HA Exam 1 Flashcards
What changes to preoperative care will we do if we delay the surgery
- optimize comorbid diseases
- refer to other specialist
- refer for specialized testing
- initiate interventions intended to decrease perioperative risk
- ID previous unrecognized comorbid conditions
How do we prepare for surgery
- preoperative instructions for surgical patient; bath/ brush teeth. Medications / supplements. OTC/herbal are anticoagulants.
- discuss perioperative care/ expectations
- arrange appropriate level of postoperative care/ plan ahead- dialysis? ICU?
What are the goals for postoperative follow up
- specialist follow up facilitated by preanesthsia evaluation
- Follow - up by anesthesiologist led service
follow up on conditions id by preoperative assessment
Medical history components
Underlying condition requiring surgery
Known medical problems/past medical issues
Previous surgeries/anesthetic history
Anesthetic-related complications-ache deficiency (genetics), mh, difficult airway, PON/V, sleep apnea
Review of systems- heart, lungs, brain,
Medications
Allergies and drug reactions- anesthetic history, family history.
Tobacco/ETOH/Illicit drug use
Functional capacity – how active?
Anesthetic physical exam
heart, lungs, airway, brain
BMI < 18.5
underweight
BMI 18.5-24.9
normal
BMI 25-29.9
overweight
BMI 30 and above
obese
Metric BMI formula
BMI = wt (KG) / Height (m) (squared)
Imperial BMI formula
BMI = 703 x wt (lbs) / height (in) (squared)
Vital signs
BP, HR, RR, O2 saturation, temperature
Height and weight
BMI
Ideal body weight
consider when they were taken
Focused physical exam
Baseline neuro exam
Based upon surgery or procedure
Establish baseline. Pupils**. Seizures/CVA/TIA
CV- CAD/MI/HTN/CHF- maximize
Pulmonary- Asthma/COPD
Airway- previous trach?
Endocrine- BG-Adrenal disorders/DM/thyroid-pheochromocytoma – mass on kidney/ something going on abd.
Hepatobiliary disorders- metabolism?
Renal
Musculoskeletal disorders
Immunocompromised- special handling/ accessing devices.
Obesity- alone increases morbidity and mortality
consider positioning
Emergent physical examination
A = Allergies
M = Medications
P = Past medical history
L = Last meal eaten
E – Events leading up to need for surgery/procedure
Special attention to the evaluation of the
Vital signs (CNS, heart, lung)- pre op spo2
Airway
If regional anesthesia is proposed
Assessment of the site of block - look at back – abcess on back??
Airway Examination
- Mallampati classification
- Inter-incisors gap- between top and bottom teeth
- Thyromental distance- thyroid and ….distance- want 3 fingers
- Forward movement of mandible- recessed/pronounced jaws or lack of mobility
- Range of cervical spine motion: flexion and extension
- Document loose or chipped teeth, tracheal deviation- meth mouth
What accounts for almost half of perioperative mortalities
cardiovasular complications
Some perioperative interventions modify risks for cardiovascular morbidity and mortality
Maxmize pt before taking them to OR
Cardiovascular disorders
Hypertension
Ischemic heart disease
Heart failure- may be baseline
Valvular heart disease
Patients with rhythm disturbances- EP lab - electrolyte abnormalities contribute
Patient with coronary stents- can reocclude w/in 90 days
Patients with pacemakers and ICD devices, pain pumps, dbs, insulin pumps.
Patients with peripheral arterial disease- also bad coronaries/ arterioles.
What has significant effects on respiratory function and lung physiology and mechanics
General anesthesia
Adverse respiratory event can occur during anesthesia and the most significant is hypoxemia
Integrative measures of respiratory function are likely predictors of outcome following anesthesia and surgery
Pulmonary disorder
Upper respiratory tract infection- kids
Asthma and COPD- maximize pts/ avoid GA
Chronic smokers- don’t stop smoking
Restrictive lung diseases- obesity,
Obstructive sleep apnea
Patients scheduled for lung resection-already have lung problems- ventilation problems
Endocrine system
Diabetes Mellitus
Thyroid disorders-medications- T3/T4 (will cause heart problems)- continue Synthroid
Hypothalamic- pituitary- adrenal disorders
Pheochromocytoma
Pit tumors -> ICU – fluid problems
Consider anesthetic effects
Renal system
Surgical stress, anaesthetic agents tend to decrease GFR
Renal impairment- CKD/ AKI
Contrast induced nephropathy
The emphases of the preoperative evaluation of patients with renal insufficiency are on the cardiovascular system, cerebrovascular system, fluid volume, and electrolyte status
BUN / creat – fluid volume status?
Hepatic disorder
Liver diseases have significant impact on drug metabolism and pharmacokinetics
Sedatives/opioids might have exaggerated effects in patients with advanced liver disease
Hepatitis
Alcohol liver disease
Obstructive jaundice
Cirrhosis
Clotting issues
Consider withdrawls
Hematologic Disorders
Anemia- poor H&H
Sickle cell disease- complicated pain management. Bad is disordered- > crisis clotting
G6PD deficiency- (inc rbc breakdown)
factor 5 leidan in pregnant women (inc clotting) - schedule anticoags ahead of time
Coagulopathies- drug induced
Neurologic disease
Cerebrovascular disease- strokes
Seizure disorders
Multiple sclerosis- temperature sensitive- warm before
Aneurysm and AV malformation- consider high bp
Parkinson disease
Neuromuscular junction disorders- avoid nm blockers
Muscular dystrophy and myopathy
Sz meds shortens anesthetics- reduce by 2/3-3/4
Musculoskeletal and Connective tissue disorders
Rheumatoid Arthritis- immunotherapy and joint instability – atlantooccipital joint instability
Ankylosing Spondylitis- nm deficints. Ostepcomprmise.
Systemic Lupus Erythematosus
Raynaud Phenomenon- cold and lower bp= not good
Changes in bg or pain- cold and lower bp
Informed consent
Respect for pt autonomy
Duty to inform pts about the risks and alternatives to treatment, procedures, and consequences
Salgo v Trustees of Leland Stanford Hospital
Salgo v Trustees of Leland Stanford Hospital
1957 court case that helped to establish what the practice ofinformed consentwas supposed to look like in the practice of modernmedicine. This was evaluated with respect to theCalifornia Court of Appealscase where Martin Salgo sued the trustees ofStanford Universityand Stanford physician Dr. Frank Gerbode formalpracticeas he claimed that they did not inform him nor his family of the details and risks associated with anaortogramwhich left him permanentlyparalyzedin his lower extremities.
Shared decision making
Communicating with pts about the risks and benefits of possible interventions
Eliciting pts’ goals, values, and concerns
Assisting pts in how to conceptualize the risks and benefits/how to approach the decision
Hospital to hospital decision on psych pts
Diminished capacity –MR?- POA
Do whats in the pts best interest?
High quality decisions are based on what factors?
Right operation (clinical evidence)
Right provider (certification/ privleging)
Right Place (necessary resources)
Right patient (shared decision making)
Do-Not-Resuscitate Orders in thePerioperative Period
Full attempt at resuscitation
Limited attempt at resuscitation defined with regard to specific procedures
-May refuse certain/specific resuscitation procedures
-Anesthesia should inform pt/surrogate about which procedures are essential and not essential for the success of the anesthetic and proposed surgery
Limited attempt at resuscitation defined with regard to the pt’s goals and values
-Allows the anesthesia and surgical teams to use clinical judgment in determining appropriate resuscitation procedures
High surgical risk
> 5% for morbidity and mortality
aortic and major vascular
peripheral vascular
Intermediate surgical risk (1%-5%)
(1%-5%) for morbidity and mortality
Intrabdominal surgery
intrathoracic surgery
carotid endarterectomy
head/neck surgery
Low surgical risk
(<1%) for morbidity and mortality
ambulatory surgery
breast surgery
endoscopic procedures
cataract surgery
skin surgery
urologic surgery
orthopedic surgery
RCRI
revised cardiac risk index
Prediction tool recommended by ACC/AHA
Estimates risk of cardiac complications after surgery
components;
High risk surgery (intraperitoneal, intrathoracic, or supringuinal vascular procedure)above inguinal ligament*
ischemic heart disease
history of congestive heart failure
history of cerebrovasular disease
DM requiring insulin
creatinine > 2.0 mg/dl (176 umol/L)
score
0=0.4%
1=1%
2=2.4%
>3= 5.4%
Functional Capacity
Assessment of cardiopulmonary fitness
Estimates pt risk for major post-op morbidity or mortality
Determines if further testing is necessary
Poor functional capacity = increased peri-operative risk
Measured in METs (metabolic equivalent of task)
-Rate of energy consumption at rest
-1 MET = 3.5 mL/kg/min
->4 METs- cut off- Less than that consider why they aren’t doing okay
1- eating, working at computer, dressing
2- walking down stairs or in your house or cooking
3- walking 1 or 2 blocks on level ground
4- taking leaves, gardening
cant walk normally? = stress test
Emergency surgery
life or limb would be threatened if surgery did not proceed within 6 hours or less
Proceed directly to emergency surgery w/o pre-op cardiac assessment/ workup
Focus on surveillance (serial cardiac enzymes, hemodynamic monitoring, serial ECGs) and early treatment of any post-op CV complications
Gi bleed and active MI and trying to treat both at the same time.
Urgent Surgery
life or limb would be threatened if surgery did not proceed within 6 to 24 hours.
Time- sensitive surgery
delays exceeding 1 to 6 weeks would adversely affect patient outcomes. Screenings- ECG/ coloscopy’s
Anesthesia influences on poor perioperative outcome
provider characteristics
Errors in judgment
mishaps
Surgery components on poor perioperative outcomes
errors in judgement
Location of postoperative care
Poor perioperative outcomes
death, major morbidity, minor morbidity, readmission, satisfaction
ASA 1
normal healthy patient
healthy, non smoking no or minimal alcohol use
ASA 2
A patient with mild systemic disease
Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease
ASA 3
A patient with severe systemic disease
Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis (PD), history (>3 months) of MI, CVA, TIA, or CAD/stents.
ASA 4
A patient with severe systemic disease that is a constant threat to life
Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction (<40%), shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA 5
A moribund patient who is not expected to survive without the operation
Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
ASA 5 e = emergent
ASA 6
A declared brain-dead patient whose organs are being removed for donor purposes
Pre op testing is done to…..
Testing is indicated if it can identify abnormalities, change the diagnosis and management plan, or the pt’s outcome
Tests should satisfy the following criteria to be useful
Diagnostic efficacy… correctly identify abnormalities?
Diagnostic effectiveness… change the diagnosis?
Therapeutic efficacy… change the management of the pt?- eval and treat pt
Therapeutic effectiveness… change the pt’s outcome?
CBC/Hemoglobin/Hematocrit
Surgery, potential blood loss, individualized pt clinical indications
Hx of increased bleeding, hematologic disorders, anti-coagulant therapy, poor nutritional status, septic
ASA-PS 3 or 4 undergoing intermediate-risk procedures- baseline
All pts undergoing major procedures- need baseline
Renal Function Testing
DM, HTN, cardiac disease, dehydration (N/V, diarrhea), renal disease, fluid overload. Metabolic derangement.
ASA-PS 3 or 4 undergoing intermediate-risk procedures
ASA-PS 2, 3, or 4 undergoing major procedures
GFR, BUN, Creat-
Electrolytes lab tests
Suspected undiagnosed or worsening condition that will affect peri-op management
Renal or hepatic disease, malnutrition, malabsorption, ETOH abuse, HF, arrhythmias, medications that may cause an imbalance
after dialysis
largest cause of arrhythmias- mag and K
Ectopy/ ekg changes- get chem
POC tests
ha and h. artery sample; ph, po2, pco2, bicarb, BD, K, cl, na, ca.
Liver Function Testing
Liver injury/disease and physical exam findings
Hepatitis, jaundice, cirrhosis, portal HTN, biliary disease, gallbladder disease, bleeding disorders. Abd blunt trauma, etoh consumption, meds.
GI bleed- liver figures in because of decreased clotting/ hepatic portal htn.
albumin if malnourished
Coagulation Testing
Known or suspected coagulopathy identified on pre-op evaluation
Known bleeding disorder, hepatic disease, and anticoagulant use
ASA-PS 3 or 4; undergoing intermediate, major, or complex surgical procedures; known to take anticoagulant medications or chronic liver disease
Coag- looks for bleeding gums/ petechia, hemorrhaging things, unexplained bruising, meds that cause coagulopathies.
PT/ INR- may be good but not good, may need PFT and teg.
Meds including aspirin get coag panel.
Talk to hem/onc and get coag testing. (provide recommendations)
Give ns before to dilute out hbg of 20 or pre screen and give unit of blood if the antibodies have to come from an outside area?
Serum Glucose and Glycated Hemoglobin (HbA1c)
Known DM (or family history), obesity (BMI > 50), cerebrovascular or intracranial disease, or steroids history
HbA1c long-term measurement of glucose control (3 months)
Better assessment of diabetic therapy > random/fasting blood sugar
HbA1c = ½ from previous 30 days + ½ the time period of 2 to 3 months before
All diabetic patients- know a1c and bg.
Urinalysis
Suspected UTI and unexplained fever or chills
Orthos/ total joint worry about UTI’s- high risk of infection- don’t want to get a UTI. Spilling infected urine on the joint.
Pregnancy Test
Pregnancy – anesthesia meds; benzos/ Nitric Oxide – given early in pregnancy = teratogenic- don’t want liability. Not monitoring baby if we don’t know its there. May need gal bladder out (elective)- fetal monitoring throughout procedure.
High risk of miscarriage if emergent surgery 50%. Surgical or traumatic stress. Get OB on early on.
Types of pregnancy tests- urine (easiest and cheapest), beta / quantitative HCG add on.—be sensitive
Causes of beta hcg = + tumor? – may be tracking beta HCG
Sexual activity, birth control use, and date of last menstrual period
Recommendation… all women of childbearing potential of the possibility of pregnancy and women possibly pregnant made aware of the risks of anesthesia/surgery to the fetus
ECG
Ischemic heart disease, HTN, DM, HF, chest pain, palpitations, abnormal valvular murmurs, dyspnea on exertion, syncope, arrythmia . <4.
Known IHD, significant arrhythmia, PAD, CV disease, significant structural heart disease undergoing intermediate- risk or high-risk procedures
Routine in ASA-PS 3 or 4 undergoing intermediate- risk
Routine ASA-PS 2, 3, or 4 major/high-risk procedures
Chest Xray
Based on abnormalities identified during pre-op evaluation
Advanced COPD, bullous lung disease, pulmonary edema, pneumonia, mediastinal masses, suspicious physical exam findings (rales, tracheal deviation), trauma.
Mass on trachea- may collapse trachea when nmb given. Wide mediastinum- may see aortic rupture, varices, esophagus rupture
Risk with broken ribs/flail chest
when anesthetized- hard to ventilate can cause a pneumothorax.
Chest/ pulmonary contusion ventilating and having trouble / high risk of pneumo- may not be seen on initial chest x ray.
Wide mediastinum
if high pressure bv (aorta) tears open or leaks makes that mediastinum space bigger. Esophagus rupture can also cause wide mediastinum
Wide mediastinum- may see aortic rupture, varices/ esophagus rupture
anorexia
CBC tree
wbc hbg/hct plat
Chem tree
na cl BUN glucose
k CO2 Creat
Coag tree
L = Pt
R = PTT
top= INR
GA
Total loss of consciousness and airway control
ET or LMA used- egd/ colonoscopy-
Ex: major surgeries… total joints, open-heart surgery, bowel surgery
IV/Monitored Sedation “mac” – monitored anesthesia care
Level of sedation ranges… minimal (drowsy, able to talk) to deep (sleeping, may not remember surgery/procedure
NC or face mask to oxygenate.
Ex: minor surgeries/procedures or shorter, less complex procedures… biopsy, colonoscopy
Regional
– peripheral nerve block,
Pain management method that numbs a large part of the body using a local anesthetic
Epidural or spinal
Ex: childbirth or joint replacements in elderly pts
Local
Pain management method, usually a one-time injection of local anesthetic that numbs a small area of the body
Can be used with general or conscious sedation depending on the surgery and pt history
Ex: skin or breast biopsy, bone/joint repair
Most common allergy agents
neuromuscular blockers- Roc
Antibiotics - PenG , cephlasporins
Chlorhexidine
Muscle relaxants are the most common, followed by latex, chlorhexidine, Abx and opioids.
Incidence of true anaphylaxis involving anesthesia
1:20000
Muscle relaxants are the most common causes, followed by latex, chlorhexidine, antibiotics and opioids (selective), iodine based solutions, adhesives (be aware of the tape).
Latex allergy is a concern for?
Spina bifida
Latex allergy
Risk factors – history of multiple surgeries, occupational exposure to latex (healthcare workers, food handlers/ condoms), food allergies that cross-react (mango, kiwi, avocado, passion fruit, banana, and chestnuts).
Notify surgical team immediately
ABX allergy
PCN and cephalosporins most common causes of anaphylaxis
Small risk of cross-reactivity, usually rashes
Avoid in true IgE –mediated allergy
Vancomycin… distinguish between allergy and “red man syndrome”
Histamine-induced side . Give antihistamines and give vanc slower
Cephazolin has a 10-15% risk of cross reactivity with pts that have PCN allergy- give test dose and see if they react. Usually not full blown rxn. Benedryl/ pepcid and test doses.
True anaphyalzis to pcn avoid cephazolin
Local anesthetics allergies
Amide vs ester
Ester reactions… due to preservative - para-aminobenzoic acid (PABA)
Epinephrine in LA causes adverse side effects, not an allergy
Lidocaine is amides have I’s in it. Lidocaid , pivicaidn. ”I” amide.
Neuromuscular blocking agents allergy
Quaternary ammonium compounds – where the rxn comes from.
Neostigmine and morphine may cause rxn. Neostigmine- given for a GA or have MG.
Cross-reactivity possible with allergy to neostigmine and morphine
Ammonium ions
Opioids allergies
True allergy is rare… related to side-effects (ex. nausea and vomiting)- avoid with pts with PONV- try premedicating- don’t give opioids use something else for pain management.
Antihypertensive meds pre operative
continue
Except angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), May d/c 24 hours before surgery- cause hypotension especially lisinopril under anesthesia.
Cardiac medications (ex. Beta-blockers, digoxin, amio) pre op
continue
core measure; if pt on beta blocker make sure its taken within 24 hours of surgery.
Anti-depressants, anxiolytics, and other psychiatric medications pre op
continue
Tricyclic anti-depressants… order an ECG d/t prolonged QT interval
Thyroid medications- pre op
continue
abruptly stopping can be traumatic
Oral contraceptive pills pre op
continue
High-risk pt for post-op venous thrombosis… d/c 4 weeks prior to surgery
Suggamadex may decrease effects of oral contraceptives. Use alternative contraceptive for 14 days after
Eye drops pre op
continue
Gerd meds pre op
continue -
dont want reflux/ aspiration
Opioid meds pre op
continue
dont want to get behind on pain
Anti-convulsant medications- pre op
continue
decrease life span of nmb
Asthma medications- pre op
continue
give tx before- Corticosteroids (oral and inhaled)
Statin medications- pre op
continue
increase cardiac risk if stop taking
Aspirin Pre op
why are they taking them?
Cont in pts w/ prior percutaneous coronary intervention, high-grade ischemic heart disease, significant cardiovascular disease,
Typically, d/c 10-14 days prior to surgery- wait for plat to die off
COX-2 inhibitor medications (celecoxib) pre op
continue
Unless concern regarding bone healing… may d/c prior to surgery
May give dose before
Monamine oxidase inhibitor (MAOIs) medications
pre op
continue
Adjust anesthesia plan to avoid meperidine (SZ or Serotonin syndrome) and in-direct acting vasopressors (ephedrine)(pt may not respond well to ephedrine)
ASA dc….
10-14 days before surgery
Clopidogrel, ticagrelor dc….
5-7 days
Prasugrel… d/c
7-10 days
Ticlopidine… d/c
10 days
P2Y12 inhibitors
(clopidogrel, ticagrelor, prasugrel, ticlopidine)
Do not d/c in drug-eluting stents until 6 months of dual antiplatelet therapy is completed*
Continue in pt for cataract sx w/ topical or general anesthesia*. GET PFT.
Stent- may need for it to continue- take pts off one and put on something we can reverse- lovenox -> heparin ( can reverse with protamine if they start bleeding)
Topical medications dc….
day of surgery – don’t want patch on there with electrical currents going through.
Diuretics dc….
day of surgery . Don’t want volume depleted before surgery
Thiazide diuretics should be continued- don’t want bp out of control
Sildenafil dc….
24 hours before surgery (may be before).
ED? – stop.
Taking it for pulm htn?- continue taking.
NSAID dc…
48 hours before surgery
Warfarin dc….
5 days before surgery . Usually stop and put on heparin
Continue in pt for cataract sx w/ topical or general anesthesia***
Post-menopausal HRT dc….
4 weeks prior to surgery
Non-insulin anti-diabetic medications dc…..
on day of surgery
SGLT2 inhibitors… d/c 24 hours before surgery
Pre op insulin
D/c short-acting (regular) on day of surgery
If an insulin pump, continue at basal rate
Type 1
Take a small amount (approx 1/3) of usual dose of morning long-acting insulin on day of surgery
Type 2
Take none or up to half of long-acting or combination insulin dose on day of surgery
Dm- what going on? meds they are taking and NPO status.
Pre-operative medication managementSteroids and HPA Suppression
Cortisol is produced by the adrenal gland
Hydrocortisone is an equally potent synthetic version
Exogenous glucocorticoids suppress cortisol secretion at HPA axis
May lead to adrenal insufficiency and adrenal atrophy – been taking steroids for so long
Adrenal recovery occurs gradually after steroid therapy is tapered and d/c’d
May blunt the normal cortisol hypersecretion associated with surgery
Taking steroid and doing fine until we induce stress and don’t respond because they’ve eaten up all that cortisol, treat by
Give meds that simulates adrenal gland/ release cortisol and don’t respond-> give dose of steroids- 100mg of hydrocortisone to get cortisol level up because taking steroids for so long they got used to it.
Long term steroids- adrenal wont respond to how they’re supposed to,
Steroids taken for ; pain or neuro muscular diseases, copd.
HPA Suppression
No HPA suppression with short duration, low-dose steroids – dexamethasone 4-8 mg for nausea and pain cocktail.
HPA suppression with >20 mg prednisone/day >3 weeks and in pts with Cushingoid appearance- hydrocortisone 100 mg- may stay on afterwards.
Pre-op
Assess duration, dose, and potency of all steroids taken during the past year
Stress dose
Physiologic replacement doses are required
Dosage varies based on surgical procedures
Stress dose steroids
Hydrocortisone 100 mg q8 hours
Echinacea (purple coneflower root)
activation of cell-mediated immunity
long term immunosuppressant
Ephedra (ma huang)
increases heart rate and bp through direct and indirect sympathomimetic effects
used to be taken for wt loss
try something other than ephedrine if not working
Garlic (ajo)
inhibts plat aggregation
increase fibrinolysis
equivocal anthypertesive activity
hold for 10-14 days
given to cardiac pts
Ginger
antiemetic
antiplat- increased risk of bleeding
aggregation
Ginkgo (duck-foot tree, maiden hair tree, silver apricot)
inhibits plat- activating factor
Ginseng
lowers bg, inhibits plat aggregation, increase pt/ptt
green tea
inhibit plat aggregation, inhibits TXA2 formation
KAVA (pepper)
sedation/ anxiolysis
Saw palmetto
inhibits 5alpha reductase
inhibits cyclooxygenase
st johns wort
inhibits nt reuptake
mao inhibition unlikely
can cause seratonin sydrome
Valerian
sedation
NPO 8 hours
full meal
full meal, fatty foods , enternal tf not post pyloric
Diabetic/ gastric reflux pts have delayed gastric emptying- so wait 8 hours.
NPO 6 hours
Light meal
toast, and liquids, infant formula, nonhuman milk , coffee with milk
NPO 4 hours
Breast milk
NPO 2 hours
clear liquids
water, sports drinks, carbonated bev, coffee, tea, juice w/o pulp
Mendelson syndrome
increased risk of aspiration
>25 mL gastric residual volume
pH <2.5- acidic substance
Aspiration prophylaxis
Decrease gastric volume and acidity – npo and give meds that reduce acid content (bicitrate/ sodium citrate) - raises gastric PH (tastes horrible)
Non-particulate antacids (sodium citrate)… increase gastric pH
Histamine-2 receptor antagonists (ranitidine, cimetidine, famotidine… increase gastric pH, decrease gastric acid secretion
Proton pump inhibitors (omeprazole, pantoprazole)… increase gastric pH, decrease gastric acid secretion
Dopamine-2 antagonist (metoclopramide)… reduces gastric volume
Curtis Lester Mendelsons
original 1946 description of his namesake syndrome, chemical pneumonitis was described in young and healthy obstetrical patients following aspiration of gastric acid under anesthesia. The standard use of regional anesthesia for most laboring women and increased awareness among anesthesia providers regarding the high risk of aspiration and potential difficult airway management in parturients has increased the safety in this population. This complication of anaesthesia led, in part, to the longstandingnil per os(abbr. NPO; a Latin phrase meaning nothing by mouth) recommendation for women in labour
Risk factors for pulm aspiration
hx of incompetense of lower esophageal sphincter w/ reflux
active n/v
symptomatic hiatal hernia
pregnancy
esophageal and gastric motility disorders
dm (poorly controlled or with gastroparesis)
significant opioid use
nm disorders (ALS(amyotrophic lateral sclerosis)/ parkinsons) and muscular dystrophies
AMS/ acute head injury
morbid obesity (BMI >40)
intra-abdominal masses, abd compartment syndrome
acute abdomen
bowel obstruction
emergency surgery
acute trauma
hx of gastric sx (gastrectomy, bariatric sx)
Apfel score
PONV risk scoring
female gener
history of ponv/ motion sickness
non smoking status
postoperative opioids
Kovuranta risk scoring system
female gener
history of ponv/ motion sickness
non smoking status
age (less than 50 years old )
duration of the surgery - less than 1 hours and longer than 4 hours.
Short surgery- eyes, toncile, ear tubes- increase risk of n/v
Low-, intermediate-, or high-risk based on pre-op PONV score
1 to 2 risk factors = moderate-to-severe risk
Prevention with 2 to 3 drugs from different classes
3 to 4 risk factors = severe risk
Consider avoiding GA or use a propofol-based anesthetic (TIVA)
Minimize opioids
Prevention with 3 drugs from different classes
Scopolamine
acetylcholine muscarinic antagonist
Crosses blood-brain barrier
TD patch can be applied night before surgery, lasts up to 72 hours
S/E: sedation, dry mouth, blurry vision, confusion, mydriasis… can worsen narrow-angle glaucoma
Pregabalin
Gabapentin/ lyrica
GABA analogue
Effects on PONV unclear, reduces opioid requirement
Administered pre-induction
S/E: visual disturbances, risk of respiratory depression
Ondansetron
serotonin antagonist
Administer before conclusion of surgery. Good preventative. 4mg. 20mg in chemo pts.
S/E: blurred vision, headache, prolong QTc
Promethazine
phenergan
histamine H1 antagonist
Administer small doses – dilute and have a good IV. 5-10 mg, burns and caustic to veins
S/E: sedation, dry mouth, blurred vision, prolong QTc
Dexamethasone
decadron
steroid
Administer after induction
May modulate release of endorphins or inhibit prostaglandin synthesis
S/E: perineal irritation/burning, increased blood sugars
Premedication ANTIBIOTICS
Core measure SCIP-INF (Infection)
All pts should have received prophylactic antibiotics within 1 hour before surgical incision
Pts who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within 2 hours before surgical incision
Pt needs 15 minutes before and no more than an hour at time of incision
Tourniquets? Get abx in 15 minutes before.
Cefazolin (cephalosporin)
Most commonly administered antibiotic for surgery
Broad-spectrum β-lactam antimicrobial agent
Most aerobic gram-positive bacteria that cause surgical site infections
Staphylococci, streptococci strains
Cross-reactivity to PCN
Clindamycin (lincosamide)
Effective against gram-positive aerobic bacteria
Staphylococci, streptococci, pneumococci strains
Most gram-positive and gram-negative anaerobic bacteria
Alternative for a β-lactam allergy or a MRSA infection
Treats infections of the head and neck, respiratory tract, bone, soft tissue, abdomen, and pelvis
Recommended in hysterectomies, cesareans, appendectomies, gastroduodenal tract, biliary tract, small intestine, colon, and rectum
Vancomycin (glycopeptide)- most powerful we use routinely
Gram-positive bacteria
Staphylococci, streptococci strains
Alternative for a β-lactam allergy or MRSA infection
Recommended for distal ilium, colon, appendix surgical sites
Health assessment consists of what 3 components
health assessment
health history
physical assessment
who are more prone to infection
old aged people and children / extremes of age
Problems with substance abuse and anesthesia
cocaine- chronic htn, bleed
meth- bp drop/ hard to treat bp
Lbs to kg
half and subtract 10%
kg to lbs
double and add 10%
core measure for temp in OR
recovery have to be 96 degrees
Celsius to Fahrenheit
(C x 2) + 30
Fahrenheit to celsius
(F-30) / 2
Anthropometry
the scientific study of the measurements and proportions of the human body.
Ht , wt, BMI, abd girth, mid arm circumference, neck circumference
Obesity and anesthesia
difficult to intubate
wound healing
dm
factors that may impact the ability to measure a bp
movement, neuro monitoring, hypoperfusion
Axilllary temp should be ____ than core temp
1F less
Risks of rectal temp
risk of perforation
avoid in uncooperative or immuno-suppressed pts
Calculate PPY
20 cigs per pack
1 ppd x 365 days = PPY
median overal survival was ____ in pts with > 15 ppy history compare to _____ in those with < 15ppy
lung ca pts (stage 3b/4)
10.8 months vs 14.7 months
Considered High risk for lung ca if____
adult pt >55 with >30 ppy history
should undergo screening wiht low-dose CT
Legionnaires disease
respiratory disease that came from hot tubs and air conditioners
current medication factors to consider
medication
dose/ frequency
route
last dose taken
Leading cause of BB od’s
accidental excess intake
What meds to avoid in bed bound patients
sux
Light Palpation
Apply tactile pressure slowly, gently and deliberately.
The hand is placed on the part to be examined and depressed about 1-2cm.
Deep Palpation
It is done after light palpation.
It is used to detect abdominal masses.
Technique is similar to light palpation except that the finger are held at a greater angle to the body surface and the skin is depressed about 4-5 cm.
Bimanual Palpation
It involve using both hand to trap a structure between them. This technique can be used to evaluate spleen, kidney, breast, uterus and ovary.
Sensing hand – Relax & place lightly over the skin.
Active hand – Apply pressure to the sensing hand.
Percussion
Percussion involve tapping the body with the fingertips to evaluate the size, border and consistency of body organs and to discover fluid in body cavity.
Most often done with lungs- may here resonance.
Mediate or Indirect Percussion
It can be performed by using the finger on one hand as a plexor (Striking finger) and the middle finger of the other hand as a pleximeter (the finger being struck).
Used mainly to evaluate the abdomen or thorax.
Immediate Percussion
Used mainly to evaluate the sinus or an infant thorax.
It can be performed by striking the surface directly with the fingers of the hand.
Fist Percussion
Used to evaluate the back and kidney for tenderness.
It involves placing one hand flat against the body surface and striking the back of the hand with a clenched fist of the other hand.
Sound : Tympany
Intensity : Loud
Pitch : High
Duration : Moderate
Quality : Drumlike- fluid fillled
Common location : Air containing space, enclosed area, gastric air bubble, Puffed out cheek
Sound : Resonance
Intensity : Moderate to Loud Pitch : Low
Duration : Long Quality : Hollow
Common location : Normal lungs
Sound : Hyper Resonance
Intensity : Very Loud
Pitch : Very Low
Duration : Longer than resonance Quality : Booming
Common location : Emphysematous lungs
Sound : Dullness
Intensity : Soft to moderate
Pitch : High
Duration : Moderate
Quality : Thudlike
Common location : Liver
Sound : Flatness
Intensity : Soft
Pitch : High
Duration : Short
Quality : Flat
Common location : Muscle
Circumoral cyanosis
refers to blue discoloration around the mouth only. It’s usually seen in infants, especially above the upper lip. If your child has darker skin, thediscolorationmight look more gray or white. You might also notice it on their hands and feet.
Jaundice
All causes occur from an elevated bilirubin, assume liver function is impaired
meds?
ECRP
endoscopic retrograde cholangiopancreatogram (ECRP)
done for cholestasis
Vitiligo
is anautoimmune disorderin which the systems in the body that fight off infection begin to fight off the healthy cells (melanocytes) that control the coloring of skin, hair, and mucous instead. Generally, vitiligo first shows up after a triggering event, like a cut, scrape or bruise to the skin.
Ecchymosis around eyes
Bad sign, whether its due to basilar skull fx, orbital injury or spontaneous bleeding. Assume the worst.
Sinus infections, cocaine ->epistaxis can carry to sinuses
Petechiae causes
Capillary rupture
Prolonged Straining
Medications- allergic reactions
Infectious Diseases- septic
Leukemia
Thrombocytopenia
Asphyxiation/ strangulation
skin lesions
Are they naturally occurring, abuse, signs of an infection or disease process. Think of everything from Kaposis sarcoma to cigarette burns to diabetic ulcers.
HIV kaposis- might be late stage aids
Poor skin turgot
dehydration and chronic condition, fluid status
EDEMA
Edema can occur as a result of a systemic issue such as cardiac failure or a localize issue such as an inflammatory response to a bee sting.
Pedal edema w/ HF
Infections
Tissue injury
DVT’s- obstruction to venous drainage
Ortho trauma- consider compartments
Grades 1 pitting edema
( trace , 2 mm)
Disappear rapidly
Grade 2 pitting edema
( moderate , 4 mm)
10-15 sec
Grade 3 pitting edema
(deep, 6 mm)
≥ 1min
Grade 4 pitting edema
+4 (very deep, 8 mm)
2-5min
Koilonychia
also known asspoon nails, is anail diseasethat can be a sign ofhypochromicanemia, especiallyiron-deficiency anemia.It refers to abnormally thin nails (usually of the hand) which have lost their convexity, becoming flat or even concave in shape. In a sense, koilonychia is the opposite ofnail clubbing. In early stages nails may be brittle and chip or break easily.
Nail clubbing
also known asdigital clubbingorclubbing, is a deformity of the finger or toenailsassociated with a number of diseases, mostly of theheartandlungs. When it occurs together withjoint effusions, joint pains, and abnormal skin and bone growth it is known ashypertrophic osteoarthropathy. Clubbing is associated withlung cancer, lung infections,interstitial lung disease,cystic fibrosis, orcardiovascular disease.Clubbing may also run in families,and occur unassociated with other medical problems.
consider RA
Paronychia
is an inflammation of theskin around the nail, which can occur suddenly, when it is usually due to the bacteriumStaphylococcus aureus, or gradually when it is commonly caused by the fungusCandida albicans.The term is fromGreek:παρωνυχίαfrompara, “around”,onyx, “nail” and the abstract noun suffix-ia.
Risk factors include repeatedly washing hands and trauma to the cuticle such as may occur from repeatednail biting.orhangnails.
Treatment includes antibiotics and antifungals, and if pus is present, the consideration ofincision and drainage.
Paronychia is commonly misapplied as a synonym forherpetic whitloworfelon.
Beau’s lines
can develop as a result of injuries, illnesses, or environmental factors such as:
picking at the nails or cuticles
getting an infection around the edge of the nail
getting a manicure
The appearance of Beau’s lines may offer insight into their cause. More than one line on one of your nails is usually a sign of repeated external injury to the nail matrix or an infection.
However, if you have more than one nail with Beau’s lines, the cause is likely a systemic illness, prolonged exposure to certain environmental factors, or chronic disease
Acute kidney failure
Mumps
Thyroid disease
Syphilis
Side effect of chemotherapy
Endocarditis
Melanoma
Diabetes
Pneumonia
Scarlet fever
Zinc deficiency
Beau’s lines
can develop as a result of injuries, illnesses, or environmental factors such as:
picking at the nails or cuticles
getting an infection around the edge of the nail
getting a manicure
The appearance of Beau’s lines may offer insight into their cause. More than one line on one of your nails is usually a sign of repeated external injury to the nail matrix or an infection.
However, if you have more than one nail with Beau’s lines, the cause is likely a systemic illness, prolonged exposure to certain environmental factors, or chronic disease
Acute kidney failure
Mumps
Thyroid disease
Syphilis
Side effect of chemotherapy
Endocarditis
Melanoma
Diabetes
Pneumonia
Scarlet fever
Zinc deficiency
RA concerns
Joint pain
long term steroid
atlantooccipital joint instability
Terminal Hair
long, thick, found on axilla and pubic area.
Vellus Hair
small, soft, found all over body except palm or sole
Brittle hair causes
Polycystic ovary syndrome (PCOS).
Cushing syndrome
Congenital adrenal hyperplasia
Tumors
Medications
Battle signs concerns
with orbital fractures we are concerned or entrampment of nerve, is their visual field limited because of the entrapment
Exophthalmoses
bulging eyes
Strabismus
Think about endocrine disorders or trauma. Funny looking kids (FLK) often have challenging airways
ectropion
(eversion, lid margin turn out)
entropion
(inversion, lid margin turns inwards)
ptosis
(abnormal drooping of lid over pupil)
(miosis)
A persistently small pupil
consider opiod use
(anisocoria)
A notable difference in pupil size between the two eyes
upside-down ptosis
Slight elevation of the lower lid
(anhidrosis)
Little or no sweating (anhidrosis) either on the entire side of the face or an isolated patch of skin on the affected side
Horners syndrome
oculosympathetic paresis
constellation of clinical signs including the classic triad of ptosis, miosis, and anhidrosis. It results from a lesion to the sympathetic pathway that supply the head and neck region
can get from an interscalene block
Treatment for a sty?
Warm moist towel, helps increase perfusion and unclog the duct.
Stage 2 of anesthesia eye features
Presence of roving eye ball (maximum movement of eye).
Pupil is partially dilated.
Loss of eyelash reflex -> 1st reflex to be lost.
No loss of eyelid reflex.
Deconjugate gaze= not anesthetized enough
Stage 3 anesthesia eye features
pupils are back to midline
Arcus senilis
is a depositing of phospholipid and cholesterol in the peripheral cornea in patients over the age of 60 which appears as a hazy white, grey, or blue opaque ring (peripheral corneal opacity).Arcusis common and benign when it is in elderly patients.
PERRLA
Pupils Equal Round and Reactive to Light Accommodation
Accommodation
Accommodation refers to your eyes’ ability to see things that are both close up and far away. If your pupils are nonreactive to accommodation, it means they don’t adjust when you try to shift your focus to an object in the distance or near your face.
Processing issue with the ocular nerve
EXTRA OCULAR MOVEMENTS
Why do they matter, consider nerves that may be impacted by regional anesthesia or injury. An orbital fracture with nerve or muscle entrapment is an emergency vs a delayed procedure.
blcoked by anesthesia/ regional anesthesia, stroke, entrapment in optical field. Strokes of only eye ; retinal artery occlusion
Basic causes of peripheral vision loss include
Glaucoma
Retinitis pigmentosa
Eye strokes or occlusions (retinal artery)
Detached retina
Brain damage from stroke, disease or injury
Neurological damage such as fromoptic neuritis
Compressed optic nerve head (papilledema)
Concussions (head injuries)*
ROP = retinopathy of prematurity
Otoscope
is used to see internal ear structure
Weber’s test
Tuning fork placed on top of head
Rinne test
tuning fork measures
air vs bone conduction
What can cause air trapping
N2O -> lungs -> Blood stream-> diffuses out, if in fluid or air trapped space = pressure.
if concerned about barotrauma or air trappid avoud N2O
meds for hemorrhagic control for nasal intubation
phenylephrine/ afrin/
cocaine- vasoconstrictor and anesthetic agent
THE MOUTH, PHARYNX AND NECK
You may be the only one to recognize abnormal findings, likewise friable tissue in the mouth, pharynx and neck can be bad news for anesthesia. Discuss surgical procedures involving the neck, high risk of airway issues
LIPS:lesions ,pallor (anemia), cyanosis(respiratory cardiovascular problems), cherry colored
BUCCAL MUCOSA , GUMS AND TEETH: teeth look for alignment , dental caries.buccal mucosa is a good site to visualize jaundice and pallor.leukoplakia (thick white patches ) is a precancerous lesion.
bright red tongue seen in
deficiency of iron b12 or niacin,
Which nair is usually the largest?
Right
Causes of epistaxis
anticoagulations, chronic htn, cocaine
Cherry lips
carbon-monoxide poisoning
Pallor lips
anemia/ hypoperfused
Cyanosis
Hypoxia or Hypoperfusion
Halitosis
bad breath
Discoloration of enamel may be?
Dental caries
Spongy gums bleed easily
(Vit-C deficiency)
liver issues
on anticoags
Leukoplakia
thick white patches because of smoking and alcohol
Pharynx assessment
Procedure : Extend his neck slightly, open the mouth widely and say “ah‟.
Place tongue depressor on the middle third of tongue. Use penlight for inspection.
Inspect for edema, ulcer, inflammation, lesions.
Dysphagia
difficulty swallowing
Thyroid gland anterior assessment
using the pads of the index and middle finger, palpate the left lobe with the right hand and right lobe with left hand.
Thyroid gland posterior part
Both hands are kept around the neck with two finger of each hand on the side of trachea
Thyroid gland general assessment
It lies anterior lower neck, in front of neck and both side of trachea.
Inspect for visible mass of thyroid gland, symmetry and fullness at the base of neck.
Give water then see for bulging of the gland.
Palpation: Flex the neck forward and laterally toward the side being examined.
Have the patient hold a cup of water and take a sip to swallow.
Common sign of COPD
Barrel chest
Butterfly rashes are associated with what autoimmune disorder
systemic lupus erthyematous
Clubbing of the fingers is associated with what congenital heart defects
ventricular septal defect
pulmonary stenosis
overriding the aorta
right ventricular hypertrophy
Pill rolling tremors are associated with what neurologic disorder
Parkinsons
Pill rolling tremors are associated with what neurologic disorder
Parkinsons
What sign, also known as RUQ pain accompanies cholecystitis
Murphys sign
What vision change accompanies glaucoma
Tunnel vision
1 inch is how many cm
2.54 cm
25.4mm
0.0254m
1 cm is how many inches
0.393
Apical pulse
To find the apical pulse locate the 5th ICS just to the left to the sternum and move the fingers laterally, just medial to the left mid- clavicular line.
difference of radial pulses
Aortic aneurysm
subclavian steal syndrome
devices- migration of port
clavicle fractures
Ominous sign for aortic stenosis
fatigue and syncope
Common urinary complication with OB patients
slicing Ureter with C section - pay attention to baseline urine
Hypospadias
penile opening being some place different
Most common nerve injury in anesthesia
peroneal nerve injury from bad positioning
cant dorsiflexion
have permanent plantar flexion
Lordosis
Increased lumber curvature
increase abd pressure
difficult to get epidural
consider coming in from the side
Kyphosis
Exaggeration of posterior curvature of thoracic spine
increased pressure on lung and not ventilating well
Romberg test
evaluate proprioception
Van positive
Vision, aphasia, neglect
+ pronator drift
high risk for LVO (large vessel occlusion) needs thrombectomy
Bicep reflex
Identify biceps tendon have patient flex elbow against resistance while you palpate antecubital fossa
Place arm so it’s bent ~ 90 degrees
Place one of your fingers on tendon and strike it.
Reflex: Flexion of arm at elbow.
Triceps reflex
Flex patient’s arm at elbow, holding arm across chest or hold upper arm horizontally.
Strike triceps tendon just above elbow.
Reflex : Extension at elbow.
Patellar reflex
Have client sit with leg hanging freely over side of table.
Tap patellar tendon just below patella.
Reflex : Extension of lower leg.
Achilles reflex
Have patient assume same position as for patellar reflex.
Slightly dorsiflex patient’s ankle by grasping toes in palm of your hand. Strike Achilles tendon just above heel at ankle malleolus.
Reflex : Planter flexion of foot.
Plantar reflex
Have patient lie supine with legs straight and feet relaxed.
Take handle end of reflex hammer and stroke lateral aspect of sole from heel to ball of foot, curving across ball of foot toward big toe.
Reflex : Planter flexion of all toes.
babinski reflex
Gluteal reflex
Have patient assume side lying position.
Spread buttocks apart and lightly stimulate perineal area with cotton applicator.
Reflex : Contraction of anal sphincter
looking for gluteal tone, blood and checking prostate
Ultrasounds is defined by….
frequency above 20,000 Hz, which is above the threshold of what can typically be heard by the human ear. Diagnostic ultrasound typically operates in a range between 2 and 18 megahertz (2,000,000 to 18,000,000 Hz).
range of audible sound
20Hz and 20,000Hz.
Linear probe
for high frequency
For the best visualization of superficial structures, such as tendons in the fingers, higher frequencies (10MHz or higher) are required
Good resolution, poor penetration
Phased Probe (medium to low frequency)
smaller footprint allows for easier imaging between rib spaces, perfect for cardiac scanning and the abd.
lower frequency allows for deeper imaging but sacrifice resolution for superficial structures.
Visualization of deeper structures, such as the abdominal aorta, require a lower frequency range (~4MHz or less).
Curved probe (medium to low frequency)
Broad range of frequencies to image anatomy needing a wider and deeper field of view
Focal Zone and Focal Point
The point at which the ultrasound beam is the narrowest and beam intensity is the greatest.
The focal zone is the area around the focal point.
Lateral resolution is the best within this zone.
Field (Fraunhofer Zone):
The area distal to the focal point.
The beam within this field diverges and creates gaps within the beam.
Higher frequency and larger piezoelectric elements = less divergence in the far field.
Lower frequency and smaller piezoelectric elements = more divergence in the far field.
Lateral resolution within this zone is greatly reduced
Near Field (Fresnel Zone):
This area is proximal to the focal zone.
Beam diameter is initially the same width as the transducer.
The beam will converge and decrease in diameter with depth.
Higher frequency = longer near field zone.
Lower frequency = shorter near field zone
Lateral resolution in this region is good.
Impedance equation
Impedance = Density × propagation speed of the sound wave
Impedance determines whether sound waves reflect, refract, or attenuate.
Impedance is the resistance to ultrasound propagation as it moves through a specific medium
Reflection coefficient
soft tissue and air has a greater reflection coefficient than muscle and liver. (%)
If a reflection coefficient is zero this corresponds to total transmission and no reflection, the acoustic impedances of the two interfaces/structures are the same. Notice the high coefficient of Soft tissue - air and Soft tissue - bone.
mirror artifact
occurs due to the reflection of sound waves after they propagate through a medium
Refraction
occurs when sound waves strike two adjacent mediums with slightly different impedance values. This causes the propagation speed to change somewhat and the sound waves change direction
Attenuation
As sound waves travel through tissues the intensity and amplitude decreases, a phenomenon known as attenuation. High frequency sound waves are affected to a greater degree than low frequency sound waves.
Absorption
Absorption occurs when the sound wave loses energy as it travels through a medium. As ultrasound travels through tissues part of the energy is lost to heat. The higher the frequency of the sound wave the greater the amount of absorption that occurs.
Echogenicity
refers to the ability to reflect or transmit ultrasound waves in the context of surrounding tissues
Anechoic
refers to structures that appear black, meaning that there are no internal echoes. Typical of fluid-filled structures such as cysts, gallbladder, urinary bladder, and blood vessels
Why do we ultrasound eyes?
difference of pressure/ loss of symmetry
open globe
retinal detachement
Hypoechoic
structures appear darker than surrounding structures; gives off fewer echoes. Often seen in tissues with increased density such as fibrous masses
Hyperechoic
is the opposite of hypoechoic. It is used to describe structures that appear brighter than surrounding structures; these structures give off more echoes. This can be seen in structures with lower density than the surrounding structures allowing for increased propagation speeds
Isoechoic
is used to describe a structure that gives off similar echoes relative to another structure in the same image.
Reverberation
occurs in the presence of highly reflective surfaces. The sound strikes the reflector and essentially bounces back and forth between the reflector itself and the ultrasound transducer
Gain
Gain is a feature of ultrasound machines to compensate for sound wave attenuation.
contrast
Color doppler
Red towards probe, blue away from probe
Sliding
Moving the transducer along its long axis.
Sweeping
Moving the transducer along its short axis.
Tilting or Fanning
While maintaining a fixed position on the body, the transducer is moved along its short axis to change the angle of incidence < 90°.
Rocking or Heeling
While maintaining a fixed position on the body, pressure is applied to one side of the transducer to move in the long axis and reduce the incident angle < 90°.
Rotating
Turning the transducer in a clockwise or counterclockwise direction over a fixed point on the body to change between a short and long axis view.
short axis view
transverse plane
out of plane view
long axis view
longitudinal plane
in plane
Anohter name for leprosy
Hansen’s disease
chipmunk face is associated with what eating disorder?
bulimia nervosa
spider angioma is associated with what liver disorder
Cirrhosis
Pyloric stenosis is associated with what shape of mass
olive
Hyperthyroidism is associated with what ophthalmic change?
exopthalmus
what physical feature is commonly associated with Cushing syndrome
Buffalo hump
Rice water stool is commonly found with what illness
Cholera
Contractile Cells
The contractile cells make up the bulk of the myocardium (99%), and they are the cardiac myocytes (muscle cells) responsible for contraction of the heart.
They mainly rely on the above conduction system to become depolarized, which will lead to cardiac contraction and movement of blood forward.
Smallest box on ekg strip
0.04
1st degree heart block
pr longer than .2
normal PR
0.10-0.2
Atrial depolarization/ ventricle filling
normal qrs
<0.12 seconds
represents ventricular depolarization
normal p wave
Duration < 0.12 seconds
+ in; 1,2 ,avf, V4-6.
ST segment elevation significance
Elevation/depression > 1mm significant
T wave
Ventricular repolarization
Positive in I, II, V3-V6
PSVT
Starts and stop svt
normal v tach rate
150-180
Halothane/enflurane causes what dysrhythmia?
sensitive myocardium
Sevoflurane triggers what dysrhthmia?
bradycardia in infants
five and dime reflex when holding mask. oculcardiac reflex.
Desflurane causes what dsyrhythmia?
Prolonged QT during induction
risk of r on T
Local anesthetics given iv can cause?
severe bradycardia/ asystole
treat with lipid rescue
Causes of bradycardia
abnormal ABG with hypoventilation
lytes/ hyperkalemia
Intubation
Vagal, peritoneum or cervix reflex
Correct diagnosis can be made in_____ % of cases on the basis of history alone
56
Test the Function of sternocleidomastoid muscle
As the patient to flex the neck with the chin to the chest
Test the function of the trapezius muscle
Movement of the head sideway so that the head moves towards the shoulder
How long does the av node delay conduction for?
0.1 seconds
Bundle of his intrinsic rate
40-60bmp
Also known as the atrioventricular bundle
Purkinje Fiber intrinsic rate
20-40bpm
Normal Junctional rate
40-60
Retrograde p wave
IBW MALE
Height in cm minus 100= kg IBW
IBW FEMALE
Ht in cm minus 105= kg IBW
