exam 1 Flashcards

1
Q

ENT goal:
Balance ______ relaxation with _______ recovery

A

DEEP relaxation
RAPID recovery

painful/very stimulation (deep)
short cases (rapid)

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2
Q

ENT

muscle relaxation ___________ paralytics

A

withOUT

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3
Q

Goals of ENT

A

preventing fire

minimize blood loss (highly vascular)

specialized techniques

relax the muscle withOUT paralytics

deep but rapid

maintain CV stability

preventing postop airway obstruction

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4
Q

3 types of ET tubes for ENT surgery

A

RAE

anode

laser tube

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5
Q

ENT
ET tube

Cuffed, uncuffed (rare)

Sometimes difficult to fit, due to BEND

Helps make it less obstructed for the surgeon

The bigger the tube, the further out from the mouth

Nasal tube is good for dentists

A

RAE (oral or nasal)

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6
Q

ENT
ET tube

Flexible, good at bending, can create knots, resists kinking

However, can be occluded easily with biting (without mouth block)

A

anode (armored, reinforced)

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7
Q

ENT
ET tube

Metal impregnated tube, reduces risk of fire

However, markings are covered if you wrap it, so need to line it up with another tube; use breath sounds

A

laser tubes

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8
Q

Most LAs are _______-based

A

amide

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9
Q

3 drugs used for ENT

A

LAs

anticholinergics (secretions)

steroids (prolong LA, reduce edema + PONV)

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10
Q

ENT have a high risk of _______

A

PONV

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11
Q

which ENT case has the highest risk of PONV

A

middle ear procedures
8th cranial nerve

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12
Q

to decrease blood loss by reducing MAP, while STILL MAINTAINING cerebral and systemic autoregulation

A

deliberate hypotension

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13
Q

deliberate hypotension

Maintain MAP ≥ greater than or equal to ___

A

60

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14
Q

true or false

deliberate hypotension
patients with HTN may need HIGHER MAP

A

true
could need 65 or 75

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15
Q

true or false

deliberate hypotension can be done without aline, unless using nipride

A

true

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16
Q

2 surgeries for deliberate hypotension

A

o Extensive dissections
o Functional endoscopic sinus surgery (FESS)

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17
Q

drugs used for deliberate hypotension

A

Nipride (always use an a-line)
o Dexmedetomidine
o Esmolol
o Nitroglycerin (NTG)
o Nicardipine
o Remifentanil
o Propofol

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18
Q

risk of deliberate hypotension

A

postop vision loss (irreversible)

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19
Q

laser surgery types (4)

A

CO2
Nd: YAG
Ho: YAG, KTP
argon

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20
Q

laser surgery drawback

A

most surgical fires are related to this

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21
Q

What are the 3 biggest concerns with laser surgery)

A

1) Eye protection (patient + staff)

2) Plume dispersion (viral papillomas); can cause ETT to be dislodged

3) Fires

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22
Q

which ETT is best for fires

A

laser tube, metal impregnated

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23
Q

safety with laser surgery

A

matte finish

inflate cuff with methylene blue

shield tissue with wet gauze

suction plume

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24
Q

if patient needs O2 AND needs to respond to verbal commands, do this for O2

A

deliver minimum amount of O2 (30% or less)

if needed above 30%, deliver 5-10L/min of air under drapes to washout excess O2

stop O2 >1 min before laser use

use adherent incise drape

keep towel edges far away

coat facial hair with jelly

use bipolar

do not use electrocautery to cut into trachea

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25
Q

complications of endoscopy

A

Eye trauma
o Epistaxis
o Laryngospasm
o Bronchospasm
o Adverse effects to LAs from epi, etc. (LAST)

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26
Q

bronchs require vocal cord ___________*

A

relaxation

avoid paralytics!

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27
Q

true or false

ONLY use AWAKE extubation with someone who has bleeding in their airway*

A

true

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28
Q

No ETT involved! It is from an independent source

unprotected airway

A

High Frequency Jet Ventilation

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29
Q

HFJV, always use lowest ____ possible

A

O2

<30%

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30
Q

CONTRAindication to HFJV

A

full stomach
obese
pulm disease (difficult to maintain O2)

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31
Q

difficulties of HFJV

A

air trapping
SQ emphysema
PTX

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32
Q

type of anesthesia to use for HFJV

A

TIVA

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33
Q

what bronchus is most common with children for aspiration

A

Right

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34
Q

gold standard for foreign body aspiration

A

rigid bronch with GA

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35
Q

foreign body:

inhalational induction with ______________ ventilation

A

spontaneous

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36
Q

avoid ______ with foreign body

A

PEEP

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37
Q

postop foreign body

A

steroids
breathing treatment
mask on face, chin lift

Avoid ETT unless necessary

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38
Q

what 2 drug classes are CONTRAindicated for nerve monitoring/preservation/stimulation

A

NMBs
LAs

nitrous (avoid >15 min before closing)

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39
Q

2 indications for nerve preservation

A

parotid glands

mastoidectomies

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40
Q

how long should nitrous be turned off for

A

> 15 min before closing

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41
Q

myringotomy

A

ear procedure

usually does NOT require IV access

nitrous is okay to use (short procedure)

nasal fentanyl/dex for calmness

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42
Q

most common ped surgery

A

tonsillectomy and adenoidectomy (T+A)

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43
Q

true or false
LMAs are NOT recommended for tonsil surgery

A

true

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44
Q

contraindicated drug for tonsils

A

NSAIDS (however, studies have not proven they cause worse bleeding)

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45
Q

when are the ONLY times you can use DEEP extubation for ENT cases

A

“dry field” or VERY NORMAL cases

otherwise, always WAKE them

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46
Q

2 risk factors of bleeding tonsil complication

A

> 15 years old
within 6 hours (SLOW onset, swallowing blood)

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47
Q

true or false
bleeding tonsils extubate fully AWAKE*

A

true

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48
Q

true or false
ALL bleeding tonsils are “full stomachs”: MUST HAVE TRUE RSI*

A

true

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49
Q

thyroid procedures

Increased incidence of myasthenia gravis (increased ____________ to muscle relaxants!)

A

sensitivity

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50
Q
  • Vocal Cords Motor Innervation (2)
A

o Recurrent laryngeal
o EXTERNAL branch of SUPERIOR laryngeal

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51
Q

gold standard thyroid surgery monitoring

A

intraop nerve monitoring

ETT with 4 electrodes
NIM tube (neuro inegral monitoring)

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52
Q

NIM electrodes
red: _______
blue: _____

A

red: RIGHT
blue: LEFT

electrodes should be in contact with vocal cords

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53
Q

thyroid surgery
treat hypotension with _______-________

A

direct-acting
(phenylephrine)

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54
Q

what can occur following thyroid surgery

A

HYPOcalcemia

(numb/tingling, laryngospasm, seizures, CV arrest)

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55
Q

treatment for HYPOcalcemia (2)

A

calcium gluconate or chloride

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56
Q

thyroid hematoma

A

Post-op hematoma
leads to
ER airway obstruction
leads to
emergent to the OR

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57
Q

true or false
cleft LIP is more difficult

A

true
difficult to mask and to intubate
done first

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58
Q

facial trauma
assume ___________ injury

A

cervical spine
use c-collar, F/O

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59
Q

Le Fort fracture

Horizontal, nose/palate, septum, posterior pterygoids

Usually, no issues

Oral or nasal ETT GOOD TO USE

A

I

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60
Q

Le Fort fracture

Triangular, nose, orbit, below zygoma, lateral maxilla + pterygoids

A

II

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61
Q

Le Fort fracture

Complete separation of midface from the cranial base across nose, ethmoid, orbit, sphenopalatine fossa

AVOID NASAL ETT without F/O guidance if basilar skull fracture suspected

A

III

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62
Q

basilar skull fracture signs (4)

A

o CSF from nose or ears

o Blood behind tympanic membrane (ears)

o “Raccoon eyes”: ALWAYS BILATERAL

o Bruising behind ears: “battle signs”

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63
Q

basilar skull fracture signs are delayed ___-___ days

A

2-3 days

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64
Q

facial fractures

true or false
ALL are full stomachs

Wire cutters must be available and stay at the bedside throughout the postop course

usually, not an emergency procedure

extubate AWAKE (need to be able to clear the airway)*

A

true

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65
Q

with any nerve thing, what do we avoid

A

NMBs or muscle relaxants

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66
Q

radical neck dissection (3)

A

difficult intubation (due to radiation, movement issues)

LONG procedure

AVOID fluid overload

risk of VAE (due to head-up position

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67
Q

opthalmic surgery
anesthesia type

A

LAs “epidural”
a little propofol

EXCEPT young children

they cause less PONV

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68
Q

most common + effective for profound analgesia/akinesia (no movement) of eye and eyelids (2)

A

RETROBULBAR LA*
peribulbar LA

Sub-tenon, infraorbital, supraorbital

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69
Q

which nerves are anesthetized with opthalmic

A

III, IV, V, VI, VII (3-7)

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70
Q

young children opthalmic surgery anesthesia type

A

GA

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71
Q

true or false

okay to use anticoags with eye surgery

A

true

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72
Q

opthalmic surgery

Sch causes transient ____________ IOP

A

increased

still considered safe

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73
Q

opthalmic surgery

decreases IOP + maintains akinesis

A

NON-depolarizers

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74
Q

opthalmic surgery

extubate ______

A

DEEP

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75
Q

2 risks from eye muscles

A

MH
PONV

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76
Q

opthalmic surgery

Prolonged PONV may be sign of increased ____!

A

IOP

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77
Q

For FULL stomach, OPEN-EYE INJURY patient

easy airway =
difficult airway =

A

easy = roc
difficult = Sch

(if sugg is available, use roc, less risk of increased IOP)

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78
Q

Oculocardiac Reflex

Afferent/towards = *

A

trigeminal (V)

five and dime

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79
Q

Oculocardiac Reflex

Efferent/away = *

A

Vagus (X)

five and dime

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80
Q

stimulus (4) of Oculocardiac Reflex

A

Globe pressure
optic nerve pressure conjunctival pressure
muscle traction

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81
Q

true or false
oculocardiac reflex occurs in children more

A

true

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82
Q

o Sudden, profound bradycardia, asystole, etc

A

Oculocardiac Reflex

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83
Q

treatment for Oculocardiac Reflex

A

stop stimulus

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84
Q

Oculocardiac Reflex

If unresolved (the second time it happens) = use ________ (2)

A

atropine or glycopyrrolate

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85
Q
  • CN ____ nerve block = Bell’s Palsy
A

VII (facial)

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86
Q

Max SQ lidocaine

A

35 mg/kg

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87
Q

Max SQ epi

A

70 mCg/kg

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88
Q

1L SQ of tumescent solution

A

700ml absorbed

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89
Q

max amount of SQ tumescent solution

A

5L

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90
Q

tumesecent solution (3)

A

saline + epi + lidocaine

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91
Q

risks with liposuction

A

VTE*
abd wall perf
sepsis
fluid overload; pulm edema (from tumescent)
hypothermia
LA toxicity

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92
Q

o Highest incidence of death is d/t VTE

A

abdominoplasty “tummy tuck”

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93
Q

GREATEST risk of VTE

A

combined procedures

abdominoplasty + liposuction

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94
Q

biggest cause of VTE

A

smoking

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95
Q

VTE increased risk

long procedures
>__ hr GA
>__hr sedation

A

> 1 hr GA
2 hr sedation

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96
Q

facial cosmetic surgery

cocaine increases SNS

avoid ____, _________/_________

A

avoid HTN, swelling/bleeding

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97
Q

fiO2 <30% is =

A

150-200ml

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98
Q

safety checklist for office based surgery is from

A

ISOBS (institute for safety in office based surgery)

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99
Q

most common cause of death from OFFICE/PLASTICS based anesthesia

A

PE

(abdominoplasty)

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100
Q

Only ___ states have guidelines, policies, or position statements regarding office-based surgery and anesthesia (OBA)

A

33

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101
Q

true or false

standardization of safe practice with adequate safety protocols and practice standards are NOT legal guidelines*

A

true

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102
Q

true or false

Only 24 states have at least one law that regulated OBA

A

true

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103
Q

true or false
Heavy/deep or moderate MAC or deep sedation techniques require ETCO2*

however, this is NOT state/legal regulation, this is a standard of practice*

A

true

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104
Q
  • DECREASED cost
  • Increased patient and surgeon convenience and satisfaction
  • Consistent staffing
  • Efficiency
  • Patient privacy
  • Increased autonomy of practice
  • DECREASED risk of infection
  • Aging population + drive for cosmetic surgery
A

advantages of OBA

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105
Q
  • Absent or inconsistent state regulations (someone who is not credentialed can perform)
  • Lack of peer review and credentialing
  • Logistical limitations
  • Lack personnel support (solo provider)
  • Possible poor quality/amount of equipment
  • Lack organizational resources and human infrastructure
A

disadvantages of OBA

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106
Q

OBA facilities must have

A

positive pressure ventilation device (bag valve mask)

2 H tanks of oxygen

monitor/defibrilator

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107
Q
  • What is the most common cause of death in OBA
A

inadequate ventilation and oxygenation

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108
Q

what should you keep in mind when monitoring fluids for liposuction

A

70% of tumesecent is absorbed (so calculate that into the number!)

do not overhydrate

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109
Q

true or false

If a bad trauma event happens, get them to a Level 1 trauma center; it does NOT matter how far it is!

A

true

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110
Q

modern trauma system has replaced the ________________ _____ ________

A

community care model

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111
Q

ATLS PRIMARY Survey:

A

 ABCDE’s of trauma care
 Vitals
 Making sure the patient is stable

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112
Q

o ATLS Secondary Survey

A

 Resuscitation and stabilization in progress
 Complete head-to-toe assessment, including neuro exam!

 Example: turning on the side, pupils, breath sounds, neuro assessment

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113
Q

 Most common type of blunt trauma

A

MVAs and falls

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114
Q

blunt trauma

Always assume ___________, until confirmed otherwise

A

unstable C-spine

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115
Q

o What is the worst blunt trauma

A

thoracic (MVA/steering wheel)

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116
Q

most common symptom of blunt trauma

A

PTX (40%)

many times, it does NOT show up on x-ray

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117
Q

Tension PTX signs (6)

A
  • HYPOtension
  • SQ emphysema
  • Unilateral ↓ BS
  • ↓ chest wall motion
  • Distended neck veins
  • Tracheal shift to opposite side
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118
Q

treatment for tension PTX

A
  • Emergent needle aspiration

2nd ICS (above 3rd rib, MCL)

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119
Q
  • Beck’s Triad is associated with
A

pericardial tamponade

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120
Q

Beck’s Triad (3)

PERICARDIAL TAMPONADE
“beck was heart sick”

A

1) HYPOtension
2) increased CVP
3) jugular distention/muffled heart tones

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121
Q

what is NOT included in becks triad, but IS a symptom of pericardial tamponade

A

pulsus paradoxus (decreased SBP on inspiration)

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122
Q

what 2 drugs can be given for pericardial tamponade during INDUCTION

A

ketamine*
etomidate

AVOID PROPOFOL

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123
Q

hemothorax treatment (2)

A

1st fluid resuscitation
2nd chest tubes

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124
Q

 What are common signs of tracheal injury

A

SQ emphysema
crepitus

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125
Q

most airway injuries occur _______ the carina

A

below

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126
Q

FAST stands for

A

Focused Assessment with Sonography in Trauma

great, highly sensitive, 4 views

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127
Q

lethal triad is for what

A

penetrating trauma, death

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128
Q

lethal triad**

PENETRATING TRAUMA

“lethal trauma”

A

1) acidosis
2) HYPOthermia
3) coagulopathy

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129
Q

Damage control surgery (DCS) with Damage Control Resuscitation (DCR)

prevent ________ triad

A

lethal

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130
Q

DCS and DCR
trauma

Limit/decrease _____________, but increase blood products

A

crystalloids

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131
Q
  • DCS examples (2)
A

abd packing
external fixator

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132
Q

3 things used in Damage control resuscitation (DCR)

A

POC testing (TEG + ROTEM)
RAPTOR
REBOA

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133
Q

what is RAPTOR

A

resuscitation with angiography, percutaneous techniques and operative repair

(IR)

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134
Q

what is REBOA

A

Resuscitative endovascular balloon occlusion of the aorta

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135
Q

3 major assumptions with AIRWAY trauma

A

1) full stomach
2) c-spine issue
3) hypotensive + hypoxic

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136
Q

what NMBs for patients with AIRWAY trauma

A

Sch or Roc for RSI

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137
Q

 Manual in-line stabilization (MILS)

A

after front of C-collar removed
* Many people helping!

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138
Q

true or false
AIRWAY trauma

NO outcome difference between DL (miller), VL, and FOB (provider dependent)!

A

true

you can use any!

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139
Q

what is the LAST resort (avoid it!) for airway trauma

A

front of neck access (FONA) with crichotomy

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140
Q

what is a dilemma for BREATHING trauma

A

↓ Decreased compliance (and need for ↑ increased PIP)
vs
barotrauma (with worsening disease)

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141
Q

protected lung ventilation (6)

A

1) LOW Vt
2) PEEP
3) Permissive HYPERcapnia (hypoventilating) ***
4) Limited fluids
5) Prone positioning
6) NMBs (can help with ventilating)

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142
Q

3 GOALS for breathing trauma

A

LOW Vt

LOW PIP (<32 cmH2O)

SpO2 90-94% (avoid O2 toxicity!)

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143
Q

excessive oxygen leads to

A

atelectasis
free radicals, ROS
cellular necrosis/apoptosis

however, ROS is also caused by oxygen toxicity

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144
Q

Current theory: “Golden Hour” is __________ _____ that is age and health status dependent

A

nonspecific time

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145
Q

Stages of Hemorrhagic Shock

  • Blood volume normalized by shifting fluids
A

Stage I
NONprogressive or compensated

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146
Q

Stages of Hemorrhagic Shock
CV depression due to ISCHEMIA thrombosis, toxins, cellular damage

A

Stage II
Progressive

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147
Q

Stages of Hemorrhagic Shock

ATP depleted, cellular death with toxins released

o 1) Acute Irreversible: massive hemorrhage  death FAST

o 2) SUB-Acute Irreversible: significant shock and cellular ischemia  multi-organ failure/death over time/SLOW

A

Stage III
Irreversible

will die!

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148
Q

treatment of hemorrhagic shock

minimal bleeding:

A

<2 L crystalloid

(too much fluid can worsen it)

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149
Q

“Hypotensive Resuscitation”

when bleeding is UNCONTROLLED, minimize bleeding by maintaining SBP of ____-____ mmHg

A
  • Controversial; primarily for penetrating trauma

SBP of 85-90

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150
Q

what is the exception to “Hypotensive Resuscitation”

A

TBI

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151
Q

“Hypotensive Resuscitation”

when bleeding is CONTROLLED, maintain SBP of >____ mmHg and HR <____

A

> 100 SBP
<100 HR

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152
Q

for CVLs, access ______ the diaphragm when possible

A

ABOVE

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153
Q

replace EBL with __:__:__

A

1:1:1 (PRBCs, FFP, PLTs)

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154
Q

IV fluids resuscitation

________ cause rapid restoration but ↑ increased risk of pulmonary edema and bleeding

A

colloids

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155
Q

IV fluids resuscitation

Avoid ________, except for documented hypoglycemia + peds

A

glucose

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156
Q

Evidence: BG >____ mg/dL lead to adverse neuro outcomes

A

> 170

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157
Q

trauma

maintain glucose at ____-____

A

140-180

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158
Q

trauma

majority of initial injury survivors are _______________ at death

A

coagulopathic

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159
Q

trauma

elevated ___ on admission = massive injury, hemorrhage, poor perfusion state

A

PT
prothrombin

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160
Q

(4) Trauma-Induced Coagulopathy (TIC) *

A

Dilution (too many fluids)
HYPOthermia*
Acidosis
TBI + Shock (coagulopathy)

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161
Q

When labs ARE available/have resulted, transfuse accordingly*

INR <____
PLT >_______

until then, use targeted transfusion (1:1:1)

A

1.5
PLT >50,000

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162
Q

hypothermia can result in _______

A

dysfunctional CLOTS

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163
Q

during resuscitation, ______ everything

A

WARM

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164
Q

acidosis with pH of <____ + hypothermia can result in significant clots

A

<7.1

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165
Q

true or false

bicarb is NOT effective for clotting issues

A

true

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166
Q

theory:
TBI + shock releases tissue factor, leading to __-__ complex

A

T-T complex

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167
Q

T-T complex leads to

A

activated protein C (APC) pathway

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168
Q

APC pathway inhibits ___ and ____,
+
promotes fibrinolysis

A

V and VIII

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169
Q

net result of T-T complex and APC pathway

A

systemic ANTI**coagulation

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170
Q

treatment for TBI and shock

A

EARLY FFP

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171
Q

assessment of blood consumption score (ABC)

and

trauma-associated severe hemorrhage score

(4)

A

penetrating injury
SBP <90
HR >120
positive FAST

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172
Q

ABC score of > or = ___

increased RISK of needing massive transfusion (may not be necessary)

A

2

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173
Q

keep PT level ____

A

low

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174
Q

TXA
> 12 years = ___ gm bolus over 10 min, then ___ gm over 8 hrs

A

1 gm over 10 min, then 1 gm over 8 hr

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175
Q

TXA

< 12 years = ___mg/kg bolus, then ___ mg/kg/hr over 8 hours

A

15 mg/kg
2mg/kg

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176
Q
  • TXA should be administered less than < ___ hours post-injury
A

< 3

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177
Q

what is the up-to-date coagulation pathway

A

initiation, propagation

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178
Q

intubate with a GCS < __

A

8

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179
Q

for patients with low GCS score (neuro injury), use ______ IN*tubation

A

DEEP

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180
Q

diagnosis of ICP

A

> 10 mmHg

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181
Q

when do you treat ICP

A

> 25 mmHg

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182
Q

until ICP monitoring is available,

maintain MAP >____ to maintain CPP >____
maintain PaCO2 ___-___

A

MAP >80

CPP >60

PaCO2 30-35 (HYPO**carbic)

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183
Q

o ACS 3-Tiered Approach
(neuro)

ICP 10 – 20 mmHg

A

Tier 1

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184
Q

o ACS 3-Tiered Approach
(neuro)

ICP > 20 - 25 mmHg

A

Tier 2

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185
Q

o ACS 3-Tiered Approach
(neuro)

UNRESOLVED
ICP > 20 – 25 mmHg

A

Tier 3

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186
Q

o ACS 3-Tiered Approach
(neuro)

  • Surgical evacuation, med-induced coma, HYPO**thermia
A

Tier 3

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187
Q

o ACS 3-Tiered Approach
(neuro)

EVD, mannitol or hypertonic saline, neuromonitoring, CT, NMBs

A

Tier 2

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188
Q

o ACS 3-Tiered Approach
(neuro)

Elevate HOB 30 deg, short acting sedation/analgesia, monitor ventricular drainage, repeat diagnostics

A

Tier 1

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189
Q

cushing’s triad is for what

A

impending herniation

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190
Q

cushing triad (3)

BRAIN HERNIATION

“you want some cushion for your brain”

A

1) HTN**

2) BRADYcardia

3) irregular respirations

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191
Q

what 2 drugs should you AVOID with increased ICP

A

nitrous
ketamine

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192
Q

increased ICP, BEST choice for neuro protection, unless myocardial depression is a risk

A

propofol

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193
Q

drug treatment for ICP (3)

A

propofol

mannitol (0.25-1gm/kg)

lasix

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194
Q

true or false

Steroids are NOT effective for ↑ ICP

A

true

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195
Q

Signs of spinal cord injury (6)

A

1) Paralysis
* 2) Pain
* 3) Position
* 4) Parasthesias
* 5) Ptosis
* 6) Priapism (erection)

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196
Q

Sch

fasciculations can _______ spinal cord injuries

A

worsen

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197
Q

> ____ hours until forever, AVOID Sch with spinal cord injury

A

> 24 hours

UP-regulation, hyperkalemia

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198
Q

Be aware of spinal cord injury withOUT radiographic abnormality (_________) and vertebral artery injury (VAI)

this can occur in up to 88% of patients

A

CIWORA

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199
Q

what is needed for c-spine injury intubation

A

MILS, c-collar, halos

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200
Q

what 2 drugs do you avoid for spinal injury

A

Sch
nitrous

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201
Q

spinal cord injury

intra op evoked potentials

maintain _____ anesthetic

A

LOW

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202
Q

spinal cord perfusion

have MAP at ____-____

A

85-90

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203
Q

spinal shock triad (3)

A

1) HYPOtension (dilation)
2) BRADYcardia
3) HYPOthermia (heat loss)

“warm shock”

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204
Q

spinal cord

___ and above leads to major CNS impairment

A

T6

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205
Q

spinal cord SHOCK

true or false
aline is required to avoid pulm edema and guide pressors

A

true

206
Q

Massive SNS response due to stimulus BELOW the spinal INJURY

A

autonomic dysreflexia

207
Q

autonomic dysreflexia is most common with injuries above ___

A

T6

208
Q

causes of autonomic dysreflexia (3)

A

bladder distention

fecal impaction (constipation)

nitrous/opioid GA or regional anesthesia (NOT with VOLATILES)

209
Q

symptoms of autonomic dysreflexia (6)

A
  • HTN*
  • Seizures
  • Pulm edema
  • MI
  • Acute renal injury
  • Cerebral hemorrhage
210
Q

treatment for autonomic dysreflexia (5)

A
  • Nitrates
  • Nifedipine
  • Hydralazine
  • Labetalol
  • Foley*
211
Q

what surgery is a major risk for fat emboli, PE emboli, hemorrhage, shock

A

orthopedics

212
Q

symptoms of bone fractures (3)

A

Hypoxic respiratory failure due to continuous fat emboli syndrome (FES)

ARDS

HIGH morbidity and mortality (with pelvic fractures)

213
Q

treatment for bone fractures (4)

A

REBOA (occlusion of aortic artery)

repair it early

treat as FULL stomach, RSI

regional? depends

214
Q

what is the cause of death for junctional trauma

A

life-treatening hemorrhage

they are NON-compressible**

treatment: junctional tourniquets

215
Q

what are most INTRAop deaths for trauma patients from (3)

A

HYPERkalemia
HYPOcalcemia
acidosis

NOT hemorrhage/exsanguination

216
Q

what are POSTop deaths for trauma patients

multiorgan failure

early:
later:

A

early: CV failure*

later: PIICS (persistent inflammatory, immunosuppressed catabolic syndrome)

217
Q

peds burns are mostly due to

A

scalding (NAT? possible abuse)

218
Q

burns

main causes of EARLY death < 48 hours (2)

A

shock or inhalational injury

219
Q

burns

main causes of LATE death
> 48 hours (2)

A

multiorgan failure + sepsis

220
Q

true or false

rule of nines

The difference in % for the head in children is MORE severe*

A

true

head is 18%

adults it is only 9%

221
Q

major burn:

> 10% TBSA (adult) or 20% (age extremes): ___degree

> 10% TBSA (adult: ___ degree

A

2nd degree
3rd degree

222
Q

true or false

electrical burn or inhalational injury
are considered major burns, regardless of degree

A

true

223
Q

burn**

If
patient age + % TBSA
is >____,
that means the patient has a
> 80% mortality

A

> 115

224
Q

mortality ________ with added inhalation injury

A

doubles

225
Q

burns

Suspect ____________ injury until ruled out

A

inhalation

226
Q

burns

true or false

heat in UPPER airway is dissipated, reflex laryngospasm occurs, which CLOSES the airway, so the LOWER airway damage is uncommon

A

true

227
Q

burns

what is LOWER airway damage due to

A

toxins

NOT the hot air/steam

228
Q

gold standard for airway exam for burn

A

fiberoptic

229
Q

true or false

with upper airway damage, EARLY intubation is required, even if asymptomatic

A

true

230
Q

burns

if swelling/obstruction is present, ________ intubation is the best choice

A

AWAKE

231
Q

burns

Progressive air leak around ETT indicates airway swelling is ___________

A

subsiding

232
Q

burn AIRWAY

treatment (3)

A

topicals, ketamine, dex

233
Q

burn AIRWAY

avoid this class of drug

A

avoid NMBs (we want spontaneous ventilation)

234
Q

CO binds to Hgb with 200x the affinity of O2 (______ shift), decreased SaO2 & metabolic acidosis

A

LEFT shift

235
Q

true or false

pulse ox does NOT detect carbon monoxide

A

true

it will be falsely high

236
Q

treatment for carbon monoxide poisoning

100% O2 until CoHgb <___% for ___ hours

A

100% O2 until CoHgb <5% for 6 hours

237
Q

cyanide (HCN) causes metabolic __________

A

acidosis

238
Q

symptoms of cyanide (HCN) toxicity

A

o Changes in LOC
o Seizures
o DILATED pupils
o HYPOtension
o Apnea
o High lactate levels

239
Q

treatment for cyanide (HCN) toxicity

A

Hydroxocobalamin (vitamin B12a)

240
Q

burns

fluid loss is greatest in the FIRST ___ HOURS

A

12 hrs

241
Q

burns

HYPERmetabolism

highest stress response is 1st ___ days after injury

A

3 days

242
Q

burns

HYPERmetabolism

plasma catecholamines are ___-___x higher than usual

A

10-50x higher

243
Q

burns

when does the PRONOUNCED hypermetabolic phase set in

___ hrs post injury

A

48 hours post-injury

lasts up to 2 years following

244
Q

burns

treatment for hypermetabolic phase

A

abx
beta-blockers
warming devices
anti-hyperglycemia
nutrition

245
Q

fluid resuscitation

Parkland***

__ ml LR fluid x TBSA % x kg

over the first ___ hours

A

4ml

example: 70 kg pt with 30% TBSA burn = 8,400 mL

over 1st 24 hours = average of 350 mL/hr

(a lot of fluid!)

246
Q

2 types of fluid resuscitation

A

parkland
modified brooke

247
Q

what type of fluid for parkland resuscitation

A

heavy isotonic crystalloid (LR)

248
Q

parkland resuscitation

children require ________ additionally

A

glucose

249
Q

burns

CV

A

hypovolemia
hypotension
decreased CO

then, hypermetabolic
HTN
tachycardiac

250
Q

burns

pulm

A

decreased function (even with no inhalational injury)

acute lung injury

decreased FRC

decreased compliance

increased capillary permeability, pulm edema, ARDS

251
Q

burns

pulm treatment

A

use low Vt
use low PIP

252
Q

burns

renal

A

myoglobinuria

hemoglobinuria

AKI

253
Q

burns

AKI categorized by RIFLE

A

 Risk
 Injury
 Failure
 Loss
 End-stage kidney disease

254
Q

burns

immune

A

sepsis
pneumonia

255
Q

what is the leading cause of death for burns

A

sepsis

256
Q

burns

GI/nutrition

A

metabolic rate 2x normal

insuline RESISTANCE (hyperglycemia)

ileus

use RSI

257
Q

burns

true or false

if intubated, do NOT stop enteral feedings (transpyloric)/TPN
continue them intraop*

use RSI

A

true!
otherwise, patient will get hypoglycemic fast

258
Q

burns

common guidelines for when to stop debridement (3)

A

1) no more than 20% body surface at a time

2) core temp < 35 C

3) 10 units PRBCs given (approx 3500ml)

259
Q

burns

true or false

even if Hct is normal (30), the patient could be dehydrated, so the Hct would be FALSELY HIGH

a number is just a number, until you put it into perspective of the patient; it doesn’t matter if their Hct is 35 or 45*

A

true

260
Q

burns

anesthesia implications

A

thorough assessment

MINIMALLY safe NPO orders

2 large IVs/CVLs

labs/blood available

INCREASED opioids/NMBs due to hypermetabolic state

warm everything

postop ventilation

261
Q

burns

absolute CONTRAindication

A

Sch

262
Q

burns

fluid/blood replacement

start blood _________

A

as SOON as blood loss begins

KEEP UP AND STAY AHEAD OF THE GAME

263
Q

burns

true or false
they require INCREASED amount of NMB

A

true
due to up-regulation

264
Q

burns

true or false
anesthetic effects may be EXAGGERATED if hypovolemic

A

true

265
Q

burns

true or false
regional should be AVOIDED

A

true

(sympathetic blockade, needle through burned tissue, coagulopathy)

266
Q

burns

when is regional the ONLY good choice (otherwise, avoid it!)

A

children with caudal (lower extremity) burns

267
Q

burns

utilize _______ extubation*

A

AWAKE

268
Q

burns

avoid _________ due to oozing

A

NSAIDS

269
Q

burns

which drug might be a good choice for postop/emergence

A

dex

270
Q

what is the majority of MH from gene ______
chromosome _________

A

RyR1 gene
chromosome 19q13.1

271
Q

MH

true or false

you can have the RyR1 variation, but not have MH

A

true

272
Q

MH

true or false

Up to 50% have had 2 or more UNEVENTFUL GAs in the past!

A

true

273
Q

MH
only < __% have positive family history

A

< 7%

274
Q

causes of MH

A

volatiles (NOT nitrous)
Sch

275
Q

explain MOA of MH

A

depolarization,

opens RyR1,

SUSTAINED calcium release,

cannot be re-uptake into SR fast enough,

sustained muscle contraction,

anaerobic metabolism,

acidosis, hyperthermia,

ATP is depleted

hypoxia, cell death, rhabdo

massive hyperkalemia (cause of death)

276
Q

what is the cause of death for MH

A

massive hyperkalemia

277
Q

MH peak age of incidence

A

3 years old

278
Q

true or false

black box warning for Sch with children

A

true

279
Q

what is the 1st sign of MH

A

hypercarbia

280
Q

what are the EARLY signs of MH

A

hypercarbia (first)
hyperthermia
tachycardia

281
Q

MH

hyperthermia occurs __ degree C every 10 minutes

A

1 degree every 10 min

282
Q

when does MH occur

A

intraop (98%) of the time
or
1st hour postop

283
Q

dantrolene MOA

A

BINDS to RyR1 receptor

promotes closing state
and
calcium reuptake

284
Q

MH

skeletal muscle relaxant properties of dantrolene occur at the ______________ level

A

INTRAcellular (not the NMJ)

285
Q

dantrolene pH

A

9.5

286
Q

dantrolene reduces mortality of MH from >40% to ___%

A

1.4%

287
Q

dantrium

____mg per vial
____ml per vial sterile water

A

20mg per vial
60ml per vial
contains mannitol

288
Q

ryanodex

____mg per vial
____ml per vial sterile water

A

250mg per vial
5 ml per vial

small amount of mannitol (drawback)

289
Q

MH

what 2 types of patients do you use non-triggering anesthetic*

A

For patients with blood relative with known MH
or
a myopathy with high association to MH

290
Q

what are the 3 core myopathies for MH*

A

1) central core
2) multi-minicore
3) king-denborough

291
Q

MH

flush machine with ___ L/min O2

A

10 L/min

292
Q

MH

some machines need up to ____ min of flush time!

A

120

293
Q

anesthesia type for MH patients

A

TIVA
propofol, opioids, non-depolarizer, nitrous

294
Q

what type of thermometer is needed for MH risk patients

A

esophageal
axillary
nasopharyngeal

NOT skin temp

295
Q

1st thing to do when MH is suspected

A

discontinue the agent

296
Q

treatment for MH*

A

discontinue agent

hyperventilate 100% O2 or 10 L/min flow

get help

dantrolene

cooling measures

propofol/benzos

foley

lab tests

bicarb, hyperventilate, insulin (for hyperkalemia)

297
Q

dantrolene BOLUS/LOADING dose

_____ mg/kg

repeat every ___-___ min

A

2.5 mg/kg

5-10 min until symptoms abate

298
Q

dantrolene
dose to prevent reoccurence

___ mg/kg

repeat every ___ hours
for ____-____ hours

A

1 mg/kg

every 6 hours

24-48 hours

299
Q

MH

true or false
NO direct ice on skin

A

true

300
Q

MH

for NON-RESPONSIVE hyperthermia:

A

invasive/internal cooling (chilled NS)

301
Q

MH

stop cooling measures at ___C*

A

38C

302
Q

MH

INSERT FOLEY

keep UOP >__ml/kg/hr*

A

> 2

303
Q

what is CONTRAindicated with dantrolene

A

calcium channel blockers
-pine

304
Q

MH

bicarb dose for acidosis

___-___mg/kg

A

1-2mg/kg

305
Q

MH

gold standard diagnostic test (ONLY ONE)

A

Caffeine Halothane Contracture Test (CHCT)

post-pubescent

306
Q

MH

For a pregnant patient not believed to be at risk for MH, but whose partner is susceptible to MH, which of the following is “Best Practice” *

A

Treat as MHS until delivery of fetus (OKAY TO GIVE Sch** for RSI)

307
Q

Dantrolene ___ mg/kg should be accessible within ___ minutes of the first MH signs*

A

10mg/kg
within
10 min

308
Q

true or false

masseter muscle rigidity after Sch administration could be a sign of MH

A

true

309
Q

true or false

MH can still occur in neonates

and

starting symptoms for children may be different (such as hyperkalemic cardiac arrest)!

A

true

310
Q

later findings of neonate with MH

A

anasarca
mottling
anuria
creatinine kinase 2,900
DIC

311
Q

symptoms of muscular dystrophy

A

muscle weakness
contractures
resp/CV weakness

possible:
learning disabilities
deafness
vision deficits

312
Q

true or false

MH is NOT necessarily linked to musclar dystrophy

A

true

however, AVOID triggers and use TIVA to avoid hyperkalemia, etc

313
Q

most common type of muscular dystrophy

A

myotonic

314
Q

2nd most common type of muscular dystrophy

A

dystrophinopathy

(x-linked recessive)

315
Q

what is the MOST severe phenotype of dystrophinopathy muscular dystrophy*

A

Duchenne Muscular Dystrophy (DMD)

316
Q

what is the less severe phenotype of dystrophinopathy muscular dystrophy

A

becker MD

317
Q

___% of muscular dystrophy has NO family history

A

30%

318
Q

for muscular dystrophy, preop ___ should be drawn

A

CPK, it can be 100x normal

(however, always use TIVA, no matter the results)

319
Q

wheelchair bound before adolescence

A

Duchenne Muscular Dystrophy (DMD)

320
Q

if duchenne muscular dystrophy patient gets triggers, that can cause severe ______________ and _____________, leading to cardiac arrest (30% mortality!!)

A

rhabdomyolysis
hyperkalemia

321
Q

What is a frequent 1st sign of DMD

A

cardiac arrest during inhalational induction

322
Q

for DMD patients,
by ___ years old, serial ______ MUST BE DONE to evaluate cardiomyopathy*

A

8 years old, serial ECHOs

323
Q

treatment for DMD (1)

A

glucocorticoid (prednisone)

324
Q

with down syndrome, up to ___% have CARDIAC DEFECTS

A

50%

VSD, TOF, PDA, AV

325
Q

what can occur upon induction with down syndrome*

A

BRADYCARDIA

326
Q

true or false

downs syndrome
you MUST know cardiac status (ECHO) if non-emergency case

A

true

327
Q

what are the 2 issues with patients with congenital defects*

A

intubation/mask difficulty

cardiac issues (have ECHO)

often have pacemakers, may need a magnet!!

328
Q

what is the MOST DIFFICULT intubation for congenital defects

A

pierre robin

329
Q

cystic fibrosis
symptoms

A

chronic inflammation/infection

hepatic dysfunction/clotting disorders*

OBSTRUCTIVE disease

INCREASED FRC

decreased FEV1
decreased expiratory flow
decreased VC

malnutrition

330
Q

cystic fibrosis

true or false
do NOT dry the patient out

use humidity in the circuit

use SHORT acting agents (des, sevo, remi, prop, atracurium, nimbex)

A

true

331
Q

cystic fibrosis

CONTRAindications (2) *

A

anticholinergics (glyco)

antagonists of NMBs (neostigmine)

332
Q

cystic fibrosis

extubate ______*

A

AWAKE

333
Q

sickle cell anemia

mutant Hgb ___

A

A

(recessive)

334
Q

true or false

sickle cell TRAIT doesnt matter!
we only care about sickle cell DISEASE

A

true

335
Q

sickle cell

acute chest syndrome (ACS) (1)

A

throwing clots/pulm emboli

more likely to occur after surgery, pregnancy, increased age

336
Q

sickle cell

transfuse ONLY to Hct of ___%

avoid over transfusing

A

30%

337
Q

sickle cell

WARM
WET
GREEN***

A

warm: keep them warm

wet: keep them hydrated
CANNOT BE NPO

green: keep them oxygenated

338
Q

for craniofacial abnormalities, what is the best type of airway

A

LMA

339
Q

when you dont know what you are dealing with, _________ the case

A

cancel

340
Q

what are the 4 POTENTIALLY difficult airways for congenital disease***

A

turner’s/noonan’s
apert’s
arthrogryposis
goldenhar

“TAAG”

341
Q

what are the 6 KNOWN difficult airways for congenital disease***

A

pierre robin**
treacher collins*
down’s syndrome
crouzon’s
beckwith/gigantism

342
Q

which 3 congenital diseases do NOT have heart issues

A

pierre robin
crouzon’s
goldenhar
“PCG”

343
Q

VSD heart issue

A

arthrogryposis

344
Q

coarctation of AORTA=females

coarctation of PULM ARTERY=males

A

noonan’s turner’s

345
Q

NORA

ambu bag must be able to inflate >___% O2

A

> 90%

346
Q

what is an important thing for NORA

A

dependable communication devices

347
Q

NORA has _________ incidence of death compared to the OR

(conventional belief)

A

HIGHER death

however, the NACOR thinks NORA has a lower mortality rate!!!

348
Q

> 50% of NORA deaths are _______________

A

preventable, sub-standard care

349
Q

what are most NORA claims related to

A

inadequate oxygenation/ventilation

OVER-sedation, resp depression

350
Q

what is the most common anesthetic technique for NORA

A

MAC

351
Q

for NORA claims related to over-sedation, what is the issue

A

limited ETCO2 monitoring or none at all

moderate and deep require ETCO2!

352
Q

mean age of NORA patients is 3.5 years _________ than OR patients

A

OLDER

353
Q

NORA patients are _______ medically complex than OR

A

more

(there are more ASA III-V)

354
Q

NORA patients are _______ likely to be discharged earlier than OR patients

A

MORE likely to be discharged

355
Q

MRI challenge:
distance between patient and anesthesia machine

A

> 1 person needed for airway management

356
Q

what is a difference in NORA and OR staff

A

uncertainty how to delegate during a crisis

357
Q

MRI

Radiofrequency radiation emitted by MRI scanners is absorbed by the patient as heat energy, which can cause _____

A

burns

358
Q

magnet strength is measured in ________

A

teslas (T)

359
Q

most common teslas

A

1.5 and 3 T

360
Q

true or false

teslas
the larger the number (T), the stronger the MRI, the clearer the pictures, but the higher the risks

A

true

361
Q

MRI
4 zones: ____T - ___T

A

0.5T-4T

362
Q

most common NORA adverse outcomes (minor) (3)

A

PONV
pain
hemodynamic instability

363
Q

Highest NORA mortality categories (2)

A

cardiology and radiology

364
Q

highest NORA adverse outcomes

A

GI endoscopy (might be related to sheer volume of cases though!)

365
Q

NORA has a ________ amount of emergency procedures

A

greater

366
Q

NORA
true or false

preop evaluation must occur
+
must check for proper equipment

A

true

367
Q

NORA
prone or lateral positions (2)

A

GI procedures
ERCP

368
Q

primary process leading to CAD, stroke, extremity ischemia, and aneurysms

A

atherosclerosis

369
Q

where does atherosclerosis form

A

o Coronary arteries

o Carotid bifurcation (laminar flow changes to turbulent flow)

o Infrarenal abdominal aorta

o Iliac arteries

o Superficial femoral artery

370
Q

atherosclerosis
What are the reasons for the ultimate injury (3)

A

plaque enlargement (reduced blood flow)

embolism of plaque (thrombi)

advanced plaque (occlusion)

371
Q

risk factors for atherosclerosis

A

o Smoking (8x more likely)
o Hyperlipidemia
o Diabetes
o HTN (60%)
o Family history
o Male
o Advanced age
o Insulin resistance
o Physical inactivity
o Elevated C-reactive protein, elevated lipoprotein

372
Q

3 types of Arteriosclerosis

A

infrarenal
thoracoabdominal
descending thoracic

373
Q

1 type of cystic medial necrosis

A

degeneration of aortic media
(ascending aorta)

374
Q

ELECTIVE AAA repair mortality rate ___%

A

5%

1-11%

375
Q

surgery is recommended for AAA diameter

A

4 to >5.0!!! cm

376
Q

RUPTURED AAA mortality rate ___%

A

75%

35-94%

377
Q

PREhospital mortality rate of ruptured AAA

A

80-90%

378
Q

AAA grow ___mm a year

A

4 mm

even with treatment

379
Q

untreated mortality rate AAA

5 year

A

81%

380
Q

untreated mortality rate AAA

10 year

A

100%

381
Q

law of LAPLACE*

A

T = P x r

tension = pressure x radius

382
Q

<4 cm rupture risk

A

0%

383
Q

4-5cm rupture risk

A

0.5-15%

384
Q

5-6cm rupture risk

A

3-15%

385
Q

6-7cm rupture risk

A

10-20%

386
Q

7-8cm rupture risk

A

20-40%

387
Q

> 8cm rupture risk

A

30-50%

388
Q

Originates in the proximal ascending aorta and usually involves the ascending aorta, arch, and can go to abdominal aorta

A

DEBAKEY
Type 1

389
Q

o Confined to the ASCENDING aorta

A

DEBAKEY
Type 2

390
Q

o Confined to the DESCENDING thoracic aorta

A

DEBAKEY
Type 3a

391
Q

DESCENDING thoracic aorta

May extend into the abdominal aorta and iliac arteries

A

DEBAKEY
Type 3b

392
Q

o The ASCENDING aorta is involved, with or without the ARCH or the DESCENDING aorta

A

STANFORD
Type A

393
Q

o The DESCENDING thoracic aorta is involved, with or without PROXIMAL or DISTAL extension

A

STANFORD
Type B

394
Q

Where do aneurysms occur most commonly (2)

A

ascending thoracic aorta (close to aortic valve)

descending thoracic aorta (distal to L subclavian artery)

395
Q

AAA major causes of death (4)

A

MI* (40-70%)
resp failure
renal failure
stroke

396
Q

cross-clamping

hemodynamics depend on (3)

A

site of clamp
preop cardiac reserve (LV)
intravascular volume

397
Q

during cross-clamping

cardiac
INCREASED

A

afterload
wall tension
MAP
SVR
preload
coronary flow

LVEDP (wedge): poor patients only

398
Q

during cross-clamping

cardiac
UNCHANGED

A

HR

CO (good LV function)
LVEDP (wedge): good patients

399
Q

during cross-clamping

cardiac
DECREASED

A

CO (lousy/bad LV!)
LVEDP

400
Q

HTN occurs ______ the cross-clamp, hypotension occurs _________

A

HTN=above
hypotension=below

401
Q

the longer the __________ of the cross clamp, the GREATER the INCREASE in SVR and DECREASE in CO

A

duration

time matters!

402
Q

the ________/_________ the cross-clamp is placed, the GREATER the hemodynamic effect

A

HIGHER/MORE PROXIMAL

“the closer to the heart, the bigger the impact”

403
Q

infrarenal __________ effect

suprarenal/infraceliac ____________ effect

supraceliac ___________ effect

A

infrarenal=LOWEST effect

suprarenal/infraceliac= MODERATE effect

supraceliac= GREATEST effect

404
Q

proximal = ________ the cross-clamp

A

ABOVE

405
Q

if splanchnic venous tone is HIGH, preload will _________

A

increase

406
Q

if splanchnic venous tone is LOW, preload will _________

A

decrease

407
Q

cross-clamp

increased pulm HTN/wedge + increased permeability =

A

pulm edema

408
Q

cross-clamp

pulm damage related to (4)

A

hypervolemia

metabolites: prostaglandins, free radicals (bronchoconstriction)

activation of renin-angiotensin (BP rises)

complement cascade (inflammation)

409
Q

INFRArenal cross-clamp:
renal blood decreased ____%

A

40%

410
Q

INFRArenal cross-clamp:
renal vascular resistance increased ____%

A

75%

411
Q

SUPRArenal and JUXTArenal:
renal blood flow is decreased ___%

A

80%

412
Q

cross-clamp

renal failure is due to

A

reperfusion injury (acute tubular necrosis)

413
Q

cross-clamp

where does damage occur for spinal cord

A

artery of adamkiewicz occlusion

414
Q

cross-clamp

spinal cord: no collateral flow to _________ portion of spinal cord (_________)

A

ANTERIOR, MOTOR is injured

415
Q

true or false

somatosensory evoked potential (SSEP) does NOT provide info about anterior spinal cord/motor

A

true

it is sensory/posterior ONLY

416
Q

o Anterior Spinal Syndrome

 Elective infrarenal ___%

A

0.2%

417
Q

o Anterior Spinal Syndrome

 Ruptures of the descending aorta ____%

A

40%

418
Q

artery of adamkiewicz is found where

A

T5-L2

origin is unknown

419
Q

spinal cord perfusion = _____ - _____**

A

MAP - CSF pressure

to help perfusion, you want to either:
INCREASE MAP
or
DECREASE CSF

420
Q

how to prevent spinal cord injury

limit cross clamp time to ____ min

A

30 min

421
Q

spinal cord injury
prevention:

A

drains (best option)

30 min or less

shunt (retrograde flow)

HTN

methylprednisone

HYPOthermia

AVOID hyperglycemia

mannitol

422
Q

what temp do you want patient for reduced spinal cord injury

A

30-32 C

423
Q

signs of spinal cord injury
(2)

A

motor function loss
pinprick sensation loss

preserved: vibration and proprioception

424
Q

DURING the cross-clamp ______________ ALKALOSIS
central/proximal portion

A

RESPIRATORY

distal

425
Q

DURING the cross-clamp ______________ ACIDOSIS
DISTAL/periphery portion

A

metabolic

426
Q

cross-clamp
__________ total body O2 extraction

A

decreased

427
Q

cross-clamp
___________ SvO2*

A

INCREASED

428
Q

cross-clamp
____________ catecholamines

A

INCREASED

429
Q

NTG (nitroglycerin) reduces __________ *

A

preload/venous

effects O2 consumption (improves supply/demand)

430
Q

Nipride reduces ___________*

A

afterload

potentially improve CO

431
Q

DURING cross-clamp, keep them _______volemic

A

normo (goal directed)

432
Q

DURING cross-clamp, ___________ mV

A

DECREASE (due to ETCO2 being lower)

433
Q

Milrinone decreases ___________*

A

afterload

434
Q

DURING cross-clamp, you want the patient _____thermic

A

hypo

435
Q

AFTER/RELEASE of cross-clamping

DECREASED:

A

afterload/SVR
MAP
preload
wedge (PCWP)
pH
temp

436
Q

AFTER/RELEASE of cross-clamping

what can increase, have no change, or decrease?

A

CO

dependent on LV

437
Q

AFTER/RELEASE of cross-clamping

INCREASED

A

ETCO2

438
Q

after unclamping, hypotension shock syndrome can involve myocardial ____________ factors

A

depressant

decreased myocardial contractility

439
Q

what can happen to the lungs AFTER cross-clamp

A

pulm edema

(increased permeability, mediator washout)

440
Q

Wedge (PCWP) should be ____________ by ___-___ mmHg from PRECLAMP values

A

INCREASED by 3-4 above PRE-clamp values

this is to help with hypotension

441
Q

AFTER release of cross-clamp

intraop interventions:

A

Increase Mv

use bair hugger

decrease anesthesia/vasodilation

increase fluids

consider mannitol

bicarb

442
Q

what is a big challenge with cross-clamp release

A

fluid management

potential for blood loss

443
Q

cross-clamp AFTER

maintain UOP ___ml/kg/hr*

A

1

goal-directed

444
Q

what is the best prevention of renal failure

A

preventing hypovolemia

445
Q

___-___ min PRIORRRRR to cross-clamp, give mannitol ____GM/kg

A

20-30 PRIOR
0.5*** gm/kg

446
Q

dopamine for cross-clamp dose

___-___ mCg/kg/min

A

3-5 mCg/kg/min

447
Q

use ________-sided aline for DESCENDING THORACIC

A

RIGHT=descending

448
Q

PA cath looks at the _____ side

A

LEFT

449
Q

best leads for EKG

A

II, V5

450
Q

which congenital disorder has “no chin” or micrognathia

A

pierre robin (most difficult intubation)

451
Q

what is the best type of anesthesia for AAA

A

combined! general + regional

452
Q

regional for AAA requires ______-______ml MORE IV FLUID

A

1600-2000ml more

453
Q

what are the 3 high risk AAA

they will need ventilation/intubation postop!

A

1) ascending aorta
2) aortic arch
3) thoracic aorta

454
Q

who is more at risk for RUPTURED AAA

A

older
women
non-white
comorbidities (CHF, renal failure, valve disease)
insurance status

455
Q

what is the best fluid (to get volume in fast) for RUPTURED AAA

A

crystalloids

456
Q

what 2 vascular repairs require CPB (cardiopulm bypass)

A

ascending aorta
aortic arch

457
Q

use ______sided aline for ASCENDING aorta

innonminate (brachiocephalic artery) clamped

A

LEFT=ascending

458
Q

avoid ________cardia with aortic regurgitation

A

bradycardia

we dont want it!
due to the slow diastolic time

459
Q

aortic arch repair: use hypothermia ___-___ C

A

15-18 C

protects brain

460
Q

true or false

DESCENDING thoracic surgery does NOT use CPB

A

true

461
Q

true or false

DESCENDING thoracic has GREATERRR risk/effects of cross-clamp, ischemia, renal insufficiency
compared to abdominal (AAA)

A

true

462
Q

____________ thoracic requires ONE LUNG ventilation (double-lumen tube)

A

descending

463
Q

mesenteric traction syndrome

high concentrations of ____

symptoms (4)

A

F1a (prostaglandin)

decreased BP/SVR
tachy
increased CO
facial flushing

464
Q

peripheral vascular disease

what is the best anesthesia option

A

regional (sympathectomy allows for better perfusion)

465
Q
  • What is the most significant factor predicting postop stroke incidence
A

PREop neuro dysfunction

466
Q

CEA

PERIoperative strokes

___% in asymptomatic patients
___% in symptomatic patients (TIAs)
___% in existing strokes

A

3% in asymptomatic patients

5% in symptomatic patients (TIAs)

10% in existing strokes

467
Q

CEA

OR mortality

___-___%

A

0.5-2.5%

468
Q

what is mortality for CEA patients due to

A

myocardial infarction

469
Q

increased risks CEA (6)

A

o Age >75

o Symptomatic lesions

o Uncontrolled HTN

o Angina

o Carotid thrombus

o Occlusions near the CAROTID SIPHON

470
Q

you want _____tension for patients who are getting a CEA intraop

A

HTN! (for perfusion)

neo

471
Q

cerebral protection for CEA drugs (3)

A

barbiturates
propofol
dex

passive HYPOthermia!

472
Q

HTN shifts autoregulation to the _______

A

RIGHT (higher)

473
Q

CPP =

A

MAP - ICP

474
Q

gold standard monitoring for CEA

A

awake

EEG

475
Q

indicator of neuro dysfunction:

loss of ____ wave activity
emergence of _____ wave

A

loss of BETA
emergence of SLOW

loss of amplitude

476
Q

carotid stump pressure
< ___ needs a shunt!

A

< 50 mmHg

477
Q

inhalational agents at >___ MAC interfere with assessment of EEG/SSEP

A

> 1 MAC avoid this

478
Q

best anesthetic choice for CEA

A

there is no difference in outcome!

479
Q

CEA

carotid sinus _______________ causes HYPOtension

A

baroreceptor

480
Q

CEA

drugs for HYPOtension (3)

A

LA
ephedrine
neo

481
Q

CEA

carotid sinus _______________ causes HTN

(and decreased response to hypoxemia)

A

denervation

often, postop

482
Q

CEA

while cross-clamp is ON, KEEP SBP >____

A

> 150

483
Q

CEA

after cross-clamp is OFF, KEEP SBP <____

A

<140

484
Q

CEA

postop, SBP >____ is associated with higher incidence of stroke or MI

A

> 180

485
Q

EVAR is most beneficial for _____-risk patients*

A

HIGH

486
Q

where is EVAR performed

A

IR
OR

487
Q

EVAR 1

criteria
____cm
>___years old

A

5.5cm

> 60 years old

488
Q

DREAM
for EVAR

criteria
___cm

A

5cm

489
Q

EVAR

patient criteria

renal arteries should be >___cm away from TOP of aneurysm

A

> 1.5 cm

490
Q

EVAR

patient criteria

aortic bifurcation should be >___cm away from DISTAL end of aneurysm

A

> 1 cm

491
Q

EVAR

femoral artery should be able to handle introducer or at least ___ Mm diameter

withOUT tortuosity

A

8 Mm

492
Q

EVAR

ACT >____ seconds

Heparin ___-___ units/kg

___fr sheath

A

> 300 seconds

50-100 units/kg

12 fr sheath

493
Q

EVAR

PRIOR to graph attachment/balloon expansion, REDUCEEE
the SBP to ____ mmHg and MAP to ___mmHg during balloon inflation

A

SBP 100
MAP 60

during balloon inflation

494
Q

EVAR

where is ischemia most likely to occur

A

distal (check peripheral pulses)

495
Q

EVAR

Persistence of blood flow outside the graft; or between the graft and the aneurysmic vessel wall

biggest complication*

A

endoleak

496
Q

EVAR

endoleak

inadequate seal

Type __

A

Type 1

497
Q

EVAR

endoleak

retrograde flow

Type __

A

Type 2

498
Q

EVAR

endoleak

tear or defect, leak

Type __

A

Type 3

499
Q

EVAR

endoleak

porous graft flow

Type __

A

Type 4

500
Q

EVAR

you want normothermia, normotensive except when

A

inflating balloon (then reduce it)

501
Q

EVAR

kidney damage is due to

A

contrast

(it is NOT a perfusion issue)

502
Q

EVAR

_____ is CONTRAindicated with pulm comorbidities

A

GA

503
Q

EVAR

what is the ONLY difference between GA and regional outcomes

A

length of hospital stay

longer for GA

504
Q

parkland, how do you split up the fluid in 1st 24 hours

A

1/2 in the first 8 hours
1/2 in the last 16 hours

505
Q

parkland

2nd 24 hours, what do you do

A

D5W at maintenance rate with colloid 0.5 mL/% TBSA/kg

506
Q

avoid _________________ with CF

A

glycopyrollate

507
Q

LOUSY LV = decreased CO =

A

decreased coronary flow, decreased heart contractility

508
Q

cross-clamp = GOOD LV = increased CO =

A

increased coronary flow, increased heart contractility

509
Q

cross clamp = ____________ venous capacitance

A

DECREASED

510
Q

Pulm vascular resistance goes ____ when UNclamping

A

goes UP

511
Q

CROSS CLAMP: ABG

A

respiratory ALKAlosis

512
Q

AFTER cross clamp: ABG

A

metabolic acidosis