HA Exam 1 Flashcards
1
Q
What changes to preoperative care will we do if we delay the surgery
A
- optimize comorbid diseases
- refer to other specialist
- refer for specialized testing
- initiate interventions intended to decrease perioperative risk
- ID previous unrecognized comorbid conditions
2
Q
How do we prepare for surgery
A
- 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?
3
Q
What are the goals for postoperative follow up
A
- specialist follow up facilitated by preanesthsia evaluation
- Follow - up by anesthesiologist led service
follow up on conditions id by preoperative assessment
4
Q
Medical history components
A
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?
5
Q
Anesthetic physical exam
A
heart, lungs, airway, brain
6
Q
BMI < 18.5
A
underweight
7
Q
BMI 18.5-24.9
A
normal
8
Q
BMI 25-29.9
A
overweight
9
Q
BMI 30 and above
A
obese
10
Q
Metric BMI formula
A
BMI = wt (KG) / Height (m) (squared)
11
Q
Imperial BMI formula
A
BMI = 703 x wt (lbs) / height (in) (squared)
12
Q
Vital signs
A
BP, HR, RR, O2 saturation, temperature
Height and weight
BMI
Ideal body weight
consider when they were taken
13
Q
Focused physical exam
A
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
14
Q
Emergent physical examination
A
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??
15
Q
Airway Examination
A
- 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
16
Q
What accounts for almost half of perioperative mortalities
A
cardiovasular complications
Some perioperative interventions modify risks for cardiovascular morbidity and mortality
Maxmize pt before taking them to OR
17
Q
Cardiovascular disorders
A
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.
18
Q
What has significant effects on respiratory function and lung physiology and mechanics
A
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
19
Q
Pulmonary disorder
A
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
20
Q
Endocrine system
A
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
21
Q
Renal system
A
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?
22
Q
Hepatic disorder
A
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
23
Q
Hematologic Disorders
A
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
24
Q
Neurologic disease
A
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
25
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
26
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
27
Salgo v Trustees of Leland Stanford Hospital
1957 court case that helped to establish what the practice of informed consent was supposed to look like in the practice of modern medicine. This was evaluated with respect to the California Court of Appeals case where Martin Salgo sued the trustees of Stanford University and Stanford physician Dr. Frank Gerbode for malpractice as he claimed that they did not inform him nor his family of the details and risks associated with an aortogram which left him permanently paralyzed in his lower extremities.
28
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?
29
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)
30
Do-Not-Resuscitate Orders in the Perioperative 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
31
High surgical risk
>5% for morbidity and mortality
aortic and major vascular
peripheral vascular
32
Intermediate surgical risk (1%-5%)
(1%-5%) for morbidity and mortality
Intrabdominal surgery
intrathoracic surgery
carotid endarterectomy
head/neck surgery
33
Low surgical risk
(<1%) for morbidity and mortality
ambulatory surgery
breast surgery
endoscopic procedures
cataract surgery
skin surgery
urologic surgery
orthopedic surgery
34
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%
35
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
36
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.
37
Urgent Surgery
life or limb would be threatened if surgery did not proceed within 6 to 24 hours.
38
Time- sensitive surgery
delays exceeding 1 to 6 weeks would adversely affect patient outcomes. Screenings- ECG/ coloscopy's
39
Anesthesia influences on poor perioperative outcome
provider characteristics
Errors in judgment
mishaps
40
Surgery components on poor perioperative outcomes
errors in judgement
Location of postoperative care
41
Poor perioperative outcomes
death, major morbidity, minor morbidity, readmission, satisfaction
42
ASA 1
normal healthy patient
healthy, non smoking no or minimal alcohol use
43
ASA 2
A patient with mild systemic disease
Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30
44
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.
45
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
46
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
47
ASA 6
A declared brain-dead patient whose organs are being removed for donor purposes
48
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
49
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?
50
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
51
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-
52
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
53
POC tests
ha and h. artery sample; ph, po2, pco2, bicarb, BD, K, cl, na, ca.
54
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
55
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?
56
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.
57
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.
58
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
59
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
60
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
61
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.
62
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
63
CBC tree
wbc hbg/hct plat
64
Chem tree
na cl BUN glucose
k CO2 Creat
65
Coag tree
L = Pt
R = PTT
top= INR
66
GA
Total loss of consciousness and airway control
ET or LMA used- egd/ colonoscopy-
Ex: major surgeries… total joints, open-heart surgery, bowel surgery
67
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
68
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
69
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
70
Most common allergy agents
neuromuscular blockers- Roc
Antibiotics - PenG , cephlasporins
Chlorhexidine
Muscle relaxants are the most common, followed by latex, chlorhexidine, Abx and opioids.
71
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).
72
Latex allergy is a concern for?
Spina bifida
73
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
74
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
75
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.
76
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
77
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.
78
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.
79
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.
80
Anti-depressants, anxiolytics, and other psychiatric medications pre op
continue
Tricyclic anti-depressants… order an ECG d/t prolonged QT interval
81
Thyroid medications- pre op
continue
abruptly stopping can be traumatic
82
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
83
Eye drops pre op
continue
84
Gerd meds pre op
continue -
dont want reflux/ aspiration
85
Opioid meds pre op
continue
dont want to get behind on pain
86
Anti-convulsant medications- pre op
continue
decrease life span of nmb
87
Asthma medications- pre op
continue
give tx before- Corticosteroids (oral and inhaled)
88
Statin medications- pre op
continue
increase cardiac risk if stop taking
89
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
90
COX-2 inhibitor medications (celecoxib) pre op
continue
Unless concern regarding bone healing… may d/c prior to surgery
May give dose before
91
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)
92
ASA dc....
10-14 days before surgery
93
Clopidogrel, ticagrelor dc....
5-7 days
94
Prasugrel… d/c
7-10 days
95
Ticlopidine… d/c
10 days
96
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)
97
Topical medications dc....
day of surgery – don’t want patch on there with electrical currents going through.
98
Diuretics dc....
day of surgery . Don’t want volume depleted before surgery
Thiazide diuretics should be continued- don’t want bp out of control
99
Sildenafil dc....
24 hours before surgery (may be before).
ED? – stop.
Taking it for pulm htn?- continue taking.
100
NSAID dc...
48 hours before surgery
101
Warfarin dc....
5 days before surgery . Usually stop and put on heparin
Continue in pt for cataract sx w/ topical or general anesthesia***
102
Post-menopausal HRT dc....
4 weeks prior to surgery
103
Non-insulin anti-diabetic medications dc.....
on day of surgery
SGLT2 inhibitors... d/c 24 hours before surgery
104
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.
105
Pre-operative medication management Steroids 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.
106
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
107
Stress dose steroids
Hydrocortisone 100 mg q8 hours
108
Echinacea (purple coneflower root)
activation of cell-mediated immunity
long term immunosuppressant
109
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
110
Garlic (ajo)
inhibts plat aggregation
increase fibrinolysis
equivocal anthypertesive activity
hold for 10-14 days
given to cardiac pts
111
Ginger
antiemetic
antiplat- increased risk of bleeding
aggregation
112
Ginkgo (duck-foot tree, maiden hair tree, silver apricot)
inhibits plat- activating factor
113
Ginseng
lowers bg, inhibits plat aggregation, increase pt/ptt
114
green tea
inhibit plat aggregation, inhibits TXA2 formation
115
KAVA (pepper)
sedation/ anxiolysis
116
Saw palmetto
inhibits 5alpha reductase
inhibits cyclooxygenase
117
st johns wort
inhibits nt reuptake
mao inhibition unlikely
can cause seratonin sydrome
118
Valerian
sedation
119
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.
120
NPO 6 hours
Light meal
toast, and liquids, infant formula, nonhuman milk , coffee with milk
121
NPO 4 hours
Breast milk
122
NPO 2 hours
clear liquids
water, sports drinks, carbonated bev, coffee, tea, juice w/o pulp
123
Mendelson syndrome
increased risk of aspiration
>25 mL gastric residual volume
pH <2.5- acidic substance
124
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
125
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 longstanding nil per os (abbr. NPO; a Latin phrase meaning nothing by mouth) recommendation for women in labour
126
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)
127
Apfel score
PONV risk scoring
female gener
history of ponv/ motion sickness
non smoking status
postoperative opioids
128
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
129
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
130
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
131
Pregabalin
Gabapentin/ lyrica
GABA analogue
Effects on PONV unclear, reduces opioid requirement
Administered pre-induction
S/E: visual disturbances, risk of respiratory depression
132
Ondansetron
serotonin antagonist
Administer before conclusion of surgery. Good preventative. 4mg. 20mg in chemo pts.
S/E: blurred vision, headache, prolong QTc
133
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
134
Dexamethasone
decadron
steroid
Administer after induction
May modulate release of endorphins or inhibit prostaglandin synthesis
S/E: perineal irritation/burning, increased blood sugars
135
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.
136
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
137
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
138
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
139
Health assessment consists of what 3 components
health assessment
health history
physical assessment
140
who are more prone to infection
old aged people and children / extremes of age
141
Problems with substance abuse and anesthesia
cocaine- chronic htn, bleed
meth- bp drop/ hard to treat bp
142
Lbs to kg
half and subtract 10%
143
kg to lbs
double and add 10%
144
core measure for temp in OR
recovery have to be 96 degrees
145
Celsius to Fahrenheit
(C x 2) + 30
146
Fahrenheit to celsius
(F-30) / 2
147
Anthropometry
the scientific study of the measurements and proportions of the human body.
Ht , wt, BMI, abd girth, mid arm circumference, neck circumference
148
Obesity and anesthesia
difficult to intubate
wound healing
dm
149
factors that may impact the ability to measure a bp
movement, neuro monitoring, hypoperfusion
150
Axilllary temp should be ____ than core temp
1F less
151
Risks of rectal temp
risk of perforation
avoid in uncooperative or immuno-suppressed pts
152
Calculate PPY
20 cigs per pack
1 ppd x 365 days = PPY
153
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
154
Considered High risk for lung ca if____
adult pt >55 with >30 ppy history
should undergo screening wiht low-dose CT
155
Legionnaires disease
respiratory disease that came from hot tubs and air conditioners
156
current medication factors to consider
medication
dose/ frequency
route
last dose taken
157
Leading cause of BB od's
accidental excess intake
158
What meds to avoid in bed bound patients
sux
159
Light Palpation
Apply tactile pressure slowly, gently and deliberately.
The hand is placed on the part to be examined and depressed about 1-2cm.
160
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.
161
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.
162
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.
163
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.
164
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.
165
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.
166
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
167
Sound : Resonance
Intensity : Moderate to Loud Pitch : Low
Duration : Long Quality : Hollow
Common location : Normal lungs
168
Sound : Hyper Resonance
Intensity : Very Loud
Pitch : Very Low
Duration : Longer than resonance Quality : Booming
Common location : Emphysematous lungs
169
Sound : Dullness
Intensity : Soft to moderate
Pitch : High
Duration : Moderate
Quality : Thudlike
Common location : Liver
170
Sound : Flatness
Intensity : Soft
Pitch : High
Duration : Short
Quality : Flat
Common location : Muscle
171
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, the discoloration might look more gray or white. You might also notice it on their hands and feet.
172
Jaundice
All causes occur from an elevated bilirubin, assume liver function is impaired
meds?
173
ECRP
endoscopic retrograde cholangiopancreatogram (ECRP)
done for cholestasis
174
Vitiligo
is an autoimmune disorder in 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.
175
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
176
Petechiae causes
Capillary rupture
Prolonged Straining
Medications- allergic reactions
Infectious Diseases- septic
Leukemia
Thrombocytopenia
Asphyxiation/ strangulation
177
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
178
Poor skin turgot
dehydration and chronic condition, fluid status
179
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
180
Grades 1 pitting edema
( trace , 2 mm)
Disappear rapidly
181
Grade 2 pitting edema
( moderate , 4 mm)
10-15 sec
182
Grade 3 pitting edema
(deep, 6 mm)
≥ 1min
183
Grade 4 pitting edema
+4 (very deep, 8 mm)
2-5min
184
Koilonychia
also known as spoon nails, is a nail disease that can be a sign of hypochromic anemia, especially iron-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 of nail clubbing. In early stages nails may be brittle and chip or break easily.
185
Nail clubbing
also known as digital clubbing or clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs. When it occurs together with joint effusions, joint pains, and abnormal skin and bone growth it is known as hypertrophic osteoarthropathy. Clubbing is associated with lung cancer, lung infections, interstitial lung disease, cystic fibrosis, or cardiovascular disease. Clubbing may also run in families,and occur unassociated with other medical problems.
consider RA
186
Paronychia
is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium Staphylococcus aureus, or gradually when it is commonly caused by the fungus Candida albicans.The term is from Greek: παρωνυχία from para, "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 repeated nail biting. or hangnails.
Treatment includes antibiotics and antifungals, and if pus is present, the consideration of incision and drainage.
Paronychia is commonly misapplied as a synonym for herpetic whitlow or felon.
187
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
187
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
188
RA concerns
Joint pain
long term steroid
atlantooccipital joint instability
189
Terminal Hair
long, thick, found on axilla and pubic area.
190
Vellus Hair
small, soft, found all over body except palm or sole
191
Brittle hair causes
Polycystic ovary syndrome (PCOS).
Cushing syndrome
Congenital adrenal hyperplasia
Tumors
Medications
192
Battle signs concerns
with orbital fractures we are concerned or entrampment of nerve, is their visual field limited because of the entrapment
193
Exophthalmoses
bulging eyes
194
Strabismus
Think about endocrine disorders or trauma. Funny looking kids (FLK) often have challenging airways
195
ectropion
(eversion, lid margin turn out)
196
entropion
(inversion, lid margin turns inwards)
197
ptosis
(abnormal drooping of lid over pupil)
198
(miosis)
A persistently small pupil
consider opiod use
199
(anisocoria)
A notable difference in pupil size between the two eyes
200
upside-down ptosis
Slight elevation of the lower lid
201
(anhidrosis)
Little or no sweating (anhidrosis) either on the entire side of the face or an isolated patch of skin on the affected side
202
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
203
Treatment for a sty?
Warm moist towel, helps increase perfusion and unclog the duct.
204
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
205
Stage 3 anesthesia eye features
pupils are back to midline
206
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). Arcus is common and benign when it is in elderly patients.
207
PERRLA
Pupils Equal Round and Reactive to Light Accommodation
208
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
209
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
210
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 from optic neuritis
Compressed optic nerve head (papilledema)
Concussions (head injuries)*
ROP = retinopathy of prematurity
211
Otoscope
is used to see internal ear structure
212
Weber's test
Tuning fork placed on top of head
213
Rinne test
tuning fork measures
air vs bone conduction
214
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
215
meds for hemorrhagic control for nasal intubation
phenylephrine/ afrin/
cocaine- vasoconstrictor and anesthetic agent
216
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.
217
bright red tongue seen in
deficiency of iron b12 or niacin,
218
Which nair is usually the largest?
Right
219
Causes of epistaxis
anticoagulations, chronic htn, cocaine
220
Cherry lips
carbon-monoxide poisoning
221
Pallor lips
anemia/ hypoperfused
222
Cyanosis
Hypoxia or Hypoperfusion
223
Halitosis
bad breath
224
Discoloration of enamel may be?
Dental caries
225
Spongy gums bleed easily
(Vit-C deficiency)
liver issues
on anticoags
226
Leukoplakia
thick white patches because of smoking and alcohol
227
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.
228
Dysphagia
difficulty swallowing
229
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.
230
Thyroid gland posterior part
Both hands are kept around the neck with two finger of each hand on the side of trachea
231
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.
232
Common sign of COPD
Barrel chest
233
Butterfly rashes are associated with what autoimmune disorder
systemic lupus erthyematous
234
Clubbing of the fingers is associated with what congenital heart defects
ventricular septal defect
pulmonary stenosis
overriding the aorta
right ventricular hypertrophy
235
Pill rolling tremors are associated with what neurologic disorder
Parkinsons
236
Pill rolling tremors are associated with what neurologic disorder
Parkinsons
237
What sign, also known as RUQ pain accompanies cholecystitis
Murphys sign
238
What vision change accompanies glaucoma
Tunnel vision
239
1 inch is how many cm
2.54 cm
25.4mm
0.0254m
240
1 cm is how many inches
0.393
241
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.
242
difference of radial pulses
Aortic aneurysm
subclavian steal syndrome
devices- migration of port
clavicle fractures
243
Ominous sign for aortic stenosis
fatigue and syncope
244
Common urinary complication with OB patients
slicing Ureter with C section - pay attention to baseline urine
245
Hypospadias
penile opening being some place different
246
Most common nerve injury in anesthesia
peroneal nerve injury from bad positioning
cant dorsiflexion
have permanent plantar flexion
247
Lordosis
Increased lumber curvature
increase abd pressure
difficult to get epidural
consider coming in from the side
248
Kyphosis
Exaggeration of posterior curvature of thoracic spine
increased pressure on lung and not ventilating well
249
Romberg test
evaluate proprioception
250
Van positive
Vision, aphasia, neglect
+ pronator drift
high risk for LVO (large vessel occlusion) needs thrombectomy
251
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.
252
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.
253
Patellar reflex
Have client sit with leg hanging freely over side of table.
Tap patellar tendon just below patella.
Reflex : Extension of lower leg.
254
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.
255
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
256
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
257
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).
258
range of audible sound
20Hz and 20,000Hz.
259
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
260
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).
261
Curved probe (medium to low frequency)
Broad range of frequencies to image anatomy needing a wider and deeper field of view
262
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.
263
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
264
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.
265
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
266
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.
267
mirror artifact
occurs due to the reflection of sound waves after they propagate through a medium
268
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
269
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.
270
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.
271
Echogenicity
refers to the ability to reflect or transmit ultrasound waves in the context of surrounding tissues
272
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
273
Why do we ultrasound eyes?
difference of pressure/ loss of symmetry
open globe
retinal detachement
274
Hypoechoic
structures appear darker than surrounding structures; gives off fewer echoes. Often seen in tissues with increased density such as fibrous masses
275
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
276
Isoechoic
is used to describe a structure that gives off similar echoes relative to another structure in the same image.
277
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
278
Gain
Gain is a feature of ultrasound machines to compensate for sound wave attenuation.
contrast
279
Color doppler
Red towards probe, blue away from probe
280
Sliding
Moving the transducer along its long axis.
281
Sweeping
Moving the transducer along its short axis.
282
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°.
283
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°.
284
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.
285
short axis view
transverse plane
out of plane view
286
long axis view
longitudinal plane
in plane
287
Anohter name for leprosy
Hansen's disease
288
chipmunk face is associated with what eating disorder?
bulimia nervosa
289
spider angioma is associated with what liver disorder
Cirrhosis
290
Pyloric stenosis is associated with what shape of mass
olive
291
Hyperthyroidism is associated with what ophthalmic change?
exopthalmus
292
what physical feature is commonly associated with Cushing syndrome
Buffalo hump
293
Rice water stool is commonly found with what illness
Cholera
294
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.
295
Smallest box on ekg strip
0.04
296
1st degree heart block
pr longer than .2
297
normal PR
0.10-0.2
Atrial depolarization/ ventricle filling
298
normal qrs
<0.12 seconds
represents ventricular depolarization
299
normal p wave
Duration < 0.12 seconds
+ in; 1,2 ,avf, V4-6.
300
ST segment elevation significance
Elevation/depression > 1mm significant
301
T wave
Ventricular repolarization
Positive in I, II, V3-V6
302
PSVT
Starts and stop svt
303
normal v tach rate
150-180
304
Halothane/enflurane causes what dysrhythmia?
sensitive myocardium
305
Sevoflurane triggers what dysrhthmia?
bradycardia in infants
five and dime reflex when holding mask. oculcardiac reflex.
306
Desflurane causes what dsyrhythmia?
Prolonged QT during induction
risk of r on T
307
Local anesthetics given iv can cause?
severe bradycardia/ asystole
treat with lipid rescue
308
Causes of bradycardia
abnormal ABG with hypoventilation
lytes/ hyperkalemia
Intubation
Vagal, peritoneum or cervix reflex
309
Correct diagnosis can be made in_____ % of cases on the basis of history alone
56
310
Test the Function of sternocleidomastoid muscle
As the patient to flex the neck with the chin to the chest
311
Test the function of the trapezius muscle
Movement of the head sideway so that the head moves towards the shoulder
312
How long does the av node delay conduction for?
0.1 seconds
313
Bundle of his intrinsic rate
40-60bmp
Also known as the atrioventricular bundle
314
Purkinje Fiber intrinsic rate
20-40bpm
315
Normal Junctional rate
40-60
Retrograde p wave
316
IBW MALE
Height in cm minus 100= kg IBW
317
IBW FEMALE
Ht in cm minus 105= kg IBW
