Concepts Cold Flashcards
What is your differential for tachycardia and how will you evaluate it in the OR.
Differential is:
Hypoxia, hypercapnea, arrythmia, pain, anemia, hypovolemia, tamponade, PTX, inotrope running wide open (medications), visceral distention, malignant hyperthermia, sepsis, thyrotoxicosis, pheo, carcinoid.
I would evaluate by checking my other vital signs, doing a visual sweep from ventilator to monitor
EKG
Pulse oximetry
ETCO2
BP
Peak pressures
Listen to the patient and check tube position, suction
Talk to the surgeon about blood loss or traction
Review meds being given and just given: treat pain, vasopressors as needed. Fluids, beta blockers
If these interventions did not improve the patient’s condition,
I would send an ABG
Order a chest X-ray
Consider a TEE to assess for ventricular filling and function, wall motion abnormalities
What is the differential for bradycardia?
Primary: Sick sinus or complete heart lock secondary: Ischemia Drug-induced Vagal stimulation
What is the differential for HTN?
Pre-E Kidney disease Increased ICP Autonomic hyperreflexia Pheo Carcinoid
Pain
Hypoxia
Hypercapnea
Light anesthesia
What is the differential for hypotension?
Preload - hypovolemia, or decreased venous return from PEEP, tamponade, PTX
Afterload - sepsis, neurogenic shock, anaphylaxis!
Contractility - ischemia, volatile, sepsis, cardiomyopathy
Blood components: anemia, carbon monoxide, Methb
Heart - rate, rhythm, valves
(H’s and T’s)
Your patient is hypotensive in the OR, how will you evaluate?
Check for a pulse and recycle BP cuff.
I would do a visual sweep from the ventilator to the monitor checking for vital signs and ventilatory settings and pressures that would help me narrow down the problem and treat accordingly. Specifically, the EKG for rate and rhythm, ETCO2, pulse oximetry (which would also alert me that the monitors were functioning correctly)
I would alert the surgeon and ask about blood loss while assessing suction canisters.
I would open my fluid lines and treat with vasopressors as necessary while evaluating
I would switch to hand ventilation and listen to the patient for muffled heart sounds that would alert me to tamponade, unilateral breath sounds for PTX or endobronchial intubation, or mucus plug, wheezing for bronchospasms.
I would look at the color of the patient to assess oxygenation and drainage of the face and neck.
I would check my access and establish more if needed. Call for help
I would send for blood, make sure I had a type and cross and if I didn’t - I would get one.
I would consider ABG and labs to further evaluation.
I would consider a TEG for ongoing bleeding despite balanced resuscitation.
Your patient’s oximeter drops, what do you think of this? What do you do?
I would assess all other vital signs on the monitor and ventilatory settings checking to make sure i am delivering the right gas mixture and that it is reaching the patient.
I would switch the patient to 100% FiO2 and begin hand ventilation to get a feel for pulmonary compliance as I check the position and patency of the tube assessing for malposition like endobronchial intubation or extubation and kinking or substances within the tube such as mucus or blood. I would auscultate the chest listening for muffled heart sounds, murmurs, wheezing, unilateral breath sounds, movement of air.
If these measures did not improve the patient’s hypoxemia, I would consider a chest X-ray and ABG for further evaluation.
What is the differential for hypoxemia?
From wall to ET tube:
Wrong gas composition
No gas delivery - Disconnect, kink, power failure, valve incompetency
From ETT to lungs: Kink Clog Aspiration Disconnect Endobronchial, esophageal or subq intubation Extubation
Lung itself: Intraparenchymal bleed PTX effusion ARDS, PNA Atelectasis CHF PE Right to left shunt
What is the differential for hypercapnea?
Hypoventilation
Exhausted CO2 absorber
Incompetent valve
Low flows
Malignant hyperthermia
Sepsis
Thyrotoxicosis
What TEE views would you use to assess a trauma patient?
Mid-esophageal 5 chamber view to assess filling of both sides of the heart, pericardial stripe, LVOT, clot in LA and wall motion abnormalities
Mid-e 4 chamber for wall motion abnormalities and filling
Transgastric short axis view for overall volume status and can calculate fractional area of change (preload dependent and measurement of RV/LV fxn)
Mid-E ascending aorta short axis to assess for pulmonary embolism, proximal ascending aorta (can calculate VTi)
What are you assessing on an ABG?
Acid/base status
Lactate (greater than 2 would alert me to inadequate delivery of oxygen to tissue versus impaired utilization of oxygen leading to anaerobic metabolism, hepatic insufficiency)
Base deficit (the amount of acid or base that must be added for blood ph to return to 7.4 and PaCO2 to return to 40 at full oxygen saturation at 37 C) It represents the noncarbonic buffering in the blood and thus the metabolic component of an acid/base disturbance.
Hypoxemia
Electrolyte status
Strong ion difference - alerts to the fact there are other unmeasured ions if present. Normal is 35
What are the diagnostic criteria for preeclampsia?
Two readings of BP > 140/90 (taken 4 hours apart)
> 20 weeks gestation
Proteinuria of greater than 300 or increase in urine protein/CR ratio of 0.3
What is the definition of severe pre-eclampsia?
SBP >160/110 Evidence of end organ damage: Creatinine > 1.1 or doubling Headache Vision changes Pulmonary edema Liver dysfunction RUQ pain TCP
What if you got assess a patient and they’re obtunded and have bitten their tongue? What would you do?
- Quickly assess their vital signs: oxygen saturation, EKG tracing
- Ensure adequate oxygenation and IV access
- Perform a quick exam focusing on Neuro status, cardiopulmonary function
- If I felt their mental status was significantly impaired, I would secure the airway as soon as possible to reduce risk of aspiration and inadequate ventilation/oxygenation that could lead to increasing ICP.
What would you do if the fetal heart rate went down in a pregnant patient?
Ensure and provide adequate oxygenation and blood pressure
Place in LUD
Proceed with c-section
What would you do for PEA arrest?
Start CPR and call for help
Apply monitors - ensure no shockable rhythm
Secure airway and apply oxygen
Establish IV access
Epinephrine 1 mg IV push every 3-5 minutes
Get labs
Consider TEE to evaluate for H’s and T’s
What are the H’s and T’s?
Hypovolemia Hypoxia Acidosis Hyperkalemic Hypothermia
Toxins
Thrombosis (MI, stroke, PE)
PTX
Tamponade
When do you initiate therapeutic hypothermia?
When patient is a comatose after out of hospital Vfib or PEA cardiac arrest or in-hospital arrest by using cooling blankets, ice packs or infusion of ice cold fluids to bring temperature to 32-34 C for 12-24 hours. Watch with esophageal temp or PAC
What things do you need for an anterior mediastinal mass case?
Fiber optic scope
Armored ETT
Surgeon + rigid bronchoscope + sternal saw
CPB bypass machine, femoral cutdown under local
Ketamine, dexmedetomidine, volatile
Shortly after induction, prior to placement of ETT, airway movement ceases and you are unable to ventilate. What would you do?
Recognizing that this could be secondary to bronchospasm, laryngospasm, aspiration, or mass compression, I would
Place oral airway and attempt to two-hand mask with 100% FiO2. Applying positive pressure and call for help.
Auscultate the chest And trachea, treat accordingly
Attempt intubation with a video laryngoscopy, intubating Bougie
Treat laryngospasm
Place ETT over bronchoscope versus rigid bronchoscope (if a mass)
Consider placing patient prone to relieve mass obstruction
What are the reasons for placing an arterial line?
Beat to beat BP monitoring for intraoperative optimization of a patient who is at risk for developing life threatening anemia or blood pressure lability
Hemodynamic instability
What would you do if you lost access on a patient who is actively bleeding out?
Apply oxygen and monitors Attempt central line and/or IO Call for help, call for surgeon to do cutdown Prepare emergency drugs Call for blood and infused
What are the signs and symptoms of malignant hyperthermia?
Rigidity Hyperthermia Peripheral mottling Mixed respiratory and metabolic acidosis Cyanosis Rhabdo Hyperkalemic Myoglobin uria Sweating
What’s the differential for delayed emergence?
Medications: opioids, volatile, NMB, pseudo cholinesterase deficiency
Hypothermia
Hypoglycemia
Electrolyte abnormalities
Hypoxia/hypercarbia/hypocarbia
Medication error
Liver or kidney disease : decreased metabolism/excretion of drugs, ammonia, uremia
How would you evaluate for delayed emergence?
Ensure adequate oxygenation/ventilation and hemodynamics with vital signs and monitors
Use nerve stimulation to assess for residual blockade
Look at pupils and ventilation to assess for opioid. OD versus intracranial pathology
Get ABG to check glucose and electrolyte status
Consider reversal agents: naloxone, flumazenil, physostigmine
Consider CT scan
What is your differential for dyspnea in the PACU?
Pulmonary edema Airway edema, hematoma formation Inadequate reversal Narcosis Atelectasis BRONCHOSPASM MI, CHF PTX
Patient gets masseter rigidity before placement of the tube, what do you do?
Call for help Place nasal airway and attempt to mask Call surgeon for possible invasive airway and then Try to intubate nasally Cancel case Prepare for rhabdo Admit the patient for 12-24 hours Place arterial line Monitor ETCO2, CK, temperature, acid-base status and electrolytes Monitor urine for myoglobin Monitor for rigidity Recommend MH testing
If a patient has severe masseter rigidity on induction, what should you do?
Cancel the case and treat for MH
What are the potential causes for sudden drop in blood pressure?
Massive hemorrhage Embolism MI Anaphylaxis Arrythmia Too much anesthesia
What would you do in the setting of sudden drop in BP?
Deliver 100% FiO2 Check other vital signs, EKG Verify proper position of the tube Auscultate the chest Communicate with the surgeon Administer fluids and vasopressors as indicated Consider Precordial Doppler Consider CXR and ABG
What do you do if you suspect a VAE?
Flood the field with saline
Put surgery sit below the heart
100% FiO2
Pull back in CVC
Consider occluding jugular veins
Provide fluid, vasopressors, chest compressions as necessary
Consider left lateral decubitus to move air into RA if possible and safe
How would you treat thyrotoxicosis?
- Give beta blocker for tachycardia and HTN
Give hydrocortisone to reduce thyroid hormone secretion
Give PTU and iopanic acid
Give APAP for fever and cool the patient
Hydrate
Consider reserpine or guanethidine to deplete catecholamines
What is the definition of conscious sedation according to the ASA?
Drug-induced depression of consciousness during with patients respond purposefully to verbal commands (alone or by light tactile stimulation)
No interventions are required to maintain airway and spontaneous ventilation is adequate
Who can administer conscious sedation besides an anesthesiologist?
Physicians, dentists, podiatrists who have education, training and licensure
RN or PA under the supervision of non-anesthesiologist, with training in the area
What equipment would you have in the area for conscious sedation?
2 oxygen sources ASA standard monitors Airway equipment Emergency medications Crash cart Battery powered flashlight CPR trained personnel
How would you resuscitate a neonate with Apgar score less than 3?
Assess tone, ventilation, color
Warm, dry and stimulate the baby
Provide supplemental oxygen (pulse ox on right UE)
If HR < 100, provide PPV
Consider ECG
If HR < 60, start compressions and intubate
Get venous access thru umbilical vein or IO
Check for hypoglycemia, narcosis, magnesium toxicity
For Mg toxicity - give 100mg/kg of Ca gluconate (associated with cerebral calcification! Only give for Mg toxicity!
For hypoglycemia - give 8 mg/kg/min of 10% solution
While resuscitating a newborn of less than 35 weeks GA, what FiO2 do you start with ?
21-30%
If a newborn has labored breathing or is unable to maintain target saturation with 100% FiO2, what should you do next?
CPAP
When should epinephrine be administered with resuscitating a newborn?
After 30 seconds of effective ventilation + 60 seconds of ventilation with 100% FiO2 with chest compressions
When would you place a pulse oximeter on a baby during resuscitation?
Persistent cyanosis
Need for CPAP or O2
How would you guide your fluid resuscitation?
ABG to look at Hct and Base excess (<2) Titrate to UOP between 0.5-1 mg/kg/HR MAP > 65 HR Titrate to mixed venous oxygen tension of 35-45
What is the differential for hypotension after induction?
Anesthetic induced hypotension or cardiac depression
Anaphylaxis
Vagal response to tracheal stimulation
What’s the differential for syncope?
Vasovagal Hypoglycemia Seizure Autonomic neuropathy Medications Aortic stenosis Cardiac arrythmia or ischemia Vertigo HOCM TIA/CVA
What is your differential for PONV?
Hypotension
Hypoglycemia
Hypoxia
Pain
How would you treat anaphylaxis?
Call for help Discontinue all drugs Apply 100% oxygen,Secure airway Start infusing fluid Give epinephrine (double every 1-2 minutes Titrate to BP, steroids, H2 blocker, B2
Refractory: vasopressin infusion, TEE
How would your extubate a morbid obese patient with an eye injury?
Empty the stomach with OG tube Suction the pharynx Ensure full reversal Administer 100% oxygen Sit the head up/ reverse Trendelenburg Administer IV lidocaine during emergence Let patient regain consciousness
If you believed a patient had MH, what would you do?
Call for help
Administer 2.5 mg/kg of dantolene, repeat every 5-10 minutes up to 10mg/kg. Repeat every 6 hours for 24-48 hours after
100% FiO2 and hyperventilate
Cool the patient (ice packs over major arteries, cooled IVF/gastric and bladder lavage
Give IVF, mannitol, lasix to maintain urine output
Treat hyperkalemia
Acidosis
Monitor LFTs, ABGs, CK and coags
What is the differential for hypotension in a trauma patient?
Hemorrhagic shock due to unrecognized vascular trauma
Neurogenic shock due to cervical spine injury
PTX due to trauma or line placement
Cardiac tamponade
Anaphylaxis
Fat embolism due to unrecognized long bone fracture
What are options for cooling a patient?
Ice packs over major arteries
Lavage in all orifices
Peritoneal dialysis
CPB
What is antidromic AVRT?
It is wide complex tachydysrhythmia because the impulse travels antegrade from the atrium thru an accessory pathway and returns via the AV node
What is the treatment of antidromic AVRT?
Procainamide 10 mg/kg IV
Amiodarone 150 mg over 10 minutes
What is orthodontic AVRT.
Narrow complex because it travels thru the AV node and returns via the accessory pathway
Tx: adenosine, vagal maneuvers, beta blockade of CCB
What is the cardioversion dose for narrow regular SVT
50-100 J
What is the cardioversion dose of irregular narrow SVT?
120-200 $ biphasic
200 J Monophasic
What is the cardioversion dose for regular wide SVT?
100 J
What is the cardioversion dose for irregular wide ?
Defib!
Not synchronized
What are the signs that someone is unstable?
Hypotension Chest pain Ischemic changes on EKG Pulmonary edema Mental status changes Hypoxia Shortness of breath
If you believed a patient had aspirated, what would you do?
Place lateral or head down Add air to the cuff Support ventilation with 100% FiO2 Suction oropharnyx and ETT or trach PEep Suction stomach out Bronch CXR Tracheal aspirate Monitor patient for 24-48 hours
