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Clinical prep > Clinical prep > Flashcards

Clinical prep Flashcards

1
Q

Ventilator vt formula for mask ventilation

A

4-6 ml/kg

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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

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3
Q

VT formula for ventilator

A

6-8 ml/kg of IBW

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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)

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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

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6
Q

APL setting while mask ventilating

A

18-20 cmH20

minimup pressure / open (0cmh20)

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7
Q

Axis aligned while in sniffing position

A

oral axis, pharyngeal axis, laryngeal axis

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8
Q

Volume control

A

constant inspiratory flow until set tidal volume is met

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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

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10
Q

Pressure control

A

decelerating inspiratory flow as the set pressure is being reached.

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11
Q

Pressure support (PSV pro)

A

Pressure support, inspiratory flow is decelerating and in synch with the patients

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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

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13
Q

Assist control

A
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14
Q

Resistive vs elastic pressure

A

resistive pressure = airways
elastic pressure =

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15
Q

IMV

A

not in synch = can cause breath stacking

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16
Q

Volume-guaranteed pressure control

A
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17
Q

SIMV

A

synchronized intermittent mandatory ventilation;

Can be VCV or PCV, or PCV-VG.

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18
Q

CPAP/ PS

A

Primary setting is peep and inspiratory flow is decelerating and in synch with the patient

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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

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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.

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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

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22
Q

How does creatine work

A

is a byproduct of skm and is in constant production. it is proportional to muscle mass

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23
Q

normal GFR

A

125 ml/min

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24
Q

normal bili and what does it indicate

A

0-11
broken down hbg stored in the liver

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25
Q

normal lactate

A
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26
Q

normal ammonia

A

15-40 microns/ dL

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27
Q

normal bicarb

A

22-26

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28
Q

normal osmotic pressure

A

280-290 mosmo

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29
Q

Body weight is what percent water?

A

60%……..60% of 70kg = 42kg = 42 L

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30
Q

Where is body water stored

A

2/3 = intracellular
1/3= extracellular

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31
Q

What is osmotic pressure

A

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.

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32
Q

The difference between gray and white matter

A

white matter - myelin
gray matter = non myelin (uses more energy)

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33
Q

Ratio of glial cells to normal neurons

A

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

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34
Q

Where is cox 1 and Cox 2 found

A

Cox 1=plat and blood products
Cox 2= inducible and cns/pain area, produced constantly in the kidneys

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35
Q

What are the roles of prostaglandins

A

inc blood flow
inc inflammation
relax smm
inc pain sensitivity

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36
Q

normal alk phos

A

30-100

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37
Q

significance of alk phos

A
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38
Q

normal albumin

A

3.5-5

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39
Q

where is albumin synthsized

A

synthesized by hepatocytes

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40
Q

main inhibitor nt in the brain and where on the neuron it has an impact

A

GABA

axon hillock

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41
Q

Brainstem parts

A

midbrain most superior
pons
medulla oblongota

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42
Q

Spinal cord ends at____ and the name of it

A

L1
conus medularis

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43
Q

Purpose of the cerebellum

A

complex movements
sensory information, complicated tasks, muscle to contract and relax.

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44
Q

term for the connection point between the L and R side of the brain

A

Corpus collosum

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45
Q

area of brain for understanding language/ language comprehension

A

werknickes area
between temporal and parietal lobe

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46
Q

word formation/ speaking area of the brain

A

brocas area in the frontal lobe

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47
Q

brachial plexus

A
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48
Q

cervical plexus

A
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49
Q

Lumbar plexus

A
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50
Q

Sacral plexus

A
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51
Q

names for C1 and C2

A

C1= atlas
c2= axis

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52
Q

ligaments of the spine

A

supraspinous ligament
interspinous ligament
ligmenta flavum
epidural space
dura mater
subdural space
arachnoid mater
subarachnoid space
pia mater

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53
Q

what is the ligamenta flava made of?

A

elastic, ligaments are usually made of collagen

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54
Q

arching the back for a spinal/ epidural changes what?

A

gives better visual/ opening of the interlaminar foramen

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55
Q

where does the dural sac end

A

S2

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56
Q

Why do we sweat

A

from increased cellular energy / atp use increases the work of sodium pumps in our sweat glands that pump salt and water follows

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57
Q

nerves that control the diaphragm

A

C345= phrenic nerves

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58
Q

Cardiac accelerators

A

T1-4

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59
Q

CSF produced by and how much per day, how much do we have at any one time, and when is it produced

A

ependymal cells produce
450 ml/day
150 ml at any one time
swapped out 3 times/day
produced more when sleeping/uncouscious (anesthesia)

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60
Q

normal ICP

A

5-10 cmh20

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61
Q

What medications do not knock out the electrophysiologic activity of the brain?

A

nitrous and ketamine

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62
Q

what perfuses the front and what perfuses the back of the brain and cerebellum

A

front= carotid arteries
back = vertebral arteries

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63
Q

What organs have no pain receptors

A

inside of the Brain, lung, liver

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64
Q

Where is the Great radicular artery found

A

T9-T12

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65
Q

3 branches that come off the aortic arch

A

brachiocephalic
L common carotid
L subclavian

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66
Q

Valvular disease contraindications for spinal

A

AS < 1 cm2 or MS < 1 cms

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67
Q

superior illiac crest line and significance

A

Tuffiers line = intercristal line

Space of L3-L4

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68
Q

Nerve blockade for spinals/epidurals

A
  1. B fibers - sympathectomy
  2. C & A delta- pain / temp
  3. A gamma- muscle tone
  4. A beta- touch / pressure
  5. A alpha- motor
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69
Q

Bainbridge reflex

A

nodal tissue stretch-> decrease vagal tone firing -> increase HR

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70
Q

Bezold-Jarish reflex

A

Sympathetic stimulation -> serotonin to chemo R in the LV -> inc para symp and dec symp -> hypotension/bradycardia

zofran inhibits

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71
Q

treatment for “LAST”

A

local anesthetic systemic toxicity (LA in vasculature)

SZ? = give benzo

tx; interlipids 20% 1.5ml/kg(bolus)
gtt; 0.25ml/kg

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72
Q

most common drug allergy in anesthesia

A

Roc

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73
Q

What causes allergy in LA

A

Esters; because of PABA

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74
Q

horners syndrome

A

ptosis, miosis, anyhydrosis

high sympathetic spread of LA

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75
Q

Nerves to block for awake intubation

A

Glossopharyngeal nerve - CN9- (suck on cotton swab)
Vagus nerve- cough to spread to trachea
trigeminal nerve (V2) - CN5 (cotton swab in nose)

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76
Q

Epidural test dose

A

3 ml of 1.5% lidocaine w/ 1:200000 epi

lid = 45mg
epi= 15 mcg

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77
Q

Normal distance to epidural space

A

4-6 cm

epidural cath should be 3-5 cm within epdiural space

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78
Q

Normal PR interval

A

0.12-.2

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79
Q

EKG paper numbers

A

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

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80
Q

1st degree HB

A

Pr longer than 0.2

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81
Q

Normal QRS

A

<0.12 seconds

longer or RSR = BBB

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82
Q

PSVT

A

supravent tachycardia that start then stops

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83
Q

Pt having pvc/ pacs what should you think is happening?

A

electrolyte abnormality; mag or K being the cause

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84
Q

2nd degree type 1

A

longer longer longer drop = wenchebac

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85
Q

2nd degree type 2

A

fixed p then random drops

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86
Q

Side affect of sevo in infants

A

bradycardia

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87
Q

Meds that cause prolonged qt interval

A

amio
Zofran
properidol

increase QT = increased risk for early afterdepolarization-> torades

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88
Q

12 lead EKG placement and number of electrodes

A

12 Lead ECG’s use 10 Electrodes
one electrode on each limb
6 electrodes on the left chest

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89
Q

Limb leads

A

LA Left ARM
RA Right ARM
LL Left LEG
RL Right LEG

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90
Q

Precordial leads placement

A

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

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91
Q

How determine the hearts axis

A

direction of QRS of leads 1, 2and 3

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92
Q

Bundle branch block determination

A

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

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93
Q

Ischemia is seen on EKG as what?

A

symmetrical inverted T waves in 2 or more related leads

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94
Q

infarct on EKG is seen as

A

Reciprocal changes to other ST elevation

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95
Q

What makes a pathologic q wave

A

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.

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96
Q

EKG Lead memorization

A

LxS A
I L S L
I I A L

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97
Q

Normal CO

A

4-6.5 L/min

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98
Q

Normal SV

A

60-90 ml

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99
Q

Normal SVR

A

800-1600 dynes/sec/cm5

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100
Q

Normal PVR

A

40-180 dynes/sec/cm5

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101
Q

Normal Mixed venous O2 sat

A

70-80

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102
Q

Umbilicus dermatome

A

T10

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103
Q

nipple dermatome

A

T4

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104
Q

Even with epi, whats the longest a spinal will last?

A

150 min

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105
Q

MOA and SE for stygmines

A

inhibit ACHE -> increased ACH in the NMJ = outcompete NMBD.

Side effect = bradycardia and bronchoconstriction / increased salvation. (consider ach on heart and airways)

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106
Q

Predicted Postoperative FEV1 post lobectomy

A

ppoFEV1 = Preop FEV1 % x (1-% lung tissue removed/100)

segments; total of 42
RUL; 6
RML: 4
RLL; 12
LUL; 10
LLL; 10

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107
Q

Why is there a Q wave

A

part of the L vent depol before the right vent

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108
Q

If the heart is ischemic does the area stay depol or repol

A

depol (negativeoutside the cells, positive inside the cells) cant reset/ repol.

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109
Q

EKG machine paper print rate

A

25mm/second

speed up to see more detail

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110
Q

TOTAL lung capacity and each volume

A

TLC = 6L

RV= 1200
ERV= 1200 ml
vt= 500 ml
IRV; 3,100

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111
Q

What is dromotropy

A

conduction speed of the heart. beta agonsits increase conduction speed by making L type ca channels more sensitive/ open for longer.

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112
Q

What is lusitropy

A

resetting the heart faster-> makes way for another ap in shorter period of time = beta agonists because they speed up the serca pump

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113
Q

Aorta cross sectional area

A

2.5 cm2

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114
Q

Vena cavae cross sectional area

A

8cm2 (4cm2 each)

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115
Q

Map formula

A

(1 SBP + 2DBP)/3

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116
Q

Pressure the aortic valve closes at

A

100 mmg

117
Q

Normal Pulmonary Artery pressure

A

25/8mmhg

118
Q

Normal wedge pressure

A

8mmhg

119
Q

Normal Hematocrit

A

0.4

Hematocrit is the percentage by volume of red cells in your blood

120
Q

Stages of General anesthesia

A

Stage 1: Analgesia

Stage 2: Delirium

Stage 3: Surgical Anesthesia

Stage 4: Medullary Paralysis

121
Q

Components of General Anesthesia (Stage 3)

A

Hypnosis- sleep state
Analgesia- pain free
Muscle Relaxation- safe
Sympatholysis- HD stability
Amnesia- don’t remember

122
Q

Stage 2 characteristics of excitement

A

undesired CV instability excitation, dysconjugate ocular movements, laryngospasm, and emesis.

Response to stimulation is exagerrated and violent.

123
Q

What is medullary paralysis

A

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
Q

how many cm in 1 inch

A

2.54

125
Q

What does GABA stand for and what is it

A

Gamma-aminobutyric acid (GABA) is the main inhibitory neurotransmitter in the brain

126
Q

Compliance formula

A

Delta V / Delta P

Beginning - End

127
Q

Velocity formula

A

force/ area

128
Q

flow formula

A

Flow = delta P / Resistance

129
Q

Where are baroreceptors located

A

carotid sinus/ bifurcation-> herrings nerve -> glossopharyngeal nerve -> NTS (medulla)

aortic arch -> Vagus nerve -> NTS (medulla)
stretch sensors

130
Q

Components of General Anesthesia

A

Hypnosis
Analgesia
Muscle Relaxation
Sympatholysis
Amnesia

131
Q

CPP formula

A

cerebral perfusion presusre = MAP - ICP

132
Q

Boyles Law

A

given a constant remperature

pressure and volume of gas are inversly proportional

133
Q

Effects of tachypnea on reaching necessary PI of volatile

A

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
Q

Henry’s Law

A

the amount of dissolved gas in a liquid is proportional to its partial pressure above the liquid

135
Q

Spinal dose based on height

A

1 ml + 0.1ml/inch over 5 ft

136
Q

What do the cvp wave forms symbolise

A

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
Q

Normal venous return

A

5 L/ min, same as CO

138
Q

Steps to set up room

A

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
Q

Normal pipeline pressures

A

45-55 PSI

140
Q

items needed for needle cricothyoidomy

A

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
Q

contraindications for art line placement

A

raynauds
advanced atherosclerosis
coagulopathy
thromboangiitis obliterans (Buerger disease)

142
Q

IJ central line landmarks

A

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
Q

CL placement depths

A

RIJ - 16 cm
LIJ = 19cm
LsubC=18cm
R SubC= 15cm

144
Q

respiratory alkalosis may result in what electrolyte abnormality?

A

hypocalcemia
inhibits ionized ca by increasing ca to albumin binding

145
Q

what nerve supplies sensation below the vocal cords

A

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
Q

The most significant cuase of heat loss in anesthesia pts

A

radiation

147
Q

vitamin K is required by the liver for production of what factors?

A

2,7,9,10 and procein c and s

148
Q

Light emitting diodes (LEDS) in the pulse ox sensor emit red and near infrared light at what rate?

A

660-940nm

149
Q

WHich inhaled anesthetic is metabolized the most?

A

sevo

150
Q

what is the only muscle capable of widening the rima glottis

A

posterior cricoarytenoid muscle

151
Q

what is the cushing reflex

A

responsible for acute ICP increase

triad = wide PP, bradycardia and irregular respirations

152
Q

what is the five and dime reflex

A

oculocardiac reflex

sensory = trigeminal nerve/ cn5
motor = vagus nerve / cn10

153
Q

Emergency physical examination

A

A = Allergies
M = Medications
P = Past medical history
L = Last meal eaten
E – Events leading up to need for surgery/procedure

154
Q

What abx need to be given 2 hrs prior to sx for prophylaxis

A

vanc and fluoroquinolone

155
Q

CPR H’s+ T’s

A

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
Q

Where are the vocal cords?

A

attached to the arytenoid cartilage and the thyroid cartilage at the thyroid notch

157
Q

Hypoxia during case, things to consider

A

Check etco2
hand ventilate; compliant?
right main stem
secretions
pneumo?
PE / air embolism
anaphylaxis
aspiration
MI/ cardiac failure
bronchospasm

158
Q

How to perform needle decompression for tension pneumothorax

A

14 to 16 gauge needle 2nd intercostal space at midclavicular line

159
Q

Anaphylaxis treatment

A

fluids
epi
bronchodilator
100% o2
H1 and H2 antagonists (benedryl/ ranitidine)
Corticosteroid (methylprednisolone 125mg)

160
Q

What heart valve only has two cusps

A

mitral/ bicuspid valve

161
Q

Why are the coronaries perfused during diastole

A

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
Q

Quick SVR formula

A

(map-cvp)/CO x 80

163
Q

What is a major concern in sitting position

A

venous air embolism

becuase of decreased venous pressure at surgical site due to gravitational effects

164
Q

effects of low Ca+

A

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
Q

micrognathia

A

receding mandible

166
Q

Bronchospasm wave form/ signs/ treatment

A

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
Q

Delayed emergence; things to check

A

Double check meds given/ everything is off
check twitches
hypoxia, hypercarbia, hypothermia
neuro exam
hypoglycemia
abg w/ lytes
consider dosing error

168
Q

Unanticipated difficult airway considerations

A

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
Q

Airway fire considerations

A

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
Q

Each unit of PRBC raises hbg_____

A

1 g/dl

171
Q

Each apheresis unit raises platelets _______

A

50, 000 per micoliter

172
Q

FFP dose

A

1–15 ml ffp per kg of body wt. (for massive transfusion)

173
Q

each _____ units of cryprecipitate raises fibrinogen ______

A
  1. 50 mg/dl
174
Q

things to rule out with severe hypotension

A

hemorrhage
Auto peep
vasodilators (volatile, anesthetics, gtts)
Embolism

pneumothorax
IVC COMP
cardiac event (TEE to assess)
anaphylaxis
pneumoperitoneium

175
Q

Early signs of MH

A

increased ETO2
tachycardia
tachypnea
mixed acidosis
masset spasm
sudden cardiac arrest

176
Q

Normal pulmonary compliance

A

40-70 mL/cmh2o

177
Q

Normal compliance in children

A

1mL/cmh20/ kg

178
Q

What to set I;E ratio in COPD pt and why

A

> 1:2, ie 1:3, 1: 4 = prevents breath stacking

179
Q

What forms of calcium should be given centrally and what forms should be given peripherally

A

calcium chloride= centrally
calcium gluconate = peripherally

180
Q

What is the relationship between calcium and albumin

A

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
Q

Acidemia and calcium and albumin relationship

A

H+ ions can displace the calcium from albumin resulting in increased free// ionized calcium levels.

182
Q

How much does decadron increase blood sugar by?

A

The maximum rise in blood glucose was in the range of 40–45 mg/dl in the patients who received dexamethasone

183
Q

How does stress dose steroids affect blood pressure

A

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
Q

Indocyanine Green

A

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
Q

Treatment of auto-peep

A

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
Q

Type and cross vs type and screen

A

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
Q

Auto Peep wave form

A

if the expiratory line on the flow curve doesnt go back to the baseline before inhalation

188
Q

auto peep test

A

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
Q

What is auto peep

A

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
Q

What are the concerns with auto peep

A

decreased venous return because of persistent increased intrathoracic pressure

flattening of diaphragm = increased work of breathing and inability to trigger the vent

191
Q

Treatment of auto-peep

A

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
Q

Treatment for hyperkalemia

A

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
Q

Possible complications from interscalene nerve block

A

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
Q

Who are nasal airways contraindicated in

A

coagulation or plat abnormalities and those with basilar skull fractures

195
Q

What pathway is involved in the transmission of pain

A

lateral spinothalamic

x at sc

196
Q

What pathway is involved in the transmission of motor

A

pyramidal/ corticospinal tract

x at pyramidal decussation

197
Q

What pathway is involved in the transmission of sensory of fine touch and two point discrimination

A

DCML
Dorsal column medial lemniscus

x at medulla

198
Q

What electrolyte abnormality is acute pancreatitis likely to cause

A

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
Q

what is the normal apneic threshold for paco2

A

max Paco2 that does not initiate spont breathing is only 3-5 mmhg lower than the paco2 present during spont breathing

200
Q

the nucleus is made up of how many chromosomes

A

46

201
Q

hypocalcemia has what affect on na+ channels

A

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
Q

effects of acidosis and alkalosis on neuron excitability

A

acidosis - depresses neuon excitabilty
alkalosis - enhances neuron ecitatilbiyt

203
Q

Relationship between liver disease and lung disease

A

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
Q

Anatomical dead space formula

A

1ml/pound
2ml/kg

205
Q

Right shift oxy-Hbg curve causes and meaning

A

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
Q

What is 2,3 DPG

A

byproduct of cellular metabolism

207
Q

Relationship of blood products and 2,3 DPG

A

Blood products have decreased 2,3 DPG = increased oxygen affinity for hbg = decreased oxygen unloading.

208
Q

Left shift oxy-Hbg curve causes and meaning

A

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
Q

What prostaglandin is named prostacyclin

A

PGI2

210
Q

What is the primary function of mature lymphocytes?

A

synthesis of antibodies

211
Q

What medications cover MRSA infection and what doesnt

A

Lenzolid doesnt cover MRSA

Cefazolin, clindamycin and vancomycin cover MRSA

212
Q

What antibiotics can cause tendonitis and arthropathy and is effective against gram- negative and pseudomonas

A

ciproflaxacin

213
Q

What Antagonizes the most prominent excitatory amino acid in the body

A

Ketamine. (glutamate = most prominent)

214
Q

What drug can lead to inhibition of oxidative phosphorylation with high dose prolonged infusion

A

Propofol

215
Q

What nerve is the eyeash reflex

A

Afferent lime is mediated by the trigeminal nerve and the efferent lim is via the facial nerve

216
Q

When is stress dose steroids with prednisone use NOT indicated

A

< 3 weeks of steroids at any dose
prednisone <5mg/day for any duration
Prednisone < 10 mg every other day

217
Q

What law allows the measurement of flow rates via flow meter

A

Poiseuilles Law
laminar flow of viscous fluid thorugh pipes or tubes

218
Q

Side effects of hydralazine

A

tachycardia, sale and water retention , lupus-like syndrome

219
Q

How much does succ increase IOP

A

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
Q

Halflife of heparin

A

90 min

221
Q

Changes to IE ratio with Obesity

A

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
Q

normal Vd/Vt ratio for spont ventilation and mechanical vent

A

spont V = 33%
Mechanical vent = 50%

223
Q

Oxygen consumption equation

A

( 125 ml/min) x BSA

3.5ml/kg/min

VO2 = CO x (CaO2-CvO2) x 10

224
Q

BSA formula

A

The square root of (Height(cm) x wt (kg) / 3600

225
Q

What makes a good research article

A

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
Q

What changes in anesthesia with marijuana use

A

decreased Bp increased HR increase Airway reaction. change to mac (increase or decrease) delayed wakeup?
post op anxiety?

227
Q

A-a gradient formula

A

( Age + 10 )/ 4

228
Q

Sensory only cranial nerves

A

1- olfactor
2- opotic
8- vesibulocochlear

229
Q

Motor primarily cranial nerves

A

3- oculomotor
4- trochlear
6- abducent
11- accessory
12- hypoglossal

230
Q

What nerves cause the eyelash reflex

A

afferent trigeminal nerve and efferent facial nerve

231
Q

What nerves are responsible for the motor of the eye

A

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
Q

Gag reflex nerves

A

afferent = glossopharyngeal
efferent= vagus nerve

233
Q

how long is the delay on the etco2

A

20 seconds

234
Q

What does nims tube stand for and how does it work

A

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
Q

Alveolar oxygen formula

A

Used to compare blood case to alveolar gas to see if ventilating well.

PAO2 = ((PB-PH20) x FiO2) - (PaCO2 / R)

236
Q

Respiratory quotient

A
237
Q

What is the normal A-a gradient

A

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
Q

Normal Vital Capacity (weight based )

A

65-75 ml/kg

239
Q

Normal FRC weight based

A

35 ml/kg

240
Q

Closing capacity it what?

A

RV + CV

closing volume = The volume above RV where small airways begin to close

241
Q

Age based normal CV

A

30% of TLC at age 30
55% of TLC at age 70

242
Q

Factors that increase closing volume

A

(CLOSE-p)
COPD
Left vent failure
Obesity
Surgery
Extemes of age
Pregnancy

243
Q

Side effect of succinylcholine in Peds

A

Bradycardia

244
Q

LMA Maximium amount of time

A

2 hours

245
Q

S/s of serotonin syndrome

A

SHIVERS
shivering
hyperreflexia
myoclonus
increased temp
vital sign abnormalities
encephalopathy
Restlessness
sweating

246
Q

Causes of sweating during surgery

A

pain
low bg
MI
serotonin syndrome

247
Q

Normal VBG

A

pH 7.36
PCO2= 45 mmhg
PO2 = 40 mmg
SaO2 = 70-80%

248
Q

Causes of increased CO2 production

A

sepsis
MH
overfeeding
shivering
seizure
thyroid storm
Burns

249
Q

Consequences of High CO2

A

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
Q

MAC of CO2

A

200 mmhg

CO2 is a respiratory depressant between 80-100 mmhg

251
Q

Why are nsaids contraindicated in asthmatics

A

decreaesd cyclooxygenase -> increase lipoxygenase -> bronchospasms

252
Q

how does dexamethasone decrease wound healing

A

Dexamethasone suppressed the secretion of pro-inflammatory cytokines (IL-6 and TNF-α)

253
Q

Possible diagnosis of metabolic acidosis

A

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
Q

calculate anion gap

A

na - (hco3 + cl- )

> 12 = Gap

255
Q

On Q pump

A

Bupivicaine catheter thats inserted in the sub q tissue para spinal and rib cage.

256
Q

pin index safety system

A

oxygen 2:5
N2O 3:5
Air 1: 5

257
Q

Venturi effect

A

the reduction in fluid pressure when a fluid flows through a constricted section

258
Q

Disease that results from the temporary or permanent loss of blood supply to the bone

A

Avascular necrosis

259
Q

Low Vapor pressure agent in a high vapor pressure vaporiser results in….

A

low output

260
Q

High vapor pressure agent in a low vapor pressure vaporizer results in….

A

high output

261
Q

Smoking effects

A

decreased ciliary production

6-8 weeks cessastion = decrease mucous and ciliary production

262
Q

O2, CO2 and N2O changes with inhalation and exhaltion

A

O2; 21%->19%->13.6%->15%

CO2; 0.04%-> 0.04%-> 5.3% -> 3.6%

N2O; 79%->74% ->75% -> 75%

263
Q

Edinger Westphal Nubleus stimulation is likely to cause…..

A

miosis

264
Q

What patients can be sensitive to protamine

A

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
Q

What is porphyrias

A

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
Q

Branches of the femoral nerve anesthetized during a ankle block include…

A

saphenous nerve block (femoral nerve), deep peroneal nerve, posterior tibial nerve, sural nerve and superficial peroneal nerve. (sciatic nerve)

267
Q

Ammonia/ creatine facts

A

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
Q

What meds to avoid is LAST

A

vasopressin, ccb, BB, local anesthetics

269
Q

interpleural analgesia can be accomplised by placing local anesthetic …

A

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
Q

Propofol is a vasodilator due to…..

A

reduction in sympathetic activity

271
Q

Propofol antiemetic action may be explained by…

A

decrease in serotonin levels (area postrema)

272
Q

what may cause an increase in bp from stimulation of A2B adrenoreceptors

A

Dexmedetomidine

273
Q

What does a dibucaine number reflec

A

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
Q

pin index safety sytem positions

A

AIR; 1,5 (I=1)
O2; 2,5 (2 molecules = 2)
N2O; 3,5 (3 molecules = 3)
CO2; 2, 6

275
Q

Which has coronary antispasmodic and vasodilatory effects more than systemic arterial vasodilatory effects

A

nicardipine

276
Q

What are the four types of lipids

A

triglycerides, phospholipids, steroids and eicosanoids

277
Q

What affects calcium levels

A

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
Q

contraindications for nerve block

A

coagulopathy
local anesthetic allergy
lymphadenopathy
skin infection
preexisting neulolgic disease of anatomy

279
Q

Where do the axillary and musculocutaneous nerves leave the brachial plexus

A

at the level of the coracoid process. part of the scapula that wraps around the anterior side

280
Q

short and medium acting LA

A

prilocaine, 2 chloloprocaine, lidocaine, or mepivacaine

LA for 3-4 hrs or 1.5-2 hrs for 2 chloroprocaine

281
Q

dose of clonidine for regional

A

0.5 mcg/kg with intermediate acting LA

282
Q

Complications from regional anesthesia

A

vasular puncture
hematoma
intravasula injection
LAST
nerve injury

283
Q

phrenic nerve is responsible for how much function of the diaphragm

A

20-25%

284
Q

what afferents are poorly blocked by opioids

A

A alpha and A delta afferents

285
Q

what muscles make up the errector spinae

A

longissimus thoracis
spinalis thoracis
iliocostalis

286
Q

what is the inferior angle of the scapula indicative of what vertebral level

A

T7

scapula spine= T3

287
Q

Complications of ESP blocks

A

epidural spread
sympathetic block
LAST
Pneumothorax

288
Q

Femoral triangle

A

“sail”
sartorius
adductor longus
inuinal ligament

Clinical prep (21 decks)

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