Exam 1 Plus Some Peds :/ Flashcards

Question

Other symptoms of MS

Answer 1

-bowel retention and urinary incontinence -central neuropathic pain -trigeminal neuralgia -spasticity -tonic seizures

Answer 2

20-40 years

Answer 3

s/s of CNS white matter disease -2 or more attacks separated by a month or more -involvement of 2 or more noncontiguous anatomic areas -elevated levels of IgG and albumin in the CSF is abnormal -MRI: demyelinated plaques in the CNS

Answer 4

-memory problems -slow walking -balance issues or frequent falls -difficult performing two or more activities at once, such as walking and talking at the same time -mood changes, such as depression -urinary incontinence

Answer 5

modulate the immunologic and inflammatory responses that damage the CNS

Answer 6

Disease-modifying agents->interferon beta (SE=flu like symptoms, elevated liver enzymes and neutropenia) Immunosuppressants (azathioprine) Corticosteroids IV immunoglobulins Symptomatic treatments for spasticity, depression and neuropathic pain (gabapentin, baclofen, and SSRIs)

Answer 7

1. Last neurologist appointment 2. last time they had exacerbation of the disease 3. bulbar or respiratory symptoms (post op ventilation) 4. What medications are they taking? 5. Lhermitte sign: neck flexion induces an "electrical sensation" 6. visual disturbances due to optic neuritis 7. Unthoff sign: worsening symptoms by increased body temperature (Exercise, hot temps); more remission in colder environments 8. depression

Answer 8

-exacerbation of symptoms with hyperthermia, stress, surgery, infection, emotional and physical trauma, postpartum -versed in preop -consider stress steroids -spinal anesthesia may exacerbate symptoms due to potential neurotoxicity -epidural and peripheral blocks ok because staying out of CNS -Avoid SUXX due to occurrence of hyperkalemia -NMDR careful use (avoid if you can) -post op respiratory support

Answer 9

-amyloid-beta protein -this protein begins a cascade of events ending with deposits of: - amyloid plaques -neurofibrillary tangles -neuronal apoptosis -these cause a loss of cholinergic activity and loss of glutamatergic neurons

Answer 10

-loss of cognition -poor decision-making -language and gait issues -seizures -agitation -psychosis

Answer 11

acetylcholinesterase inhibitors and a NMDA inhibitor

Answer 12

1. postoperative cognitive dysfuction, careful with sedative premeds (i.e. versed) 2. use glycopyrrolate (will not cross BBB) 3. patients already receiving cholinesterase inhibitors to increase Ach, may have prolonged Sux response because they will have massive amount of Ach in system do not want to use scopolamine or atropine because they can cross BBB and decrease Ach levels in brain

Answer 13

-degenerative CNS disease caused by loss of dopaminergic cells in the basal ganglia (Lewy Bodies) -diminished inhibition of the extrapyramidal motor system due to dopamine deficiency

Answer 14

-resting tremor -cogwheel rigidity of the upper extremities -bradykinesia -shuffling gait -stooped posture -facial immobility (frozen face)

Answer 15

Levodopa (multiple other drugs available) Deep Brain stimulatorys

Answer 16

-1/2 life of Levodopa is short, interruption of therapy for more than 6-12 hours can result in severe skeletal muscle rigidity and ventilation issues -avoid dopamine antagonists (Reglan, Phenergan) -dopamine antagonists-phenothiazines, droperidol and metoclopramide should be avoided -increased risk of neuroleptic syndrome with dopamine agonists -autonomic dysfunction, upper airway dysfunction, postoperative confusion and hallucinations -problems with swallowing and secretions -alfentanil and fentanyl may produce dystonic reactions when administered rapidly

Answer 17

2 part surgery: stimulator and generator placement -most effective in people who suffer severe tremors -suffer wearing-off spells or medication induced dyskinesia (uncontrolled shakes) -not thought to improve speech or swallowing issues or thinking problems -doesnt slow down disease process -if doing sedline or bis monitoring will pick up stimulation so readings may not be accurate

Answer 18

upper, lower or mixed neuron involvement of the cerebral cortex, brainstem and spinal cord ALS (Lou Gehrig's disease):mixed Kennedy's Disease (spinobulbar muscular atrophy) Friedreich's Ataxia: mixed Spinal muscular atrophy: lower motor neurons

Answer 19

-selective and progressive motor neuronal death -progressive degeneration of the upper and lower motor neurons causing: 1. amyotrophy (muscle wasting) 2. lateral sclerosis autonomic dysfunction

Answer 20

Males>females -40-60 years onset

Answer 21

EMG and neuro exam that demonstrates early spastic weakness of the upper and lower extremities, subcutaneous muscle fasciculations and bulbar involvement affecting pharyngeal function, speech and facial muscles

Answer 22

non curative -tx symptomatically

Answer 23

-bulbar involvement: aspiration risk and pulmonary complications (highest) -increased sensitivity to respiratory depressant effects of sedatives and hypnotics (avoid opioids and benzos) -sympathetic hyperactivity and autonomic failure -avoid Sux (risk of hyperkalemia due to denervation and immobilization) -nondepolarizers may be prolonged and pronounced -regional OK -use short-acting anesthetics -prone to atelectasis

Answer 24

sodium channel defect causes prolonged depolarization and flaccid paralysis K>5.5mEq/L during symptoms -skeletal muscle weakness may be localized to tongue and eyelids

Answer 25

-hyperkalemic periodic paralysis -hypokalemic periodic paralysis -sodium channel myotonia -thyrotoxic periodic paralysis -myotonia congenita -paramyotonia congenita -andersen-tawil syndrome

Answer 26

-rest after excercise -potassium infusions -metabolic acidosis -cold exposure (OR hypothermia)

Answer 27

calcium or sodium channel defect K level <3 mEq/L during symptoms -chronic myopathy with aging (70+)

Answer 28

-high glucose meals -strenuous exercise -glucose-insulin infusions -stress -hypothermia

Answer 29

-preoperative electrolytes and abnormalities corrected before surgery -keep normothermic -careful with medications that cause changes in potassium (insulin, diuretics) that can cause weakness or paralysis -avoid anectine -constant monitoring for potassium-related dysrythmias -may be sensitive to nondepolarizing muscle relaxants due to chronic myopathy

Answer 30

-autoimmune disorder characterized by: -onset of ascending skeletal muscle weakness or paralysis of the legs usually due to viral or bacterial infection -group of disorders known as the inflammatory neuropathies -autonomic dysfunction with wide fluctuations in HR/BP -physical stimulation can precipitate HTN, tachycardia and cardiac dysrhthmias -respiratory muscle weakness

Answer 31

based on symptoms plasma exchange immunoglobulin mechanical ventilation

Answer 32

-avoid rapid movement of patient (autonomics) -aspiration (reglan, pepcid) -maintain temperature -airway respiratory failure -maintain preload and afterload -careful with PPV (may cause autonomic instability) can trigger ganglia along spinal cord by pressure to cause autonomic dysfunction -muscle relaxants (avoid Sux), increased sensitivity to NMDR; do not want to cause K release from cells because they will be upregulated

Answer 33

a decrease in the number of functional postsynaptic, Ach receptors in the neuromuscular junction available for Ach binding -abnormal thymus tissue frequently involved

Answer 34

fatigability which improves with rest

Answer 35

bimodal disease: -young women 30-40 yo -older men >50 yo

Answer 36

1. major antigen in MG is acetylcholine receptor on the muscle membrane 2. some patients without AChR antibodies have autoantibodies against Muscle Specific Kinase (MuSK) -protein that allows AchR clustering at the NMJ 3. less commonly there are low-density lipoprotein receptor-related protein 4 (LRP4) in MG patients without MuSK or AChR -receptor for neural agrin that relays the signal to MuSK to initiate AChR clustering -patient without detectable antibodies against any of these 3 antigens are referred to as seronegative

Answer 37

skeletal muscle weakness that is aggravated by repetitive muscle use and improves with rest

Answer 38

-"weakness of extra-ocular muscles" -diplopia (double vision) common presenting complaint (cranial nerves)

Answer 39

-muscles of facial expression, muscles of talking, chewing and swallowing especially affected -weakness of arms/legs, bulbar symptoms or weakness of muscles of respiration -environmental, physical, and emotional factors can affect the disease (surgery, pregnancy) -myocarditis in patients with thymomas-will usually see cardiac defects (decreased EF)

Answer 40

Clinical tests of fatigability: 1. maintaining upward gaze 2. holding out an affected limb 3. respiratory function test Electrophysiologic (EMG or supramaximal stimulation of peripheral nerve at 2 Hz) Pharmacologic (Edrophonium/Tensilon test) immunologic (anti-Achr antibody titer) -85% have anti-AChR antibodies -5% have no detectable antibodies -10% may have antibodies against MuSK or LRP4

Answer 41

-thymoma -thymic hyperplasia -thymic atrophy higher incidence of heart disease

Answer 42

thymus hyperplasia

Answer 43

-progression of severe muscle weakness -respiratory failure -bundle branch blocks and A-fib

Answer 44

pregnancy exacerbates symptoms of MG in 33% -some pregnant women experience remission or no change

Answer 45

-poor control of MG, underdosing of meds -emotional stress -hyperthermia -pulmonary infection (severe PNA or bronchitis)

Answer 46

1st trimester or 6 weeks post-partum Anti-AchR antibodies cross the placenta Magnesium should be avoided (for tocolysis and preeclampsia)?

Answer 47

transient neonatal myasthenia

Answer 48

-difficulty feeding -ptosis -facial weakness -respiratory distress at birth

Answer 49

-in newborns of women with active MG -can begin 12-48 hours after birth and last for weeks -spontaneous remission at 2-4 weeks when maternal antibodies clear circulation -edrophonium testing (tension test): improvement in strength==positive result -serologic testing -tx of symptom management and immunomodulation

Answer 50

-thymus hyperplasia/thymoma -hyper/hypothroid -rheumatoid arthritis -ulcerative colitis -pernicious anemia -diabetes mellitus

Answer 51

5 7 9 10 11 12

Answer 52

-difficulty swallowing (dysphagia) -difficulty chewing, choking on fluids, nasal regurgitation -slurring of speech, dysphonia, dysarthria, dysphasia -difficulty breathing -weakness of neck muscles

Answer 53

Acetylcholinesterase inhibitors (AchEI): -oral pyridostigmine, less muscarinic SE than neostigmine -onset: 15-30 min -peak: 1-2 hours -duration: 3-4 hours (60mg can last 3-6 hours) -daily dosage: 30-120mg orally in divided doses -improves muscle strength for several hours but does not affect the course of the dz increases concentration of Ach at the postsynaptic membrane -pyridostigmine: quaternary cannot cross BBB -other typical symptoms are: diaphoresis, hypersalivation, rhinorrhea, lacrimation, bronchorrhea, bronchospasm, miosis, bradycardia, hypotension

Answer 54

immunosupressants -corticosteroids (reduced AchR antibody levels) -cylclosporine -azathioprine (interferes with production of AchR antibodies) -plasma exchange patients with respiratory compromise -IV immune globulin Thymectomy (Goal is remission or reduction in dosage of medications) -indicated in patients with thymoma -thymus gland hyperplasia -drug resistant MG -transsternal (open) or video-assisted transcervical

Answer 55

pre op: medication list (steroids, pyridostigmine dose), PFT, abilities to maintain airway, CT/MRI of thymoma, EKG (bradycardia or rhythm issues) -d/c or taper pyridostigmine dose before sx -sensitive to sedative medications, aspiration risk (reglan) -avoid muscle relaxants (TIVA/inhalational and/or regional) Anectine: resistance or unpredictable (not taking MG meds)or normal/prolonged response (taking MG meds) NMDR: dramatic sensitivity (decrease in functional receptors) especially when combined with inhalationals -use of nonopioid analgesia -patients should be informed that postop ventilation may be needed -patients with MG are sensitive to NMDBs because of decreased number of postsynaptic receptors at the motor end plate extubation (safe to extubate?) reversal: cholinergic crisis, better to use sugammadex check negative inspiratory force (how well diaphragm is pulling in >30cm H20), head lift, cough, gag, reflex, ensure full return of twitch

Answer 56

-forced vital capacity (FVC) <2.7 liters -vital capacity < 4mL/kg -previous hx of myasthenic crisis -disease duration greater than 6 yrs (Nagelhout 2-6 hours) -pyridostigmine daily dose of 750mg or more -COPD -bulbar symptoms

Answer 57

-non-opioid pain meds -pulmonary toilet -avoid meds that depress respiration or delay extubation -watch for postoperative respiratory failure -cholingergic vs myasthenic crisis (edrophonium 10mg)

Answer 58

Lambert-Eaton Myasthenic Snydrome is associated with small cell lung cancer and in contrast to MG, exercise may improve the muscle weakness-related symptoms

Answer 59

autoimmune disorder, paraneoplastic (immune-mediated associated with small cell lung ca) -IgG antibodies are produced and attack pre-synaptic calcium channels (acts similar but different mechanism) -decreased release of Ach from presynaptic terminals and decreased postjunctional response (muscle weakness) -number and quality of postjunctional AchRs is unaltered-different from MG -typically 50-70 yo male complains of proximal extremity weakness (hip and shoulder) that affects gait -improvement with exercise, no improvement with anticholinesterase or steroids

Answer 60

-hip and shoulder weakness, difficulty walking and standing -autonomic dysfunction with dry mouth reduced sweating and erectile dysfunction, orthostatic hypotension -sensitive to both depolarizing and non-depolarizers (try to avoid) -patients presenting with tumor/cancer and weakness..suspect LEMS -tx with surgery for cancer and/or and 3,4 diaminoyridine -prednizone and azathioprine can help with symptomes

Answer 61

hereditary disorders characterized by muscle fiber necrosis and regeneration, leading to muscle degeneration and progressive weakness Muscular Dystrophies: -duchenne''s muscular dystrophy (most common and severe type of MD) 1/3500 live male births -Becker's muscular dystrophy (Rare) 1/18,000 -myotonic dystrophy -limb-girdle -congenital muscular dystrophy Congenital Myopathies -central core disease -centronuclear myopathy

Answer 62

-inherited X-linked recessive disease, the muscles (incl myocardium) are gradually replaced with: fat and connective tissue -presents in childhood (between 3-5 years of age) as proximal muscle weakness and painless muscle atrophy in boys -loss of functional dystrophin proximal muscle weakness and gait issues, gradual onset of muscle wasting, contractures (kyphoscoliosis)

Answer 63

-protein that plays a major role in: stabilization of the muscle membrane signaling between cytoskeleton and extracellular matrix

Answer 64

-succumb to cardiopulmonary complications by middle age -cardiomyopathy, mitral regurgitation and rhythm disorders common (tx with ACE inhibitors, diuretics, Beta blockers)---avoid cardiac depressants -sensitive to myocardial depressant effects of: -inhalationals - sedatives -narcotics

Answer 65

-serum creatinine kinase levels consistently elevated (used to screen newborns. assessment of muscle degeneration) -as they age, the more the muscle trophies the CK levels begin to decrease

Answer 66

succinylcholine is contraindicated due to risk of : -hyperkalemia -rhabdomyolysis

Answer 67

-aspiration risk (decreased laryngeal reflexes) -delayed gastric motility-delayed gastric emptying -poor respiratory function, pulmonary HTN from chronic sleep apnea, kyphoscoliosis -increased sensitivity to non-depolarizers -associated with MH-like response, avoid inhalationals if possible -recurrent PNA due to ineffective cough and inadequate secretion clearance -post-operative respiratory failure, restrictive ventilatory pattern even with recent improvements in supportive care, cardiorespiratory complications cause most of the mortality that occurs before the 4th decade of life typical EKG abn include an R;S ratio >1 in lead V1; deep Q waves in leads I, aVL, V5 and V6; right axis deviation or R BBB

Answer 68

-decrease in normal amounts of dystrophin -milder disease course than DMD -onset ~12 yrs -mortality: similar to DMD but usually live until 5th or 6th decade

Answer 69

-caused by mutations in 2 proteins -typically presents with contractures of the ankles, elbows, and neck -progressive weakness of humeral and peroneal muscles -cardiomyopathy and cardiac conduction abnormalities (present around 30 yrs of age)

Answer 70

-greatest concerns: cardiac involvement respiratory muscle weakness -premedication and respiratory depression, impaired swallowing , GI dysfunction -avoid SCh and inhaled agents: risk for rhabdo and severe hyperkalemia -sensitive to nondepolarizing muscle relaxants -preop muscle weakness may require postop mechanical ventilation -local, regional better alternatives

Answer 71

group of hereditary skeletal muscle diseases (myotonic dytrophy, myotonia congenita, myotonia fluctuans, paramyotonia congenita common to aLL myotonias: inability of skeletal muscles to relax after chemical or physical stimulation -dysfunction of ion channels in the muscle membrane -reduced conductance of cl ions in the sarcolema and other channelopathies -progressive muscle wasting with weakness combined with multisystem involvement

Answer 72

autosomal dominant disorder (one parent has it) usually occurs in 2nd or 3rd decade of life -slow progressive deterioration of skeletal, cardiac and smooth muscle, wasting and cardiac conduction defects--death -characterized by hypoplastic, dystrophic and weak skeletal muscles and prone to persistent contraction

Answer 73

1 DM-1 (steinert's): congenital, childhood onset, adult onset and late onset 2. DM-2- proximal myotonic myopathy and myopathy)

Answer 74

most common type and subdivided by age of onset intrinsic disorder of skeletal muscle linked to: -myotonin-protein kinase gene -defect in Na and CL channel function produces electrical instability of muscle membrane -characterized by myotonia induced by voluntary or reflex contractions followed by prolonged relaxation -muscle weakness begins distally and progresses proximally -manifests as weakness of facial muscles, wasting of sternocleidomastoid muscles, ptosis, dysarthria. dysphagia and inability to relax hand grip

Answer 75

1. mental retardation (testicular atrophy in men) 2. frontal baldness 3. cataracts

Answer 76

-pulmonary issues from hyopotonia, decreased cough effectiveness and chronic aspiration, diminished ventilatory response to hypoxia and hypercapnia, OSA, hypersomnolence -smooth muscle atrophy, most common is cranial and distal limb muscles (hatchet face) -conduction defects (heart blocks and tachyarrhythmias) -sudden cardiac death (3rd degree AV block or ventricular dysrhthmias), respiratory failure or PNA -hypothyroidism and insulin resistance -treatment is supportive, NA channel blockers

Answer 77

-similar clinical features as DM-1 -milder than that of DM-1 -AV conduction delays but sudden death less likely -less likely to have diabetes (Type 1 almost always has DM with it) -disability from chronic myopathy occurs later -more likely to have myalgia, muscle strength variation, hypertrophy of calf muscles -normal life expectancy

Answer 78

=careful with pre0post op sedation (respiratory depression) -inability to secure airway (jaw muscle spasm) -avoid Sux and neostigmine? due to its potential to trigger myotonic muscle contraction (myotonic response) -increased sensitivity to NDMR (Residual block), opioids -peripheral nerve stimulation may produce myotonia that could be misinterpreted as sustained tetanus -avoid hypothermia and shivering -regional -regional and peripheral blocks -assume patient has cardiac involvement (pacer available) -pregnancy exacerbates symptoms (uterine atony, postpartum hemorrhage and retained placenta) -can use inhalational agents in this patients -risk of MH no greater than general population

Answer 79

1. Hypercarbia-unexplained rapid increase in ETCO2 2. Muscle rigidity: especially masseter muscle rigidity 3. tachycardia: elevated heart rate

Answer 80

1. hyperthermia: rapid rise in body temp 2. acidosis: metabolic and respiratory acidosis 3. rhabdomyolysis: muscle breakdown. leading to elevated CK levels and myoglobinuria

Answer 81

-respiratory/metabolic acidosis -K>6, CK increase serum and urine myoglobin increase

Answer 82

precise mechanisms unproven antipsychotic-induced dopamine blockade sudden drop in CNS dopaminergic activity nigrostrial pathway-muscle rigidity -hypothalamus-impaired heat regulation mesolimbic/mesocortical pathways-altered mental status

Answer 83

1. muscle rigidity (first sign) 2. fever 3. altered mental status (drowsiness, agitation, confusion, severe delirium and coma) 4. autonomic dysfunction (labile BP, tachypnea, tachycardia, diaphoresis, flushing skin, incontinence)

Answer 84

-adverse rxn to meds with dopamine-receptor antagonist properties -MOA: dopamine receptor blockade in the CNS (hypothalamus) leading to dysregulation of temperature and muscle control -rapid withdrawal of dopaminergic meds

Answer 85

-stop offending agent -supportive measures, benzo or dantrolene

Answer 86

-enzymatic deficiencies in the heme synthesis pathway -accumulation of neurotoxic porphyrin precursors (porphobilinogen PBG) and aminolevulinic acid (ALA) -an acute porphyria should be suspected if a patient presents with neurovisceral signs and symptoms and an initial evaluation excludes more common causes -most important first-line screening test is measurement of urinary porphobilinohen (PBG) PBG is expected to be substantially increased in all patients during acute porphyria attacks but not in other medical conditions -PBG test is both sensitive and specific for dx of acute porphyria under most circumstances an exception is ADP in which ALA and porphyrins but not PBG are elevated

Answer 87

-fever, tachycardia, nausea, emesis, severe abd pain, weakness, seizures, confusion and hallucinations -respiratory failure -hyponatremia secondary to inappropriate secretion of ADH young adults and usually women attacks can last for 2 weeks

Answer 88

-hormone changes during menstrual cycle -fasting -infection -exposure to triggering agents (barbiturates, etomidate) AIP may be considered in patients with unexpected delayed emergency from anesthesia or postop muscle weakness

Answer 89

anterior (carotid) posterior (vertebrobasilar)

Answer 90

provide collateral blood flow between the anterior and posterior circulations of the brain, protecting against ischemia in the event of vessel disease or damage in one or more areas.

Answer 91

the internal jugular veins

Answer 92

4 ventricles that include 2 lateral ventricles (1 in each cerebral hemisphere) 3rd ventricle in the diencephalon 4th ventricle in the hindbrain inferiorly it is continuous with the central canal of the spinal cord

Answer 93

protects and maintains the central nervous system by absorbing shock, supplying nutrients , maintaining intracranial pressure, removing waste, controlling temperature, and containing immune cells. -The fluid-filled ventricles also help keep the brain buoyant and cushioned

Answer 94

ependymal cells in the choroid plexus of the lateral 3rd and 4th ventricles

Answer 95

lateral ventricles-->interventricular foramina-->3rd ventricle-->cerebral aqueduct--->4th ventricle-->subarachnoid space via 4 openings in the 4th ventricle

Answer 96

arachnoid granulations and drained into the dural venous sinuses of the arachnoid mater into the sinuses with one-way valves

Answer 97

Foramen magnum as a continuation of the medulla oblongata at the base of the skull. It is located within the vertebral or spinal canal.

Answer 98

longitudinal columns of nuclei (Gray matter) surrounded by ascending and descending tracts (white matter)

Answer 99

anterior (ventral) posterior (Dorsal) lateral (intermediate) horns

Answer 100

posterior horns

Answer 101

the white matter into posterior (Dorsal), lateral, and anterior (ventral) columns

Answer 102

ascending and descending tracts

Answer 103

periphery to brain

Answer 104

brain to periphery

Answer 105

1. dorsal column (posterior area): conveys tactile sensation, vibration, and proprioception 2. spinothalamic tract (anterior): conveys pain, temp and crude touch.

Answer 106

corticospinal tract: controls find motor movement. Crosses midline at the upper part of midbrain

Answer 107

vertebral artery

Answer 108

anterior 2/3 of the spinal cord and medulla

Answer 109

Artery of Adamkiewicz (great radicular artery)

Answer 110

left side between T9-T12.

Answer 111

inferior cerebellar artery, as well as, the segmental spinal arteries (originating from the intercostal and lumbar arteries) supply the posterior 1/3 of spinal cord

Answer 112

anterior and deep portions of the SC due to fewer anterior medullary feeder vessels than the posterior region and can lead to anterior spinal artery syndrome

Answer 113

ischemia of the b/l corticospinal and spinothalamic tracts This causes loss of motor function and loss of pain and temperature sensation below the level of the lesion

Answer 114

aortic dissection emboli covering large segments of the thoracoabdominal aorta with endovascular stents surgical dissection during thoracoabdominal aortic aneurysm repair

Answer 115

3.5mL O2/min/100g brain tissue or 5.5 mg glucose/min/100g skeletal muscle=0.29 ml O2/min/100g

Answer 116

15% 2% this disproportionately large blood flow is a result of high metabolic rate of the brain

Answer 117

5 min= cell death

Answer 118

CPP=MAP -ICP (CVP substituted fro ICP if higher than ICP)

Answer 119

describes the relationship between the contents of the cranium and ICP

Answer 120

-brain tissue -blood -CSF

Answer 121

substantial redistribution of CSF

Answer 122

vascular structures collapse

Answer 123

high risk for herniation

Answer 124

-nausea -vomiting -headache -downcast eyes -papilledema -altered mental status and/or -acute focal neuro deficit

Answer 125

progression to brain herniation

Answer 126

1. HTN 2. Irregular Respirations 3. Bradycardia -reflects severe, increased ICP

Answer 127

ability of the body to maintain constant CBF despite changes in CPP. -protects the brain from hypo-or hypoperfusion secondary to decrease or increase in CPP, respectively.

Answer 128

MAP 60-160mmHg CPP 50-150mmHg

Answer 129

constricts dropping CBF by 1-2cc/100g/min for every 1mmHg drop in PaCO2. very low PaCO2 will significantly drop CBF. This can be useful in extenuating circumstances (ie. impending brain herniation) but also places the brain at a real risk for ischemia-related damage.

Answer 130

really doesnt affect CBF in hyper-oxia. As patient becomes more hypoxemic, CBF will increase once the PaO2 drops below ~40-50mmHg to deliver more blood (and therefore oxygen content ) to the brain

Answer 131

when PaCO2 is within the range of 25-70mmHg, it correlates with CBF. 1 mmHg increase in PaCO2 will result in 1-2 mL/100g/min (or 4%) increase in CBF.

Answer 132

6 hours. Prolonged hyperventilation should be avoided secondary to the risk of cerebral ischemia

Answer 133

hypothermia results in a dose-dependent reduction in CMRO2

Answer 134

hyperthermia increases CMRO2, increased uptake of glucose: severe hypoglycemia (blood glucose <2mmol/L or 36mg/dL) results in increased CBF.

Answer 135

cerebral autoregulation is impaired or absent in severe TBI. In these patients, decreases in CPP result in decreases in CBF that may reach ischemic levels and lead to secondary brain injury.

Answer 136

cerebral tumors are frequently associated with disruption of the BBB, leading to the development of vasogenic edema and increase in ICP. Cerebral autoregulation in peritumurol areas is impaired and these areas are more

Answer 137

with HTN, cerebral autoregulation curve shifts to the right, BP management should aim to keep MAP within 20-25% of baseline if not monitoring autoregulation specifically

Answer 138

endothelial dysfunction, alterations in cerebral blood flow and impaired autoregulation are some of the mechanisms of cerebral edema in preeclampsia.

Answer 139

aims to protect the integrity of the peripheral and CNS during surgical manipulation

Answer 140

all inhalational agents and nitrous oxide

Answer 141

IV agents.

Answer 142

Ketamine and etomidate

Answer 143

sensory pathway (through the dorsal root ganglia and posterior column) by electrical stimulation of a peripheral nerve distal to surgery and recording the potential at different landmarks as it propogates along the pathway from the peripheral nerves, through the spinal cord, subcortical and cortical regions

Answer 144

-monitor the motor pathway (including the motor cortex, corticospinal tract, nerve root and peripheral nerve) by transcranial electric stimulation of the motor cortex and recording the elicited muscle contractions by recording electrodes

Answer 145

the effects of anesthetic agents than SSEPs and MEP changes precede changes in SSEP, allowing time to react

Answer 146

affected by inhalational more than IV agents

Answer 147

-cortical electrical activity with surface scalp electrodes or brain surface electrodes to detect cortical ischemia and seizure activity -can be used to monitor depth of anesthesia

Answer 148

dose-dependent and similar to their effect on cortical evoked potentials. EEGs moderately sensitivity to inhalational agents and insensitive to NMBA

Answer 149

-monitor nerve roots and peripheral nerves by detecting muscle activity (EMG) or nerve action potentials (NCS) -spontaneous or free-run EMG provides continuous monitoring and detection of neuronal structures during surgical dissection around nerve roots, cranial and peripheral nerves -triggered EMG is used to identify and map nerve roots and nerved by delivering stimulation intermittently. It can be used for assessment of pedicle breech during pedicle screw placement.

Answer 150

no except for NMBas

Answer 151

auditory nerve and auditory pathway through the brainstem by acoustic stimulation of the auditory nerve and scalp surface electrode recording -mostly used during base of skull surgery

Answer 152

hypothermia

Answer 153

little effect

Answer 154

increased latency decreased amplitude

Answer 155

increased amplitude

Answer 156

little effect

Answer 157

increased latency decreased amplitude

Answer 158

little to no effect

Answer 159

Affects EMG and MEP no effect on SSEP, BAEP and EEG

Answer 160

CMRO2 however, due to their intrinsic vasodilatory properties, volatile agents uncouple CMRO2 and CBF. Their overall effect on CBF will result in a balance between CMRO2 related to CBF reduction and intrinsic vasodilatory-related increase in CBF.

Answer 161

at baseline

Answer 162

classically avoided -administration results in increased CMRO2 and CBF. Its effect on CBF is attenuated when administered with volatile agents and is minimal when administered with propofol.

Answer 163

decrease a major problem with barbs is that they can substantially reduce MAP which if not controlled can reduce CPP. Barbs are also effective in reducing elevated ICP and controlling epileptiform activity Methohexital is an exception with regard to epileptiform activity; it can activate some seizure foci

Answer 164

reduces it reduces the CMR similar to sevoflurane but since it does not increase CBF it is able to reduce ICP.

Answer 165

reduces in addition to the indirect effect of reduced cerebral metabolism on blood flow, etomidate is also a direct vasoconstrictor even before metabolism is suppressed. EEG effects include initially increased alpha amplitude followed by progressive decrease in activity. These effects are though to lengthen seizure duration, making etomidate a useful agent for ECT

Answer 166

-dissociative anesthetic, activated certain areas in the brain and can increase CBF and CMR -great for spines, avoid for brains -increases ICP by increasing CBF. CMRO2 rises and is mirrored by increase in CBF. Has traditionally been avoided in the setting of increased ICP.

Answer 167

no- it is thought to possess anticonvulsant activity

Answer 168

increases decreases

Answer 169

reduce CMR and CBF but effect not as pronounced as that with the barbs -blood flow reduction by benzos is thought to be secondary to a reduction in CMR -benzos may reduce ICP owing to their effect on CBF.

Answer 170

opioid anesthetics, morphine and fentanyl, cause either a minor reduction or no effect on CBF and CMR -remifentanil had similar effects to fentanyl on CBF aside from difference in recovery time. -controversy with effects of sufentanil-some has reduction in CBF whereas others had increase in BF and ICP.

Answer 171

-mild transient increase in ICP -not contraindicated in patients with an intracranial mass or increased ICP -no significant effect on CBF

Answer 172

<8 intubate!

Answer 173

-lidocaine -propofol -opioid (fentanyl or remi) -neuromuscular blockade --sux? -vasopressors and/or short acting antihypertensives

Answer 174

-avoidance of hypo-osmolar Fluids -correction of electrolyte abnormalities due to diuretics -sodium control -glycemic control

Answer 175

reduces ICP by decreasing brain metabolism, CBF, cerebral volume and CSF production. intraop, a modest degree of hypothermia, 34C, has been recommended as a way to confer neuronal protection during focal ischemia

Answer 176

particularly dangerous in neurosurgical patients because it increases brain metabolism, CBF and propensity for cerebral edema

Answer 177

avoid glucose solutions since these solutions exacerbate ischemic damage and cerebral edema -hyperglycemia augments ischemic damage by promoting neuronal lactate production, which worsens cellular injury -moderate glucose control 80-140mg/dl recommended

Answer 178

-CMRO2 -CBF-lactate production -contribute to neuronal death

Answer 179

Levetiracetam (Keppra)-500-1000mg IV Phenytoin-15-20mg/kg IV Fosphenytoin-20 PE/kg IV at a rate of <150 PE/min

Answer 180

30-35mmHg. in some pathologic conditions, PaCO2 less than 25-30 mmHg may be associated with ischemia caused by extreme cerebral vasoconstriction.

Answer 181

hyperventilation reduces brain volume by decreasing CBF through cerebral vasoconstriction elevate head: increased venous drainage keep MAC <0.5 for most volatiles

Answer 182

0.25-1.0 g/kg

Answer 183

osmotic diuretic rapid brain dehydration and ICP reduction by increasing the osmolality of blood relative to brain, mannitol pulls water across the BBB from brain to blood to restore the osmolar balance caution in CHF

Answer 184

-reduces ICP by inducing a systemic diuresis, decreasing CSF production and resolving cerebral edema by improving cellular water transport -not as effective as mannitol in reducing ICP. Can be given alone as a large initial dose (0.5-1mg/kg) or as a lower dose with mannitol (0.15-0.30mg/kg)

Answer 185

-avoidance of hypoxia, hypercarbia, fever - avoidance of hypo-osmolar fluids glucose containing -avoid excessive PEEP -treat and avoid seizures -decrease CMRO

Answer 186

abnormal collection of gas that forms a bubble in the systemic venous circulation. This bubble can act as an embolus, affecting blood flow

Answer 187

5cm or more above the right atrial level

Answer 188

-sitting position intracranial surgeries and/or posterior fossa surgeries

Answer 189

1. air lock phenomenon-right ventricular outflow obstruction 2. severe increase in pulmonary vascular resistance-vasoconstriction of the pulmonary circulation, which results in ventilation/perfusion mismatch, interstitial pulmonary edema and reduced CO as pulmonary vascular resistance increases

Answer 190

-mill-wheel murmur, loud and machinery-like -tachy or brady arrythmias -elevation in jugular venous pressure -hypotension -MI -tachypnea -rales, wheezing -cyanosis, hypoxia -AMS -seizures -Coma -transient focal neuro deficits

Answer 191

TEE (most sensitive) doppler (l or r parasternal, between 2nd and 3rd rib, mill wheel murmur PA pressure ETCO2 ETN2 (ET nitrogen)

Answer 192

-notify surgeon to flood/pack surgical field -jugular compression -lower head -aspirate RA-cath -100% Fio2 -Epi/ACLS durant's position -trendelenburg left lateral decubitus

Answer 193

-preop decreased LOC -large intracranial tumor -residual anesthetics -metabolic or electrolyte disturbances -residual hypothermia -surgical complications-seizures cerebral edema -hematoma -pneumocephalus -vessel occlusion/ischemia

Answer 194

-hypotension, bradycardia and hypothermia resulting from acute SCI -occurs with injury above T6 level -seen in 14% of isolated SCI -up to 8% major traumas -unopposed vagal tone on heart can lead to refractory bradycardia, bradyarrythmias and heart block -map goal 85-90 for first week -fluid resuscitation -pressors/inotropes -chronotropes: atropine, glyco, isoproterenol -steroids-controversal, not recommended at this time

Answer 195

Benzos Propofol/Remi TIVA common, LONG IV lines needed, intraop MRI -high paralytic requirement due to P450 activation by AEDs

Answer 196

short period of invasive EEG monitoring. EEG electrodes places directly on cortical surface and epileptiform activity identified and this can guide the extent of a resection.

Answer 197

-avoid aneurysm rupture -maintain CPP -maintain transmural aneurysm pressure -provide "slack" brain -"hypotensive induction -typical craniotomy monitoring -dynamic BP management in the case of rupture, induced burst suppression (give propofol to decrease CMRO2)

Answer 198

-decreased limb length with rhizomelia -prominent forehead -flattened midfaace -depressed nasal brdige

Answer 199

-proper positioning of extremities-lack of full elbow extension -difficult IV access and insertion-lots of redundant soft tissue -predisposition to obesity -OSA -decreased chest wall compliance -kyphosis -foramen magnum stenosis -upper airway obstruction and hyptonia of airway musculature =absense of motion/articulation at atlantooccipital level -compression of medulla and upper cervical cord because foramen magnum constricted

Answer 200

andersen-tawil long Q-T 7

Answer 201

triad of : 1. potassium sensitive periodic paralysis 2. ventricular dysrhythmias 3. dysmorphic features

Answer 202

-episodes of muscle weakness (periodic paralysis) -changes in heart rhythm-arrythmia -most common changes affecting the heart are ventricular arrhythmias and long QT syndrome

Answer 203

severe midface hypoplasia: low-set eats and widely spaced eyes Kyphoscoliosis -restrictive lung disease -decreased pulmonary function

Answer 204

-midface hypoplasia -mandibular problems -small lower jaw (micrognathia) -dental abnormalities -curving of the fingers or toes (clinodactyly)

Answer 205

angelman's snydrome

Answer 206

-ataxia -hand-flapping -seizure disorder -subtle dysmorphic features -mental retardation -happy disposition with uncontrollable laughter

Answer 207

after age 2 when characteristic behaviors become most evident

Answer 208

-aspiration precautions -potentially difficult airway -vocal cord paralysis -potential ventilation issues -latex precautions

Answer 209

congenital defect in the area of the back of the head where the brain and spinal cord connect

Answer 210

-headaches -stiffness or pain in neck or back of head area -poor feeding or swallowing -decreased strength in arms -decreased sensation in arms and legs -rapid back and forth eye movement -developmental delays -weak cry -breathing problems

Answer 211

-most common -commonly goes unnoticed until problems arise in adolescent or adult years -base of skull and upper spinal area not formed properly

Answer 212

-part of the back of the brain shifts downward through the bottom of the skull area -typically seen in infants born with spinal bifida -can be associated with hydrocephalus

Answer 213

-back of brain protrudes out of an opening in the back of the skull area

Answer 214

-back of brain fails to develop normally

Answer 215

-50% born prematurely -weight >4000gm -macrosomia (LGA) -macroglossia -microcephaly -exopthalmos -ompahlocele -medullary renal dysplasia -neonatal hypoglycemia -polycythemia -umbilical hernia -potentially difficult airway -glucose issues -impaired renal drug excretion -pre-op cardiac eval

Answer 216

-short neck -hypoplastic mandible -omphalocele -CHD -premature closure of cranial sutures -elevated ICP -psychomotor retardation -potentially difficult airway -preop cardiac eval -management of ICP

Answer 217

-chronic peripheral neuropathy -distal muscle weakness and wasting -sympathetic nervous system impairment -difficult to control body temperature -ANS hypersensitivity -impaired thermoregulation -potential post-op respiratory dysfunction -sensitive to muscle relaxants -risk of hyperkalemia with Sux

Answer 218

Colomboma ("curtailed or missing a structure (eyes)) Heart defects Atresia choanae (nasal obstruction) Retardation (Mental) Genital Hypoplasia Ear Deformations (with or without hearing loss)

Answer 219

-congenital disorder where back of nasal passage (choanae) is blocked usually by abnormal bony or soft tissue (membranous) due to failed recanalization of the nasal fossae during fetal development

Answer 220

-wide skull -proptosis -maxillary hypoplasia -coronal suture synostosis -nystsagmus, strabismus -cleft palate -elevated ICP -difficult airway -strabismus and MH -exopthalmos

Answer 221

-hydrocephalus Associated CNS Malformations -Meningomyelocele -developmental delay -microglossia -micrognathia -ICP/VP shunts -latex precautions -postop laryngeal incompetence and vocal cord paralysis

Answer 222

-first described in the 1960s -Dr. DiGeorge observed a combo of a lack of thymus gland and lack of parathyroid glands (low calcium levels in blood) -high percentage of these patients have certain forms of congenital heart disease

Answer 223

-chromosome 22q11 deletion -defect of 3rd/4th brachial arches -PTH deficiency leading to hypocalcemia, tetany and cardiac failure

Answer 224

-micrognathia -tracheomalacia -choanal atresia -airway issues? -calcium monitoring -exaggerated response to NDMR -prevent graft-versus-host reaction

Answer 225

-brachycephaly -flat occiput -dysplastic ears -epicanthal folds -upslanting palpebral fissures -enlarged tongue midface hypoplasia -skeletal and visceral anomalies -resp problems -cardiac anomalies (40%)

Answer 226

-difficult airway management -spinal cord compression secondary to occipital-atlatoaxial instability -possible endocarditis prophylaxis -bradycardia during induction -difficult vascular access -possible OSA

Answer 227

-odontoid hypoplasia/atlantoaxial instability -micrognathia -cleft palate -tracheal stenosis -small chest cavity -kyphoscoliosis -CHD -restrictive lung disease -preop C-spine -potential for difficult airway -pulmonary function -care in OR positioning

Answer 228

-10_+ types of connective tissue disorders due to abnormal production of collagen

Answer 229

joint hypermobility -skin hyper-elasticity -bruising -scarring -muscular discomfort -GI, uterus and vascular complications -mitral regurg and cardiac conduction abnormalities

Answer 230

-evaluation of CV manifestation -caution with instrumentation of nose, airway, esophagus, vascular structures -extravasation of fluids may go unnoticed because of skin laxity -must have low airway pressures during mechanical ventilation to decrease incidence of pneumo -propensity to blood -regional anesthesia not recommended

Answer 231

-growth restriction -craniofacial abnormalities -Cardiac defects (VSD) -renal abnormalities -inguinal hernia intellectual impairment +/- airway issues +/- CHF

Answer 232

-possible vascular accident occuring during fetal development leading to defects of first and second branchial arches

Answer 233

-preauricular appendages -fistulas -epibulbar dermoids -vertebral anomalies -upper eyelid colobomas -ear anomalies -hearing loss -hemifacial macrosomia -micrognathia -high arched palate -CHD -renal abnormalities

Answer 234

-preparation for difficult airway -difficult mask because of facial asymmetry -preop radiographs recommended of mandible because predict difficult laryngoscopy -absent ramus, condyle and TMJ -airway abnormalities can predispose to obstructive sleep apnea

Answer 235

-autosomal dominant connective tissue disorder characterized by tall stature, arm span > ht, high arched palate, pectus exxcavatum, joint hyperextensibility

Answer 236

pulmonary emphysema high incidence of spontaneous pneumo -ocular changes -kyphoscoliosis

Answer 237

-cardiopulmonary abnormalities (echo) avoidance of TMJ dislocation -avoidance of sustained increase in SBP

Answer 238

-defective connective tissue in aorta and heart valves lead to aortic dilation, dissection, rupture/prolapse of cardiac valves -mitral regurgitation common -cardiac conduction abnormalities (BBB) -CV abnormalities responsible for premature death

Answer 239

-scoliosis -CHD -Sprengel deformity -congenital snostosis of cervical vertebrae -renal dysfunction -VSD -care in neck manipulation for intubation -impaired renal drug excretion -assessment of CHD -progressive airway obstruction

Answer 240

-occipital encephalocele -microcephaly -micrognathia -cleft epiglottis, lip, palate -polycystic kidney -CHD -polydactlyl -cataracts -airway -renal function -cardiac evval -prophylacitc abx

Answer 241

-delayed motor development -hypotonia -intelligence normal -dysmorphic features -micrognathia -kyphoscoliosis and pectus-->restrictive lung disease, dilated cardiomyopathy, possible difficult intubation

Answer 242

-waddling gait -frequent falling -difficulty climbing -fatty infiltration of affected muscles

Answer 243

-degeneration of cardiac muscle -poss mitral regurg due to papillary muscle dysfunction with diminished contractility -chronic weakness of respiratory muscles, decreased ability to cough, and kyphoscoliiosis predisposes to URIs, restrictive lung disease, possible pulmonary HTN

Answer 244

-contraindication of sux -availablility of MH cart/ dantrolene for Duchenne's patients-mimics MH) -postop need for chest physiotherapy =hypomotility of GIT, delayed gastric emptying and weak laryngeal reflexes increase risk of aspiration -risk of rhabdomyolysis, hyperkalemic cardiac arrest or v-fib

Answer 245

-shield-shaped chest, short stature, kyphoscoliosis -webbed neck -micrognathia -renal function -hypoplastic kidneys -mild retardation -platelet dysfunction -airway -CHD, ASD. PS =hypertrophic cardiomyopathy -C-spine x-ray to exclude atlantoaxial instability -aortic coarcation -dissection aortic aneurysym

Answer 246

-difficult intubation and IV access -decreased FRC -possible bleeding diathesis or altered metabolism of drugs

Answer 247

-cNS neurofibroas -Cafe-au-lait spots -increased incidence of pheochromocytoma -kyphoscoliosis -honeycomb cystic lung changes -renal artery dysplasia and HTN -tumors may involve larynx -prolonged paralysis with NMDR difficult airway especially if tumor -preop screening for Pheo -renal and lung function

Answer 248

neurofibromatosis-von Recklinghausen syndrome

Answer 249

1. blue sclera 2. multiple fractures 3. deafness

Answer 250

-defect in synthesis of collagen and associated dysfunction of platelet aggregation

Answer 251

-small mandible -midface hypoplasia -short limbs and trunk

Answer 252

osteogenesis imperfecta

Answer 253

females very smart and intellect intact

Answer 254

-blue sclera -fractures after minor trauma -kyphoscoliosis -bowing of femur and tibia -gradual deafness -impaired platelet function -increased serum thyroxine in 50% of patients

Answer 255

-kyphoscoliosis and pectus may decrease vital capacity and chest wall compliance leading to arterial hypoxemia and V/Q mismatching -automated BP cuffs may be hazardous since inflation can cause fractures -present with a prolonged bleeding time despite normal platelet count -desmopressin may be effect in normalizing platelet function -may have mild hyperthermia

Answer 256

-C-spine eval with care during tracheal intubation -avoid sux -careful positioning -PFTs if severe kyphoscoliosis and pectus -consider NIBP vs. a-line monitoring -coagulation checks and intraop monitoring of temp

Answer 257

1. congenita occurs in utero and death often in perinatal period -tarda manifests in childhood

Answer 258

Stickler syndrome

Answer 259

group of hereditary conditions characterized by distinctive facial features, eye abnormalities, hearing loss and joint abn

Answer 260

not known usually in utero round 14 weeks gestation, during stage of formation of bones of fetus-fixed fetal position that inhibits mandibular growth -may have swallowing difficulties from abnormalities in brainstem dysfunctionW

Answer 261

Micrognathia Cleft Palate Glossoptosis

Answer 262

difficult airway

Answer 263

-prone positioning -nasopharyngeal airway -suturing of tongue to lip -tracheostomy to preserve an airway

Answer 264

deletion in chromosome 15 -proposed autosomal recessive mode of inheritance

Answer 265

hypotonia at birth but progresses to hyperphagia and obesity with endocrine abnormalities between 1-6 years

Answer 266

short stature mental retardation severe dental carries common related to chronic regurg of gastric contents

Answer 267

-hypotonia altered metabolism of carbs and fats -possible difficult mask ventilation and intubation -IV access -thermoregulation -sleep apenea -evaluation for cor pulmonale -intraop monitoring of glucose necessary and they may actually need exogenous glucose administration because these patients use circulating glucose to make fat instead of meet basal energy needs endocrine abn include hypogonadism and DM -they hide their food

Answer 268

-premature aging -start 6 month to 3 years -cardiac disease-HTN, ischemia, cardiomegaly -Alopecia -micrognathia -joint stiffness -small stature -careful padding and positioning -potential difficular airway -monitor and treat for myocardial ischemia

Answer 269

short-webbed neck broad shield like chest maxillary and mandibular hypoplasia shorter trachea length possible coarcation of aorta or bicuspid aortic valve ovarian failure

Answer 270

-difficult airway -thorough cardiac eval -optimization of medical comorbidities

Answer 271

-may be normal or slightly diminished

Answer 272

-facial and pharyngeal hypoplasia -aplastic zygomatic arches -micrognathia -microstomia -choanal atresia -CHD -marked narrowing of airway above larynx extreme difficult intubation -cardiac problems

Answer 273

"children of the night" keratosis, telangiectasia, hyperpigmentation and neoplasia in areas exposed to sunlight

Answer 274

autosomal recessive genetic disorder of DNA repair, hypersensitivity to UV radiation and progressive neurologic complications

Answer 275

Killer gene-Programmed cell death Telomere shortening-every time a cell divides

Answer 276

mitochondrial damage b/c we run out of energy from less effective energy production in the mitochondria.

Answer 277

-liver mass decreases by 20-40% -decreased liver blood flow -decreased phase-1 drug metabolism -decreased bile production

Answer 278

1ml/min/yr

Answer 279

-renal mass decreases by 20-25% -1/2 of all glomeruli decreased by 80 yr -effectively reduces renal drug excretion -slower elimination of Excess H20 vs. young kideys -sensation of thirst declines with age-chronic dehydration state less conservation of Na -reduced aldosterone secretion

Answer 280

60 years old.

Answer 281

-decreased secretion with age -increased insulin resistance (Especially skeletal) muscle

Answer 282

-Testosterone -Estrogen -Growth hormone

Answer 283

higher circulating glucose

Answer 284

50 by age 80-10% mass lost

Answer 285

-dopamine -serotonin -GABA -Ach system-connection to Alzheimers, loss of cholinergic neurons

Answer 286

-slower cognition and response times -atherosclerosis in cerebral vasculature -ironially, the brain is capable of rewiring new neurons, dendritic connections and neural pathways

Answer 287

-potential anesthesia interactions -post-op cognitive impairment and delirium -stress of sx effect on brain with a minimal reserve function

Answer 288

increased free drug available high concentration in circulation because less sequestered in the muscle group -increased drug absorption by the target organ (brain) and heart

Answer 289

-decreased drug metabolism -decreased drug clearance -increased Vd-drug reservoir -decreased liver mass and blood flow -lower GFR-lower excretion

Answer 290

1. Decreased Beta-receptor Stimulation 2. stiffening of myocardium, arteries and veins 3. Autonomic nervous system changes: increased SNS activity, decreased PNS activity 4. conduction system changes 5. defective ischemic preconditioning

Answer 291

-not believed to be beta receptors in the heart -defects in intracellular coupling -HR has less response to catecholamines -chronic HTN decreases baroreceptor control of HR -HR increase to exercise is altered (220-age) -decreased exertional capacity -impaired regulation of BP

Answer 292

increase -increase SNS activity at rest -exaggerated response to stimuli -excessive changes to vascular resistance (BP Lability) during anesthesia , wild fluctuations and profound low BP after inductions

Answer 293

decreases -may limit responsiveness to anticholinergics

Answer 294

-effective is limited or abolished with age -defined as brief period of ischemia lessen the effect of a prolonged myocardial ischemia event -in younger adults who experienced angina within 2 weeks of an infarction had less death or heart failure -protective effect of angina is not present in older adults

Answer 295

-increases work of breathing -barrel-shaped chest and flattening of diaphragm -decrease muscle mechanical advantage to generate negative pressure to breathe -increase minute ventilation and fatigue by increased effort to breathe

Answer 296

-makes lung earlier to inflate but at a cost of less springiness -small airways have less stiffness and depend on tethering to stay open -greater internal lung pressure is needed to prevent airway collapse and ventilate -closing capacity of the airways will eventually exceed lung TV -less ventilated lung tissue-reduced alveolar ventilation-->decreased PaCO2

Answer 297

-hypopharyngeal muscles -genioglossal muscles -both lead to an increased risk of upper airway obstruction -aspiration risk due to inability to clear secretions

Answer 298

Vasoconstriction-shunt blood to core Shivering-not as profound as younger patients both are triggered by the following temps: skin temp change=1 degree C core temp change=0.2C

Answer 299

-increased risk of MI -surgical wound infection -coagulopathy -impaired drug metabolism

Answer 300

1 degree C

Answer 301

1. atropine 2. opioids 3. benzodiazepines

Answer 302

-subdural hematoma -dementia -depression -delirium tremors

Answer 303

Delirium is a medical emergency (1/3rd preventable) Emotional changes Lint picking (obvious with central anticholinergic effect) Incoherent speech and swearing Reversal of sleep pattern Indifferent to what is going on Un-cooperative Memory loss

Answer 304

deterioration in cognitive function following surgery

Answer 305

abnormally high percent of body weight as fat

Answer 306

increased body weight above a standard related to height

Answer 307

1. android 2. gynecoid

Answer 308

-distribution of body fat in the upper body (truncal) -very metabolically active -increased oxygen consumption -higher rate of CV disease -visceral fat -increased CV disease - high rates of LV dysfunction -most dangerous

Answer 309

-adipose tissue mostly located in hips, buttocks and thighs -less metabolically active -to a lesser degree less associated with CV disease

Answer 310

IBW (kg)=height (cm)- X Males (x=100)-result represents 80% TBW Females (x=105)-result represents 75% TBW

Answer 311

-hypoxemia -hypercapnia

Answer 312

-decreased chest wall and lung compliance from thorax/abdominal fat -increased pulmonary blood flow-higher circulating volume -polycythemia (more blood viscosity) from chronic hypoxia -decreased lung elasticity-reduced lung compliance -decreased FRC & ERV-most commonly reported pulmonary abnormaility -lung volumes below closing capacity (small airway closure)

Answer 313

-frequent episodes of sleep apnea (>10secs and or >5/min) typically against a closed glottis (10 sec />15 sec per hour of sleep

Answer 314

> or equal to 5 but <15

Answer 315

> or equal to 15 but <30

Answer 316

> or equal to 30

Answer 317

-hypoxemia -hypercapnia -pulmonary/systemic vasoconstriction -secondary polycythemia -respiratory acidosis limited to sleep time

Answer 318

-Ischemia heart disease -cor pulmonale from hypoxic pulmonary vasoconstriction -cerebral vascular disease/events

Answer 319

(Pickwickian sydrome) -long term OSA alters breathing control (less sensitive to high PaCO2) and more reliant on hypoxic (low O2 drive) -CNS mediated apneic events -seen in 5-10% morbidly obese patients

Answer 320

-obesity -chronic hypoventilation -leads to pulmonary HTN or cor pulmonale BMI>30 -awake Pa CO2 >45mmHg

Answer 321

alveolar hypoventilation independent of intrinsic lung disease

Answer 322

increased left ventricular wall stress-->obesity cardiomyopathy -hypertrophy (ultimately fails to keep up with diastolic dysfunction) -impaired LV filling (diastolic dysfunction) -elevated LV and diastolic dysfunction) end result-->bi-ventricular failure

Answer 323

-increased total body volume (goes to adipose tissue) & polycythemia -CO increased with increased weight

Answer 324

-lower mobility -increased angina/ischemic events -dyspnea on exertion at rest, they will appear asymptomatic, minimal exertion precipitates symptoms

Answer 325

-fatty infiltration into the into the conduction system -CAD -electrolytes imbalances -hypoxia/hypercapnia

Answer 326

Leads II and V5

Answer 327

-delayed gastric emptying -gastric volumes >25mL -gastric fluid pH <2.5 -increased incidence of Hiatal hernia and GERD

Answer 328

-no solids for 8 hours -clear liquids up to 2 hours -take their antacid/H2 blockers-as scheduled consider IV

Answer 329

-NAFLD -inflammation -abnormal LFTs -focal necrosis and cirrhosis

Answer 330

LFT improvement

Answer 331

-central obesity -any (2) of the following: -high Triglycerides -low HDL -HTN -high fasting glucose

Answer 332

-abdominal obesity -glucose intolerance -HTN -dyslipidemia -increased vascular events

Answer 333

-high aspiration risk --long half life -very delayed gastric emptying -case reports of retained gastric contents up to 1-2 weeks after D/C -need to POCUS scan GI -treat as full stomach-RSI -actively vomiting/retching/symptoms for elective case-delay!

Answer 334

11-15 hours

Answer 335

-resp rate 12-24/min (stable/regular) -neg inspiratory force >20mmHg -TV >6ml/kg -hemodynamically stable -O2 saturation >93-95% -sustained head lift >5s and strong handgrip -following commands -suction airway -ETCO2 relatively normal range -extubate elevated HOB

Answer 336

-volatile agents ok-minimally metabolized -propofol GTT-good choice if not long case -remifentanil-quick on/off -shorter acting opioids -NMBDs-roc ok, cistricurium (organ independent elimination pathway) -reversal-sugammadex! -dexmedetomidine -sedline or BID-tailor anesthetic level -PEEP-only ventilatory parameter that consistently improves respiratory function

Answer 337

-ventilatory impairment -aortocaval compression -decreased FRC/oxygenation -induction -consider HOB up for preoxygenation - prolonged denitrogenating -face strap with tight mask seal -peep 5-10 cm H20

Answer 338

neck cirumference

Answer 339

DVT -Heparin 5000 U sq repeated q 8-12 hours until fully mobile or unfractionated heparin 40mg sq Q 12hours

Answer 340

-mass decreases by 20-40% -decreased liver blood flow -decreased phase 1 metabolism -decreased bile production -other than drug metabolism liver reserve should be more than adequate in the absence of disease

Answer 341

-mass decreases by 20-25% -1/2 of all glomeruli decreased by 80 years old. -decrease GFR by 1 ml/min/yr >40 year -60 yr requires reduction in drug doses -effectively reduces renal drug excretpion -less conservation of Na-reduced aldosterone secretion

Answer 342

adenotonsillar hypertrophy

Answer 343

Snoring Tired Observe Apnea Pressure (HTN) Body Mass index >35 kg/m2 Age older than 50 Neck size large >40cm/16inches Gender: Male

Answer 344

intermediate risk

Answer 345

-return to room air o2 saturation at baseline -no hypoxic episodes or periods of airway obstruction when left alone -monitoring for a minimum of 3 hours more than non-OSA -monitoring for 7 hours following episode of airway obstruction or hypoxemia on ra /unstimulated problem with surgery center

Answer 346

-unstable asa III or IV active alcohol/substance abuse -no caregiver -poorly managed OSA, morbid obesity with comorbidities -ex-premie less than 60 weeks post-conceptual age under ET Anesthesia --active infection/sepsis -potential for uncontrolled pain relief

Answer 347

time it takes for plasma concentration to decline by 50% after terminating infusion

Answer 348

1. Coronary Artery Disease 2. Congestive heart failure

Answer 349

hypotension

Answer 350

tachycardia often a reaction to, not the cause of, myocardial ischemia

Answer 351

1. drowsiness 2. N/V 3. Pain

Answer 352

1. prolonged recovery, drug metabolism decreases 2. physiologic instability (decreased oxygen, cardiac and rhythm changes) 3. post operative morbidity

Answer 353

-elderly -neonates -intoxicated -general anesthetics

Answer 354

-female -hx of motion sickness and/or PONV -age <50 years -use of post-op opioids -PONV in PACU

Answer 355

-frequently used to quantify readiness for discharge from PACU phase 1

Answer 356

-claustrophobia, anxiety, panic disorder -cerebral palsy, developmental delay or learning difficulties -seizure disorders, movement disorders, muscular contractures -pain, related to the procedure or the positioning or unrelated pain -acute trauma with unstable CV, resp, or neurologic function increased intracranial pressure -significant comorbidity grades III and Iv -child's age especially children <10

Answer 357

airway obstruction and respiratory depression

Answer 358

-normal response to verbal stimulation airway, spontaneous ventilation and CV function unaffected

Answer 359

-purposeful response to verbal or tactile stimulation -spontaneous ventilation adequate cv function usually maintained airway-no intervention required

Answer 360

-purposeful response after repeated or painful stimulation -airway intervention may be required -spontaneous ventilation may be inadequate -CV system usually maintained

Answer 361

unarousable even with painful stimulus airway-intervention often required -frequently inadequate spontaneous respiration -CV function may be impaired

Answer 362

severity of tissue damage is dose dependent, such at a cataract or infertilityS

Answer 363

probability of occurence is dose related, such as in cancer or genetic effect

Answer 364

-limiting the time of exposure to radiation -increasing distance from the source of radiation -using protective shielding -using radiation dose badges -radiation accumulates over time -inverse square rule-4ft distance decreases dose by 16 times

Answer 365

contain gadolinium-may be given IV before MRI to increase speed at which protons realign with magnetic field. The faster the protons realign, the brighter the image

Answer 366

-no ionizing radiation like CT and Xray -can see non-bony tissues more clearly (brain, SC, nerves, muscles, ligaments, tendons_

Answer 367

-more costly than CT and xray

Answer 368

-AICD, cardiac pacemakers may malfunction, insulin pumps and other implantable devices, cochlear implants, Deep brain stimulators, implanted pumps -intracerebral clips might move -large area tattoos with ferromagnetic links -transdermal medication patch may cause burn -bullet fragments and shrapnel

Answer 369

yes preferable during first trimester

Answer 370

increase in serum creatinine of 0.5mg/dl or a 25% increase from baseline within 48-72 hours after iodinated contrast medium

Answer 371

-renal disease -prior renal surgery -proteinuria -diabetes -dehydration -hypertension -advanced age -concominant use of nephrotoxic drugs and patients on metformin

Answer 372

-adequate hydration -maintaining good UOP -using sodium bicarb infusions to improve elimination of contrast agent

Answer 373

pruritis and urticaria

Answer 374

pruritis and exanthema

Answer 375

-stop causative agent -oxygen -secure airway -fluids -vasopressors and inotropes -bronchodilators -pre-tx with corticosteroids and antihistamines questionable

Answer 376

-tx by endovascular access for the purpose of delivering therapeutic drugs and devices -hybrid environment -occlusive or opening procedures -cerebral aneurysm, AVMs and vascular tumors -ABSOLUTE immobility

Answer 377

-usually under local with MAC -General/ET (stroke, subarachnoid,hemm, increased ICP or depressed LOC) -need a motionless field -contrast dye injections into cerebral arteries can cause burning and/or pruritus around face and eyes -full bladder from IV fluid andIV contrast administration

Answer 378

-significant hepatic dysfunction -bridge to transplant

Answer 379

Theraspheres placement (liver tumors)

Answer 380

treats spinal compression fractures using a balloon like device to present bones from collapsing

Answer 381

-monoamine neurotransmitter theory (increasing dopamine, serotonin, adrenergic and possible GABA and glutamine neurotransmission -neuroendocrine theory (release of pituitary or hypothalamic hormones) -neurotrophic theory (increasing signaling in the brain)

Answer 382

methohexital

Answer 383

1-1.5mg/kg

Answer 384

-can paradoxically increase or activate cortical EEG seizure discharges in patients with temporal lobe epilepsy -this property makes a bolus dose of methohexital the IV anesthetic of choice for ECT therapy

Answer 385

tonic-clonic seizures that can last 60 sec or more

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Exam 1 Plus Some Peds :/ Flashcards

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