Deck2 Flashcards
Functions of bile
Emulsification of fat -> ADEK absorption
Elimination of cholestero
Where is bile reabsorbed
terminal ileum
How is billirubin formed
RBCs broken down to Haem and globin
Haem converted to biliverdin
Biliverdin = unconjugated bilirubin and iron
How is unconjugated bilirubin transported to liver
insoluble
Binds to albumin
How is bilirubin conjugated
In liver
Becomes water soluble excreted in bile
Relationship between preload and cardiac output
Frank-Starling Law
Increase end diastolic volume, stretches the cardiac muscle, allowing it to contract more forcefully
What causes Frank Starling curve to become flatter and shift to right
Reduced contractiliy:
Acidosis
B blockers
Heart failure
What makes the Frank Starling curve to shift to left
Increased contractility or reduction in afterload:
- adrenaline
Indications for a central line
- Monitoring
- CVP
- CO (Swann-Ganz catheter) - Intervention
- TPN
- Adenosine rich solution
- high K content
- Haemodialysis
CVP trace
Incision landmarks for fasciotomy for compartment syndrome of leg
Anterolateral: just above ankle to tibial tuberosity
Posteromedial: 5 cm above medial mal to tibial tuberosity
Closure of fasciotomy
Should not be closed
Loose subcuticular suture could be place to later reduce the size of the defect
Blood test for rhabdomyolysis
CK elevated 5 times normal range
Also AKI
Most common cervical fracture
C5
What further investigation should be considered when the is a cervical fracture
CT angio of neck damage to carotids
Spinal shock fx
Flaccid paralysis
Areflexia
Lack of sensation to spinal cord
Neurogenic shock
Lack of sympathetic outflow (unopposed parasympathetic innervation)
Bradycardia
Hypotension
Cause of neurogenic or spinal shock
Spinal cord injury/trauma
How to test improvement from spinal shock
Bulbocavernous reflex returns:
Tugging on Foley catheter or pressing on clitoris or glans causes contraction of anal sphincter (S2-4)
What is autonomic dysreflexia
Autonomic dysfunction to an insult (eg infection or urinary retention) in spinal injury above T6
- Sympathetic response below level of insult: hypertension and peripheral vasoconstriction
- Parasympathetic response above the level of insult: bradycardia and vasodilation: headache/blurred vision/CVE
Why right IJV preferred over left IJV for central line insertion
Right has a straighter more direct route into SVC and right ventricle
Why right IJV preferred over left IJV for central line insertion
Right has a straighter more direct route into SVC and right ventricle
Where should the tip of central line be placed
In SVC just before right atrium
How to troubleshoot a central line that is not flushing
Make sure no kinks
Slowly move the line whilst pt coughing/deep breathing and flush simultaneously
Anti-thrombolytics such as urokinase could be used
Tissues producing ALP
Bile duct epithelial cells
Bone
Placenta
Which of ALT and AST more specific for liver
ALT (L for liver)
AST found in heart kidney brain intestine
Complications of central line insertion
Immediate: bleeding/ haematoma, pneumothorax
Early: pseudoaneurysm, Chylothorax
Late: infection, thrombosis
Complications of central line insertion
Immediate: bleeding/ haematoma, pneumothorax
Early: pseudoaneurysm, Chylothorax
Late: infection, thrombosis
National guidance for standards of central line insertion
- USS guided
2. Post insertion CXR to check position and r/o pneumothorax
Where to approach a IJV central line
The apex of triangle between two heads of sternocleidomastoid inserting on to the clavicle and sternum and clavicle itself
Step by step of central line insertion through IJV
- USS to identify IJV and carotid
- either medial border of SCM at upper border of thyroid cartilage (C4) or apex of the clavicular triangle
- aim the needle at 30 degrees towards to ipsilateral nipple
- incision made -> guidewire inserted through dilator -> line inserted of guidewire -> sutured in place
Anatomical landmark for central line insertion through subclavian
Inferior surface of midpoint of clavicle, towards jugular notch
Anatomical landmark for central line insertion through subclavian
Inferior surface of midpoint of clavicle, towards jugular notch
Which layers do you go through when inserting a subclavian line
Skin Subcut fascia Pec major Subclavius Subclavian vein
Blood results for DIC
High PT, APTT, d-dimmer
Low fibrinogen
Causes of DIC
Infection
Malignancy
Trauma
Transfusion
Define core temp
Temp of blood and internal organs
Measurement of core temp
Axilla
Rectum
Sublingual
Consequences of hypothermia
Increased Hb affinity for oxygen ->hypoxia
Platelet dysfunction
Enzyme dysfunction
Cardiac arrhythmia
Diverticular abscess mx
<3cm -> conservative with abx
Hinchey 1 (>3cm) or 2 -> IR drainage Hinchey 3 and 4 -> Surgery
Factors determining the area/level of analgaesia achieved with an epidural
Patient position
Initial bolus
Level that is placed
Rate of infusion
Clinical sx of hypovolaemic shock
Pale, anxious and SHOCKS Sinus tachy Hypotension Oliguria CK cool Klammy peripheries S slow capillary refill
Difference between spinal and epidural anasthaesia in terms of area of blockade
Spinal: blocks everything below the level of insertion
Epidural: segmental blockade (if inserted at T3/4, blocks T2-T6, sparing legs)
Consequence of high thoracic spinal block
Paralysis
Numbness
Respiratory compromise (intercostal nerves)
Cardiovascular compromise (loss of sympathetic)
Consequence of high thoracic spinal block
Paralysis
Numbness
Respiratory compromise (intercostal nerves)
Cardiovascular compromise (loss of sympathetic)
Indications for CT head within 1 hr post trauma
GCS >13 or >15 after 2 hrs Seizure >1 vomiting Skull # Base of skull signs Focal neurology
Indications for CT head post trauma within 8 hrs
> 65
Coagulopathy
Dangerous mech of injury
30 min retrograde amnesia before the head injury
Indications for ET intubation
GCS < = 8 Failure to ventilate/oxygenate Inhalational injuries from burns Maxillofacial fractures Neck injury
Indications for extradural haematoma conservative (series CTs and neurological obs) mx
- Extradural haematoma <30cm3
- <15mm thickness
- <5mm midline shift
- GCS>8 and no neurological deficit
Cerebral perfusion pressure
CPP = MAP - ICP MAP = diastolic + 1/3 pulse pressure
Causes of raised ICP
Hydrocephalus (infection)
Space occupying lesion
Bleeding
Cushings reflux
Result of raised ICP:
Low HR
High BP
Irregular breathing (Cheyne-Stokes)
