBW
4
Q
Goal airway pressure while mask ventilating
A
< 20 cmH20
> 20 -> pressure will open the LES and cause air to enter the stomach (aspiration risk)
5
Q
Steps between giving sedatives and paralytics during intubation
A
stimulate pt
check eye lid reflex
prove ventilation; chest r/f, expired vt, peak airway pressure, etco2, Hr/ SPO2/ BP
check twitches
6
Q
APL setting while mask ventilating
A
18-20 cmH20
minimup pressure / open (0cmh20)
7
Q
Axis aligned while in sniffing position
A
oral axis, pharyngeal axis, laryngeal axis
8
Q
Volume control
A
constant inspiratory flow until set tidal volume is met
9
Q
Confirmation of correct intubation
A
mist in tube/ fog/ condensation
chest rise and fall
Bilateral breath sounds
3 ETCO2 wave forms of equal height
10
Q
Pressure control
A
decelerating inspiratory flow as the set pressure is being reached.
11
Q
Pressure support (PSV pro)
A
Pressure support, inspiratory flow is decelerating and in synch with the patients
12
Q
Pressure control volume guaranteed
A
Tidal volume is the primary setting
decelerating inspiratory flow as the set pressure is being reached
ventilator delivers set tidal volume at intervals based on set respiratory rate, for each breath the ventilator adjusts the inspiratory pressure to use the lowest pressure required to deliver the tidal volume, based on the patient’s compliance and the inspiratory pressure for subsequent breaths.
inspiratory pressure ranges;
low end; PEEP + 2 cmh2o
Max; Pmax - 5 cmh2p
13
Q
Assist control
A
14
Q
Resistive vs elastic pressure
A
resistive pressure = airways
elastic pressure =
15
Q
IMV
A
not in synch = can cause breath stacking
16
Q
Volume-guaranteed pressure control
A
17
Q
SIMV
A
synchronized intermittent mandatory ventilation;
Can be VCV or PCV, or PCV-VG.
18
Q
CPAP/ PS
A
Primary setting is peep and inspiratory flow is decelerating and in synch with the patient
19
Q
How do cain derivaties work
A
bind to the inside H/ innactivation gate of the fast sodium channels to prevent an ap from being sent
20
Q
CPAP vs BIPAP
A
BiPAP machine provides different air pressure levels for inhalation and exhalation. In contrast, a CPAP machine uses the same amount of air pressure whether the user is breathing in or out.
21
Q
How does atropine work
A
antimuscarninic, it inhibits the Vagus nerve from secreting ach on the muscarninc receptors in the heart that are responsible for hyperpolarizing the cell by transporting K+ out of the cell which typically keeps the heart rate low. Blocking this will increase the hear rate
benedryl is also an antimuscarninc
22
Q
How does creatine work
A
is a byproduct of skm and is in constant production. it is proportional to muscle mass
23
Q
normal GFR
A
125 ml/min
24
Q
normal bili and what does it indicate
A
0-11
broken down hbg stored in the liver
25
normal lactate
26
normal ammonia
15-40 microns/ dL
27
normal bicarb
22-26
28
normal osmotic pressure
280-290 mosmo
29
Body weight is what percent water?
60%........60% of 70kg = 42kg = 42 L
30
Where is body water stored
2/3 = intracellular
1/3= extracellular
31
What is osmotic pressure
physical pressure required to prevent osmosis from occurring through a semipermeable membrane into an osmotically active solution. - move water towards the pure side. 1mosm=19.3mmhg in 1 L.
32
The difference between gray and white matter
white matter - myelin
gray matter = non myelin (uses more energy)
33
Ratio of glial cells to normal neurons
10:1
cells in the nervous system that support, nourish, and protect neurons.
outnumber actual neurons 10:1
Oligodendorcytes/ schwann cell
astrocytes = check csf comp, provide support and regrowth
ependemyl= make csf
microglial= repair damage
34
Where is cox 1 and Cox 2 found
Cox 1=plat and blood products
Cox 2= inducible and cns/pain area, produced constantly in the kidneys
35
What are the roles of prostaglandins
inc blood flow
inc inflammation
relax smm
inc pain sensitivity
36
normal alk phos
30-100
37
significance of alk phos
38
normal albumin
3.5-5
39
where is albumin synthsized
synthesized by hepatocytes
40
main inhibitor nt in the brain and where on the neuron it has an impact
GABA
axon hillock
41
Brainstem parts
midbrain most superior
pons
medulla oblongota
42
Spinal cord ends at____ and the name of it
L1
conus medularis
43
Purpose of the cerebellum
complex movements
sensory information, complicated tasks, muscle to contract and relax.
44
term for the connection point between the L and R side of the brain
Corpus collosum
45
area of brain for understanding language/ language comprehension
werknickes area
between temporal and parietal lobe
46
word formation/ speaking area of the brain
brocas area in the frontal lobe
47
brachial plexus
48
cervical plexus
49
Lumbar plexus
50
Sacral plexus
51
names for C1 and C2
C1= atlas
c2= axis
52
ligaments of the spine
supraspinous ligament
interspinous ligament
ligmenta flavum
epidural space
dura mater
subdural space
arachnoid mater
subarachnoid space
pia mater
53
what is the ligamenta flava made of?
elastic, ligaments are usually made of collagen
54
arching the back for a spinal/ epidural changes what?
gives better visual/ opening of the interlaminar foramen
55
where does the dural sac end
S2
56
Why do we sweat
from increased cellular energy / atp use increases the work of sodium pumps in our sweat glands that pump salt and water follows
57
nerves that control the diaphragm
C345= phrenic nerves
58
Cardiac accelerators
T1-4
59
CSF produced by and how much per day, how much do we have at any one time, and when is it produced
ependymal cells produce
450 ml/day
150 ml at any one time
swapped out 3 times/day
produced more when sleeping/uncouscious (anesthesia)
60
normal ICP
5-10 cmh20
61
What medications do not knock out the electrophysiologic activity of the brain?
nitrous and ketamine
62
what perfuses the front and what perfuses the back of the brain and cerebellum
front= carotid arteries
back = vertebral arteries
63
What organs have no pain receptors
inside of the Brain, lung, liver
64
Where is the Great radicular artery found
T9-T12
65
3 branches that come off the aortic arch
brachiocephalic
L common carotid
L subclavian
66
Valvular disease contraindications for spinal
AS < 1 cm2 or MS < 1 cms
67
superior illiac crest line and significance
Tuffiers line = intercristal line
Space of L3-L4
68
Nerve blockade for spinals/epidurals
1. B fibers - sympathectomy
2. C & A delta- pain / temp
3. A gamma- muscle tone
4. A beta- touch / pressure
5. A alpha- motor
69
Bainbridge reflex
nodal tissue stretch-> decrease vagal tone firing -> increase HR
70
Bezold-Jarish reflex
Sympathetic stimulation -> serotonin to chemo R in the LV -> inc para symp and dec symp -> hypotension/bradycardia
zofran inhibits
71
treatment for "LAST"
local anesthetic systemic toxicity (LA in vasculature)
SZ? = give benzo
tx; interlipids 20% 1.5ml/kg(bolus)
gtt; 0.25ml/kg
72
most common drug allergy in anesthesia
Roc
73
What causes allergy in LA
Esters; because of PABA
74
horners syndrome
ptosis, miosis, anyhydrosis
high sympathetic spread of LA
75
Nerves to block for awake intubation
Glossopharyngeal nerve - CN9- (suck on cotton swab)
Vagus nerve- cough to spread to trachea
trigeminal nerve (V2) - CN5 (cotton swab in nose)
76
Epidural test dose
3 ml of 1.5% lidocaine w/ 1:200000 epi
lid = 45mg
epi= 15 mcg
77
Normal distance to epidural space
4-6 cm
epidural cath should be 3-5 cm within epdiural space
78
Normal PR interval
0.12-.2
79
EKG paper numbers
hash marks = 3 seconds apart
1 big box = 0.2 seconds (five little 0.04 boxes)
3 hash marks = 6 seconds
vertical box = 0.5mV
print speed = 25 mm/s, increase to 50 to see more spaced out
80
1st degree HB
Pr longer than 0.2
81
Normal QRS
<0.12 seconds
longer or RSR = BBB
82
PSVT
supravent tachycardia that start then stops
83
Pt having pvc/ pacs what should you think is happening?
electrolyte abnormality; mag or K being the cause
84
2nd degree type 1
longer longer longer drop = wenchebac
85
2nd degree type 2
fixed p then random drops
86
Side affect of sevo in infants
bradycardia
87
Meds that cause prolonged qt interval
amio
Zofran
properidol
increase QT = increased risk for early afterdepolarization-> torades
88
12 lead EKG placement and number of electrodes
12 Lead ECG’s use 10 Electrodes
one electrode on each limb
6 electrodes on the left chest
89
Limb leads
LA Left ARM
RA Right ARM
LL Left LEG
RL Right LEG
90
Precordial leads placement
V1 4th intercostal space, right of sternum
V2 4th intercostal space, left of the sternum
V3 between V4 and V2
V4 5th intercostal space, left of sternum- mid clavicular line
V5 5th intercostal space, left of sternum- anterior axillary line
V6 5th intercostal space, left of sternum- mid axillary line
91
How determine the hearts axis
direction of QRS of leads 1, 2and 3
92
Bundle branch block determination
Must use V1 and QRS complex must be at least .12sec ( (120 ms) or wider (or 3 little squares)
J point -> back to the qrs. If up = Right, if down = left
93
Ischemia is seen on EKG as what?
symmetrical inverted T waves in 2 or more related leads
94
infarct on EKG is seen as
Reciprocal changes to other ST elevation
95
What makes a pathologic q wave
It is evidenced by a pathological Q wave that is either greater than 40 milliseconds wide or measures 1/3 of the height of the R wave.
When seen without acute changes such as ST elevation or ST depression it is considered to be “old” or of undetermined age.
96
EKG Lead memorization
LxS A
I L S L
I I A L
97
Normal CO
4-6.5 L/min
98
Normal SV
60-90 ml
99
Normal SVR
800-1600 dynes/sec/cm5
100
Normal PVR
40-180 dynes/sec/cm5
101
Normal Mixed venous O2 sat
70-80
102
Umbilicus dermatome
T10
103
nipple dermatome
T4
104
Even with epi, whats the longest a spinal will last?
150 min
105
MOA and SE for stygmines
inhibit ACHE -> increased ACH in the NMJ = outcompete NMBD.
Side effect = bradycardia and bronchoconstriction / increased salvation. (consider ach on heart and airways)
106
Predicted Postoperative FEV1 post lobectomy
ppoFEV1 = Preop FEV1 % x (1-% lung tissue removed/100)
segments; total of 42
RUL; 6
RML: 4
RLL; 12
LUL; 10
LLL; 10
107
Why is there a Q wave
part of the L vent depol before the right vent
108
If the heart is ischemic does the area stay depol or repol
depol (negativeoutside the cells, positive inside the cells) cant reset/ repol.
109
EKG machine paper print rate
25mm/second
speed up to see more detail
110
TOTAL lung capacity and each volume
TLC = 6L
RV= 1200
ERV= 1200 ml
vt= 500 ml
IRV; 3,100
111
What is dromotropy
conduction speed of the heart. beta agonsits increase conduction speed by making L type ca channels more sensitive/ open for longer.
112
What is lusitropy
resetting the heart faster-> makes way for another ap in shorter period of time = beta agonists because they speed up the serca pump
113
Aorta cross sectional area
2.5 cm2
114
Vena cavae cross sectional area
8cm2 (4cm2 each)
115
Map formula
(1 SBP + 2DBP)/3
116
Pressure the aortic valve closes at
100 mmg
117
Normal Pulmonary Artery pressure
25/8mmhg
118
Normal wedge pressure
8mmhg
119
Normal Hematocrit
0.4
Hematocrit is the percentage by volume of red cells in your blood
120
Stages of General anesthesia
Stage 1: Analgesia
Stage 2: Delirium
Stage 3: Surgical Anesthesia
Stage 4: Medullary Paralysis
121
Components of General Anesthesia (Stage 3)
Hypnosis- sleep state
Analgesia- pain free
Muscle Relaxation- safe
Sympatholysis- HD stability
Amnesia- don’t remember
122
Stage 2 characteristics of excitement
undesired CV instability excitation, dysconjugate ocular movements, laryngospasm, and emesis.
Response to stimulation is exagerrated and violent.
123
What is medullary paralysis
Stage 4 of GA.
May lead to death.
Marked hypotension with weak, irregular pulse
Flaccid paralysis
All reflexes are absent
Associated with cessation of spontaneous respiration and medullary cardiac reflexes.
124
how many cm in 1 inch
2.54
125
What does GABA stand for and what is it
Gamma-aminobutyric acid (GABA) is the main inhibitory neurotransmitter in the brain
126
Compliance formula
Delta V / Delta P
Beginning - End
127
Velocity formula
force/ area
128
flow formula
Flow = delta P / Resistance
129
Where are baroreceptors located
carotid sinus/ bifurcation-> herrings nerve -> glossopharyngeal nerve -> NTS (medulla)
aortic arch -> Vagus nerve -> NTS (medulla)
stretch sensors
130
Components of General Anesthesia
Hypnosis
Analgesia
Muscle Relaxation
Sympatholysis
Amnesia
131
CPP formula
cerebral perfusion presusre = MAP - ICP
132
Boyles Law
given a constant remperature
pressure and volume of gas are inversly proportional
133
Effects of tachypnea on reaching necessary PI of volatile
Faster breath = more molecules from alvolis to the brain but if we breathe faster PaCO2 = decreases- > cerebral blood flow will constrict and decrease rate/ speed of cbf and dont carry as fast to the brain
134
Henry’s Law
the amount of dissolved gas in a liquid is proportional to its partial pressure above the liquid
135
Spinal dose based on height
1 ml + 0.1ml/inch over 5 ft
136
What do the cvp wave forms symbolise
a wave = atrial contraction
c wave = ventricular contraction
X descent= decreased p from contracting vent
V wave = volume building back up in the atria
Y descent = tricuspid valve opens
137
Normal venous return
5 L/ min, same as CO
138
Steps to set up room
Suction
Airway
Monitor
Machine
Tape/Table
IV supplies
Drugs
other things
mask straps
air/ blanket warmer
fluid warmer
ng/og
stethoscope
IV poles/ drape clamps
139
Normal pipeline pressures
45-55 PSI
140
items needed for needle cricothyoidomy
14 g iv catheter
10 ml syringe w/ saline (look for bubles)
connect 7.5 ett connector to 3 ml syringe (attache to catheter)
ambu bag
141
contraindications for art line placement
raynauds
advanced atherosclerosis
coagulopathy
thromboangiitis obliterans (Buerger disease)
142
IJ central line landmarks
Head to the r = makes IJ more lateral
sternocleidomastoid anterior sternal head and lateral sternal head of scm -> apex of triangle -> should be lateral to thyroid cartilage and more lateral and superficial than the carotid pulse
needle at 45 degree angle to ipsilateral nipple
143
CL placement depths
RIJ - 16 cm
LIJ = 19cm
LsubC=18cm
R SubC= 15cm
144
respiratory alkalosis may result in what electrolyte abnormality?
hypocalcemia
inhibits ionized ca by increasing ca to albumin binding
145
what nerve supplies sensation below the vocal cords
recurrent laryngeal nerve supplies sensory to the interior glottis and motor control to ann intrinsic muscle in the laryx except the criothyroid muscle which is supplied by the external laryngeal nerve
146
The most significant cuase of heat loss in anesthesia pts
radiation
147
vitamin K is required by the liver for production of what factors?
2,7,9,10 and procein c and s
148
Light emitting diodes (LEDS) in the pulse ox sensor emit red and near infrared light at what rate?
660-940nm
149
WHich inhaled anesthetic is metabolized the most?
sevo
150
what is the only muscle capable of widening the rima glottis
posterior cricoarytenoid muscle
151
what is the cushing reflex
responsible for acute ICP increase
triad = wide PP, bradycardia and irregular respirations
152
what is the five and dime reflex
oculocardiac reflex
sensory = trigeminal nerve/ cn5
motor = vagus nerve / cn10
153
Emergency physical examination
A = Allergies
M = Medications
P = Past medical history
L = Last meal eaten
E – Events leading up to need for surgery/procedure
154
What abx need to be given 2 hrs prior to sx for prophylaxis
vanc and fluoroquinolone
155
CPR H's+ T's
hypovolemia- fluids, labs, high spinal?
hypoxia- chest x ray, intubate, suction, bbs
hydrogen ions; HCO3 (50 meq), ventilation
hypo kalemia; K+ and Mag+
hyper kalemia- CA+ chloride, 10 units insulin,D50 (25 grams), bicarb
hypothermia- warm
tension pnex- bbs? JVD? Needle decomp-> Chest tube
tamonade- TEE or TTE -> pericardiocentesis
toxins- antidotes? LAST? Dantrolene?
thrombosis, pulm/coronary- get TEE
156
Where are the vocal cords?
attached to the arytenoid cartilage and the thyroid cartilage at the thyroid notch
157
Hypoxia during case, things to consider
Check etco2
hand ventilate; compliant?
right main stem
secretions
pneumo?
PE / air embolism
anaphylaxis
aspiration
MI/ cardiac failure
bronchospasm
158
How to perform needle decompression for tension pneumothorax
14 to 16 gauge needle 2nd intercostal space at midclavicular line
159
Anaphylaxis treatment
fluids
epi
bronchodilator
100% o2
H1 and H2 antagonists (benedryl/ ranitidine)
Corticosteroid (methylprednisolone 125mg)
160
What heart valve only has two cusps
mitral/ bicuspid valve
161
Why are the coronaries perfused during diastole
because LV wall pressure is low (o) and arotic pressure is high (120) so if perfusion happens down a gradient (delta P) then diastole is a good time to be perfused because the delta p is the greatest then
162
Quick SVR formula
(map-cvp)/CO x 80
163
What is a major concern in sitting position
venous air embolism
becuase of decreased venous pressure at surgical site due to gravitational effects
164
effects of low Ca+
ECF Ca+ sits in front of Na+ channels and keeps the breaks on the nervous system.
low Ca+ causes a hyperexcitable membrane resulting in tetany
165
micrognathia
receding mandible
166
Bronchospasm wave form/ signs/ treatment
increase peak airway pressure
wheezing
increased expriatory time
increased etco2 w/ upsloading etco2 waveform
decreased tidal volumes if pressure control
deepen
100% o2
check ett; sucktion, bbs
Beta 2 agonist / anticholinergic
ketamine
hydrocortizone
neb w/ epi
167
Delayed emergence; things to check
Double check meds given/ everything is off
check twitches
hypoxia, hypercarbia, hypothermia
neuro exam
hypoglycemia
abg w/ lytes
consider dosing error
168
Unanticipated difficult airway considerations
BURP -> bougie -> Glydescope -> nasal/ oral airway-> awaken pt -> viberoptic bronchoscopy -> LMA into ett
cant ventilate = difficult airway card. Place LMA. still unable to ventilate? perform circothyrotomy
169
Airway fire considerations
Stop airway gas flow
remove ett / foreign bodies
pour saline into airway
examine airway w/ brochosopy
prompt reintubation
prevention;
wet gauze by ett
fio2 < .3
laster resistant ett
170
Each unit of PRBC raises hbg_____
1 g/dl
171
Each apheresis unit raises platelets _______
50, 000 per micoliter
172
FFP dose
1--15 ml ffp per kg of body wt. (for massive transfusion)
173
each _____ units of cryprecipitate raises fibrinogen ______
10. 50 mg/dl
174
things to rule out with severe hypotension
hemorrhage
Auto peep
vasodilators (volatile, anesthetics, gtts)
Embolism
pneumothorax
IVC COMP
cardiac event (TEE to assess)
anaphylaxis
pneumoperitoneium
175
Early signs of MH
increased ETO2
tachycardia
tachypnea
mixed acidosis
masset spasm
sudden cardiac arrest
176
Normal pulmonary compliance
40-70 mL/cmh2o
177
Normal compliance in children
1mL/cmh20/ kg
178
What to set I;E ratio in COPD pt and why
> 1:2, ie 1:3, 1: 4 = prevents breath stacking
179
What forms of calcium should be given centrally and what forms should be given peripherally
calcium chloride= centrally
calcium gluconate = peripherally
180
What is the relationship between calcium and albumin
Approximately 40% of serum calcium is bound to albumin, with a smaller percentage bound to lactate and citrate. The remaining 4.5 to 5.5 mg/dL circulates unbound as free (ie, ionized) calcium (iCa)
181
Acidemia and calcium and albumin relationship
H+ ions can displace the calcium from albumin resulting in increased free// ionized calcium levels.
182
How much does decadron increase blood sugar by?
The maximum rise in blood glucose was in the range of 40–45 mg/dl in the patients who received dexamethasone
183
How does stress dose steroids affect blood pressure
Adrenal glucocorticoid stimulates Phenylethanolamine N methytansverase to convert NE to EPi in the adrenal medulla
stress dose steroids are provided supraphysiologic dose of a glucocorticoid steroid to prevent adrenal insufficiency / cardiovascular collapse in pts with suppressed HPA axis from taking steroids long term
avoid etomidate in pts taking steroids because it will further worsen adrenal suppresstion
when administered with vasopressors, glucocrtoids enhance vascular reactivity with vasopressors
184
Indocyanine Green
ICG; used to eval real time tissue or organ perfusion.
mix 25 mg of the sterile powder with 5 ml of sterle water to yield 5 mg/ ml
new bolus can be given after 15 minutes.
don't admin > 25 mg/kg total
moa = tightly binds to plasma proteins like albumin and becomes confined to the vasulur system
185
Treatment of auto-peep
fix obstruction
decrease VT
increase expiratory time (decrease RR or increase I:E)
increase Peep (make for less negative pleural pressure that the lungs have to generate to reach alveolar demand)
186
Type and cross vs type and screen
the patient's blood type is identified, and a screen will have identified potential antibodies that could complicate obtaining blood. A crossmatch to find compatible units can be done more easily following a "type and screen." "Type and Cross" - This is requested when it is likely that blood will be needed.
187
Auto Peep wave form
if the expiratory line on the flow curve doesnt go back to the baseline before inhalation
188
auto peep test
do an end expiratory hold. see the pressure at the end of expiration and if that pressure is greater than what the peep is set at = auto peep
189
What is auto peep
At end expiration, there is still a pressure/air gradient that is remaining in the alveoli when the inspiration starts as compared to that alveoli pressure being less than or empty. This contributes to a Larger FRC. A persistently increasing FRC = increased remaining volume in the lungs = dynamic hyperinflation at the end of expiration = auto Peep.
190
What are the concerns with auto peep
decreased venous return because of persistent increased intrathoracic pressure
flattening of diaphragm = increased work of breathing and inability to trigger the vent
191
Treatment of auto-peep
fix obstruction
decrease VT
increase expiratory time (decrease RR or increase I:E)
increase Peep (make for less negative pleural pressure that the lungs have to generate to reach alveolar demand)
192
Treatment for hyperkalemia
Ca + chloride 10 mg/kg max = 2000 mg
Ca + gluconate 3 mg / kg Max = 3000 mg
HCO3 = 1-2 mg/kg max = 50 meq
1 amp = 25 grams of d50
10 units of IV insulin
193
Possible complications from interscalene nerve block
puncture of vasculature
high spinal
horners syndrome
hemiparalysis of the diaphragm (100% of patients)
pneumothorax
hoarsness (10-20% of the time because of its closeness to the RLn)
194
Who are nasal airways contraindicated in
coagulation or plat abnormalities and those with basilar skull fractures
195
What pathway is involved in the transmission of pain
lateral spinothalamic
x at sc
196
What pathway is involved in the transmission of motor
pyramidal/ corticospinal tract
x at pyramidal decussation
197
What pathway is involved in the transmission of sensory of fine touch and two point discrimination
DCML
Dorsal column medial lemniscus
x at medulla
198
What electrolyte abnormality is acute pancreatitis likely to cause
hypocalcemia
In acute pancreatitis, there is inflammation and damage to the pancreas. Calcium ions that are normally bound to proteins in the blood can precipitate and bind to necrotic (dead) pancreatic tissue
During the inflammatory process in pancreatitis, there is an increase in free fatty acids. These fatty acids can bind to calcium ions in the blood, forming complexes that are not biologically active
Pancreatitis can interfere with the activation of vitamin D, which is crucial for the absorption of calcium from the intestines
199
what is the normal apneic threshold for paco2
max Paco2 that does not initiate spont breathing is only 3-5 mmhg lower than the paco2 present during spont breathing
200
the nucleus is made up of how many chromosomes
46
201
hypocalcemia has what affect on na+ channels
hypocalcemia prevents the na channels from closing from between ap (tetany). ca + usually sits in front of an tones down the ap transduction velocity
the cell membrane is mostly negatively charged, and the + ion calcium will bind to the cell membrane and cause it to stabilize. lack of calcium = membrane instability
202
effects of acidosis and alkalosis on neuron excitability
acidosis - depresses neuon excitabilty
alkalosis - enhances neuron ecitatilbiyt
203
Relationship between liver disease and lung disease
Lungs have intrinsic protease ability allows it to destroy proteins and rips amino acids apart.
Protease = chop up amino acids.
Alpha 2 antitrypsin inhibits proteolytic activity/ inhibits the lung digestive feature and is produced in the liver.
204
Anatomical dead space formula
1ml/pound
2ml/kg
205
Right shift oxy-Hbg curve causes and meaning
causes; increased O2 environment, decrease CO2, decreased H+, increased ph, decreased temp, decreased 2,3 DPG
increased oxygen affinity for hbg = decreased oxygen unloading.
206
What is 2,3 DPG
byproduct of cellular metabolism
207
Relationship of blood products and 2,3 DPG
Blood products have decreased 2,3 DPG = increased oxygen affinity for hbg = decreased oxygen unloading.
208
Left shift oxy-Hbg curve causes and meaning
causes; decreased O2 environment, increased Co2, increased H+, increased pH, increased Temp, increased 2,3 DPG
decreased oxygen affinity for hbg = increased oxygen unloading.
209
What prostaglandin is named prostacyclin
PGI2
210
What is the primary function of mature lymphocytes?
synthesis of antibodies
211
What medications cover MRSA infection and what doesnt
Lenzolid doesnt cover MRSA
Cefazolin, clindamycin and vancomycin cover MRSA
212
What antibiotics can cause tendonitis and arthropathy and is effective against gram- negative and pseudomonas
ciproflaxacin
213
What Antagonizes the most prominent excitatory amino acid in the body
Ketamine. (glutamate = most prominent)
214
What drug can lead to inhibition of oxidative phosphorylation with high dose prolonged infusion
Propofol
215
What nerve is the eyeash reflex
Afferent lime is mediated by the trigeminal nerve and the efferent lim is via the facial nerve
216
When is stress dose steroids with prednisone use NOT indicated
< 3 weeks of steroids at any dose
prednisone <5mg/day for any duration
Prednisone < 10 mg every other day
217
What law allows the measurement of flow rates via flow meter
Poiseuilles Law
laminar flow of viscous fluid thorugh pipes or tubes
218
Side effects of hydralazine
tachycardia, sale and water retention , lupus-like syndrome
219
How much does succ increase IOP
in the intact eye succ raises IOP by 6-8 torr. Blinikning raises IOP by 10-15 torr. occurs within 1-4 min and return to normal within 5-7 min.
220
Halflife of heparin
90 min
221
Changes to IE ratio with Obesity
Expiration is passive. if pt doesnt have any respiratory/ obstructive problems then increase inspiration time since the speed of expiration will be increased since the pt is on their back and the weight of the chest is assisting with expiration. inspiration will be more difficult because there is increased chest wall resistance. / need more time for inspiration.
222
normal Vd/Vt ratio for spont ventilation and mechanical vent
spont V = 33%
Mechanical vent = 50%
223
Oxygen consumption equation
( 125 ml/min) x BSA
3.5ml/kg/min
VO2 = CO x (CaO2-CvO2) x 10
224
BSA formula
The square root of (Height(cm) x wt (kg) / 3600
225
What makes a good research article
Validity; accurate? Threats to internal validity include investigator bias, the Hawthorne effect, attrition bias, and selection bias
reliability; are the instruments consistent
Precision; what is the central tendency? Variation? statistical sig? (are the findings due to chance? Effect Size?
226
What changes in anesthesia with marijuana use
decreased Bp increased HR increase Airway reaction. change to mac (increase or decrease) delayed wakeup?
post op anxiety?
227
A-a gradient formula
( Age + 10 )/ 4
228
Sensory only cranial nerves
1- olfactor
2- opotic
8- vesibulocochlear
229
Motor primarily cranial nerves
3- oculomotor
4- trochlear
6- abducent
11- accessory
12- hypoglossal
230
What nerves cause the eyelash reflex
afferent trigeminal nerve and efferent facial nerve
231
What nerves are responsible for the motor of the eye
there are 6 muscles of the eye
3- oculomotor; 4/6
4- trochlear; pulls on the superior oblique muscle
6- abducent; lateral rectus muscle (pulls view to lateral fields)
232
Gag reflex nerves
afferent = glossopharyngeal
efferent= vagus nerve
233
how long is the delay on the etco2
20 seconds
234
What does nims tube stand for and how does it work
neural integrity monitor electromyogram tracheal tube
non-depolarizing neuromuscular blocking agents is contraindicated
minimum outer diameter of at least 8.8 mm
When attempting to identify LNs, a stimulating electrical current of 0.5-2.0 mA is used by the surgeon. This current is administered via a sterile probe, which is placed directly on the anatomical site in question. Additionally, return electrodes are positioned in the skin above the sternum
When a LN is located, an electrical signal is subsequently generated by the motion of the vocal cords. An audibly recognizable “machine gun click” is then produced from the device's associated monitor. This sound has a set frequency of 4 times/s (4 Hz). Simultaneously, an oscilloscope-like screen displays an identifiable sinusoidal response.
235
Alveolar oxygen formula
Used to compare blood case to alveolar gas to see if ventilating well.
PAO2 = ((PB-PH20) x FiO2) - (PaCO2 / R)
236
Respiratory quotient
237
What is the normal A-a gradient
5-15 mmhg
because the thebsian, bronchial and pleual veins bypass the alveolar capilaries and deliver deoxygenated blood to the L heart.
increased gradient = increase shunt, VQ mismatch or diffusion defect
shunt = 1% for every 20 mmhg in A-a difference
238
Normal Vital Capacity (weight based )
65-75 ml/kg
239
Normal FRC weight based
35 ml/kg
240
Closing capacity it what?
RV + CV
closing volume = The volume above RV where small airways begin to close
241
Age based normal CV
30% of TLC at age 30
55% of TLC at age 70
242
Factors that increase closing volume
(CLOSE-p)
COPD
Left vent failure
Obesity
Surgery
Extemes of age
Pregnancy
243
Side effect of succinylcholine in Peds
Bradycardia
244
LMA Maximium amount of time
2 hours
245
S/s of serotonin syndrome
SHIVERS
shivering
hyperreflexia
myoclonus
increased temp
vital sign abnormalities
encephalopathy
Restlessness
sweating
246
Causes of sweating during surgery
pain
low bg
MI
serotonin syndrome
247
Normal VBG
pH 7.36
PCO2= 45 mmhg
PO2 = 40 mmg
SaO2 = 70-80%
248
Causes of increased CO2 production
sepsis
MH
overfeeding
shivering
seizure
thyroid storm
Burns
249
Consequences of High CO2
Right shift in oxyhb dissociaction curve
myocardial depresseant
dilates peripheral vasculature
increased ICP
SNS stimulation
PVR increased (R heart strain)
increased H+/K+ pump -> hyperkalemia
increased calcium
CO2 narcosis/ LOC when paco2 > 90.
250
MAC of CO2
200 mmhg
CO2 is a respiratory depressant between 80-100 mmhg
251
Why are nsaids contraindicated in asthmatics
decreaesd cyclooxygenase -> increase lipoxygenase -> bronchospasms
252
how does dexamethasone decrease wound healing
Dexamethasone suppressed the secretion of pro-inflammatory cytokines (IL-6 and TNF-α)
253
Possible diagnosis of metabolic acidosis
mudpiles (anion gap present)
methanol
uremia
DKA
polyethylene glycol (antifreeze)
INH/Iron overdose
lactic acidosis
Ethanol
Salicylates
Hardass(non angion gap (<10))
Hyperalimentation
Addisons disease (adrenal insufficiency)
renal tubular acidosissi
diarrhea
acetazolamide
spironolactone
saline infusion
254
calculate anion gap
na - (hco3 + cl- )
>12 = Gap
255
On Q pump
Bupivicaine catheter thats inserted in the sub q tissue para spinal and rib cage.
256
pin index safety system
oxygen 2:5
N2O 3:5
Air 1: 5
257
Venturi effect
the reduction in fluid pressure when a fluid flows through a constricted section
258
Disease that results from the temporary or permanent loss of blood supply to the bone
Avascular necrosis
259
Low Vapor pressure agent in a high vapor pressure vaporiser results in....
low output
260
High vapor pressure agent in a low vapor pressure vaporizer results in....
high output
261
Smoking effects
decreased ciliary production
6-8 weeks cessastion = decrease mucous and ciliary production
262
O2, CO2 and N2O changes with inhalation and exhaltion
O2; 21%->19%->13.6%->15%
CO2; 0.04%-> 0.04%-> 5.3% -> 3.6%
N2O; 79%->74% ->75% -> 75%
263
Edinger Westphal Nubleus stimulation is likely to cause.....
miosis
264
What patients can be sensitive to protamine
vasectomy
pulmonary htn pts
allergy to certebrate fish
protamine is used as an antidote for heparin and also as a component in certain insulin preparations, including NPH (neutral Protamine Hagedorn) insulin. patients previously exposed to NPH insulin might have been sensitized to protamine
265
What is porphyrias
group of rare conditions caused by excessive buildup of porphyinogens, which are precursors of heme.
durgs such as barbituates, etomidate, halothane, clonidine, metoclopramide, lidocaine, prilocaine, diclofenace and ranitide have ben implicated in precipatating an acute attack in susceptible individuals
266
Branches of the femoral nerve anesthetized during a ankle block include...
saphenous nerve block (femoral nerve), deep peroneal nerve, posterior tibial nerve, sural nerve and superficial peroneal nerve. (sciatic nerve)
267
Ammonia/ creatine facts
Generated from amino acid metabolism in the liver and is converted to urea (measured as BUN).
creating is end product of creatine phosphate metabolism , that's generated from muscle tissue and excreted through the kidney
because treating production is proptionate to muscle mass, catchetic patients (chronic illness, advanced age, decondiditned patients) may have a normal creatine, despite a markedly reduced GFR.
268
What meds to avoid is LAST
vasopressin, ccb, BB, local anesthetics
269
interpleural analgesia can be accomplised by placing local anesthetic ...
immediately deep to the parietal pleura via catheter between the parietal and visceral pleura . LOR at T6-T8 intercostal space or the surgeon places it via ultrasound. pneumothorax is a significant complication
270
Propofol is a vasodilator due to.....
reduction in sympathetic activity
271
Propofol antiemetic action may be explained by...
decrease in serotonin levels (area postrema)
272
what may cause an increase in bp from stimulation of A2B adrenoreceptors
Dexmedetomidine
273
What does a dibucaine number reflec
reflects inhibition of psudocholinesterase by dibucaine .
Dibucaine a LA inhibits normal pseudocholinesterase. Homoygoups pts with abnormal pseudocholinesterase characteristically have a dibucaine number of about 20%, heterozygous patients have numbers of 40-60% and normal patients usually have a dibucaine number of 80%. The dibucaine number is proportional to pseudocholinesterase function, but is independent of the amount of the enzyme.
274
pin index safety sytem positions
AIR; 1,5 (I=1)
O2; 2,5 (2 molecules = 2)
N2O; 3,5 (3 molecules = 3)
CO2; 2, 6
275
Which has coronary antispasmodic and vasodilatory effects more than systemic arterial vasodilatory effects
nicardipine
276
What are the four types of lipids
triglycerides, phospholipids, steroids and eicosanoids
277
What affects calcium levels
Hyperventilation leads to dec CO2. in alkalosis calcium binds more tightly to proteins in the blood (albumin). This binding leads to a dec concentration of ionized calcium. The biologically active form of ca.
Bicarbonate administration can also cause alkaosis by increasing pH. binding of calcium to albumin increases in alkalotic conditions.
citrates chelates / binds to calcium inions reducing the levels of ionized calcium. most of the time the liver quickly metabolizes citrate and ca levels return to normal. in MTP w/ liver dysfunction, citrate accumulation can cause sig hypocalcemia,
Thiazeide diurectics affect ca by reducing the amount of ca excreted in the urine. This results in increased ca reabsportion in the kidney and higher levels of ca in the blood.
278
contraindications for nerve block
coagulopathy
local anesthetic allergy
lymphadenopathy
skin infection
preexisting neulolgic disease of anatomy
279
Where do the axillary and musculocutaneous nerves leave the brachial plexus
at the level of the coracoid process. part of the scapula that wraps around the anterior side
280
short and medium acting LA
prilocaine, 2 chloloprocaine, lidocaine, or mepivacaine
LA for 3-4 hrs or 1.5-2 hrs for 2 chloroprocaine
281
dose of clonidine for regional
0.5 mcg/kg with intermediate acting LA
282
Complications from regional anesthesia
vasular puncture
hematoma
intravasula injection
LAST
nerve injury
283
phrenic nerve is responsible for how much function of the diaphragm
20-25%
284
what afferents are poorly blocked by opioids
A alpha and A delta afferents
285
what muscles make up the errector spinae
longissimus thoracis
spinalis thoracis
iliocostalis
286
what is the inferior angle of the scapula indicative of what vertebral level
T7
scapula spine= T3
287
Complications of ESP blocks
epidural spread
sympathetic block
LAST
Pneumothorax
288
Femoral triangle
"sail"
sartorius
adductor longus
inuinal ligament
289
Bohr equation
calculates physiologic dead space
vd/vt = (PaCO2 -PeCo2)/ PaCo2
290
Alveolar oxygen concentration equation
FiO2 x (Pb x PH20) - (paco2/RQ)
291
