Exam 2 Flashcards
1
Q
For people age 5-29 years, 3 of the top 5 causes of death are:
A
injury related, namely road traffic injuries, homicide and suicide
2
Q
Injuries and violence are responsible for an estimated _____% of all years lived with disability.
A
10%
3
Q
The general approach to evaluation of the acute trauma victim has 3 sequential components:
A
- rapid overview
- primary survey
- secondary survey
4
Q
The primary survey is designed to do what?
A
to access and treat life-threatening injuries rapidly
5
Q
What are the leading causes of death in trauma patients:
A
-airway obstruction
-respiratory failure
-hemorrhagic shock
-brain injury
therefore, these are the areas targeted by the primary survery
6
Q
What is the most frequent cause of asphyxia?
A
airway obstruction
-may result from posteriorly displaced or lacerated pharyngeal soft tissues, hematoma, bleeding, secretions, foreign bodies or displaced bone or cartilage fragments
7
Q
signs of upper and lower airway obstruction
A
-dyspnea
-hoarseness
-stridor
-dysphonia
-Sq emphysema
-hemoptysis
8
Q
Initial steps in airway management are:
A
-chin lift
-jaw thrust
-clearing of the oropharyngeal cavity
-placement of an oropharyngeal or nasopharyngeal airway
and in inadequately breathing patients, ventilation with a self-inflating bag
9
Q
if the initial steps in airway management are inadequate definitive airway management should be achieved by:
A
intubation or cricothyroidotomy
-LMA can be useful in intermediary
-blind passage of nasal tubes should be avoided
10
Q
What are the most common trauma-related causes of difficult tracheal intubation:
A
-maxillofacial neck
-chest injuries
-cervicofacial burns
-airway assessment should include a rapid examination of the anterior neck for feasibility of access to the cricothyroid membrane
11
Q
Maxillofacial injury
A
-obstruction by blood, bone, teeth, pharyngeal tissues
-a hematoma or edema in the face, tongue or neck may expand during the first several hours after injury and ultimately occlude the airway
-many isolated facial injuries do not require intubation
12
Q
Cervical penetrating
A
-escape of air, hemoptysis and coughing
-may intubate through defect
13
Q
blunt cervical
A
-hoarseness, muffled voice, dyspnea, stridor, dysphagia, odynophagia, cervical pain and tenderness, ecchymosis, subcutaneous emphysema and flattening of the thyroid cartilage
-CT if stable
-thoughtful intubation strategy
14
Q
thoracic
A
-penetrating can obviously be anywhere
-blunt unjury usually involves the posterior membranous portion of the trachea and the mainstem bronchi, usually within approx 3cm from the carina
-pneumo, pneumomediastinum, SQ emphysema, and continuous airleak from chest tube are the usual signs of this injury
-they occur frequently but are not specific for thoracic airway damage
-in patients intubated without the suspicion of a tracheal injury, difficulty obtaining a seal around the endotracheal tube or the presence on a chest radiograph
-of a large radiolucent area in the trachea corresponding to the cuff suggests a perforated airway
15
Q
Rapid inspection–primary survey: breathing
A
-cyanosis
-tracheal deviation
-significant chest wounds
-fail chest
-paradoxical chest movement
-asymmetric chest wall excursion
-auscultation of both lungs should be conducted to identify decreased asymmetric lung sounds
16
Q
Tension Pneumothorax
A
-life-threatening emergency wherein a large air collection in the pleural space comprises respiration and cardiac function
17
Q
s/s of tension pneumo
A
-cyanosis
-tachypnea
-hypotension
-neck vein distension
-tracheal deviation
-diminished breath sounds on affected side
18
Q
tx for tension pneumo
A
-needle decompression by insertion of an angio cath in the 2 intercostal space midclavicular line
-followed by chest tube placement
19
Q
Open pneumothorax
A
-when an injury creates a hole in the chest wall that allows air from the environment to enter the pleural cavity
-similar s/s to tension pneumo
-air that gets entrained though the wound but not able to escape–>tension physiology
-tx three sided dressing and chest tube
20
Q
Flail chest
A
-may occur when 3 or more ribs are broken in at least 2 places
-arises when these injuries cause a segment of a chest wall to move independently of the rest of the chest wall
-continuity of the chest wall is disrupted and the physiologic action of the ribs is altered. The motion of the flail segment is paradoxical to the rest of the chest. It is paradoxical because the flail segment moves inward while the rest of the chest wall moves outward
-ineffective ventilation because of increased dead space, decreased intrathoracic pressure and increased oxygen demand from injured tissue
-pulmonary contusion in adjacent lung tissue is almost universal with flail chest. Pulmonary contusion impairs gas exchange and decreases compliance. Hypoventilation and atelectasis result from the pain of the injury.
Tx: maintain adequate ventilation, fluid management, pain management and management of the unstable chest wall
21
Q
What is the most common cause of shock in trauma patients?
A
blood loss-second cause of death
TBI is first
22
Q
how is blood loss assessed?
A
-level of responsiveness
-obvious hemorrhage
-skin color
-pulse (presence, quality, and rate)
23
Q
Level of responsiveness can be quickly assesed by _______.
A
AVPU
24
Q
What is a warning sign of hypovolemia?
A
pale or ashen extremities or facial skin
-rapid, thread pulses in the carotids or femoral arteries are also concern for hypovolemia
25
In trauma, hypovelemia is addressed by what first
addressed first with 1L-2L isotonic solutions but should then be followed by blood products. CRT can be used to assess the adequacy of tissue perfusion.
26
A CRT > _____sec may indicate poor perfusion.
2
27
Any patient presenting with pale, cold extremities is in ______ until proven otherwise.
shock
-with no obvious signs of hemmorhage and when there is hemodynamic compromise a pericardial tamponade must be considered and if suspected, corrected through creation of pericardial window
28
Class I blood loss
Blood loss in %: <15
Pulse: <100
BP normal
Pulse pressure; normal or increased
RR: 14-20
Mental Status: slightly anxious
UOP: >30
29
Class II blood loss
Blood loss in %: 15-30%
Pulse: 100-120
BP: normal
Pulse pressure: decreased
RR: 20-30
Mental Status: mildly anxious
UOP: 20-30
30
Class III blood loss
Blood loss in %=30-40
Pulse: 120-140
BP: decreased
Pulse pressure-decreased
RR: 30-40
Mental Status: anxious, confused
UOP: 5-15
31
Class Iv blood loss
Blood loss in %: >40
Pulse: > 140
BP: greatly decreased
Pulse pressure: dereased
RR: >35
Mental Status: confused, lethargic
UOP: minimal
32
Primary survey: disability
-neurologic status
-a rapid assessment of the patient's neurologic status is necessary on arrival in the ED
-this is assessed by the patient's Glasgow coma scale
-if the GCS <8-intubate
-a maximum score of 15 is reassuring and indicates the optimal level of consciousness, whereas a minimum of 3 signifies a deep coma
33
AVPU
A-alert and conscious
V-responds to verbal stimulus
P=responds to painful stimulus
U=unresponsive to any form of stimulus
34
Management of TBI
-hypoxia and hypotension is TERRIBLE for injured brain
-maintain MAP >80mmHg, SpO2> 92%
-goal to maximize CPP
-mannitol/furosemide to decrease ICP
-head elevation
-isotonic/hypertonic fluid resusitation-may be prudent to avoid Lr (no colloids)
temporary hyperventilation (prolonged worsens cerebral ischemia)
-sedation (to decreased CMRO2)
35
Management of Spinal cord injury
-focused neuro assessment
-immobilization until clinical or imaging clearance
-spine is like the brain-hypotension and hypoxia bad
-spinal shock=hypotension from vasodilation and brady cardia from unopposed vagal tone (may require inotropes and vasopressors)
-catecholamine surge can-->pulm edema
-C4 injuries or above likely impair respiration
-loss of gastric sphincter tone--> may increase risk of aspiration
--steroids controversial-generally avoided
-surgical intervention-when able-<72 hrs ideally
36
Secondary survey
indicated in all trauma patients who have had primary survey completed
-purpose is to obtain a detailed history, perform a head to-toe physical exam, reassess all vital signs and obtain pertinent lab and imaging studies to identify injuries and metabolic abnormalities
-these are injuries you may manage later
37
Anesthetic management of trauma patients
-airway management
-manage hemodynamic instability
-lung-protective ventilation
-maintenance of normothermia
-maintenance of adequate cerebral blood flow, oxygenation, and ventilation is prudent to avoid
-prevention of unpleasant experiences during painful interventions
38
<____MAC if TBI suspected
<0.5 MAC
-nitrous avoided
39
in addition to early surgical control of hemorrhage what other strategies limit ongoing blood loss?
-maintenance of a low to normal SBP at 90 mmHg (or <110mmHm in older adults) and/or mean arterial pressure at 50-65mmHg. Once hemostasis has been achieved higher BP values are targeted
-although increasing BP indicated increasing macrocirculatory pressure, microcirculatory flow may still be abn
40
Current ATLS guidelines recommend no more than _____ of warm 0.9% saline prior to administration of blood components
1L
41
True/false: availability should not rely on full crossmatch in patients with hemorrhagic shock since uncrossmatched blood can be administered until crossmatched blood is available.
true
42
acute coagulopathy after severe traumatic injury has multifactorial etiologies including:
-acidosis related to tissue injury and shock
-hypothermia related to exposure and fluid administration
-systemic anticoagulation with activation of protein C and protein S
-hyperfibrinolysis from amplification of tissue plasminogen activator
-platelet dysfunction following platelet activation
-hemodilution due to fluid or component blood product administration
-consumption of clotting factors manifesting as DIC
43
TXA administration
initial 1g IV bolus over 10 minutes with TEG guided determination of further dosing or following by 1g infusion over 8 hours if TEG unavailable
-TXA is part of MTP protocol in most major trauma centers in US and military
44
ESA in trauma suggests target fibrinogen concentration of?
>150-200mg/dL
45
Lethal Triad
1. Acidosis
2. Coagulopathy
3. Hypothermia
46
Targets of rescuscitation
-SBP>90mmHg
-Hgb 7-10 depending on coexisting disease
-normothermia T36-38C
-INR<1.5
-base deficit <6
-pH >7.2
-normocalcemia (0.5-1g calcium every 2-3 units of product)
-frequent use of TEG and ABG recommended to guide overall rescuscitation transfusion requirements and to correct coagulopathy
47
Other etiologies of shock
-volume, volume, volume
-SCI
-vasoplegic shock
-ischemic myocardial dysfuction causing cardiogenic shock
-tension pneumo
-pericardial tamponade
-increasing intra-abdominal pressure
-vasopressors/inotropes thoughtfully deployed to manage shock refractory to volume resuscitation
48
REBOA
-resuscitative endovascular balloon occlusion of the aorta-in selected patients, resuscitative endovascular balloon occlusion of the aorta is a temporizing measure to support vital organ perfusion , decrease amount of bleeding distal to the occluded site, and provide a window of opportunity for rescuscitation and definitive hemorrhage control
49
Inflation-Proximal aortic occlusion during REBOA does what?
-increases SVR, BP and cardiac afterload thereby increasing cerebral and myocardial perfusion
50
deflation-Proximal aortic occlusion during REBOA does what?
attempted when hemostasis has been achieved or to check for sources of ongoing hemorrhage
51
deflation of intra-aortic balloon cath may result in:
-severe hypotension due to a sudden decrease in SVR, decreased preload due to venodilation,
hypoxia-mediated reactive hyperemia and decreased myoardial contractility due to metabolic (lactic)acidosis. Metabolic acidosis and washout of ischemic muscle tissue may result in hyperkalemia, malignant arrhythmias and cardiac arrest
52
Lung protective ventilation
-lung-protective strategy used during controlled ventilation for patients with trauma and shock
-low tidal volumes 6-8ml/kg predicted body weight
-mild permissive hypercapnia 40-45mmHg unless patient has metabolic acidosis or known or suspected TBI
-maintenance of low plateau pressure < or equal to 30cmH20
-adjustment of FiO2 to maintain O2 sat > or equal to 92%
-initial PEEP at 0 cmH20 until hemodynamic stability and control of hemorrhage and adequate resuscitation has been achieved. Subsequently PEEP may be slowly and incrementally increased to 5-10cmH20 if tolerated without provoking hypotension
53
goal of protective lung ventilation
provide an optimal balance between minimizing lung injury and preventing hemodynamic instability.
in patients with hemorrhagic shock it is particularly important to avoid high levels of PEEP and auto-peep increase intrathoracic pressure and decrease venous return, CO and systemic BP
54
Pregnant patients and trauma
-airway consideration
-LUD
--aggressive volume resuscitation
-in maternal cardiac arrest, C-section is recommended for viable pregnancies >or equal to 23 weeks, if possible no later than 4 minutes following arrest. this facilitates both maternal resuscitation and fetal salvage
55
Neurogenic shock s/s
-hypotension, bradycardia and hypothermia resulting from acute SCI
56
neurogenic shock occurs with injury above _____ level
T6
-seen in 14$ isolated SCI
-up to 8 % major traumas
57
neurogenic shock most common in:
-complete c-spine transection
58
neurogenic shock less common in:
incomplete c-spine/thoracolumbar
59
in neurogenic shock unopposed vagal tone on heart can lead to :
-refractory bradycardia, bradyarrythmias, and heart block
60
Hemostasis
process by which the body maintains the delicate balance btwn bleeding and clotting
61
procoagulants
initiators of coagulation/clot formation
62
anticoagulant
inhibit coagulation/clot formation
63
fibrinolytic
dissolve clots
64
Tunica Intima
-most interior/closest to blood
broken down into:
1. endothelium (synthesizes vWf)
2. subendothelial layer (highly thrombo genic
3. internal elastic lamina
65
3 layers of vessel wall
1. tunica intima
2. tunica media
3. tunica externa (aka adventitia)
66
Which vessel layer is a smooth muscle layer and thicker in arteries?
tunica media
67
Which layer is connective tissue and provides vessel protection?
tunica externa/adventitia
68
Primary Hemostasis
unstable platelet plag
1. adhesion
2. activation
3. aggregation
69
Secondary Hemostasis
stable platelet plug
coagulation cascade:
-intrinsic
-extrinsic
-common
70
tertiary hemostasis
fibrinolytic system
71
When endothelial lining of blood vessel is disrupted, the vessel contracts to cause a tamponade and decrease blood flow:
-autonomic nervous system reflexes
-thromboxane A2
-ADP
then areas adjacent to injury vasodilate
-distributes blood to surrounding organs/tissues
-bring factors and platelet to injured site
72
Where are platelets formed?
in the bone marrow
73
Do platelets reproduce?
no
74
life span of platelets
7-12 days
75
normal platelet count
150,000-300,000/mm3
76
Which cell roams active until activated by vascular trauma?
platelets
77
they do patch minor vascular injuries that occur in perpetuity (using 7,000 each day)
platelets
78
What do platelets contain?
-vWF
-fibrinogen
-fibronectin
-histamine
-epi
-PLT factor 4
--platelet growth facator
-serotonin
-ADP
-ATP
-contains thrombin
79
Adhesion phase of primary hemostasis
-vWF is mobilized from within the endothelial cells and emerges from the endothelial linine
-vWF makes the platelet "sticky" and allows them to adhere to the site of injury
-Glycoprotein Ib receptors emerge from the surface of the platelet
-Gp1b (receptor on platelet) adheres to vWF (on endothelial surface)
80
Activation phase of primary hemostasis
1. the binding of Gp1b to vWF causes platelet activation
-platelets dislike structure swells and becomes oval and irregular
-glycoprotein IIb-IIIa receptor complex project on surface of platelet
2. The binding of Gp1b to vWF causes platelet degranulation
-vWF, fibrinogen, fibronectin, histamine, epi, PLT factor 4, platelet growth factor, serotinin, ADP, ATP, Thromboxane A 2, Thrombin
-some of the mediators released recruit other platelets to site of injury
81
Aggregation phase of primary hemostasis
-GpIIb-IIIa complex links to other activated platelets
-these mediatorys are responsible for platelet aggregation and form a primary unstable clot/unstable platelet plug
- in less threatening injuries, a primary unstable clot may be enough to maintain hemostasis
-in larger injuries, activation of coagulation clotting cascade required for permanent repair to create and stabilize a secondary clot to cease bleeding
82
Drugs that block GpIIa-IIIb
Abciximab
Tirofiban
Eptifibatide
83
Factor 1
fibrinogenf
84
Factor 1a
fibrin
85
Factor 2
prothrombin
86
Factor 2a
thrombin
87
Factor 3
tissue factor or thromboplastin
88
Factor 4
calcium
89
Factor 5
proaccelerin
90
Factor 7
proconvertin
91
Factor 8
Antihemophiliac
92
Factor 9
Christmas
93
Factor 10
Stuart-Prower
94
Factor 11
plasma thromboplastin antecedent
95
Factor 12
Hageman
96
Factor 13
fibrin stabilizing
97
Prekallikrein
Fletcher
98
Which factors are synthesized in the liver?
1
2
5
7
8
9
10
11
12
13
99
Where is factor 3 synthesized?
vascular wall
and extravascular cell membranes
released from traumatized cells
100
Where is vWF synthesized?
endothelial cells
101
Which factors are Vitamin K dependent?
"1972"
10, 9, 7, 2
102
Action of Prothrombin
when active form activated:
1, 5, 7, 13, platelets and protein C
103
What is a cofactor of factor 7?
prothrombin
104
Action of calcium in clotting cascade?
promotes clotting reactions
105
Which factor is a cofactor of 10 and forms a prothrombinase complex?
Factor 5 (proaccelerin)
106
Which factor activates 9 and 10?
Factor 7-proconvertin
107
Which is a cofactor to 9?
factor 8, antihemophiliac
108
Which factor activates 10?
9-christmas
109
Which activates 2 and forms a prothrombinase complex with 5?
Factor 10
110
Which factor activates 9?
Factor 11-plasma thromboplastin antecedent
111
Which factor activates 11?
Factor 12-Hageman
112
Which cross-links fibrin?
Factor 13-fibrin stabilizing
113
Which aactivates 12, cleaves HMWK?
prekallikrein
114
Which supports activation of prekallikrein, 12, 11?
high molecular weight kininogen (HMWK) or contact activation factor
115
When is the extrinsic pathway activated?
when injury occurs outside vessel wall
-organ trauma or crushing injuries
116
Which factors are part of the extrinsic pathway?
3 (tissue factor) and 7 (proconvertin)_
3+7=10
117
When is the intrinsic factor activated?
also contact activation pathway
-occurs with damage to blood vessel themselves
which then activates the common pathway (10)
118
Which factors are involved in the intrinsic pathway?
8
9
11
12
prekallikrein
if you cant buy the intrinsic pathway for $12, you can always purchase it for $11.98
119
Common pathway
starts with Factor 10
1,2, 5, 13
ends with stable secondary plug
120
Cell-based theory of coagulation
new concept that platelets, extrinsic and intrinsic pathways form a very interdependent relationship, not independently
-explains why certain deficiencies fail to cause bleeding despite changes in lab values (such as PT or PTT_
121
3 phase of the cell-based theory of coagulation
1. initiation
2. amplification
3. propagation
122
initiation
-endothelial surface injury which exposes TF (3)
-TF makes the phospholipid surface acidic and less repellent to platelets
-TF down regulates anti-coagulants that reside in the subendothelial layer (ATIII)
-TF activates Factor 7
123
amplification
Factor 9 activates 8, which activates 10 to produce more and more thrombin
-thrombin generation has a positive feedback to activate more clotting factors 5, 8, 9
124
Propagation
-all coagulation factors are actively influencing one another, promoting coagulation and finally activating prothrombin, resulting in large burst of thrombin
-enough thrombin must be present to convert fibrinogen to fibrin to the stable secondary hemostatic plug
-from the burst of thrombin
125
Fibrinolytic system/tertiary hemostasis
counterbalance system that degrades fibrin
-starts with an increase in blood flow that washes away procoagulant mediators
Plasminogen-->plasmin (breaks down fibrin into fibrin degradation products)
Protein C and S (inhibit factor 3, 5, 8)
Antithrombin III (sequesters factors 9, 10,11, 12) which then inhibits thrombin (3)
Thrombin (initially acting as procoagulant), now acts as an anticoagulant and activates other anticoagulant mediators
Tissue factor pathway inhibitor (also calls to stop the fibrinolysis when clot has been digested)
126
PLT count <150,000
thrombocytopenia
127
Sufficient PLT count for hemostasis
>100,000
128
high risk surgery platelet count
>100,000
129
low risk surgery PLT count
>50,000
130
central line placement PLT count
>20,000
131
Spontaneous bleeding PLT count
<10,000
132
tests to assess platelet function and anti-platlet therapy
verify now and PFA-100
133
What tests evaluate extrinsic factor (VII) and the common pathway (1, 2, 5, 10)?
PT (prothrombin time) and INR (international normalized ratio)
-tests for coumadin/warfarin
-fails to identify specific factor, the existing problem may or may not cause bleeding
134
Normal PT
12 -14 seconds but is reagent dependent
135
Normal INR
0.8-1.2
136
Therapeutic levels for Warfarin
INR 2-3
137
aPTT evaluates:
intrinsic pathway (8, 9, 11, 12)
also evaluates common pathway (1 ,2 ,5 ,10)
138
normal PTT
25-32 secs
139
Normal ACT
70-150
140
A factor deficiency must be decreased by _____% before evidence of prolonged PT or PTT can be appreciated.
30%
141
What does thrombin time measure?
conversion of fibrinogen to fibrin
Factors 1 and 2
assess fibrinogen level and function (dysfibrinogenemia)
142
Normal Thrombin time
15 seconds
143
Normal fibrinogen
>150
(200-350mg/dl)
can treat with fibrinogen or cryoprecipitate
144
What does D-dimer measure?
specific degradation by-products of fibrinolysis
145
normal D-dimer
<500mg/ml
146
3 parts of the TEG or ROTEM
1. clot initiation
R time: clotting factors
2. Clot strength
K value: fibrinogen
Alpha angle: fibrinogen
MA: platelets
3. Clot stabilization
LY-30: antifibrinolytic agents
147
What measures the time to start forming a clot?
R time
148
Normal R time
5-10 miniutes
149
R time problem with?
coagulation factors
150
Treat R time with
FFP
151
What measures the time until clot reaches a fixed strength?
K time
152
Normal K time values
1-3 minutes
153
K time problem with
fibrinogen
154
treat K time with
cryoprecipitate
155
Alpha angle
speed of fibrin accumulation
156
normal alpha angle
53-72 degrees
157
alpha angle problem with
fibrinogen
158
treat alpha angle with
cryo
159
maximum amplitude
highest vertical amplitude of TEG
160
normal MA
50-70mm
161
MA problem with
platelets
162
treat MA with
platelets and/or DDAVP (if normal plt count but max amplitude low so PLT not functioning well)
163
LY 30
percentage of amplitude reduction after 30 minutes after max amplitude
lysis at 30 minutes
164
normal LY 30
0-8%
165
LY 30 problem with
excess fibrinolysis
166
tx with LY 30
TXA and or aminocaproic acid
167
Antiplatelets
stop platelets from sticking together and forming a clot
works by inhibiting primary hemostasis (platelet plug)
168
ADP antagonists (thienopyridines)
Ticlodipine
Clopidogrel
Prasugrel
169
Anticoagulants
work to inhibit coagulation pathway (secondary hemostasis)
4 main categories:
1. FActor Xa inhibitors (Xarelto, Eliquis)
2. Thrombin inhibitors (Pradaxa, dabigatran, argotroban, bival)
3. Coumarin and indandiones (warfarin)
4. Heparins (activates AT III)
170
Drugs that act on tertiary hemostasis
1. fibrinolytic (thrombolytic)
-works to activate tertiary hemostasis or fibrinolytic system
-break down thrombus
-"clot busters"
-tpA, streptokinase, urokinase
2. Antifibrinolytic
-prevent the breakdown of clots
-work to inhibit the tertiary/fibrinolytic system
-allows clots to stay formed and used to prevent bleeding
-TXA or aminocaproic acid
171
Apheresis
-used forplatelets and plasma components
-blood components separated while a single donor is attached to separate device
-collection component is removed and other components given back to donor
172
Benefits of apheresis
-can remove more of selected component because giving other components back
-transfusion recipients patients have less exposure with single donor
173
Once FFP is thawed can be transfused within ______ days if kept refrigerated
5 days
174
Cryo average volume
15ml per bag, usual dose 4-6 bagsPL
175
Platelets whole blood derived average volume
-50mL per bag, usual dose 4-6 bags
176
Leukoreduction
-process used to filter and remove white blood cells from blood products
-no benefit to recipient but increases risk
-leukored decreases risk of infection (CMV and EBV)
-decreases risk of immunologic transfusion reactions
-decreased risk of febrile nonhemolytic rxn. TRALI and TRIM
177
CPDA preservative solution
improved RBC shelf life to 35 days
Citrate-anticoagulation binding to calcium
Phosphate-buffer
Dextrose and Adenine-to maintain ATP levels and maintain RBC integrite
178
1 unit of PRBC will increase HGB approx_____g/dL
1
179
pediatric dosing of PRBC
3-5ml/kg to increase Hgb by 1
180
Restrictive goal of PRBC
6-10g/DL
181
Asymptomatic ICU patient hgb level
>7g/DL
182
CV disease Hgb level
>8d/DK
183
Physiologic compensation for anemia
-increase CO
-sympathetic surge from anemia and hypoxia (increased HR/SV)
-altered microcircualtory blood flow (decreased blood viscosity improves blood flow; nitric oxide released from endothelial cells during hypoxia)
-improved tissue oxygen extraction from Hgb
-right shift of O2 curve, unloading of O2
-anemia causes increased 2,3 DPG, acidosis, and increased CO2
184
When you are transfusing RBC you are giving the ___________
antigens
185
RBC changes during storage
at end of shelf life of additive solutions RBC:
pH=6.5
Plasma K=50mmol/L from RBC leakage and hemolysis
15-20% of RBCs nonviable
-2,3 DPG depleted within the first 2 weeks of storage
186
RBC transfusion issues
-hyperkalemia (contain as much as 7mEq of K)
-hypothermia
-metabolic alkalosis-citric and lactic acid quickly metabolized to bicarb in liver
-citrate binds to calcium causing hypocalcemia (cardiac depression and prolonged QT, acquired coagulopathy)
187
Which have the highest bacterial infection risk?
platelets because stored at higher temps
188
1 unit of whole blood derived platelets by ________ in average adult
6,000
189
1 unit of apheresis platelets =
5-6 units of platelets =pooled platelet pack
increases platelets by approx 25K-60K
190
Plasma contains all coagulation factors and other proteins found in blood except:
5 (only 80%)
8 (only 60%)
191
use of plasma
global or multiple factor deficiences
or when a specific factor concentrate is unavailable
for hemostasis: need 30% of coagulation factors and 100mg/dl of fibrinogen
dose: 10-20m/kg
192
Plasma takes ______minutes to thaw
20-30 minutes
193
Forms of plasma
-FFP, PF24, and thawed plasma used interchangeable
plasma Cryo reduced/cryopoor plasma: plasma without cryo
missing factor 8, 13, vWF and fibrinogen
-suitable for patients with vitamin K deficiency when specific factors or factor concentrated are unavailable
194
When transfusing plasma you are giving____________
the antibodies
195
What is the universal donor of plasma since there are no antibodies?
AB
196
O blood type can only receive _______ for plasma
O
197
Cryoprecipitate contains:
-fibrinogen
-factor 8
-factor 13
-vwF
-fibronectin
198
1 unit cry per 10kg body weight will raise fibrinogen level by ______
50mg/gl
usually pooled into 5 units (usually receive 1-2 pools
199
fibrinogen concentrate
-derived from plasma with viral inactivation
-stored at room temperature and can be reconstituted for administration
200
Prothrombin complex concentrate 3 contains factors
2
9
10
201
Prothrombin complex concentrate 4 contains factors
2
7
9
10
202
Recombinant activated FVII (rFVIIa)
-factor 7 stimulated thrombin formation
-names: novoseven
-for localized sites of injury that express TF
-not for systemic levels of TF because can lead to systemic activation of thrbomin and thrombosis
203
Recombinant activated FV7 contraindicated in
CNS bleeding
huge trauma, bleeding from multiple sites
204
adverse reactions due to blood transfusion is reported to be _____%
0.2%
9% of these are severe or life threatening
205
most common cause of adverse blood transfusion reactions
clerical error, miscommunication, delay in care and over transfusion
206
All blood donors checked for:
-HIV
HepB
-Hep C
-Syphillis
-Human T-cell lymphotropic virus
-West nile
207
Which test significantly shortened the window period between donor infection and viral load is detectable because screens for viral DNA or RNA?
nucleic acid Amplification Testing (NAT)
208
Most common type of transfusion reaction?
febrile nonhemolytic transfusion reaction
209
Acute reactions
within 24 hours
210
Delayed reactions within
more than 24 hours
211
Symptoms of Hemolytic transfusion reaction
-fever
-chills
-rigors
-chest/back/abd pain
-infusion site pain
-N/V
-dyspnea
-hemoglobinuria
-oliguria/anuria
-diffuse bleeding
-acute kidney failure
-shock
-DIC
-death
212
Treatment of hemolytic transfusion reaction
-stop transfusion
-send blood for transfusion reaction workup (positive direct COOMBs test)
-monitor for DIC
-fluids to maintain UOP
213
Hemolytic Transfusion reaction
most commonly due to ABO incompatibility
-noncompatible blood causes intravascular hemolysis
214
Febrile nonhemolytic transfusion reaction
-most common transfusion reaction
-mild and self limiting
-diagnosis of exclusion
-due to cytokines released by WBC in stored blood products
215
symptoms of Febrile non-hemolytic transfusion reaction
-fever >100.4 (38C) and a change of at least 1.8F (1.0C) from pretransfusion level during or within 4 hours of transfusion.
-occasionally fever may be absent with presence of chills and rigor only
216
treatment of febrile non-hemolytic transfusion reaction
-stop transfusion
-transfusion reaction work up
-tylenol
217
Symptoms of allergical/anaphylactic reactions
-hives
-edema
-pruritis
-angioedema to serious life threatening reactions like anaphylaxis presenting with hypotension and bronchospasm
218
Anaphlyactoid reactions are from ________deficient recipient
IgA
219
treatment of allergic rxn
- stop transfusion, transfusion reaction work-op
-benedryl to epinephrine
220
Alloimmunization
-IgG mediated immunity creating antibodies to foreign proteins in allogenic blood.
-concern is on second exposure to foreign proteins
-2-4% in patients who have had a blood transfusion
- concern is patients who require frequent transfusions (up to 35-80%)
-decrease risk with matching RBC beyond ABO blood groups
221
Transfusion related immunomodulation (TRIM)
immunosuppressant effect of stored allogenic blood products
-increases incidence of healthcare associated infections
-increases recurrence of malignancies in patients undergoing cancer sx
222
Transfusion associated graft versus host disease
-rare but fatal complication
-donor T-cell lymphocytes engraft in recipient and attack host cells they recognize as foreign
-8-10 days after transfusion
-no treatment
-prevention with pathogen inactivation techniques for T-cell destruction
223
Posttransfusion purpura
-severe thrombocytopenia
-<25% pretransfusion level or <10,000
-previously pregnant women with platelet alloantibodies
-tx: immunoglobulin or plasmapheresis to remove antibody
224
Transfusion related acute lung injury (TRALI) also called
low pressure noncardiogenic pulmonary edema
225
4 criteria for TRALI
1. life-threatening lung injury within 6 hours of transfusion
2. hypoxemia:O2 saturation or < or equal to 90% on RA; PaO2/Fio@< or equal to 300mmHg
3. new onset B/L infiltrates on chest x-ray in absence of any other cause of acute lung injury
4. no evidence of left atrial htn
226
Treatment of TRALI
stop transfusion and transfusion reaction owrkup
chest x-ray
respiratory support (Positive airway ventilation and oxygen)
227
1: ____________ transfusions are associated with TRALI but ______% of fatalities.
1:10,000
15-20%
228
Transfusion associated circulatory overload (TACO)
(high pressure pulmonary edema)
-multiple blood products and fast rate of transfusion
-acute respiratory distress within 6 hours of transfusion
229
Symptoms of TACO
-dyspnea, hypoxemia, tachycardia, HTN
-increased CVP
-signs of volume overload
-B/L acute pulmonary edema
-elevation of Beta-natriuretic peptide (BNP)
230
treatment of TACO
-stop transfusion and transfusion reaction workup
-chest x-ray
-BNP lab
-diuretics-symptomatic relief with diuretics favor TACO over TRALI
231
Transfusion associated dyspnea (TAD)
-mild respiratory symptoms iwthin 24 hours of transfusion -tachypnea, mild hypoxemia, SOB
-diagnosis of exclusion
-slow transfusion rates can mitigate risk
232
Rhesus incompatibility
Mom Rh- , Baby Rh + isdangeroous for pregnancy
-ok first time because baby is delivered and mom
-second time antibodies are so small they can cross placenta and attach Rh + baby blood
-baby blood cells are broken down and bilirubin levels
-HDN (Hemolytic disease of newborn)
233
Which sensitizing events in Rh incompatiblity are where blood from mom and baby mix
-miscarriage >12 weeks
-abdominal trauma/bleeding during pregnancy
-at birth
234
Prevention of HDN-RhoGam
-anti-D immunoglobulins
-works by killing off Rh+ blood before mom can become sensitized and prevent mom from developing her own Anti-D antibodies
-IM injection at any sensitizing event (lasts 13 weeks)
-mom gets injection at 28 weeks in prep for child birth
-at birth, baby cord blood is checked and if Rh +, mom gets another anti-D injection
235
Massive transfusion
>/ 10 units of RBCs in 24 hours
-replacement of >50% of total blood volume within 3 hours
-transfusion of >4 units of RBCs within 1 hour with expected need for additional transfusions
-loss of one blood volume (70kg pt is appro 5L)
O- blood (especially females of childbearing age )until crossmatch blood is available during trauma
-1:1:1 ratio still controversial
-TXA helpful if given within 3 hours of trauma
236
Complications of MTP
-metabolic alkalosis
-citrate toxicity
-hyperkalemia
-hypothermia
TACO
237
Resuscitation goals of Massive transfusion
-MAP within range of 60-65mmHg
-hgb level between 7-9 gdL
INR below 1.5
fibrinogen levels within the range of 150-200mg/dL
-plt count above 50,000
-pH between 7.35-7.45
-core temp above 35C
238
What is the most common inherited bleeding disorder?
von Willebrand's disease
-vWF function
facilitates platelet adhesion
-blinds platelets GP ib to subendothelial matrix
-plasma carrier for factor 8 and protects factor 8 from degradation from protein c or s
-elevated aPTT (factor 8 is intrinsic pathway)
-normal PT (extrinsic pathway)
239
Which type of VW disease is DDAVP contraindicated?
Type 2B
-qualitative variants with increased affinity for platelet
contraindicated because causes thrombocytopenia
240
Which type of vW disease is DDAVP useful?
Type 1
Type IIa: helpful in some
Type IIM: helpful in some
241
Which type of Vw disease is DDAAVP not helpful?
Type IIN and Type III,
type IIB
242
Hemophilia primarily affects__________
men
are on X gene, X-linked recessive, women can carry gene
243
Most common type of Hemophilia?
Hemophilia A (85%)
244
Hemophilia A is due to factor ______deficiency.
8
245
Hemophilia B is due to factor ______deficiency.
9
14%
246
Hemophilia C is due to factor ______deficiency.
11
1%
247
Labs for Hemophilia's
PTT will be prolonged (intrinsic pathway)
then look at specific factor activities and mutation testing of the genes
248
Tx of hemophilias
replace missing or nonfunctional clotting factor
if patient has a severe deficiency (absent/very low) the replacement factors can be seen as foreign and antibodies (AKA: inhibitors) form against the factor
-inhibitors can diminish the effectiveness of tx
-bethesda test : detects inhibitors
249
Tx of Hemophilia A
Desmopressin (DDAVP)-helpful in mild VIII deficiency because it stimulates release of vWF
Emicizumab (mimics Faactor 8 function)
250
Hemophilia and bleeding
-initiate tx immediately, do not delay for testing
-maintain factor level above 50% at all times
-initial dose of 80-100% of factor
-subsequent dosing based on peak and trough levels
251
Hemiarythrosis
-give factor early-goal to raise levelabove 50%
-common manifestation of hemophilia
-bleeding into hip presents concern due to greater risk of increased intra-articular pressure and osteonecrosis
-some patients develop a "target" joint
252
Vitamin K deficiency decrease in what faactors?
2, 7, 9, 10 protein C and S
253
Vitamin K is absorbed by the small intestine and depends on availability of ___________.
bile sales from liver
-liver insufficiency, sterile gut of newborn and oral abx can cause vitamin K deficiency
254
Oral Vitamin K replacement can take _____ hours for full effect
24
255
IV Vitamin K can take ______hours for full effect.
6-8 hours
256
Protein C and S deficiencies
-protein C inactivates F 5a and Factor 8a
-protein S is a cofactor for proper function
-deficiences result in prothrombotic state
257
Factor 5 Leiden Thrombophilia
5% of caucasians
-gene mutation that makes factor 5 resistance to the inactivation by protein C
-protein C cannot suppress coagulation due to resistance from factor 5
-high risk for development of DVT
258
Heparin induced thrombocytopenia (HIT)
-life threatening complication of exposure to heparin (any form of heparin but most commonly due to UFH)
-mortality rates improved with earlier recognition and interventions >2%
-igG antibodies bind to Heparin PF 4 complexes and activate plts
-thrombocytopenia in HIT caused by consumption of activated platelets
259
Hypercoagulable state in HIT
1. venous thrombi-limb gangrene
2. arterial thrombi-organ ischemia/infarction
3. skin necrosis
260
HIT Type I
-not clinically significant
-non-immune and caused by direct effect of heparin on platelets
-mild transient platelet drop that occurs within first two days after heparin-platelet count returns to normal even with continued heparin exposure
261
HIT Type II
clinically significant
-IgG immune mediated where autoantibodies to platelet factor 4 (PF4) complexed with heparin activate plt
-platelet drop 5-10 days after exposure
262
HIT treatment goals
-halt platelet activation
-stop all heparin
-therpeutic dose anticoagulation with non-heparin anticoagulant
DTI: argatroban and bival
-plt count should see improvement in platelet counts w/in 3-4 days heparin discontinuation
263
subacute/subclinical HIT
recovered platelet count but still have positive antibodies (would not give heparin)
264
Remote HIT
-recovered plt count and negative antibodies
may be able to give heparin
265
Disseminated intravascular coagulation (DIC)
potential for causing both thrombosis and hemorrhage
-process of coagulation and fibrinolysis become abnormally activated-consumptive coagulopathy
266
sequence of events DIC
-procoagulant exposure
-coagulation
-fibrinolysis
-end organ damage: from decreased perfusion, thrombosis and/or bleeding
267
Acute/decompensated DIC
-rapid onset and large amounts of procoagulant substances
-rapid consumption of coagulation factors and platelets that outpace their production
-liver unable to remove FDPs
-at risk for bleeding and consumption coagulopathy
268
labs for acute /decompensated DIC
-prolonged Pt/PTT
-low fibrinogen
-elevated d-dimer
-thrombocytopenia
269
Chronic/compensated DIC
-continuous or intermittent exposure to smaller amounts of procoagulants
-coagulation factors and platelet production are able to keep up with consumption rate
-live is able to clear FDPs
-thrombosis risk but many patients are asymptomatic
270
Labs in chronic/compensated DIC
Normal or mildly prolonged PT/PTT
normal fibrinogen
elevated D-dimer
normal platelets
271
sickle cell disease
genetically inherited condition and occurs when obtains two non-HgbA genes (A is normal form of hgb) and at least one HgBS
272
HgBSS
2 sickle cell genes (most severe form)
aka sickle cell anemia
273
Beta thalassemia (sickle beta thalassemia)
2 types of Beta thalassemia "0" or "+"
HgbS beta 0 thalassemia-more severe
HgbBS beta + thalassemia (milder)
274
HgBS lifespan is ______days
7
275
Hgb A lifespan _______days.
120 days
276
baseline chronic anemia in SCD around _______
8-10g/dL
277
Vasoocclusion in SCD
tissue ischemia or infarction-high risk for stroke, TIA, Acute chest pain syndrome
-acute and chronic pain: never withhold or underdose pain meds
-multiorgan failure: life-threatening complication where multiple organs are affected by ischemia and or infarction
278
preop for SCD
-recommend preop transfusion for most patients
standard of care for SC anemia and those with Hgb-sBeta 0 undergoing surgery that requires more than 30 minutes
-goal is to raise hgb >10 with simple transfusion
-if starting Hgb >10 then can consider exchange transfusion
279
Indications for Tonsillectomy and Adenoidectomy
-chronic or recurrent acute tonsillitis
-peritonsilar abcess
-tonsillar hyperplasia
-obstructive sleep apnea syndrome
-valvular heart disease at risk for endocarditis from recurrent streptococcal infection of tonsils
280
Goal of tonsillar hyperplasia
to relieve airway obstruction and increase cross-sectional area of pharynx
281
Patients with ______,______, and _______ can develop cor pulmonale
-hypoxemia
-hypercarbia
-increased airway resistance
282
_______ of patients with ECG evidence right ventricular hypertrophy will reveal a chest x-ray consistent with cardiomegaly.
1/3C
283
Cor Pulmonale
defined as an alteration in the structure and function of the right ventricle (RV) of the heart caused by a primary disorder of the respiratory sysem
284
Pumonary HTN
common link between lung dysfunction and the heart
285
Digitalis medicines
strengthen the force of heartbeat by increasing the amount of calcium in the heart's cells
286
Complications of tonsillectomy
1. to prevent emesis
-suction stomaach
-ondansetron 0.10-0.15mg/kg
-dexamethasone 0.5mg/kg
2. postop hemorrhage (avg EBL: 4ml/kg or 5% blood volume)
3. Pain (cautery, laser, sharp dissection)
4. acute postoperative pulmonary edema
287
Where does blood flow to the tonsils arise from?
external carotid
287
Blood flow to tonsils arises via the external carotid and its branches:
-ascending pharyngeal artery
-facial artery
-dorsal lingual artery
-and palatine branch of maxillary artery
288
Sensory innervation to the palatine tonsils is supplied by the:
--glossopharyngeal (tongue control)
-lesser palatine nerves
289
Post-tonsillectomy bleeding
290
Is peritonsillar abscess an emergency?
yes, emergency surgical intervention
291
Peritonsillar abscess (Quinsy tonsil)
-generally in older children and young adults
-fever, pain, and trismus (restricted Jaw rOM)
-surgical drainage, removal and IV antibiotics
-mask ventilation Okay, visualization of vocal cords should not be impaired, as abscess is supraglottic and well above laryngeal inlet
-gentle intubation
292
Ludwig's angina location
submandibular cellulitis out of 2nd and 3rd molars
patient describes "suffocating sensation
-tongue is elevated and displaced with hard firm induration of the floor of the mouth and perioral edema
-trismus=lockjaw
-airway generally secured via nasal fiberoptic or tracheostomy
293
What is ludwigs angina caused by?
cellulitis of the floor of the mouth caused by a bacterial infection of the sublingual and submandibular tissues
-can lead to stridor and eventually asphyxia and death
-abx therapy is usually ineffective due to the mixed bacterial flora
294
Ear surgery for myringotomy and tube insertion (BMT)
-chronic serous otitis in children can lead to hearing loss
-treatment drainage of middle ear
-mask management/short procedure
current URI status-may perform sx despite URI
295
Intraoperative management of tympanoplasty and mastoidectomy
-avoid nitrous oxide!
-hemostasis
-facial nerve identification
-post operative vertigo, N/V-high risk
-positioning (extreme lateral neck turn)
296
What indicates an upper airway obstruction/
inspiratory stridor
297
What indicates a lower airway obstruction?
expiratory stridor
298
What indicated mid-tracheal lesions?
biphasic stridor (inspiratory and expiratory)
299
most common cause of stridor
laryngomalacia (soft larynx)
-inherited (tx time)
300
Clinical components of evaluation of patients with stridor
-respiratory rate
-chest retractions
-heart rate
-nasal flaring
-wheezing
-LOC
-cyanosis
301
Vast majority of airway foreign bodies occur in children under age _____ with peak incidence occurring between 1 and 2 years of age.
3
302
Most common aspirated item in younger children:
-peanut
followed by: popcorn, jelly-beans and hot dogs
303
Most common site of AFB
main stem bronchus-->right side-->more often than left
304
Classic triad of aspirated foreign body:
-wheezing
-cough
-diminished breath sounds
305
what is a good indication of aspiration
-coughing
-choking
-cyanosis occuring while eating
306
common radiographic findings of AFB
-radiopaque object
-atelectasis
-emphysema (obstructive with mediastinal shift)
-consolidation
-+/- normal x-ray depending on time of injury
307
anesthetic management of AFB
+/- premed
-EMLA cream before starting IV
-Full stomach RSI
-consider sevo induction if not at risk for aspiration
-spontaneous ventilation may be preferred but gentle assisted ventilation may be necessary if oxygenation/ventilation is insufficient vs controlled ventilation with muscle relaxants to avoid coughing and bucking during bronch
-if spontaneous ventilation induction, consider 1-2% lidocaine spray for larynx and vocal cords to facilitate fiberoptic bronchoscopy
308
What is the most common procedure for chronic sinusitis
functional endoscopic sinus surgery (FESS)
309
Nasal surgery issues
optimal visualization of surgical field, bleeding kept to minimum
310
nasal surgery practice
vasoconstrictors
elevation of head and modest hypotension (issues systemic absorption of vasoconstrictors
311
Complications of nasal surgery that can lead to death
right cribiform plate traumatic defect
anterior cerebral artery injury with frontal lobe damage
-basilar subarachnoid hemorrhage
312
Upper third facial bones
facial frontal bones
313
middle third facial bones
zygoma
maxilla
nasal bones
orbits
314
lower third facial bones
mandible
sympheal area
ramus
body of angle condyl
coronoid process
315
Can oral or nasal intubation be used in Lefort 1 fracture?
yes can be accomplished in almost all cases
-often used to correct dental fascial deformities
316
What is contraindicated in Lefort II?
nasal intubation
pyramidal
involving the thick upper part of the nasal bone and the thinner part forming the upper margin of the anterior nasal aperture
317
Lefort III airway issues
loss of supporting facial structure=difficult intubation, early tracheostomy
318
Lefort III facture
-runs parallel to base of the skull, separating the midfacial skeleton from the base of the skull
-basal skull-->CSF rhinorrhea and exposure of ethmoidal sinuses of "air cells" to air to infection
319
What does Laser stand for?
Light Amplification Stimulated Emission Radiation
320
Which is the most powerful laser?
Nd: YAG
green glasses
uses: tissue debulking trachea, upper bronchus
321
Which laser is used when precision is needed and absorbed by water
CO2
322
Which laser is absorbed by Hgb?
Argon
-uses: eye, dermatologic
Glasses: orange
323
Uses of CO2 laser
oropharynx
vocal cords
plastic surgery
urology
GYN
Clear glasses
324
Safety protocol for surgical lasers
-post warning signs outside any OR
-matt finish (black) surgical instruments reduce beam reflection and dispersion
-avoid N2O as it supports combustion
-patient's eyes should be protected with appropriate colored glasses and/or wet gauze
-use the lowest concentration of oxygen as possible>: FiO2<30%
-lasers should be placed in Standby mode when not in use
325
Safety protocol for surgical lasers
-use ETT specifically prepared for use with lasers
-inflate cuff of laser tube with dyed saline so that cuff perforation is readily apparent
-all adjacent tissues should be shielded by wet gauze to prevent damage by reflected beams
-plume should be suctioned and evacuated from the surgical field
326
Estimated frequency (2010) per year of OR fires
600 or higher
(550-650 fires occur in the OR every year)
-20/ yr result in serious injury
-1-2 patient deaths annually
327
Ignition sources
surgeons
-ESUs
-lasers
-
328
Oxidizer
anesthesia providers
-O2, N20
329
Fuel
nurses-drapes, prepping agents
330
Common causes of OR fires
1. Oxygen rich environment-involved in 75% of OR fires
2. Alcohol based prep solutions-involved in 4% of OR fires
3. Heat (ignition) sources
-70% electrocautery
-10% laser
-remaining 20%: light sources, defibrillators and high-speed burns account for remaining 20% of OR fires
331
Increased risk procedures for airway fires
-head, neck and upper chest (above T6-anything above xyphoid process)
-use of an ignition source (electrosurgical, electrocautery devices or laser) in proximity to an oxidizer-enriched (oxygen and nitrous oxide) atmospheres
-laser use during procedures involving the airway
332
The tracheal cuff of the laser tube should be filled:
-saline rather than air
-saline in the tracheal cuff should be tinted with methylene blue to act as a marker for cuff puncture by a laser
333
Airway fires and Association with decreased risk
-determine if patient is at risk for a surgical fire
-surgical team discusses: the strategy for preventing and managing a surgical fire in a high-risk patient
-minimize the concentration of oxidizer near surgical site
-safely manage ignition sources
-safely manage fuels (drapes, cannulas, hair, gowns)
334
Wait time for hairless skin
3 min
335
wait time for hair
1 hour
336
wait time for O2 to dissipate
1 minute for O2 to dissipate (turn it off) before using an ignition source
337
Airway management of fire steps
1. remove ETT
2. stop the gas flow
3. pour water or saline into airway
4. care for patient
338
Types of head and neck cancer surgery
-laryngectomy
-glossectomy
-pharyngectomy
-parotidectomy
-hemimandibulectomy
-radical neck dissection
339
Preoperative considerations for head and neck cancer surgery
heavy tobacco and alcohol usage, co-existing disease
-abnormal airway issues, preop radiation, direct laryngoscopy, fiberoptic or elective tracheastomy
340
Monitoring for head and neck cancer surgery
-blood loss, co-existing diseases, a-line, CVP (consider location of surgery-->fem line)
-if forearm flap, consider IV lines
-forced air warming
-intraop nerve monitoring (anterior neck operations) preserve SLN, RLN and vagus nerves
-meditronic Xomed NIM ETT
341
Superior laryngeal nerve unilateral nerve injury
minimal effect
342
Superior laryngeal nerve bilateral nerve injury
hoarseness, tiring of voice
343
Recurrent laryngeal nerve unilateral nerve injury
hoarseness
344
Bilateral recurrent nerve injury
Acute=stridor, respiratory distress
chronic=aphonia
345
Unilateral vagus nerve injury
hoarseness
346
bilateral vagus nerve injury
aphonia
347
348
348
Maintenance of anesthesia for head and neck cancer surgery
1. surgeon may request no NMBs during EENT procedures
2. moderate controlled hypotension-may be helpful but be mindful of cerebral perfusion (a-line zeroed at external auditory meatus)
3. microvascular free flap-->issues with vasoconstrictor and vasodilators; avoid excessive diuresis
4. transfusion decisions (recurrence of cancer rates increase)
5. manipulation of carotid sinus and stellate ganglion
349
Macula
dark mass near center of retina, containing color-sensitive rods and central point of sharpest vision
350
Retina
-back of eye is lined with thin layer=retina
-this is where photoreceptors are located
-retina would be the film of camera
-also contains nerves that tell the brain what the photoreceptors are seeing
351
2 types of photoreceptors
rod and cones
352
Rods
-work at very low levels of light (night vision) only a few bits of light (photons) can active rod
-rods do not help with color vision, this is why at night we see everything in gray scale
353
how many rod cells does the human eye have?
100 million
354
cones
-require more light for color vision
3 types:
blue
green
red
355
how many cones does the human eye have?
6 million
356
Many of the cones are packed into:
fovea, a small pit in the back of the eye that helps with sharpness or detail of images
357
requirements for ophthalmic surgery
-akinesia
-analgesia
-minimal bleeding
-avoidance or obtundation of oculocardiac reflex
-control of IOP
-awareness of drug interactions
-smooth emergence (avoid coughing, N/V
358
Which pressure has a greater role in IOP?
venous pressure>arterial
359
Extraocular factors that will increase IOP
-contraction of orbicularis oculi muscle or contraction of other extraocular muscle
blink-10mmHg
forceful lid closure=50mmHg
360
Clinical conditions increasing IOP
-hypercarbia
-hypoxia
-airway obstruction
-coughing/straining increases IOP 40mmHg
-vomiting
-overhydration
-retrobulbar hemorrhage
-ETT intubation
361
Oculo-cardiac reflex
5 and dime
-bradycardia
-junctional rhyhm or asystole can occur secondary to traction on eye and ocular muscles
Tx: atropine, stope eye manipulation
362
Factors that contibute to Oculo-reflex
preoperative anxiety
light GETA
hypoxia
hypercarbia
increased vagal tone due to age or drugs
363
which nerve is the afferent limb of the OCR
trigeminal nerve
364
efferent limb of OCR
vagus nerve
365
Oculocephalic reflex
"doll's eye"
movement of eye for maintaining forward gaze in response to rotation of the neck in a particular direction
366
which block is conal?
retrobulbar
367
which block is extraconal
peribulbar
368
IS regional anesthesia okay for open globe?
no, relatively contraindicated
369
General anesthesia for open globe
aspiration risk and increasing IOP with laryngoscopy (Sch increases 8mmHg for 5-7 minutes)
370
Strategies to prevent increases in IOP for open globe
1. avoid direct pressure on globe-patch eye with fox shield, no retrobulbar or peribulbar inj;careful with face mask techniques
2. avoid increase in CVP: prevent coughing during induction and intubation; avoid head down position
3. extubate under deep anesthesia (suction with OGT secondary to full stomach issues)
4, avoid pharm agents that increase IOP-->phenylephrine and epinephrine (if change in venous pressure will change IOP)
371
What are the anesthetic issues relative to retinal detachment procedures?
-sulfurhexafluoride (SF6) is used during retinal detachment repairs to form a bubble in the posterior chamber of the eye that flattens the retina and promotes correct healing
-nitrous oxide issues (35x more soluble than N2 and 117x more soluble than SF^)
-increase bubble volume, increase IOP, decreased retinal blood flow and compromising retinal repair
-SF6 remains the posterior chamber for 5 or more days
-avoid Nitrous oxide for at least 10 days
372
Needle placement for retrobulbar block
needle punctures the bulbar fascia and enters the orbital muscle cone
373
needle placement for peribulbar block
needle directed parallel and lateral to the bulbar fascia rather than passing through it
374
LA volume for retrobulbar
2-4mL
375
Peribbulbar LA volume
4-12ml
combo of lidocaine and bupivacaine
376
onset of retrobulbar (intarconal) block
2 minutes
377
onset of peribulbar (extraconal) block
10-20 minutes
378
advantage of retrobulbar block
quick onset
379
limitation of retrobulbar block
often requires supplemental cranial nerve (facial-7) block to prevent movement of eyelid
380
advantage of peribulbar block
reduce risk of injury to optic nerve, globe perforation and subdural injection
381
limitation of peribulbar block
cause swelling of the conjunctiva which may disrupt the surgical field
382
minor complication of ophthalmic anesthesia
-corneal abrasion
-bruising
-subconjunctival hemorrhage
-chemosis (conjunctival swelling)
-transient diplopia
383
symptoms of brainstem anesthesia
-contralateral amaurosis (partial or total blindness without visible change in the eye, typically due to disease of the optic nerve , spinal cord, or brain)
-slurred speech
-hemiparesis
-altered consciousness
-hypertension
-cardiovascular collapse
384
strabismus repair concerns
forced duction testing
OR
oculogastric reflex
MH
385
intraocular surgery concerns
proper control of IOP
akinesia
drug interactions and associated systemic diseases
386
retinal detachment surgery
OCR
proper control if IOP
nitrous oxide interaction with air
sulfur hexafluoride or perfluorocarbons
387
complications of needle based ophthalmic anesthesia
-extraocular muscle injury leading to postop strabismus, diplopia
-intra-arterial injection producing immediate convulsions
-central retinal artery occlusion
-inadvertent brain stem anesthesia-->contralateral amaurosis, mydriasis, muscle paresis, neurocardiopulmonary compromise, death
388
Cranial nerve II
optic
provides visual information from retina
sensory
389
cranial nerve III
oculomotor
-innervation of the extraocular muscles
innervation of the pupil and ciliary muscles
motor
390
CN IV
trochlear
innervation of the superior oblique muscles
motor
391
CN VI
abducens
innervation of the lateral rectus muscles
motor
392
CN VII
facial
innervation of the muscles of facial expression
motor/sensory
393
Cranial nerve 10
vagus
parasympathetic innervation associated with oculocardiac reflex
394
What is the most common form of arthritis?
osetoarthritis
395
What is osteoarthritis?
chronic degenerative joint disease that causes the breakdown of cartilage and bone in the joints
-develop slowly and worsen gradually
-pain, stiffness, swelling
396
Are women or men more likely to develop osteoarthritis?
women especially over age 50Risk factors
397
Risk factors for osteoarthritis
-obesity
-hx of injury
-overuse from repetitive movements of joints
-family hx of OA
-malformed joints
398
What is rheumatoid arthritis?
long-term autoimmune disease that causes joint inflammation and pain
-immune system attacks its own tissues
-pain welling stiffness loss of function
399
Which arthritis is symmetrical?
rheumatoid
osteo=asymmetrical
400
RA can affect:
-heart
-lungs
-blood
-nerves
-eyes
skin
401
What is RA triggered by?
-autoimmune disorder triggered by an antigen in genetically predisposed persons, chronic inflammatory disease involving diffuse joints and organ systems
-activated endothelial cells attract adhesion molecules that stimulate T cells and B lymphocytes
-release of cytokines (tumor necrosis factor, interleukins) accelerate the inflammatory process
-B lymphocytes produce antibodies (rheumatoid factor_ that further increase cytokine production
-eventually cartilage and articular surfaces are destroyed
402
_____% of RA patients have measurable levels of rheumatoid factor
75
403
Which joints are involved in RA first?
metacarpophalangeal and interphalangeal joints of hands
404
What is the most frequently involved joint of the leg in RA?
knee
405
upper cervical spine is affected in RA in _____% of patients
85
406
In RA, atlantoaxial and subaxial instability can lead to ______________.
compresssion of the spinal cord
407
Affected Larynx in RA results in ______________.
limitation vocal cord movement and laryngeal mucosal edema-->airway obstruction
408
What is the common case of mortality in RA?
cardiovascular disease
-high incidence of subclinical cardiac dysfunction
409
_________ is present in 20-50% of RA patients.
Pericarditis
can produce restrictive pericarditis and cardiac tamponade
410
Heart problems with RA
-CAD
-myocarditis
-aortitis (aortic root dilation, aortic valve insufficiency)
-diastolic dysfunction
-dysrhythmias
-pumonary HTN
411
pulmonary changes in RA
-interstitial lung disease
-reduced oxygen diffusing capacity
-obstructive and restrictive lung disease
-pulmonary nodule
-pulmonary effusions
412
true/false: mild anemia is present in almost every RA patient
-decreased erythropoiesis (process of RBC production) are SE of drug therapy
413
Nerve complications of RA
-peripheral nerve compression from joint destruction and non compressive neuropathies secondary to vasculities of blood vessels supplying affected nerves
-cervical myelopathy secondary to cervical spine compression
414
rheumatoid vasculitis can affect:
-cerebral blood vessels resulting in headache, hemiparesis, aphasia and confusion
415
4 groups of antirheumatic drugs
1. NSAIDS-reduce pain and inflammation
2. corticosteroids-side effects limit use
3. DMARDs-target T and B cells. Methotrexate very effective and initial choice
4. Biological DMARDS-target inflammatory mediators such as TNF and interleukins
416
intubation techniquie for RA
one that minimizes cervical movement is recommended
-awake intubation, video laryngoscopy, or flexible fiberscope-assisted tracheal intubatoin
417
incidence of atlanto axial (first joint between skull and C-spine) subluxation may exceed _____%, flexion of neck can compress spinal cord.
40
418
What does cricoarytenoid arythritis produce?
edema of the larynx and may decrease the size of the glottis inlet-->smaller tube size
419
Should anti-tnf biologic we withheld before surgery?
yes
420
What is anykylosing spondylitis?
type of arthritis causing inflammation of the joints and ligaments of the spine
severe cases-causes vertebrae to fuse leading to rigid inflexible spine
-inflammation causes stiffness
421
What does ankylosing spondylitis affect
peripheral joints: knees , ankles , hips
some develop eye disease uveitis, skin 9psoriasis, or gut (IBD)
422
Does ankylosing spondylitis have acure?
no, but excercise, pT/OT to improve mobility and posture,, medications to manage pain
423
General anesthesia for ortho
-rendered senseless to pain
-unconscious and unaware
-good physiologic control
-positioning
424
Regional anesthesia for ortho
-good relaxation
-may result in less blood loss
-lower rate of DVT
-can be continued for post-op analgesia
-intraop sedation can be titrated to effect
-length of procedure
-can isolate effect to surgical area
-can be combined with GA
-less N/V
-accelerated hospital discharge
425
hypotensive technique for ortho procedures
-deliberate hypotension in order to decrease overall blood loss 40--50%
-reduced need for transfusion
-used with neuraxial
-MAP 50-65, SBP 80-90
426
potential risks for hypotensive technique
cerebral perfusion and stroke
heart attack
427
How do the organs manage during hypotensive technique?
brain, heart, liver and kidneys have the ability to autoregulate flow by intrinsic elasticity of vascular smooth muscles-baroreceptors and chemoreceptors
428
Are epidural veins valveless?
yes!
429
spinal surgery posterior approach prone position
-pressure on abdomen causes inferior vena cava compression, increased bleeding from valveless epidural veins, reducing CO and increasing risk of lower limb thrombosis
-adequate foam padding under chest and anterior superior iliac spines
-arms not abducted more than 90 degrees and positioned with slight internal rotation to reduce risk fo brachial plexus stretching
-ulnar nerve at risk with elbow flexed
-eyes taped, goggles
430
anterior approach to thoracocolumbar spine is ______position.
lateral
431
adult spine surgery transfusion ranges from _____ to ____%
50-80%
432
Most blood loss during spinal instrumentation and fusion during spine surgery occurs with _________
decortication and proportional to the # of vertebral level involved
433
decreased blood losss and transfusion requireents during spinal sx
-preoperative autologous donation
-proper positioning
-use of intraop blood salvage
-administration of TXA
434
TXA is an analogue of ________.
lysine
435
MOA TXA
acts by competitively blocking the lysine binding site of plasminogen which leads to inhibition of fibrinolysis
-antifibrinolytic
-can reduce blood loss by 30-40%
436
contraindications to TXA
-history of blood clots in the lungs (PE) or vein (DVT)
-coagulopathy (DIC)
-severe renal insufficiency or chronic kidney disease
-hx of acute subarachnoid hemorrhage
-coronary or vascular stents placed within 6 months to 1 year
437
intraoperative monitoring for spinal surgery considered mandatory if cord is at risk of injury when:
-corrective forces applied to spine
-osteotomies are made
-spinal canal is surgically invaded
438
3 methods of IOM
-wake-op test
-sSEP
MEP
439
anesthesia requirements for wake up test
-reliable but quickly antagonied
-wakening should be smooth
-no pain during test
-no recall (recall occurs in 0-20%)
440
What do SEEPs assess
dorsal column pathways of proprioception and vibation supplied by posterior spinal arteries
altered by neural injury, volatile anesthetics, hypercarbia, hypoxia, hypotension and hypothermia
441
Latency
time it takes for an electrical impulse to travel from stimulation site to recording site, measured in milliseconds (MS)
442
amplitude
size of the response measured in microvolts (uV)
443
if muscles controlled by C5 nerve roots (Deltoid, biceps, brachialis and brachioradialis) are flaccid, partial ______ should be expected.
diaphragmatic
444
spinal shock occurs immediately after injury and lasts up to ______ weeks.
3
445
lesions above the cardiac accelerator fibers are at _______________ cause bradycardia
T1-T4
446
Complete cord transection above _____ -85% go on to exhibit autonomic hyperreflexia
T5
447
what is autonomic hyperreflexia?
-severe paroxysmal HTN with bradycardia from the baroreceptor reflex, dysrhthmias, and cutaneous vasoconstriction below and vasodilation above the level of injury
-induced by distension of bladder or rectum or any noxious stimulus including surgery
-remove stimulus, deepen anesthesia, direct-acting vasodilator
-seizures, intracranial hemorrhage or MI
448
respiratory failure and mechanical ventilation with cervical lesions at _______.
C3-C5
449
Lesions b/w ______-significant alterations in respiratory function due to loss of abdominal and intercostal support
C5-C7
-vital capacity reduction of 60%
-atelectasis and risk of infection d/t inability to cough and clear secretion
450
succinylcholine for first _____hours after injury
48 hours
-after that proliferation of ach receptors in muscle can cause hypersensitivity to depolarizing
-mar
- muscle relaxants-marked hyperkalemia
-maximal hyperkalemia risk from sux b/w 4 weeks and 5 months after spinal injury
-may rise to 14 mEq/L-V-fib, cardiac arrest
-non-depolarizing agents okay
451
goal of MILS (manual inline stabilization)
to apply sufficient opposite forces to head and neck to limit the movement during airway intervention
-recommended by current ATLS guidelines
452
surgery for scoliosis is considered when?
cobb angle , a measure of curvature exceeds 50 degrees in thoracic or 40 degrees in lumbar spine
453
goal in scoliosis surgery
goal is to halt progression of condition, partially correct deformity, prevent further respiratory and cardiac deterioration
-pulmonary function acutely deteriorates for 7-10 days after surgery
454
cobb angle 10 degrees
minimum angulation
455
cobb angle 20-40 degrees
back brace and PT
456
cobb angle >50 degrees thoracic and 40 degrees lumbar
corrective surgery
457
measurement of cobb angle
-draw lines paralell to upper border of superior vertebral body and lower border of lowest vertebral vertebrae of the structural curve then erecting perpendicular from these lines to cross each other
-angle between these perpendicular is the angle of the curvature
458
venous air embolism s/s
-unexplained hypotension
-increased ET nitrogen concentration
-fall in ETCO2
459
tx of VAE
flood surgical site with saline
-control sites of air entry
-reposition with surgical site below the right atrium
-aspirate air from multiorific CVC
-cessation of inhaled nitrous oxide
460
study shos that lower rate of perioperative nerve injury in patients who received ______ block
interscalene
461
radial nerve palsy in up to _____% of humeral shaft fractures
17
462
What injury is associated with proximal humerus fractures
axillary nerve and brachial plexus injury
463
Hemodynamic changes in beach chair
B/P at head wil lbe lower than arm
-every 20cm of height difference-15mmHg difference in arterial pressure
-reports of strokes but autoregulation is sufficient-no associated increase in neurologic outcome
=report of stroke but autoregulation is sufficient -no associated increase in neurologic outcome
464
four nerves of brachial plexus
-radial
-musculocutaneous
-ulnar
-median
465
advantages of peripheral nerve blocks
-earlier discharge
-decreased risk of hospital admission following rotator cuff repair
-lower 30 day mortality
-decreased incidence of thromboembolic events
-lower transfusion requirements and less blood loss
-dereased length of stay, cost and hospital complications
-superior pain control
466
How long can brachial plexus catheters be left in
4-7 days postop
467
anterior approach to hip and pelvic surgery
-gaining favor for tissue sparing
-smaller incision
-potential for less pain
-faster recovery
-improved mobility
468
posterior surgical approach to hip and pelvic surgery
-most performed
-lateral decubitus position, arms neutral and abducted/flexed less than 90 degrees
-axillary roll to prevent compression of brachial plexus and axillary artery
-GA-airway accessed prior to positioning
-RA -sitting or lateral
469
why is knee surgery more painful recovery
high incidence b/c TKA involves cutting and cementing of 2 long bones (femur and tibia)
470
intraocular proceudre imporatnt viarable
-globe akinesia
-patient movement
-control of IOPin
471
extraocular procedure imporatnt variables
-significance of IOP fades , elicitation of oculocardiaca reflex becomes concern
472
_______extraocular muscles move eye within their orbit to various positions
6
473
4 layers of eyelid
1. conjunctiva
-2. cartilagenous tarsal plate
3. muscle layer-orbicularis and levator palpebrae
4. skin
474
blood supply to eye/ orbit by emans of
branches of internal and external carotid arteries
475
venous drainage of eye through
central retinal vein then all veins empty into cavernous sinus
476
trochlear nerve supplies what
superior oblique muscle
477
abducens nerve supplies what
lateral rectus muscle
478
trigeminal nerve
most complex ocular and adnexall innervation
479
3 layers of eye
1. sclera
2. uveal tract (iris, ciliary body and choroid)
3. retina
480
What transmits optic nerve and ophthalmic artery as well as sympathetic nerve from carotid plexus?
optic foramen
481
2/3 of aqueous humor is formed where
posterior chamber by ciliary body in an active secretory process involving both the carbonic anhydrase and cytochrome oxidase systems
482
remaining 1/3 of aqueous humor formed by
passive filtration of aqueous humor from vessles on anteriors surface of iris
