Exam 1 Flashcards
What are some examples of respiratory muscle dysfunction?
respiratory muscle fatigue, chest wall abnormalities, neuromuscular disease
What are some oxygen abnormalities that are indications for mechanical ventilation?
refractory hypoxemia, need for positive end- expiratory pressure (EEP), and excessive work for breathing
What are the different types of ventilator breaths?
volume-cycled breath, time-cycled breath, and flow-cycled breath
What is a volume cycled breath?
“Volume breath” with a preset tidal volume. Volume controlled systems of ventilation are based on a measured volume variable which is set by the clinician. When the ventilator detects the set volume having been applied the ventilator cycles to exhalation.
What is a time cycled breath?
“Pressure control breath”, there is constant pressure for preset time
What is a flow-cycled breath?
“Pressure support breath”, it is constant pressure during inspiration
What is NPPV?
noninvasive positive pressure ventilation
What are the goals of mechanical ventilation?
adequate ventilation and oxygenation, decreased work of breathing, and patient comfort and synchrony
What does CPAP stand for and what does it do?
Continuous positive airway pressure, no machine breaths are delivered here, it allows spontaneous breathing at elevated baseline pressure and the patient controls the rate and tidal volume
What is pressure support ventilation?
Pressure assist during spontaneous inspiration with flow-cycled breath. Pressure assist continues until inspiratory effort decreases, Delivered tidal volume dependent on inspiratory effort and resistance/compliance of lung/thorax.
What are the advantages of pressure support ventilation?
patient comfort, decreased work of breathing, may enhance patient-ventilator synchrony, and used with SIMV to support spontaneous breaths
What are the disadvantages of pressure support ventilation?
Variable tidal volume if pulmonary resistance/compliance changes rapidly, if sole mode of ventilation-apnea alarm mode may be only backup, and gas leak from circuit may interfere with cycling
What is synchronized intermittent mandatory ventilation?
Volume or time cycled breaths at a preset rate, additional spontaneous breaths at tidal volume and rate determined by patient and it’s used with pressure support
What are the advantages of synchronized intermittent mandatory ventilation?
It is more comfortable for some patients and there are less hemodynamic effects.
What is the disadvantage of synchronized intermittent mandatory ventilation?
Increased work of breathing
What is controlled mechanical ventilation?
Preset rate with volume and or time cycled breaths and there is no patient interaction with the ventilator
What is the advantage of controlled mechanical ventilation?
rests muscles of ventilation
What are the disadvantages of of controlled mechanical ventilation?
Requires sedation/neuromuscular blockade, potential adverse hemodynamic effects
What is inspiratory plateau pressure?
Airway pressure measured at end of inspiration with no gas flow present, estimates alveolar pressure at end-inspiration, and it’s an indirect indicator of alveolar distension
What could happen during high inspiratory plateau pressure?
Barotrauma, volutrauma, and decreased cardiac output
What are the methods to decrease inspiratory plateau pressure?
Decrease PEEP and and decrease tidal volume
Inspiratory time determinants with volume breaths are what?
Tidal volume, gas flow rate, respiratory rate, and inspiratory pause
Expiratory time is determined passively, true or false
true
What is the spontaneous breathing ratio for inspiratory and expiratory?
inspiratory time:expiratory time
What is the inspiratory:expiratory ratio during mechanical ventilation?
Expiratory time is too short for expiration and you need to reduce auto-PEEP by shortening inspiratory time
What is auto peep?
Auto-PEEP is gas trapped in alveoli at end expiration, due to inadequate time for expiration, because of bronchoconstriction or mucus plugging. It increased the work of breathing. It has potential harmful physiologic effects.
How do you reduce auto peep by shortening inspiratory time during mechanical ventilation?
decrease respiratory rate, decrease tidal volume and increase gas flow rate
When would you see permissive hypercapnia?
Severe asthma and ARDs
Permissive hypercapnia is contraindicated in what?
increased intracranial pressure
Can auto peep be measured on some ventilators?
Yes
What does auto peep increase?
increases peak, plateau, and mean airway pressures
Peak inspiratory pressure initiated at 1_____ H2O in Pediatric ventilation (<5 kg)
18-20 cm
time cycled, pressure limited ventilation is good for pediatric ventilation (<5 kg), true or false
true
Adjust to adequate chest movement or exhaled tidal volume ~_____mL/kg is good for pediatric ventilation (<5 kg)
Adjust to adequate chest movement or exhaled tidal volume ~8 mL/kg
Low level of PEEP (______cm H2O) to prevent alveolar collapse is good for pediatric ventilation (<5 kg)
Low level of PEEP (2–4 cm H2O) to prevent alveolar collapse is good for pediatric ventilation (<5 kg)
Flow rate adjusted to yield desired inspiratory time Infants ______ secs Toddlers ______ secs Older _______ secs
Flow rate adjusted to yield desired inspiratory time Infants 0.5–0.6 secs Toddlers 0.6-0.8 secs Older 0.8–1.0 secs
When initiating mechanical ventilation, what should the initial tidal volume be?
8-10 mL/kg
To avoid high IPP, what should you lower the tidal volume to?
5-8 mL/kg
What is PEEP?
Abbreviation for positive end-expiratory pressure. A method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation by means of a mechanical impedance, usually a valve, within the circuit. The purpose of PEEP is to increase the volume of gas remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange. PEEP is done in ARDS (acute respiratory failure syndrome) to allow reduction in the level of oxygen being given
Initiation of mechanical ventilation starts with ____ cm H20
Typically start with 5 cm H2O; Levels > 15 cm H2O rarely needed
What are the variables usually set by the respiratory care practitioner?
Alarms – high and low pressure, low volume, apnea Humidifier temperature Inspiratory flow rate with volume ventilation
What tests do you do and rates you evaluate after initiating mechanical ventilation for someone?
Chest radiograph Inspiratory plateau pressure Exhaled tidal volume and rate Patient-ventilator synchrony Auto-PEEP SpO2 and arterial blood gas measurement Hemodynamic status
What are the primary variables for oxygenation PaO2?
FlO2 and mean airway pressure
What are the primary variables for ventilation PaCO2?
Tidal volume, Respiratory rate and dead space
What are the possible harmful consequences of mechanical ventilation?
Potential oxygen injury to lung Barotrauma/volutrauma Damage in more compliant lung zones due to high airway pressure/volume Hemodynamic compromise due to high intrathoracic pressure
What are the challenges in laparoscopic surgery?
Depth perception Limited space with in trocar for manipulation Suturing Electrosurgical safety
What are the benefits of laparoscopic surgery?
Reduces morbidity, handling of bowel, adhesion formation and exposure to drying and bacteria
What is a trocar?
a sharp-pointed surgical instrument fitted with a cannula and used especially to insert the cannula into a body cavity as a drainage outlet
What is a morecellator?
a surgical instrument used for division (“morcellation”) and removal of large masses of tissues during laparoscopic surgery.[1] It can consist of a hollow cylinder that penetrates the abdominal wall, ending with sharp edges[1] or cutting jaws,[2] through which a grasper can be inserted to pull the mass into the cylinder to cut out an extractable piece.
What is a harmonic scalpel?
a cutting instrument used during surgical procedures to simultaneously cut and coagulate tissue.
What is hydrodissection?
injection of a small amount of fluid into the capsule of the lens for dissection and maneuverability during extracapsular or phacoemulsification surgery
What area of the body are you doing surgery on when the patient is in the trendelenberg position laparoscopically?
pelvic
When the patient is supine, what area of the body are you doing surgery on laparoscopically?
small and large bowel
What position is the patient in when doing surgery laparoscopically on the stomach, liver and spleen?
head up tilt
What position is the patient in when doing surgery laparoscopically on the paracolic gutters?
lateral tilt
How do you prep the patient for surgery? In what areas?
The entire, anterior abdominal wall should be prepped from mid thigh to the nipple line and as lateral as possible. All patients must be properly grounded.
What kinds of tubing do you use on the patient while prepping for surgery?
Nasogastric intubation Bladder catheterization
When do we induce a pneumoperitoneum and how do we do it?
A pneumoperitoneum is deliberately created by the surgical team in order to perform laparoscopic surgery. This is achieved by insufflating the abdomen with carbon dioxide. CO2 is absorbed from the peritoneum and excreted from the lungs.
Why do we need a pneumoperitoneum during laparoscopic surgery?
its a visual field
What is the optimum exposure for a pneumoperitoneum?
About 12.0-16.0 mmHg- must be maintained
The most common access into the intra abdominal cavity is with what type of needle?
The most common access into the intra-abdominal cavity is with a Veress needle is the sub-umbilical area. The anterior abdominal wall is elevated to distance it from the intra-abdominal contents. 1 mm incision is made with a # 11 Scalpel below the umbilicus.
What do you palpate before beginning laparoscopic surgery?
aorta
What does a primary trocar do?
Primary trocar Introduced subq 2-3 cm the angled 45 degrees towards sacrum Remove trocar & introduce telescope
What does a secondary trocar do?
Secondary trocar Placed under direct visualization
What are ports and where are they placed during laparoscopic surgery?
In medicine, a port (or portacath) is a small medical appliance that is installed beneath the skin. A catheter connects the port to a vein. Under the skin, the port has a septum through which drugs can be injected and blood samples can be drawn many times, usually with less discomfort for the patient than a more typical “needle stick”. They are placed laterally.
Where are adhesions placed during laparoscopic surgery? What are adhesions?
9th intercostals space, anterior axillary line- adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.
What is a complication that occurs with a trocar site?
Controversial because hernias are related to multiple ports
Where are some common areas you see complications after laparoscopic surgery?
Shoulder pain, bowel, vascular, bladder, neuropathic and port site mets
What is the most common vascular injury during laparoscopic surgery? Insufflation occurs to what mm Hg?
Retroperitoneal hemorrhage most common Insufflation to 8.0 mmHg Check entire peritoneal cavity If + immediate midline lap Compress/clamp vessels, aspirate blood Replace blood- use the blood bank Call for vascular surgeon
William T. Bowie-refined electrical generator has what kind of current? What does it do?
VHF current→localized heating and tissue destruction. Can cut or coagulate
What is the most electrical generator? Why is the name misleading?
Monopolar-Most common-circle with the patient in the middle so current passes through the patient. Really not “mono” as there are active and return electrodes. Electrode may touch tissue or a clamp on the vessel. Monopolar coagulates, cutes pure and blends (argon (non-contact) and contact)
High frequency electrosurgical dissection- what are the different kinds?
Bipolar and Monopolar current
How does the monopoloar circuit flow in the electrical generator?
passes through an “active” electrode, crosses the patient’s body, and goes back to the electro-generator through a “passive” electrode
How does a bipolar circuit flow in the electrical generator?
Active and return electrodes are present in the same instrument. Allows heating of a very discrete amount of tissue.
What is bipolar cautery?
A surgical procedure involving bipolar cautery uses electrical current through a medical device, which generally cuts through human tissue and or seals bleeding vessels. Surgeons often combine this type of surgical instrument simultaneously with some type of fluid irrigation that to control the amount of tissue damage occurring during surgery. A number of medical fields typically use bipolar cautery including dentistry, general surgery and neurosurgery.
Electrosurgery performs what 3 things?
Cut (vaporization), fulgurates and dessicates
What is pure cutting?
Continuous Sine wave of current-instant vaporization Relatively low voltage Best with very small (needle) tip held just off the tissue to be cut Minimal coagulation and homeostasis, Minimal lateral tissue damage
What is blend cutting?
Less cell explosion Moderate desiccation
How does the process of coagulation work during surgery?
There is no constant waveform Debris heat up and denatures protein Desiccation or fulguration Causes deeper tissue injury than cut
What are the qualities of dessication during surgery?
Tip in direct contact with tissue Less heat, no cutting action Achieved with the “cutting” current at low power
What are the qualities of fulguration during surgery?
Tip not in direct contact with tissue Current arcs to the target Eschar formed High voltage but low frequency (The greater the heat generated with any of the methods, the greater the collateral damage.)
What is an argon beam coagulator?
Uses ionized argon gas to conduct monopolar RF current to tissue Pinpoint or spray modes Pluses-less eschar and smoke-good for wide area coagulation (liver) Minuses-can’t cut, can overheat. Can raise intraabdominal pressure when used in laparoscopy (7 liters/min)
How does a ultrasonic scalpel work?
Transducer produces vibrations around 55,000 cycles/sec. Cellular friction denatures proteins Less heat production than electrosurgery Cavitation along cell surfaces→ vaporization/cell rupture
What are the advantages of a ultrasonic scalpel?
Good in tight spaces (Laparoscopy) No risk of current “arcing” No neuromuscular stimulation Minimal lateral thermal damage No eschar/smoke Can be used in pts. with defibrillators
What is the diadvantage of an ultrasonic scalpel?
Expensive, can’t be used efficiently except for certain parts of cases, tend to break down
What are some electrosurgery problems?
Alternate Site Burns Surgical Fires Trocar burns in minimally invasive surgery Poor grounding + EKG pad = burn Fetal stimulation Pacemaker (Interfere, burn. damage device) Bowel explosion?
What can you use during electrosurgery to minimize risk of trocar burns?
using all metal cannulas
What is a Implantable Cardioverter Defibrillator?
a small battery-powered electrical impulse generator that is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation and ventricular tachycardia. The device is programmed to detect cardiac arrhythmia and correct it by delivering a brief electrical impulse to the heart.
What problems can you run in to during electrosurgery with someone who has a implantable cardioverter defibrillator?
triggers device, damages it or asystole
What should you ask about when taking a history from someone who needs surgery?
Pain: scale 1-10, type of pain, radiation Change in bowel or urinary habits: diarrhea, constipation, vomiting Trauma: must know precise details of trauma related to injury Past Medical History Medications, especially herbals and OTCs Social History: nutritional status, EtOH, smoking, illicit drug use Family History
What does AMPLE stand for?
allergies, meds, past medical hx, last meal, and events to emergency
What are the essential steps for physical exam before surgery?
inspection, palpation, auscultation (IPA)
What are some factors predisposing patient to surgery- and anesthesia-related pulmonary complications?
-COPD (asthma, chronic bronchitis, occupational lung diseases) -Obesity -Tobacco history -Neuromuscular disease -Nutritional depletion -Coma -Age
When someone has a pulmonary disease, what should the pre-op evaluation include?
Pre-op evaluation should include -baseline ABG on room air -O2 sat with pulse oximetry - pre-op PFTs
Aim of pre-op treatment for someone with pulm disease is to optimize pt’s pulmonary perfusion and may include what?
-nebulizer treatments w/ Beta agonists -steroids -chest PT
What are some screening pulm function tests for someone with pulm disease before surgery?
Screening pulmonary function tests: FVC (forced vital capacity) and FEV1 (forced expiratory volume in 1 second) If < 50% predicted then likely significant airway disease and high risk of complications
What helps clear secretions in someone with pulm disease before surgery?
Bronchodilators with twice-daily chest PT and postural drainage, it help clear secretions
What are some neuropathies in diabetics that can cause problems in surgery?
Gastroparesis - chance of aspiration Sinus tachycardia secondary to autonomic cardiac neuropathy Neurogenic bladder Most are temporary problems and resolve in recuperative period
Pre-operatively, what kind of information do you get from diabetics?
Need careful history including -duration of diabetes -insulin requirements – last dose? -diet -level of blood sugar control -history of angina, MI, arrhythmias -history of diabetic ulcers on feet or legs
How do you monitor a diabetic while in surgery?
Accuchecks bid or qid, sliding scale for insulin doses Care of feet and extremities to prevent skin breakdown (i.e., hygiene, foot cradles, lambs wool, heel pads, etc.)
Hyperthyroidism patients can have what surgical complications?
Hyperthyroidism can cause increased risk of cardiac arrhythmias, especially a-fib
Hypothyroidism patients can have what surgical complications?
Hypothyroidism is associated w/ decreased hepatic metabolism, which can cause reduced drug metabolism -occasionally see hypotension
Cirrhosis: mortality from surgery in cirrhotic pts. 10-80% depending on hepatic impairment. Complications include what?
-coagulopathies -decreased drug clearance/metabolism -encephalopathy, seizures, DTs -increased risk of intraperitoneal sepsis -electrolyte abnormalities -infection, poor healing -changes in glucose production/metabolism
When discussing coagulation abnormalities in patients what do you ask them when getting their history? What labs and physical exam components are included?
-easy bruising -excessive bleeding after minor surgical procedures -family history of bleeding problems -history of liver disease -meds (especially ASA) Physical exam -look for bruises, petechiae, hepatosplenomegaly, severe malnutrition Pre-op evaluation -PT, PTT, bleeding time if any questions
In chronic renal failure, what peri-operative problems could occur?
Chronic renal failure is associated w/ multiple peri-operative problems -fluid and electrolyte control, especially Na+ and K+ -chronic metabolic acidosis -chronic anemia -poor nutritional state -coagulopahty
Pre-operatively, what should you obtain in the history for a patient with chronic renal failure?
Pre-op evaluation -baseline weight -baseline electrolytes, BUN, Cr -baseline coagulation profile -nephrology consult to optimize fluid/electrolyte balances and proper dosing of peri-operative meds
What pre-op labs should you obtain for someone with chronic renal failure?
-CBC w/ diff -Chem 7 (electrolytes, glucose, BUN, Cr) -UA -EKG (50+) -Chest x-ray (50+)
What are some pre-op orders for any patient? What do you tell them to do and what to you give them?
NPO after midnight Pre-op antibiotics IV if necessary Consent for operative procedure Labs Type & screen or crossmatch Skin prep (i.e., betadine shower) Pre-op enema Pre-op meds Sleeping med (usually ordered by anesthesia) Pre-op sedation
Pre-op and peri-op patient orders include what? (ADCADVA-IMLNCP)
Admit: to Dr.___ or to a service (i.e.,Blue Service) Dx: reason patient was admitted Condition: fair, guarded, serious, critical, etc. Allergies: drug allergies, also food/env. allergies Diet: NPO, full liquids, clear liquids, 1800 cal ADA, etc. Vitals: per routine or however often is necessary Activity: bed rest w/wo BR privileges, OOB to chair, etc.3 IV: type and rate +/- any additives Meds: patient’s normal meds plus analgesics, etc. Labs: bloodwork, CXR, EKG, CT scan, etc. Nursing: dressing changes, I/Os, daily weights, etc. Consults: medicine, social services, PT Parameters: call MD or HO for - SBP101.5 - Pulse 110 - Urine Output 30
What does ADC-VAN-DIS-AL stand for writing the orders and needs of a patient pre and perioperatively?
A - admit D - diagnosis C - condition V - vitals A - allergies N - nursing D - diet I - IVs, I/Os S - special orders (i.e., consults) A - activity L - labs
What information does a pre-op note have?
Date, One sentence detailing significant past medical history and procedure (Example: 79 yo W female, h/o HTN, IDDM x 1yr, for cholecystectomy) Meds/Allergies H&P: done/dictated Anesthesia:done Labs:WBC, Hct, Plt, Na, K, Cl, HCO3 Bun, Cr, Gluc, ABG, PT/PTT Imaging/Studies: EKG, CXR Type & hold/crossmatch/autologous blood available Operative consent: signed or ordered Signature, Title Time/Date
What are the proper monitors for mechanical ventilation?
ECG, SpO2, and vital signs
What is FIO2?
fraction or percentage of oxygen in the space being measured. Medical patients experiencing difficulty breathing are provided with oxygen-enriched air, which means a higher-than-atmospheric FiO2. Natural air includes 20.9% oxygen, which is equivalent to FiO2 of 0.21. Oxygen-enriched air has a higher FiO2 than 0.21, up to 1.00, which means 100% oxygen.[1] FiO2 is typically maintained below 0.5 even with mechanical ventilation, to avoid oxygen toxicity.[2]
What is initial FIO2 for mechanical ventilation?
1.0
You decrease initial FIO2 (1.0) to maintain a certain SpO2 range of what?
SpO2 > 92% to 94%
What is the initial tidal volume at the beginning of mechanical ventilation?
8-10 mL/kg
Why should you lower the tidal volume in mechanical ventilation?
to avoid IPP (inspiratory plateau pressure?), lower to 5-8 mL/kg
When setting rate and minute ventilation appropriate for clinical requirements, what are you targeting?
pH, not PaCO2
PEEP is used to support what? How much H20 do you start with?
PEEP to support oxygenation Typically start with 5 cm H2O Levels > 15 cm H2O rarely needed
What are the variables usually set by the respiratory care practitioner for mechanical ventilation?
Alarms- high and low pressure, low volume, apnea, humidifier temperature, inspiratory flow rate with volume ventilation
What do you do to evaluate the patient after initiation of mechanical ventilation?
Chest radiograph Inspiratory plateau pressure Exhaled tidal volume and rate Patient-ventilator synchrony Auto-PEEP SpO2 and arterial blood gas measurement Hemodynamic status
What are the primary variables of oxygenation in mechanical ventilation? (PaO2)
FIO2 and mean airway pressure
What is the oxy saturation goal during mechanical ventilation? How much do you reduce FIO2?
SpO2 > 92%, reduce FIO2 to < 0.5
What are the primary variables in ventilation?
tidal volume, respiratory rate, and dead space
Maintain _________ ventilation without inducing harmful effects is one goal in ventilation
minute
What are some potential harmful consequences using a ventilator?
potential oxygen injury to the lung, barotrauma/volutrauma (damage in more compliant lung zones due to high airway pressure/volume), hemodynamic compromise due to high intrathoracic pressure
In someone with acute lung inflammation/ARDS, and emesis aspiration, what mode of mechanical ventilation would you choose? What do you initiate?
AC (volume) mode, Sedation and neuro-muscular blockade initiated
In an acute lung injury, decreased lung compliance results in _____ (high or low) airway pressures. _____ (high or low) tidal volume is often needed.
Decreased lung compliance results in high airway pressures Low tidal volume often needed
In an unresponsive ICU emphysema patient, what ICU ventilator settings do you use on them?
SIMV, rate 12 breaths/min FIO2 1.0 Tidal volume 600 mL PEEP 5 cm H2O Pressure support 8 cm H2O Minute ventilation 8.5 L
Obstructive airway disease patients require adequate __________ (expiratory or inspiratory) time
expiratory
Acute abdomen accounts for ___% of ER visits
5%
How many acute abdomen patients are discharged from the ER with ‘non-specific abdominal pain’?
34-56%
What are some examples of abrupt and severe abdominal pain?
AAA, peptic ulcer rupture, and renal colic
What are some examples of gradual abdominal pain?
appendicitis and diverticulitis
How long does it take for appendicitis to reveal itself?
Appendicitis reveals itself within 24-36 hours
What types of pain are there for acute abdominal pain?
Colic Steady Sharp Tearing Dull
What are some common associated symptoms that go along with acute abdominal pain?
nausea/vomiting: if after pain more likely surgical bowel function urinary symptoms genital discharge
What is extra-abdominal pain?
Abdominal Wall Pain Intrathoracic Pain Pelvic Pain
What are some extra abdominal pain metabolic disorders?
DKA, SLE, sickle cell crisis
What is a neurogenic extra-abdominal pain condition?
herpes zoster
What is gray turner’s sign and what does it indicate?
flank ecchymosis, pancreatic disease
What is cullen’s sign and what does it indicate?
periumbilical ecchymosis, pancreatic disease
What is the physical exam sequence for the abdomen?
auscultation, percussion and then palpation
What are some immediate life threatening conditions of the abdomen?:
Splenic Rupture Ruptured Ectopic Pregnancy Myocardial Infarction Ischemic Bowel Boehaave’s Syndrome
What is boehaave’s syndrome?
is rupture of the esophageal wall. 56% of oesophageal perforations are iatrogenic, usually due to medical instrumentation such as an endoscopy or paraoesophageal surgery. In contrast, the term Boerhaave’s syndrome is reserved for the 10% of oesophageal perforations which occur due to vomiting.
What labs do you get for someone with abdominal pain?
CBC Electrolytes Amylase LFT’s Serum HCG: Always for childbearing age Urinalysis: hematuria, pyuria
In someone with acute abdominal pain, what age and history should they have in order for you to get an EKG on them?
Any patient over 50, or w/ hx of cardiac disease
In someone with acute abdominal pain, what should you look for in a plain film?
Plain films: look for free air, dilated bowel, stones sentinal loops: distended loop of bowel near inflammatory process: appendicitis or pancreatitis
In someone with acute abdominal pain, what should you look for on ultrasound?
good for RUQ,ectopic renal colic, AAA, Trauma
In someone with acute abdominal pain, what should you look for with IVP? (intravenous pyelogram)
diagnostic for renal calculi
What circumstances is a barium enema used for diagnosis?
good for intussusception (Rx), volvulus and diverticulum
What abdominal emergencies would you use a CT for?
trauma, AAA, abscess
When would you use a HIDA scan for an abdominal emergency?
HIDA Scan: Definitive test for acute cholecystitis
What are the signs and symptoms for a ruptured ruptured abdominal aortic aneurysm?
sudden abdominal pain, tearing, shearing with radiation to back, flank, or genitalia. Weakness, hypotension, syncope, diaphoresis.
On physcial exam, what do you find on someone with a ruptured abdominal aortic aneurysm?
Findings: pulsatile abdominal mass, decreased pulses
What imaging and exams do you do to diagnose a AAA?
Dx: physical exam, ultrasound, CT scan
What is the treatment for an AAA?
emergent surgery
What are the signs and symptoms of an ischemic/infarcted bowel?
Age > 50, recent MI, surgery, A-fib, valvular dz, embolic events, arrhythmias, pain out of proportion to exam, pain is dull, diffuse, poorly localized.
What tests do you use to diagnose an ischemic/infarcted bowel?
Lactate, ABG, WBC, clinical exam, angiogram.
What symptoms and signs suggest an infarcted bowel?
Lactic acidosis, Hypotension, distended bowel suggests Infarction
What is the treatment for an ischemic/infarcted bowel?
Emergent Laparotomy
What are the signs and symptoms of a ruptured ectopic pregnancy?
Unilateral lower abd pain amenorrhea vaginal bleeding abd/adnexal tenderness adnexal mass peritoneal irritation enlarged uterus
What imaging do you use to diagnose an ectopic pregnancy?
ultrasound
What is the treatment for an ectopic pregnancy?
emergent surgery
What are the causes of a ruptured spleen or liver?
Spontaneous or due to trauma, or organomegaly
What are the signs and symptoms of a ruptured liver?
RUQ tenderness, guarding, diffuse peritoneal signs
What are the symptoms and signs of a ruptured spleen?
orthostatic symptoms, Kehr’s sign
What is kehr’s sign?
it’s the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated.
What tests do you perform to diagnose a ruptured liver or spleen?
ultrasound, DPL, CT, Exploratory LAP
What is a DPL or a DPA?
diagnostic peritoneal lavage (DPL) or diagnostic peritoneal aspiration (DPA) is a surgical diagnostic procedure to determine if there is free floating fluid (most often blood) in the abdominal cavity
What are the signs and symptoms of appendicitis?
Low fever, anorexia, WBC>10,000 w/ shift
What is the most common cause of appendicitis?
Most common cause: Fecalith
What do you see in the urine of someone with rectocecal appendicitis?
dysuria, hematuria
What is rovsing’s sign?
Rovsing’s sign: palpation of LLQ causes pain in RLQ
What is the obturator sign?
Obturator sign: Internal rotation of flexed hip causes pain
What is the psoa’s sign?
Psoas sign: Flexion / extension of the hips causes psoas muscle contraction and pain
What is mcburney’s point?
McBurney’s Point: pain to palpation at a point 1/3 from ischial spine to umbilicus
What are the signs and symptoms of diverticulitis?
Constant localized LLQ pain low grade fever nausea/vomiting distension
What is the occult blood greater than in diverticulitis?
>50%
What can diverticulitis result in?
Can result in obstruction, perforation, abcess or fistula formation
What imaging do you use for diverticulitis?
CT scan for mass or abscess
What is the treatment for diverticulitis?
bowel rest and antibiotics
What are the signs and symptoms of a small bowel obstruction?
crampy, poorly localized vomiting, distention, lack of BM or flatus, hypoactive Bowel sounds, local tenderness, distended
What is the treatment for an acute bowel obstruction?
decompression for a partial obstruction and surgery for a full obstruction
What is the most common cause and other causes for acute pancreatitis?
Most common: alcohol abuse, other causes: gallstones, trauma, drugs, hypercalcemia
What are the signs and symptoms of acute pancreatitis?
N/V, epigastric pain radiating to back, fever, shock
What abnormalities would you find in lab values in someone with acute pancreatitis?
amylase, lipase, WBC,LFT, Ransons criteria.
What is Ranson’s criteria?
At admission: Age in years > 55 years, white blood cell count > 16000 cells/mm3, blood glucose > 10 mmol/L (> 200 mg/dL), serum AST > 250 IU/L, serum LDH > 350 IU/L Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL), hematocrit fall > 10%, oxygen (hypoxemia PO2 < 60 mmHg, BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration, base deficit (negative base excess) > 4 mEq/L and sequestration of fluids > 6 L.
What is the treatment for acute pancreatitis?
NPO (witholding food and fluids), resuscitate, TPN, monitor for complications
What are the signs and symptoms of acute cholecystitis?
right upper quadrant pain, colicky epigastric, right shoulder or subscapular pain, N/V, low grade fever, constipation, mild illeus, Charcot’s triad (Fever, Jaundice, Abdominal pain, this is the hallmark of acute cholangitis)
What would the labs look like for someone with acute cholecystitis?
increase bili, Alk phos, leukocytosis
What imaging would you use for acute cholecystitis?
hidascan and ultrasound
What is the treatment for acute cholecystitis?
Admit with fever, intractable pain or vomiting, or jaundice. Elective surgery.
What kind of bacterial infection is pyleonephritis usually? (gram negative or positive)
Gram- negative infection usually ascending from lower urinary tract.
What are the signs and symptoms of pyleonephritis?
Flank pain, shaking chills, high fever, N/V, CVA tenderness, fever tachycardia
What labs will you see in someone with pyleonephritis?
CBC-left shift, U/A-pyuria with white cell cast may be seen
What is the treatment for pyleonephritis?
Admit, IV Abx, failure to respond warrants ultrasound
What are the signs and symptoms of salpingitis?
Unilateral lower abdominal pain, vaginal discharge, +/- fever, cervical motion or adenexal tenderness
What is the treatment for salpingitis?
Ceftriaxone 125-250mg IM + Doxycycline 100mg BID, or Azithromycin 1gm.
What are the signs and symptoms of renal colic?
abrupt colicky intermittent sharp pain, unilateral flank or growing pain, pallor, and diaphoresis
What are the exams and imaging you use to diagnose renal colic?
via history, IVP, renal ultrasound, CT scan.
What is the treatment for renal colic?
pain control, fluids, stones less than 4-mm will pass 90% of the time, admit if intractable pain
What percentage of pregnancies result in ovarian torsion?
20% occur during pregnancy
What are the signs and symptoms of ovarian torsion?
sudden unilateral ischemic pain nausea restlessness enlarged adenexal mass
What is the treatment for ovarian torsion?
emergent laparoscopy
In an acute MI, what are the symptoms? Who does it happen in typically?
Cardiac Ischemia does present in atypical manners Look for associated symptoms referring from the chest SOB Diaphoresis Diabetics, Elderly
What is the most common peptic ulcer perforation?
duodenal ulcer
What are the signs and symptoms of a peptic ulcer perforation?
sudden sharp epigastric pain, may refer to shoulder, rapid peritoneal signs, grunting, hypovolemia
What are the labs for a peptic ulcer perforation?
mild increase in serum amylase, increased WBC
What will you see on an xray for someone with a peptic ulcer perforation?
free air
What is the treatment for someone with a peptic ulcer perforation?
emergent ELAP (exploratory laparotomy)
What are the signs and symptoms of testicular torsion?
Acute unilateral scrotal pain, absence of cremasteric reflex on affected side
What imaging and treatment would you use with testicular torsion?
ultrasound and surgery
Anesthesia = Greek term meaning what?
without sedation
What does diethyl ether do?
Diethyl Ether = provide classic requirements of anesthesia, analgesia, amnesia and muscle relaxation
_________ first used ether in 1842 __________ demonstrated ether as analgesic at “Ether Dome” MGH in public demonstration 1846
Crawford Long first used ether in 1842 William Morton demonstrated ether as analgesic at “Ether Dome” MGH in public demonstration 1846
___________ used by ______________ to provide analgesia to Queen Victoria in 1853 during labor
Chloroform used by Sir James Simpson to provide analgesia to Queen Victoria in 1853 during labor
Risk of anesthesia-related deaths decreased dramatically in last ____ years Overall risk of anesthesia death in healthy patient estimated at 1: ________-________
Risk of anesthesia-related deaths decreased dramatically in last 30 years Overall risk of anesthesia death in healthy patient estimated at 1: 100,000-200,000
What are the most common problems associated with adverse outcomes while using anesthesia?
Airway compromise Medication errors Central venous cannulation Post-op neurologic complication Ischemic optic neuropathy Coronary ischemia Inadequate preoperative evaluation
What are the goals during a pre-op evaluation?
Goals: Optimize patient condition Understand and control comorbidities and drug therapy Ensure patient’s questions are answered
When do you do pre-op evaluations for high surgical invasiveness procedures, medium invasiveness and low invasiveness?
Timing High surgical invasiveness: at least 1 day prior Medium invasiveness: day before or day of surgery Low invasiveness: day of surgery
What is the American Society of Anesthesiologist Physical Status Classification classes?
ASA 1 (PS1): A normal healthy patient ASA 2 (PS2): A patient with mild systemic disease ASA 3 (PS3): A patient with severe systemic disease ASA 4 (PS4): A patient with severe systemic disease that is a constant threat to life ASA 5 (PS5): A dying patient who is not expected to survive without operation ASA 6 (PS6): A declared brain-dead patient whose organs are being removed for donor purposes E: Emergency
What is the perioperative effect of Echinacea?
Allergic reaction, hepatotoxicity, inference with immune suppressive therapy
What should you do if you find out someone takes Echinacea before surgery is done?
discharge as far in advance of surgery as possible
What is the perioperative effect of Ephedra?
Sympathetic stimulation (increased HR and BP, arrhythmias, MI, stroke)
What should you do if you find out someone takes Ephedra before surgery is done?
D/C at least 24h before surgery
What is the perioperative effect of Garlic?
Inhibition of platelet aggregation
What should you do if you find out someone takes Garlic before surgery is done?
D/C 7d before surgery
What is the perioperative effect of Ginkgo?
Inhibition of platelet-activating factor
What should you do if you find out someone takes Ginkgo before surgery is done?
D/C at least 36h before surgery
What is the perioperative effect of Ginseng?
Hypoglycemia, inhibition of platelet aggregation and coagulation cascade
What should you do if you find out someone takes Ginseng before surgery is done?
D/C at least 7d before surgery
What is the perioperative effect of Kava?
GABA-mediated hypnotic effects may decrease MAC, acute withdrawal
What should you do if you find out someone takes Kava before surgery is done?
D/c at least 24h before surgery
What is the perioperative effect of St John’s wort?
Inhibits serotonin, norepi, dopamine reuptake
What should you do if you find out someone takes st johns wort before surgery is done?
D/c at least 5d
What is the perioperative effect of valerian?
GABA-mediated hypnotic effects may decrease MAC, benzo-like withdrawal
What is the Mallampati Airway Classification system?
Class I: Soft palate, uvula, fauces, pillars visible. Class II: Soft palate, uvula, fauces visible. Class III: Soft palate, base of uvula visible. Class IV: Only hard palate visible It’s used to predict the ease of intubation. A high Mallampati score (class 3 or 4) is associated with more difficult intubation as well as a higher incidence of sleep apnea.
What are the different anesthesia types?
General Anesthesia Regional Anesthesia Monitored Anesthesia Care
How is general anesthesia administered?
Commonly induced by administration of IV drugs (ex: propofol, thiopental) or mask using inhalational anesthetic (ex: isoflurane, sevoflurane) Trachea intubated Proper positioning Must protect pressure and vulnerable sites: elbows, knees, heels, eyes
Where and how is regional anesthesia used and how long does it last?
Spinal, Epidural, Peripheral Nerve Block Excellent muscle relaxation, analgesia, avoidance of airway manipulation Last 2-5 hours
What are the advantages of regional anesthesia?
Decreased blood loss Fewer thrombotic complications Less pulmonary compromise Maintenance of vasodilation for post-op vascular surgeries Earlier discharge Avoid immune response compromise
What is monitored anesthesia care (MAC)?
Anesthesia caregiver “stands by” while surgeon performs procedure under local anesthesia Can provide sedation and analgesia for patient Good for frail in health patients Provides option to convert to general
What are the complications of anesthesia?
Peripheral nerve injury (Commonly due to poor positioning Usually resolve spontaneously) Malignant Hyperthermia – can be lethal! (Rare genetically inherited disease characterized by intense muscle contraction muscle destruction Uncontrolled release of calcium from sarcoplasmic reticulum Most commonly caused by succinyl-choline alone or in conjunction with halothane Must monitor ABG for metabolic acidosis)
What is the treatment for malignant hyperthermia? (from anesthesia)
Tx: IV dantrolene
For being a surgical PA, what are the protocols for clothing and jewelry?
Eye Protection No shirts under scrubs Rings Off Hospital-laundered scrubs only
How long do you scrub your hands for before surgery and how many strokes per side?
3 minutes, 8 strokes per side
How do you stand with other people in the OR?
Standing near sterile individual, stand front-to-front
What do operative notes include?
Surgeon Assistants Pre-Op Dx Post-Op Dx Procedure Anesthesia -General via ETT, via mask -Spinal -Regional Fluids -crystalloid -colloid -blood products EBL (estimated blood loss) UO (urine output) Drains/Tubes -Penrose, JP, Hemovac, Foley, NGT, chest tube Post-op condition -stable, critical, etc. Operative findings -any findings at the time of surgery
What different fluids do you use during surgery?
Fluids -crystalloid -colloid -blood products
What is included in post-op care? What do you evaluate?
Fluids, lytes, I/Os Cardiac/Hemodynamic status Pulmonary status Preventing infection Diet/return of bowel function Pain control Ambulation ASAP
What are the different kinds of IV fluids you use?
Lactated Ringer Normal Saline (0.9%) Half Normal Saline (0.45%) One Third Saline (0.33%) Dextrose in Water (D5W) Combinations of above
What is in lactated ringer?
Na, Cl, HCO3, and K
What is in D5 normal saline?
Glucose, Na, Cl
What is in dextrose in water (d50)?
glucose
What is in normal saline?
Na and Cl
What is in 1/2 normal saline?
Na and Cl (1/2 of the amounts of normal)
What is in NS 3%?
Na and Cl (larger amounts than normal saline)
What is the 4-2-1 rule?
4 cc/kg for the first 10 kgs of a patient’s weight 2 cc/kg for the next 10 kgs of a patient’s weight 1 cc/kg for the rest of the patient’s weight So for a 60 kg patient, he should get 100 cc/hr.
What are the things you should consider for post-op fluid replacement?
Maintenance requirements Extra needs resulting from systemic factors (ex: fever, burns) Losses from drains Requirements resulting from tissue edema and ileus
In transfusion therapy, what does whole blood contain? How much is used? How much of each component?
Whole blood = 450-500mL donor blood containing RBCs, plasma, clotting factors, anticoagulant RBCs = 250-300mL RBCs Platelets = 250-300mL of 3 x 1011 platelets FFP = 10-15mL/kg of clotting factors, albumin, fibrinogen Cryoprecipitate = 10-15mL of fibrinogen, factor VIII, vWF, factor XIII
What are blake and jackson-pratt drains?
Blake drains and Jackson-Pratt = closed drains connected to suction devices
What is a davol drain?
sump drain with airflow system to keep lumen of drain open when fluid is not passing through it, suction
What is a penrose drain?
open drain
What do you evaluate post-operatively for a patient?
-vital signs -urine output -pain control -wound drainage -nausea/vomiting -chest pain/dyspnea
What do you use for post-op pain?
Parenteral Opioids Nonopioid Parenterals Oral Analgesics Patient-Controlled Analgesia Intercostal Block
What do you include in a post-op SOAP note?
-Date/Time -Subjective Ex: Patient awake, alert, c/o mild incisional pain. Denies CP, SOB, N/V. Objective: Vitals (include range, ex: Tmax 99.9, Tcurrent 98.7) PE: heart, lungs, surgical site, dressing, drainage, neuro checks, pulses, etc. as indicated I/Os, drains, NG tube output Labs Assessment: -stable after cholecystectomy -patient has not voided yet Plan: -NPO -bed rest until am -straight cath if pt has not voided by 6 pm
What are some post-op cardiac probems?
MI 0.4% of all patients undergoing operation in US develop post-op MI Increases to 5-12% in patients undergoing other vascular operations (carotid endarterectomy, femoral-popliteal graft) -Dysrhythmias -CHF LV failure and pulmonary edema appear in 40% of patients under 40 years of age who undergo general anesthesia
A dysrithmyia occurance post-op is often related to what conditions?
Generally related to hyperkalemia, hypoxemia, alkalosis, digoxin toxicity, stress during emergence from anesthesia
LV failure and pulm edema may occur in people who get general anesthesia because why?
typically because of fluid overload
What GI dysfunctions can occur post-operatively?
-Ileus Post-op ileus: abdominal distention, absent bowel sounds GI peristalsis returns in 24 hours after non-abdominal surgeries Post-laparotomy it returns in about 48 hours -GI bleed/stress ulcers -Pseudomembranous colitis
What complications can occur post-operatively?
-Superficial phlebitis -Urinary retention
What are some post-op pulmonary complications?
Atelectasis Pneumonia -bronchial -aspiration Pulmonary Edema Pulmonary Embolus
What are some post-op wound complications?
Hematoma, Seroma, Dehiscence
What is a seroma?
A seroma is a pocket of clear serous fluid (other than blood or pus) that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid.
What is dehiscence?
Wound dehiscence is a surgical complication in which a wound ruptures along surgical suture. Risk factors are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery. -systemic risk factors -local risk factors -adequacy of closure -intra-abdominal pressure -deficient wound healing
What are some infections that occur after surgery?
Cellulitis Wound infection Intra-abdominal abscess/peritonitis/subhepatic or subphrenic abscess Generalized sepsis Anastomotic leak or breakdown/perforated viscous
What is the most common wound complication?
Hematoma- collection of blood and clot in wound, almost always caused by imperfect hemostasis
What is dehiscence?
Partial or total disruption of any or all layers of operative wound
Occurs in 1-3% of all abdominal procedures
What is evisceration?
Rupture of all layers of abdominal wall and extrusion of abdominal viscera
What are the 5 W’s of post-op fever?
Wind: Atelectasis (first 24 hours)
Water: UTI
Walking: DVT/PE
Wound: Abscess formation (5-7 days)
Wonder drug: Anesthesia
What are the early, middle and late post-op fevers that can occur?
Early (1-3 days post-op)
-atelectasis/pneumonia
Middle (4-5 days post-op)
-infection/dehiscence
Late (5-7 days post-op)
-leak/intra-abdominal abscess/pneumonia
Thrombophlebitis
Who are the challenging surgical patients?
Young, fit patients
Immunosuppressed patients
Debilitated patients
Patients with abrupt deterioration
Patients with limited reserve
When evaluating your patient, what is the primary and secondary surveys?
Primary survey
What is main physiological problem?
First minutes of initial contact
Secondary survey
What is underlying cause?
Subsequent reviews
What is the single most important indicator of critical illness?
Tachypnea is the single most important indicator of critical illness
What is the most common cardiovascular disturbance in the seriously ill patient?
Most common cardiovascular disturbance in the seriously ill is hypotension caused by hypovolemia and/or sepsis
What are some sources of error for pulse oximetry?
Physiologic/anatomic
Vasoconstriction/poor perfusion
Abnormal hemoglobin
Skin pigmentation
False nails and polish
External
Motion of sensor
Extraneous light
What are some indications and complications of central venous cannulation?
Indications
Measure central venous pressure
Access for resuscitation
Drug administration
Placement of pulmonary artery catheter
Complications
Hematoma/vessel injury/blood loss
Pneumothorax/hemothorax
Cardiac arrhythmias
Infection
What measures end diastolic pressure in a pulmonary catheter?
CVP and PAOP measure end-diastolic pressure
Estimate of end-diastolic volume
Volume/pressure relationship affected by ventricular compliance
What does an automatic BP machine do? What is necessary for it to work and when is it less accurate?
Intermittent measurements
Appropriate cuff size necessary
Less accurate during hypotension, mechanical ventilation, arrhythmias
What are the indications for arterial cannulation?
Multiple arterial blood samples
Continuous blood pressure
What are the indications for a central line and what are the complications that go along with it?
Indications
Measure central venous pressure
Access for resuscitation
Drug administration
Placement of pulmonary artery catheter
Complications
Hematoma/vessel injury/blood loss
Pneumothorax/hemothorax
Cardiac arrhythmias
Infection
