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MRCS part B- JMB > Critical Care > Flashcards

Critical Care Flashcards

1
Q

A good anaesthesia?

A

Insensitive to pain
Reversible loc
Muscle relaxation

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2
Q

Types of anaesthetics

A

Amides- lidocaine

Esters- cocaine

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3
Q

Moa of anaesthetics?

A

Reversible inhibition of sodium channels (which are proteins therefore increased protein affinity leads to increased efficacy)
Prevent action potentials

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4
Q

Why does lidocaine not work in bacterial environment

A

Exists as an ionised base- In acidic environment cannot penetrate cell membrane

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5
Q

Lidocaine/bupivicaine/prilocaine dose

A

3 (7 with epi) max 200(500)
2 (3) max 150(150)
6

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6
Q

Indication and complications of spinal anaesthesia?

A 
Surgery below the umbilicus T10
Hypotension-splanchnic pooling
Damage during insertion
Dislodgement/infection via catheter
Haematoma post removal- cord compression
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7
Q

Definition of burns

A

Tri zone injury
Central area of coagulative necrosis
Surrounded by static area of inflam and ischaemia
Surrounded by hyperaemia

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8
Q

How to calculate survival of burns patients

A

Bull chart guides survival
TBSA + age > 100 = >20% mortality

Lund and bower chart for tbsa

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9
Q

Why place a pulmonary artery catheter?

A

Ra pressure assumed to be equivocal to la pressure- no valves
Can calculate temp, o2 sats, ef, co, pressures

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10
Q

Aetiology of brain injury

A

1- at time of injury

2- hypoxia, hypotension, RICP, hypercarbia

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11
Q

Cerebral perfusion pressure equation

A

MAP- ICP

MAP= diastolic + 1/3sbp

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12
Q

What controls cerebral vasodilation

A

Co2 levels

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13
Q

Why dilated pupils in head injury

A 
Cniii palsy
Runs through tentorium cerebellum
Swelling leads to compression of this
Loss of parasympathetic 
Symph from t1
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14
Q

Indications for parenteral nutrition

Complications?

A

Compromised gi tract
Hyper catabolic state

Does not maintain bowel mucosa
Monitoring required
Tpn jaundice- tpn is hepatotoxic?
Line sepsis

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15
Q

Different types of dialysis?

A

Haemodialysis- uses a ppm where small molecules removed by DIFFUSION- cheaper and simpler
Haemofiltration- continuous convection of molecules across membrane
Peritoneal dialysis

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16
Q

Functions of kidneys?

A 
Homeostasis- Electrolyte balance, Acid base balance, Fluid balance
Plasma filtration
Metabolise drugs 
Excrete waste
Hormones- epo, renin, calcitrol(Vit d)
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17
Q

Types and indications for ventilation

A

Bipap- type 2 resp failure
Cpap- splints airways open and overcomes compliance- type 1 resp failure, cardiogenic and non cardiogenic pulmonary oedema

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18
Q

Reasons for itu admission?

A

Pathology reasons
Monitoring/expertise reason
High risk procedure
Preoptimisation

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19
Q

Definition of brain stem death?

A

Patient comatose
Coma cause known
Irreversible damage
Reversible causes excluded

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20
Q

Brain stem death assessment?

A

Cnii light reflex
Cniii & vi occulovestibular reflex (turning head and eyes follow)
Can v & vii corneal
Cnviii oculocephalic reflex (water in ear)
Cn ix x gag reflex
Motor response to pain
Ventilatatory response following apnoea testing

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21
Q

Scoring system for pancreatitis?

A

Glasgow score/Apache/Ransom

Glasgow score: PANCREAS
PaO2 <8
Age>55
Neutrophils>15
Ca <2.0
Renal- Urea >16
Enzymes LDH >600/AST >200
Albumin <32
Sugar >10
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22
Q

Reasons for hyperglycaemia and hypocalcaemia in Acute pancreatitis?

A

Hyperglycaemia- destruction of Beta cells
Hypocalcaemia- fat saponification, exocrine enzymes release due to pancreas destruction, leads to breakdown of fat to free fatty acids which chelate calcium

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23
Q

What are the pancreatic exocrine enzymes?

A

Trypsin, amylase and lipase

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24
Q

What is the pH equations?

A

Henderson-Hasslebach equation
pH= power of hydrogen

=pKa (acide dissociation constant) + log (base concentration)/acid concentration

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25
What is the chloride shift principle?
In peripheral capillaries, CO2 is taken into cells via Cl- transporter and converted into HCO3- by carbonic anhydrase Then excreted again for Cl- Contributes to buffering process ?Affects Hb affinity for O2
26
What is a buffer system?
Base and acid system that resists changes in pH
27
Aetiology of metabolic acidosis?
Gain of H+ ions or loss of bicarb High anion gap- Methanol, uraemia, DKA, lactic acidosis (Mud Piles) Normal anion gap- Addisons, Bicarb loss- RTA , Chloride excess , Diarrhoea
28
Causes of metabolic alkalosis?
Gain of bicarb or loss of H+ Vomiting, blood transfusions (citrate), Diuretics/genetic renal conditions= Barrters
29
Causes of respiratory alkalosis?
Anxiety/Pain PE Paracetamol Asthma
30
When to use CPAP vs BiPAP?
CPAP- recruits collapsed alveoli Pulmonary oedema/type 1 resp failure BiPap- type 2 resp failure with acidosis
31
Categorisation of acute limb ischaemia?
Stage I- Not threatened Stage 2a- salvagble if prompt- decreased CRT, partial sensory loss, inaudible doppler, good power Stage 2b- slow CRT, partial sensory loss, decreased power, inaudible doppler Stage 3- Nil CRT, paralysis, parasthetsia, no doppler
32
What is ARDS?
Acute resp failure and non cardiogenic pulmonary oedema Resulting in hypoxia decreased lung compliance Diffuse pulmonary infiltrates, normal PAWP, hypoxia
33
What are the causes and management of ARDS?
Lung- infection, aspirate, smoke, drowning Systemic- DIC, polytrauma, CPB, massive transfusion, acute pancreatitis, sepsis, Fat emobolus Management- Supportive, PEEP and proning
34
What is the mortality of ARDS?
30-60% 90% if associated with sepsis
35
Indications for surgical airway?
Cant intubate, cant ventilate | Laryngeal trauma/oedema/FB/Upper airway obstruction
36
Complications of poorly controlled pain?
``` Sympathetic response- tachycardia and increased metabolic demand Decreased resp effort Decreased GI motility- ileus Decreased mobility Psychological effects Chronic Pain ```
37
What is the process of pain transmission?
Painful/damaging stimuli Identified by nocioceptors AP transmitted by A-Delta/C fibres To spinal cord and up via spinothalamic tract To thalamus and then to somatosensory cortex
38
What is the MOA of paracetamol/NSAIDs?
Paracetamol- unknown aetiology NSAIDs- Inhibit COX => decreased prostagladins
39
Alternatives to medical pain relief?
``` Hot and cold packs Rubbing- gated theory of pain Acupuncture TENS Machine Splinting #s ```
40
What is the management of new acute AF?
Rhythm control if indicated first Within first 48 hours of presentation DC cardiovert if haemodynamically unstable/ electively Chemical cardioversion- flecanide vs amidodarone if not Or Ablation Rate control if not for rhythm control Anticoagulate- CHASDVASC vs HASBLED
41
What are the complications of a blood transfusion?
Immune complications: Acute haemolytic reaction-ABO incompatibility Acute febrile reaction- minor histocompatability complex reactions Anaphylaxsis TRALI GvHD ``` Non-immune Overload Hypocalcaemia (citrate) Hyperkalaemia (broken down cells) Hypothermia Infections ```
42
How many pints/litres of blood in an average human?
4-5 litres | 8/9 pints/units
43
What is a massive transfusion?
In 4 hours >/ 50% of circulating volume replaced | In 24 hours >/ 100 % of circulating volume replaced
44
What can you do for a Jehovah's witness?
``` All blood products? Involve Watchtower representative Rehydrate- IVT EPO/Iron tablets TXA Good haemostasis intra operatively Cell saver device ```
45
Medical management of IBD?
Sulfasalazine Methotrexate Azothioprine Infliximab
46
Reversible brain stem death differential Dx?
``` Hypothermia Hypoglycaemia Hypothyroidism Addisons Toxins C spine injury ```
47
Formulas for calculating burns resuscitation?
Parkland's formular- 4ml x TBSA x weight Resusication over first 24 hours Mount Vernon
48
When to refer to a specialist burns unit?
>5%/>10% TBSA affected in adults/kids <5yo/NAI/>60yo Strange burn type- high pressure/electrical/steam/chemical Hands, face, perineum, flexures, cicrumfrential burns Inhalation injuries Immunosuppressed/pregnant
49
Levels of burns?
Superfisical epidermal- Sunburn, red, painful, peels, good CRT, no blisters Superficial dermal- Red, painful, delayed CRT, blistering, moist Deep dermal- mottled red, sort of painful, non blanching Full thickness- scortched leathery skin, no pain, no crt
50
What are should you do post CV line insertion?
CXR to exclude pneumothorax and check position | US scan to ensure in tip of SVC
51
What muscles lie over subclavian vein on approach to insert line?
Pec Major and subclavius
52
How is CO measured?
Fick's principle HR x SV SV = afterload = preload
53
Draw a CVP trace?
Like JVP wave
54
Definition of compartment syndrome?
Elevated interstitial pressure in a closed osteofacial compartment leading to microvascular comprimise Downward spiral of decreased venous return leading to decreased aorto-venous gradient and therefore decreased perfusion
55
Chance of full function returning when fasciotomies performed for compartment syndrome?
<12 hour- 2/3 patient get full function back >12 hour- only 10% Sheridan et al.
56
What is rhabdomyolysis?
Release of toxic muscle cell components (myoglobin) into systemic circulation
57
Aetiology of Rhabdomyolysis and complications?
1o- congential- duchennes 2o- Trauma, burns, hypothermia, ischaemic reperfusion injury, excessive excerise, toxins Myoglobin release Complications- AKI =>failure, DIC, Electrolyte abnormalities
58
Commonest level of C spine #?
C5
59
What to check for if c spine #?
Vertebral artery injury- CTA and MRA needed
60
What is a hangman's #?
Bilateral pars interarticularis # of C2 (Between pedicle and lamina)
61
Difference between spinal shock and neurogenic shock?
Spinal shock- 2o to trauma, complete transection of spinal cord Neurogenic shock- loss of symphathetics => bradycardia and hypotension
62
What is autonomic dysfunction
Spinal injury above T6 Leading to symphathetic response below level- peripheral vasoconstriction And parasymph above lesion- vasodilation and bradycardia
63
Why does biliary pathology lead to prolonged clotting time?
As decrease functionality of gall bladder Therefore decreased biliary production/secretion from GB Therefore less fat breakdown and vitamin absorption Vitamin K clotting factors (require Vit K for activation) affected 2,7,9,10
64
Where are ALT/AST produced? | Which is more liver specific?
Produced by hepatocytes ALT more liver specific AST produced by heart, kidney, liver, brain, intestine, placenta
65
Where are ALP and GGT produced?
ALP by bile duct epithelium/bones/placental tissue GGT by hepatocytes and bile duct epithelium
66
What is the function of bile?
Excretory route for lipophilic substances Emulsifier of fats Elimination of cholesterol
67
What is the lifecycle of bilirubin?
RBCs broken down by spleen to Haem and globin Haem broken down to Biliverdin Then to bilirubin and iron Bilirubin then bound to albumin and brought to liver Conjugated by enzymes with glucuronic acid in Liver Thus making it water soluble and allowing it to be excreted in the bile Bile is then either converted to stercobilinogen and excreted in faeces Or reabsorbed in distal ileum and converted in urobilinogen and excreted in urine
68
What microorganisms are screen for routinely on a blood transfusion?
HIV Hep B/C CMV Syphilisi
69
What is CCK?
Produced by duodenum when fat detected | Leads to gall bladder contraction sphincter of oddi relaxation
70
What are the causes of DIC?
``` Infection Trauma Malignancy Massive blood transfusion Placental abruption ```
71
What are the consequences of hypothermia?
Hypoxia- left shifting of Hb-O2 curve SNS activation- vasodilation and shviering Enzyme dsyfunction Coagulopathy
72
How to classify diverticulitis?
``` Hinchley classification Stage 0- mild diverticulitis Stage 1- + pericolic abscess Stage 2- distal abscess Stage 3- purulent peritonitis Stage 4- faeculent peritonitis ``` Stage 3/4- Operative drainage Stage 0/1/2- IR Suitable for Abx if abscess <3cm
73
What are the causes of a fat emoblism?
``` Trauma/long bone reaming/massive soft tissue injury Bone marrow transplant Liposuction Acute pancreatitis Intralipid infusion ```
74
What is the pathophysiology of fat emoblism syndrome?
Fat globules gain access via damaged vasculature Plaltelet bound lipids brokendown leading to free fatty acids in blood Intravascular coagulation leads to emboli
75
What is the role of MRI in FES Mortality of FES?
Looks for cerebral Oedema- can R/O FES 5-15%
76
What is the definition of a high output stoma and what are the consequences?
>500ml/day Dehydration, electrolyte imbalance, malnutrition
77
How do you manage a high output fistulas?
A2E then MDT SNAP ``` Sepsis control Nutritional support- dieticians Anatomical assessment- fisutlogram/CT Adequate IVT/electrolytes Protect skin Plan- conservative vs surgical (tract excision) ```
78
Indications of central line?
CVP monitoring/CO monitoring | Interventions- TPN, vasoirritant medication, failed cannulation, haemodialysis
79
How do you manage variceal bleeding?
``` Endoscopy- band ligation/sclerotherapy Terlipressin Balloon tamponade TIPSS Surgical shunt Liver transplant ```
80
What is the rule of 2/3s with portal htn?
2/3 of cirrhotic patients develop portal htn 2/3 of patients with portal htn develop varices 2/3 of patients with varices present with an acute bleed
81
What are the causes of hydrocephalus?
Increased production- choroid plexus carcinoma Decreased circulation- malignancy, infection, haematoma Decreased reabsorption- thrombosis/haemorrhage
82
What does pulse oximetry detect?
Ratio of unsaturated vs saturated haemoglobin
83
What are the side effect of colloids?
Anaphylaxsis and affect platelet aggregation
84
What are the pathophysiology of the hypersensitivity reactions?
Type 1- IgE => mast cell degranulation leading to heparin, histamin and platelet activating factor release Leads to profound vasodilation, increased vascular permeability and smooth muscle spasm Type 2- cell mediated- Ag and ab- acute transfusion reactions Type 3- immune complex mediated- goodpastures/lupus Type 4- delayed- contact dermatitis- t cell Type 5- stimulatory- grave's, TSH receptor autoAbs
85
What are the causes of hyponatraemia?
Hypertonic (hyperglycaemic) Isotonic (pseudohyponatraemia (myeloma)) Hypotonic Hypervolaemic- failures Hypovolaemic- D/V or diuretics/ burns/trauma ``` Euvolaemic SIADH SCLC Infection Addisons Drugs HypoT ```
86
When do you gain immunity from tetanus?
Tetanus immunisations After 5 doses 3 given at a couple of months old 1st booster at 5 years old 2nd at 15yo
87
What is an exotoxin/endotoxin?
Exotoxin produced by gram +/- bacteria Immunogenic proteins With specific effects Endotoxins Just produced by gram -ve Lipopolysacchorides from cell wall leading to general stress response
88
What is the mortality of NEC Fasc?
30%
89
What are the different types of adrenergic receptors?
alpha 1- vascoconstrioction and increased myocardial contraction duration beta 1- intropy and chemotropy beta 2- vasodilation/bronchoconstriciton Dopamine 1/2- diuresis
90
What is starling's law?
Myocardiac contractility is proportional to myocardial stretch
91
Make up of hartmannas and NaCl?
Hartmanns Na 131, cl 111, bicarc 29, Ca 2, K 5 NaCl Na 154, Cl 154
92
Where is hartmanns, nacl, dextrose and blood distributed?
Blood just intravascularly NaCl and Hartmanns just ECF Dextroses everywhere
93
Indications for intubation?
Airway- decreased GCS, facial/laryngeal trauma, inhalation injury Breathing- resp failure, prevention of 2o brain injury
94
How to confirm ETT is in correct position?
``` Look listen feel Waveform capnography is gold standard Face mask misting Air entry No stomach rise CXR ```
95
How do you calculate ventilation?
Tidal volume x RR = 7ml/kg x 12/min
96
Why does tachycardia put one at increased risk of an MI?
Coronary artery filling occurs during diastole | Diastole shortens during tachycardia
97
Why RJV preferential site for CVP measurement?
No valves between it and RA | Less NV damage risk
98
Causes of normal anion gap metabolic acidosis?
Addisons Bicarb loss- RTA Chloride excess Diarrhoea/diuretics
99
RFs for AF?
``` Age/alcohol CXS disease Thyroid status Valvular disease DM ``` Hypovolaemia/hpoxia Potassium Acute MI Sepsis
100
What is the MI re infarction rate when performing surgery?
<1 month = 30% | <6 months= 5%
101
What is the MOA of aspirin and clopidogrel?
Both prevent platelet aggregation Clopidogrel via inhibition of ADP receptors Aspirin via COX antagonism
102
Side effects of NSAIDs?
``` Heart failure- fluid retention AKI Stomach ulcers Coagulopathy Decreased inflammation Bronchospasm ```
103
Types of Nec Fasc?
1- polymicrobial- staph/hi 2- monomicrobial- GAS 3- clostridium 4- fungal
104
What is a pancreatic psuedocyst?
fluid filled collection with fibrous capsule | due to leakage of enzyme rich fluids
105
How do you manage a pancreatic pseudocyst?
Conservatively 50% resolve 10% infected Drain- radiologically, endoscopically, open
106
What is a steroid?
Organic compounds with characterisitic four rings | Cholesterol/aldosterone/cortisol/testosterone/progesterone/thyroid hormone
107
What affect does aldosterone have?
Na/K/ATPase pump activity increase Increase H20 retention and alkalosis
108
What hormones are produced by the anterior and posterior pituitary?
``` Anterior: ACTH TSH FSH LH GH Prolactin ``` Post pituitary: Oxytocin ADH
109
What are the effects of gluccocorticoids and how are they controlled?
Metabolic- hyperglycaemic effect- inhibit insulin Non metabolic- Na in/K out- fluid retention Anti inflam immunosuppressant Decrease stress response CRH produced by hypothalamus leads to ACTH production by ant pituitary leading to cortisol production by cortex Stimulated by low cortisol levels
110
Complications of gluccocorticoids?
``` Weight gain DM Ulcers Osteoporosis Bruising/muscle weakness Mood changes Cushing's Sick day rules! ```
111
What are the general principles for operating on someone taking glucocortiocoids?
Double dose day of surgery IV hydrocortisone at induction Alert anaesthetist- pre assessment Beware of Addison's Abdo pain, N/V, shock, hypothermia
112
Criteria for day surgery?
Social factors- someone to take them home and keep an eye on them Medical factors- patient fit Surgical factors- Op generally doesnt result in serious post op complications Able to mobilise post op Good length of op/anaesthetic time
113
What is the ASA criteria?
``` 1- fit and well 2- mild systemic disease 3- severe systemic disease 4- severe systemic disease at constant risk to life 5- moribund 6- Brain dead, organ transplantation ```
114
When to refer to the coroner?
Death <24 hours since admission Suspicious/accidental/violent death After op/procedure Unknown cause of death
115
What to do facing a tracheostomy airway problem?
``` Help- anaesthetics/senior A2E O2 to face and trachy Trachy box- inner tubes/suctio catheters/scissors & tape Remove valve/inner tube Attempt to pass a suction catheter Deflate cuff if needed Remove trachy- if in doubt take it out Ventilate via mouth/nose- cover trachy with gauze ```
116
What are the types of transplant rejection?
Hyperacute- ABO mismatching Acute- HLA mismatching Chronic- MHC mismatching?
117
What is in FFP and cryoprecipitate?
``` FFP= all clotting factors, albumin, fibrinogen, vWF Cryo= F8, F13, fibrinogen and vWF ```
118
How does an osmotic diuretic work?
Eg. Mannitol Filtered by the glomerulus but can not be reabsorbed Leads to increased oslamlality which therefore is balanced out by diuresis
119
Why does Aortic stenosis lead to problems intraoperatively
AS leads to hypertrophied ventricle, which is stiff with decreased compliance Therefore this ventricle has an increased metabolic demand- so is sensitive to changing arterial pressure And has a lesser ability to respond to a changing afterload

MRCS part B- JMB (10 decks)

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