Exam 2024 Flashcards
Neural innervation of shoulder joint
Axillary, suprascapular, lateral pectorial
Methamphetamine-intoxication
Main issues
Unreliable history
Unfasted - RSI
Complications - IHD, coronary spasm, rhabdo, withdrawal
Drugs - Serotonin, monoamines, caution with use
Specific risks of interscalene block
Phrenic nerve palsy
Carotid, jugular vein, thyroid injuries
Horner’s
Specific risks of ESPB
Pneumothorax
Dose of ESPB
Single dose - 0.5% ropi, 20-30ml
Infusion 0.2%, 8-12ml/hr
Resp failure post emergency open abdominal surgery - top differentials
Splinting from inadequate analgesia
Aspiration
Drugs - OIVI
Limitations of LMA
Non-definitive airway -> aspiration risk
Pressure - difficult ventilation if high airway pressure required
Anatomical limitation - small MO, laryngeal or pharyngeal pathology can limit proper placement
First gen - can’t intubate through due to aperture bars
Complications of LmA
Airway - laryngospasm, aspiration, bronchospasm, gastric insufflation
Displacement and malposition during procedure
Dental damage, sore throat.
Dysphonia in 0.1%
What is dysphonia
Change in voice
Assessment of dysphonia
Check for pre-anaesthetic risk factors: thyroid surgery, carotid surgery.
Nature of voice change - hoarseness, breathiness
Associated pain, dysphagia.
Neck palpatation, auscultation.
CXR, ENT review, endoscopy
Peri-op issues for paeds foreign body
Pre-op evaluation
- Degree of airway obstruction -> determine urgency
- Fasting status, ability to delay to reduce aspiration risk
Induction
- Premed, only use if benefit outweighs risk of respiratory depression
- Topicalisation of airway
- Nasal tube above cord, maintain SV, allow surgical access
Maintain SV, sufficient to tolerate rigid bronch
Oxygenation technique
- SV through nasal tube.
- Ventilate through rigid brooch
- Desat - rigid bronch out, intubate.
PAC for obese G1P0 - issues
Delivery at tertiary centre given high risk
Difficult neuraxial
Difficult airway - difficult ETT, BMV, LMA, front of neck.
Thorough airway assessment.
Associated OSA, and reflux
Hypertensive disorders
Gestational diabetes
- Macrosomia for baby
Advantage of social media
rapid information dissemination - eg. Twitter for sharing of research
Global interaction - interact with medical professionals internationally, facilitate knowledge exchange
Enhanced education - i.e Youtube education videos, ultrasound videos on NYSORA
Patient education - i.e vaccination benefits
Research dissemination - highly tweeted publications are more likely to be cited.
Disadvantages of social media
Potential for misinformation - unchecked information / misleading content can be spread
Professional risks - discussion on controversial topics can lead to inadvertent reputational harm
Distraction in clinical settings - phone use in theatre
Privacy concerns - sharing patient information / images without consent = breach of confidentiality
Bullying / discrimination in a public platform
Intra-op considerations of asthma
Pre-op reliever, 30 mins prior to induction
Ventilation strategy - prolonged expiratory phase, reduce gas trapping, high RR, accept lower TV, tolerate higher Ppeak
- Balanced with effects of pneumoperitoneum
Other bronchodilators
- Ketamine, magnesium, volatile, adrenaline
Avoid histamine-releasing agents: atracurium, morphine
Disposition to respiratory care unit, liaise with Resp team, sitting upright, ensure bronchodilators charted.
Components of cell saver
Suction from patient
Anticoagulation delivery
Reservoir
Centrifuge
Filtration of large particles
Collection of PRBC for rein fusion
What is macro shock
passage of electrical current through the body via contact with skin
Typically ≥10mA to cause harm.
Can cause VF at ≥100mA
What is microshock
small currents that are applied directly to or in close proximity to heart, often through invasive devices like central access or PPM leads
Currents as low as 50-100microgA can cause VF
3 methods to prevent macro shock
General:
- Regular maintenance and testing of electrical equipment
- Ensure patient not in contact with unearthed objects
- Avoid double adaptors
Electrical system design
- Residual current device + line isolation system
- Ensure proper grounding of equipments
Principles of opioid stewardship
Appropriate prescribing and use of opioids - choice, dose, duration, follow up .
Risk mitigation - balancing analgesia with potential harm
Monitor and evaluation - frequent APS review, dynamic prescription and reduction / cessation when able
Safe disposal and storage
Patient education
Continuity of care - Safescript documentation of information
What neural structures can be damaged in IJ CVC insertion?
vagus nerve, cervical SNS chain (Horner’s), phrenic nerve, brachial plexus nerve
Describe a landmark approach to IJ CVC insertion
IJ lies deep to SCM. Look for bifurcation of SCM into lateral and medial head, palpate for carotid artery and insert needle at the apex, at 30 degrees angle, lateral to the carotid
At what level does the IJ become lateral to carotid?
Below C4
What are the trials for TXA in obstetric practice?
WOMAN trial - reduce death due to bleeding when administered within 3 hours of birth.
TRAAP2 trial - prophylactic use in CS resulted in reduction of PPH, not no change to meaningful outcome, at an increased rate of N+V.
What’s the number needed to treat for TXA in reducing death in PPH?
267
what’s the fire triad?
ignition, fuel, oxidiser
What are some of the fuels found in OT?
bedding, surgical material, alcohol prep.
Prevention of fire in OT?
Minimise oxidant rich atmosphere near surgical site (FiO2 <0.28, avoid N2O)
Safe management of ignition source (laser diathermy)
Safe management of fuel - allow alcohol prep to dry, shaving of body hair with flame-retardant lubricant
Electronic safety - regular maintenance, withdrawal fault equipment
Steps in managing fire in OT
Recognise early signs of fire
Halt procedure
Attempt to extinguish fire with saline, water, smothering
Stop the flow of all airway gases
Remove drapes, flammable and burning material from patient
Use of extinguisher
Evacuate based on protocol
Door closed to contain fire
Turn off medical gas supply if fire involves ceiling
Assess stair climbing as pre-op assessment tool
Self-reporting, subjective assessment.
Inconsistent correlation to VO2 max of 14ml/kg/min (MET of 4)
Assess DASI as a functional assessment tool
12 item questionnaire, formulae to calculate VO2 max and MET
METS study - DASI score of 34, expected to have MET of ~7, only achieving MET of 5.
Higher predictability with higher DASI score - better at identifying individuals with moderate to good functional capacity
