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Part 2 exam > Crisis and complications > Flashcards

Crisis and complications Flashcards

1
Q

What is the ECG criteria for Acute myocardial ischaemia?

A
  • ST segment depression >0.5mm at the J point in >2 contiguous leads
  • T wave inversion
  • Wellen’s T waves (Deeply inverted or biphasic) in V2-4
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2
Q

What is the ECG criteria for acute myocardial infarction?

A
  • ST elevation in 2 contiguous leads
  • > 1mm (all leads other than V2, V3)
  • > 2mm in V2 and V3
  • NSTEMI
  • new ST depression or TWI in 2 contiguous leads
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3
Q

Which leads refer to which part of the heart?

A

Lateral: I, aVL
Anterior V1-V6
Inferior: II, III, aVF

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4
Q

What is the management of acute myocardial ischaemia?

A

Aims: 1. Confirm diagnosis. 2. Optomise myocardial oxygen supply and demand

  1. Confirm diagnosis: Full set of obs, 12 lead ECG, urgent bloods eg trop and Hb

May need serial ECGs

If STEMI -> cath lab
If NSTEMI unstable -> cath lab
If NSTEMI stable, consult cardiology

  1. Optomise myocardial O2 supply and demand
    - Prepare for arrythymias
    - A: Maintain Airway
    - B: supplemental O2
    - C: Treat hypotension, treat anaemia, reduce preload (GTN), aspirin load, short acting beta blockers if tachycardic and can tolerate it
    D - treat Pain (analgesia)

Consult cardiology and surgeon

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5
Q

What is oliguria?

A

<0.5mls/kg/hr or <300-500mls/day

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6
Q

What are risks factors for venous gas embolism?

A
  • Procedures with gas insufflation
  • Procedures with open veins that may be at low pressure eg spinal/neurosurg
  • Unprimed venous lines during rapid infusion
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7
Q

What are signs of venous gas embolism?

A
  • Tachycardia/arrhythmia
  • Decreased BP
  • Sudden etCO2
  • Increased CVP
  • Mill wheel murmur
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8
Q

What is the management of venous gas embolism?

A
  • Inform surgeon and try and stop further entrainment
  • Call for help
  • Operation site below heart
  • 100% FiO2
  • Circulation - > treat BP
  • Aspirate CVC
  • Post op - consider hyperbaric/HDU/ICU/Pt informed/documentation/debriefing
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9
Q

How does venous Co2 gas embolism occur and what is the difference compared to air embolism?

A
  • Direct trocar insertion into a vessell or inadvertent inflation of a solid organ
  • Less severe compared to air due to increased solubility and rapid absorption of CO2
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10
Q

How can you recogonise accidental intra-arterial injeciton?

A
  • Pain and discomfort on injection
  • Expected physiological response to drug not seen
  • Pallor/paraesthesia/hyperaemia of limb distal to injection site
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11
Q

What is the pathophysiology of arterial drug injection injury?

A
  • Arterial spasm due to release of vasoactive substances of direct action of drug
  • Risk of drug precipitation and crystal formation with ischaemia and thrombosis
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12
Q

What are the goals of managing inadvertant intra-arterial injection?

A
  • Identify the drug administered to risk stratify
  • Maintain perfusion distal to site of injury
  • Analgesia
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13
Q

What is the management of inadvertant intra-arterial injection?

A
  • Analgesia: as needed
  • Maintain perfusion: consider anticoagulation to prevent thrombosis, elevate arm to improve venous drainage, keep art line in to monitor perfusion to arm
  • If prior to operation, observe for period of time and monitor for ischaemia
  • If concerns then plastic referral
  • Open disclosure
  • M+M
  • Refer to complication database
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14
Q

What is a useful structure talking about crticial inductions?

A

-Opening statement labelling it as a critical induction
- Outlining priorities
- Management A -> E
- With C - focus on rate/rhythm/afterload/preload/contractility
- Discuss monitoring/access/drugs for circulation
- Defending sinus rhythm important in some conditions -> with esmolol or shock if unstable

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15
Q

What are the ECG changes with RV strain?

A
  • Dominant R wave V1
  • Dominant S wave V6
  • ST changes
  • Right axis deviation
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16
Q

What are the cardiac aims in cardiac tamponade?

A
  • Maintain SR
  • High normal HR - increased filling time won’t help as filling is pressure dependent rather than time
  • Increase preload
  • Maintain normal Afterload
  • Maintain contractility
17
Q

What are neuroprotective mechanisms?

A
  • A - Avoid coughing/straining
  • B - Normal O2 sats, low/normal CO2
  • C - normal BP
  • D - decreased CMRO2 eg thiopentone, anti-epileptics
  • E - Avoid tight neck ties etc, normothermia, head up 30 degrees
  • F - Na high normal, normal glucose
18
Q

What are causes of delayed emergence?

A

Patient:
- metabolic disturbances eg hypo/hyper Na, hypoglycaemia, Mg, Ca
- Hypothermia
- Coingestion of sedating agents
- Pathology: Seizures, stroke

Anaesthetic:
- Residual anaesthetic
- Residual paralysis
- Opioid narcosis
- Benzodiazepine overdose
- Abnormal vitals eg hypotension, hypoxia
- LAST

Surgical:
- Direct surgical injury to blood supply of brain
- Positioning related injury to neck vessels/blood supply

19
Q

What are the priorities in a theatre fire?

A
  1. Identify and communicate crisis
  2. Ensure self, patient and staff safety –> evacuate
  3. contain +/- extinguish fire
20
Q

What is the management of a fire in theatre area (not intraop)?

A
  • Confirm fire
  • Declare crisis
  • Extinguish small flames with water and fire extinguisher, remove flammable material such as drapes
  • R: rescue, listen to fire warden, evacuate pt with prop infusion, laerdel bag, surgical packing, portable monitoring
  • A : Alarm
  • C: Confine , shut theatre doors after evacuation, turn off medical gases
  • E: extinguish flames using fire extinguisher
  • Post review patient for injuries and temporise/complete surgery, review staff for injury
21
Q

What is awareness?

A

Explicit awareness is explicit recall of intraoperative events after completion of general anaesthesia

22
Q

What are risk factors for awareness?

A

Patient:
- younger adults but not children
- Obesity
- Chronic substance use
- Previous awareness

Anaesthetic:
- Difficult airway
- Use of neuromuscular blockers
- Junior anaesthetic provider
- TIVA

Surgical:
- Emergency surgery
- Cardiac, neurosurgery, obstetric
- Evening/night surgery

23
Q

What are the strategies to minimise risk of awareness?

A
  • History - explore details of previous awareness, obtain previous anaesthetic records
  • Vigilance - check equipment and drugs, give repeat bolus in difficult airways, intraop vigiliance with signs of lightening eg tachycardia/BIS changes
  • Anaesthetic technique: benzodiazepine, adequate induction and maintainence doses, depth of anaesthesia monitoring, avoid TIVA, ensure reliable IV access, continous etSevo monitoring, rationalise use of NMB
  • Emergence: avoid lightening plane of anaesthesia prior to reversal, use twitcher, use of suggamadex
24
Q

What are risk factors for PONV?

A

Patient: - age 3-50, female, non smoker, hx motion sickness, hx of PONV

Anaesthetic: long anaesthetic, volatile anaesthetics, N20, large doses of opioids, emetigenic drugs eg ergometrine, general anaesthetic vs regional

Surgical: types of surgery eg inner ear, neurosurgery, bowel surgery, laparoscopic surgery

25
Q

What are strategies to prevent PONV?

A

Anaesthetic techniques: Regional rather than GA, TIVA, avoid nitrous, use volatile sparing i.e Titrate to BIS, mixed TIVA/gas

Pharmacological: Multi-modal anti-emetics (5ht3, steroids, dopamine antagonist, NK-1 antagonist, antihistamines), Multi-modal analegesia (limit pain and opioid related nausea)

Other: IV hydration

26
Q

What are causes of awareness?

A
  • Patient:
    increased anaesthetic requirement (pre op drug use)
    too unwell for adequate dosing

Anaesthetic:
- Inadequate anaesthesia:
clinician error with dosing on induction or maintainence

  • Failure of delivery:
    equipment error (Loss of IV, pump error or programming error)
    user error with pump i.e distracted, didn’t start

Surgical:
- time pressure or emergency surgery not allowing adequate induction of anaesthesia

27
Q

What are the clinical signs of cardiac tamponade?

A

Muffled heart sounds
Hypotension
Raised CVP (swollen neck veins)

28
Q

What are ECG changes of cardiac tamponade?

A
  • Low Voltage QRS, electrical alternans, global ST elevation
29
Q

What are echocardiogram signs of tamponade?

A
  • Visible pericardial effusion
  • Diastolic collapse of right atrium and ventricle (collapse happens when chambers are at their lowest pressures)
30
Q

What are the types of nerve injuries that can occur?

A

Neurapraxia: injury to myelin only -> normally full recovery
Axonotmesis: Injury to axon and myelin -> variable recovery
Neurotmesis: complete transection of nerve -> needs microsurgery

31
Q

What are risk factors for peripheral nerve injuries?

A

Patient: Obesity, T2DM, smoking, PVD, HTN, pre-op contractures/deformities

Anaesthetic: Regional technique without USS, prolonged hypotension/hypoxia/hypothermia

Surgical: Surgical inexperience, prolonged tourniquet time, post op haematoma, constrictive post op dressings

32
Q

What is the pathophysiology of peripheral nerve injuries?

A
  • Stretch
  • Compression
  • Generalised ischaemia
  • Metabolic derrangement
33
Q

What is the optimal supine positioning?

A
  • Head neutral -> rotation puts stretch on brachial plexus
  • Arm abducted <90 degrees
  • Forearm supinated
  • Head facing abducted arm
34
Q

What are the changes with head down positioning?

A
  • A: Risk of regurgitation
  • B : Loss of FRC, atelectasis, V/Q mismatch
  • C - Intracranial hypertension
  • D - Raised ICP, raised intra-ocular pressure
35
Q

What are some risks of lithotomy positioning?

A
  • Increased VR from legs -> risk of cardiac overload
  • Risk of nerve injury from hip flexion (sciatic and obturator nerves)
  • Risk of nerve injury from direct compression of distal legs eg common/deep perinoeal nerve and saphenous nerve
  • Calf compression –> risk of DVT
36
Q

What are some risks of lateral positioning?

A
  • V/Q mismatch (dependent lung gets overperfused and under ventilated and vice versa)
  • Ocular injuries from abrasions
  • Axillary roll to support the thorax and protect the neurovascular bundle in the axilla from compression (at least 2 fingers breadth gap between it and the axilla)
  • Padding between legs to prevent pressure from the legs on each other
37
Q

What is the correct way to position supine patients?

A
  • Minimal neck flexion/extension
  • Face in soft head ring with no pressure on eyes and nose
  • Shoulder with a little bit of anterior flexion, abducted and externally rotated less than 90 degrees
  • Elbow padded
  • No pressure in the axilla
  • abdomen free from pressure (can cause IVC compression and decreased VR)
38
Q

When should tryptases be taken in a patient with anaphylaxis?

A

0,1,4,24 hrs

Part 2 exam (15 decks)

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