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HA > HA Exam 1 > Flashcards

HA Exam 1 Flashcards

1
Q

What changes to preoperative care will we do if we delay the surgery

A
  1. optimize comorbid diseases
  2. refer to other specialist
  3. refer for specialized testing
  4. initiate interventions intended to decrease perioperative risk
  5. ID previous unrecognized comorbid conditions
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2
Q

How do we prepare for surgery

A
  1. preoperative instructions for surgical patient; bath/ brush teeth. Medications / supplements. OTC/herbal are anticoagulants.
  2. discuss perioperative care/ expectations
  3. arrange appropriate level of postoperative care/ plan ahead- dialysis? ICU?
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3
Q

What are the goals for postoperative follow up

A
  1. specialist follow up facilitated by preanesthsia evaluation
  2. Follow - up by anesthesiologist led service

follow up on conditions id by preoperative assessment

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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?

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5
Q

Anesthetic physical exam

A

heart, lungs, airway, brain

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6
Q

BMI < 18.5

A

underweight

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7
Q

BMI 18.5-24.9

A

normal

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8
Q

BMI 25-29.9

A

overweight

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9
Q

BMI 30 and above

A

obese

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10
Q

Metric BMI formula

A

BMI = wt (KG) / Height (m) (squared)

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11
Q

Imperial BMI formula

A

BMI = 703 x wt (lbs) / height (in) (squared)

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12
Q

Vital signs

A

BP, HR, RR, O2 saturation, temperature
Height and weight
BMI
Ideal body weight

consider when they were taken

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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

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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??

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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
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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

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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.

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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

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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

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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

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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?

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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

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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

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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

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25
Q

Musculoskeletal and Connective tissue disorders

A

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

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26
Q

Informed consent

A

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

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27
Q

Salgo v Trustees of Leland Stanford Hospital

A

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.

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28
Q

Shared decision making

A

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?

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29
Q

High quality decisions are based on what factors?

A

Right operation (clinical evidence)
Right provider (certification/ privleging)
Right Place (necessary resources)
Right patient (shared decision making)

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30
Q

Do-Not-Resuscitate Orders in thePerioperative Period

A

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

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31
Q

High surgical risk

A

> 5% for morbidity and mortality

aortic and major vascular
peripheral vascular

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32
Q

Intermediate surgical risk (1%-5%)

A

(1%-5%) for morbidity and mortality
Intrabdominal surgery
intrathoracic surgery
carotid endarterectomy
head/neck surgery

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33
Q

Low surgical risk

A

(<1%) for morbidity and mortality
ambulatory surgery
breast surgery
endoscopic procedures
cataract surgery
skin surgery
urologic surgery
orthopedic surgery

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34
Q

RCRI

A

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%

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35
Q

Functional Capacity

A

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

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36
Q

Emergency surgery

A

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.

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37
Q

Urgent Surgery

A

life or limb would be threatened if surgery did not proceed within 6 to 24 hours.

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38
Q

Time- sensitive surgery

A

delays exceeding 1 to 6 weeks would adversely affect patient outcomes. Screenings- ECG/ coloscopy’s

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39
Q

Anesthesia influences on poor perioperative outcome

A

provider characteristics
Errors in judgment
mishaps

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40
Q

Surgery components on poor perioperative outcomes

A

errors in judgement
Location of postoperative care

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41
Q

Poor perioperative outcomes

A

death, major morbidity, minor morbidity, readmission, satisfaction

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42
Q

ASA 1

A

normal healthy patient

healthy, non smoking no or minimal alcohol use

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43
Q

ASA 2

A

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

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44
Q

ASA 3

A

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.

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45
Q

ASA 4

A

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

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46
Q

ASA 5

A

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

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47
Q

ASA 6

A

A declared brain-dead patient whose organs are being removed for donor purposes

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48
Q

Pre op testing is done to…..

A

Testing is indicated if it can identify abnormalities, change the diagnosis and management plan, or the pt’s outcome

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49
Q

Tests should satisfy the following criteria to be useful

A

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?

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50
Q

CBC/Hemoglobin/Hematocrit

A

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

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51
Q

Renal Function Testing

A

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-

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52
Q

Electrolytes lab tests

A

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

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53
Q

POC tests

A

ha and h. artery sample; ph, po2, pco2, bicarb, BD, K, cl, na, ca.

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54
Q

Liver Function Testing

A

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

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55
Q

Coagulation Testing

A

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?

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56
Q

Serum Glucose and Glycated Hemoglobin (HbA1c)

A

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.

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57
Q

Urinalysis

A

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.

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58
Q

Pregnancy Test

A

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

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59
Q

ECG

A

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

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60
Q

Chest Xray

A

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

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61
Q

Risk with broken ribs/flail chest

A

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.

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62
Q

Wide mediastinum

A

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

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63
Q

CBC tree

A

wbc hbg/hct plat

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64
Q

Chem tree

A

na cl BUN glucose
k CO2 Creat

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65
Q

Coag tree

A

L = Pt
R = PTT
top= INR

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66
Q

GA

A

Total loss of consciousness and airway control
ET or LMA used- egd/ colonoscopy-
Ex: major surgeries… total joints, open-heart surgery, bowel surgery

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67
Q

IV/Monitored Sedation “mac” – monitored anesthesia care

A

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

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68
Q

Regional

A

– 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

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69
Q

Local

A

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

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70
Q

Most common allergy agents

A

neuromuscular blockers- Roc
Antibiotics - PenG , cephlasporins
Chlorhexidine
Muscle relaxants are the most common, followed by latex, chlorhexidine, Abx and opioids.

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71
Q

Incidence of true anaphylaxis involving anesthesia

A

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).

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72
Q

Latex allergy is a concern for?

A

Spina bifida

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73
Q

Latex allergy

A

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

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74
Q

ABX allergy

A

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

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75
Q

Local anesthetics allergies

A

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.

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76
Q

Neuromuscular blocking agents allergy

A

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

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77
Q

Opioids allergies

A

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.

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78
Q

Antihypertensive meds pre operative

A

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.

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79
Q

Cardiac medications (ex. Beta-blockers, digoxin, amio) pre op

A

continue
core measure; if pt on beta blocker make sure its taken within 24 hours of surgery.

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80
Q

Anti-depressants, anxiolytics, and other psychiatric medications pre op

A

continue
Tricyclic anti-depressants… order an ECG d/t prolonged QT interval

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81
Q

Thyroid medications- pre op

A

continue
abruptly stopping can be traumatic

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82
Q

Oral contraceptive pills pre op

A

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

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83
Q

Eye drops pre op

A

continue

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84
Q

Gerd meds pre op

A

continue -
dont want reflux/ aspiration

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85
Q

Opioid meds pre op

A

continue
dont want to get behind on pain

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86
Q

Anti-convulsant medications- pre op

A

continue

decrease life span of nmb

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87
Q

Asthma medications- pre op

A

continue
give tx before- Corticosteroids (oral and inhaled)

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88
Q

Statin medications- pre op

A

continue
increase cardiac risk if stop taking

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89
Q

Aspirin Pre op

A

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

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90
Q

COX-2 inhibitor medications (celecoxib) pre op

A

continue

Unless concern regarding bone healing… may d/c prior to surgery
May give dose before

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91
Q

Monamine oxidase inhibitor (MAOIs) medications
pre op

A

continue
Adjust anesthesia plan to avoid meperidine (SZ or Serotonin syndrome) and in-direct acting vasopressors (ephedrine)(pt may not respond well to ephedrine)

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92
Q

ASA dc….

A

10-14 days before surgery

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93
Q

Clopidogrel, ticagrelor dc….

A

5-7 days

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94
Q

Prasugrel… d/c

A

7-10 days

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95
Q

Ticlopidine… d/c

A

10 days

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96
Q

P2Y12 inhibitors

A

(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)

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97
Q

Topical medications dc….

A

day of surgery – don’t want patch on there with electrical currents going through.

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98
Q

Diuretics dc….

A

day of surgery . Don’t want volume depleted before surgery
Thiazide diuretics should be continued- don’t want bp out of control

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99
Q

Sildenafil dc….

A

24 hours before surgery (may be before).
ED? – stop.
Taking it for pulm htn?- continue taking.

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100
Q

NSAID dc…

A

48 hours before surgery

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101
Q

Warfarin dc….

A

5 days before surgery . Usually stop and put on heparin
Continue in pt for cataract sx w/ topical or general anesthesia***

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102
Q

Post-menopausal HRT dc….

A

4 weeks prior to surgery

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103
Q

Non-insulin anti-diabetic medications dc…..

A

on day of surgery
SGLT2 inhibitors… d/c 24 hours before surgery

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104
Q

Pre op insulin

A

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.

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105
Q

Pre-operative medication managementSteroids and HPA Suppression

A

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.

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106
Q

HPA Suppression

A

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

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107
Q

Stress dose steroids

A

Hydrocortisone 100 mg q8 hours

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108
Q

Echinacea (purple coneflower root)

A

activation of cell-mediated immunity
long term immunosuppressant

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109
Q

Ephedra (ma huang)

A

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

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110
Q

Garlic (ajo)

A

inhibts plat aggregation
increase fibrinolysis
equivocal anthypertesive activity
hold for 10-14 days
given to cardiac pts

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111
Q

Ginger

A

antiemetic
antiplat- increased risk of bleeding
aggregation

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112
Q

Ginkgo (duck-foot tree, maiden hair tree, silver apricot)

A

inhibits plat- activating factor

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113
Q

Ginseng

A

lowers bg, inhibits plat aggregation, increase pt/ptt

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114
Q

green tea

A

inhibit plat aggregation, inhibits TXA2 formation

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115
Q

KAVA (pepper)

A

sedation/ anxiolysis

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116
Q

Saw palmetto

A

inhibits 5alpha reductase
inhibits cyclooxygenase

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117
Q

st johns wort

A

inhibits nt reuptake
mao inhibition unlikely

can cause seratonin sydrome

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118
Q

Valerian

A

sedation

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119
Q

NPO 8 hours

A

full meal

full meal, fatty foods , enternal tf not post pyloric

Diabetic/ gastric reflux pts have delayed gastric emptying- so wait 8 hours.

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120
Q

NPO 6 hours

A

Light meal

toast, and liquids, infant formula, nonhuman milk , coffee with milk

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121
Q

NPO 4 hours

A

Breast milk

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122
Q

NPO 2 hours

A

clear liquids

water, sports drinks, carbonated bev, coffee, tea, juice w/o pulp

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123
Q

Mendelson syndrome

A

increased risk of aspiration
>25 mL gastric residual volume
pH <2.5- acidic substance

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124
Q

Aspiration prophylaxis

A

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

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125
Q

Curtis Lester Mendelsons

A

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

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126
Q

Risk factors for pulm aspiration

A

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)

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127
Q

Apfel score

A

PONV risk scoring

female gener
history of ponv/ motion sickness
non smoking status
postoperative opioids

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128
Q

Kovuranta risk scoring system

A

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
Q

Low-, intermediate-, or high-risk based on pre-op PONV score

A

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
Q

Scopolamine

A

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
Q

Pregabalin

A

Gabapentin/ lyrica
GABA analogue
Effects on PONV unclear, reduces opioid requirement
Administered pre-induction
S/E: visual disturbances, risk of respiratory depression

132
Q

Ondansetron

A

serotonin antagonist
Administer before conclusion of surgery. Good preventative. 4mg. 20mg in chemo pts.
S/E: blurred vision, headache, prolong QTc

133
Q

Promethazine

A

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
Q

Dexamethasone

A

decadron
steroid
Administer after induction
May modulate release of endorphins or inhibit prostaglandin synthesis
S/E: perineal irritation/burning, increased blood sugars

135
Q

Premedication ANTIBIOTICS

A

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
Q

Cefazolin (cephalosporin)

A

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
Q

Clindamycin (lincosamide)

A

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
Q

Vancomycin (glycopeptide)- most powerful we use routinely

A

Gram-positive bacteria
Staphylococci, streptococci strains
Alternative for a β-lactam allergy or MRSA infection
Recommended for distal ilium, colon, appendix surgical sites

139
Q

Health assessment consists of what 3 components

A

health assessment
health history
physical assessment

140
Q

who are more prone to infection

A

old aged people and children / extremes of age

141
Q

Problems with substance abuse and anesthesia

A

cocaine- chronic htn, bleed
meth- bp drop/ hard to treat bp

142
Q

Lbs to kg

A

half and subtract 10%

143
Q

kg to lbs

A

double and add 10%

144
Q

core measure for temp in OR

A

recovery have to be 96 degrees

145
Q

Celsius to Fahrenheit

A

(C x 2) + 30

146
Q

Fahrenheit to celsius

A

(F-30) / 2

147
Q

Anthropometry

A

the scientific study of the measurements and proportions of the human body.

Ht , wt, BMI, abd girth, mid arm circumference, neck circumference

148
Q

Obesity and anesthesia

A

difficult to intubate
wound healing
dm

149
Q

factors that may impact the ability to measure a bp

A

movement, neuro monitoring, hypoperfusion

150
Q

Axilllary temp should be ____ than core temp

A

1F less

151
Q

Risks of rectal temp

A

risk of perforation
avoid in uncooperative or immuno-suppressed pts

152
Q

Calculate PPY

A

20 cigs per pack

1 ppd x 365 days = PPY

153
Q

median overal survival was ____ in pts with > 15 ppy history compare to _____ in those with < 15ppy

A

lung ca pts (stage 3b/4)

10.8 months vs 14.7 months

154
Q

Considered High risk for lung ca if____

A

adult pt >55 with >30 ppy history

should undergo screening wiht low-dose CT

155
Q

Legionnaires disease

A

respiratory disease that came from hot tubs and air conditioners

156
Q

current medication factors to consider

A

medication
dose/ frequency
route
last dose taken

157
Q

Leading cause of BB od’s

A

accidental excess intake

158
Q

What meds to avoid in bed bound patients

A

sux

159
Q

Light Palpation

A

Apply tactile pressure slowly, gently and deliberately.

The hand is placed on the part to be examined and depressed about 1-2cm.

160
Q

Deep Palpation

A

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
Q

Bimanual Palpation

A

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
Q

Percussion

A

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
Q

Mediate or Indirect Percussion

A

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
Q

Immediate Percussion

A

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
Q

Fist Percussion

A

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
Q

Sound : Tympany

A

Intensity : Loud
Pitch : High
Duration : Moderate
Quality : Drumlike- fluid fillled
Common location : Air containing space, enclosed area, gastric air bubble, Puffed out cheek

167
Q

Sound : Resonance

A

Intensity : Moderate to Loud Pitch : Low
Duration : Long Quality : Hollow
Common location : Normal lungs

168
Q

Sound : Hyper Resonance

A

Intensity : Very Loud
Pitch : Very Low
Duration : Longer than resonance Quality : Booming
Common location : Emphysematous lungs

169
Q

Sound : Dullness

A

Intensity : Soft to moderate
Pitch : High
Duration : Moderate
Quality : Thudlike
Common location : Liver

170
Q

Sound : Flatness

A

Intensity : Soft
Pitch : High
Duration : Short
Quality : Flat
Common location : Muscle

171
Q

Circumoral cyanosis

A

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.

172
Q

Jaundice

A

All causes occur from an elevated bilirubin, assume liver function is impaired
meds?

173
Q

ECRP

A

endoscopic retrograde cholangiopancreatogram (ECRP)

done for cholestasis

174
Q

Vitiligo

A

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.

175
Q

Ecchymosis around eyes

A

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
Q

Petechiae causes

A

Capillary rupture

Prolonged Straining
Medications- allergic reactions
Infectious Diseases- septic
Leukemia
Thrombocytopenia

Asphyxiation/ strangulation

177
Q

skin lesions

A

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
Q

Poor skin turgot

A

dehydration and chronic condition, fluid status

179
Q

EDEMA

A

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
Q

Grades 1 pitting edema

A

( trace , 2 mm)
Disappear rapidly

181
Q

Grade 2 pitting edema

A

( moderate , 4 mm)
10-15 sec

182
Q

Grade 3 pitting edema

A

(deep, 6 mm)
≥ 1min

183
Q

Grade 4 pitting edema

A

+4 (very deep, 8 mm)
2-5min

184
Q

Koilonychia

A

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.

185
Q

Nail clubbing

A

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

186
Q

Paronychia

A

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.

187
Q

Beau’s lines

A

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
Q

Beau’s lines

A

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
Q

RA concerns

A

Joint pain
long term steroid
atlantooccipital joint instability

189
Q

Terminal Hair

A

long, thick, found on axilla and pubic area.

190
Q

Vellus Hair

A

small, soft, found all over body except palm or sole

191
Q

Brittle hair causes

A

Polycystic ovary syndrome (PCOS).
Cushing syndrome
Congenital adrenal hyperplasia
Tumors
Medications

192
Q

Battle signs concerns

A

with orbital fractures we are concerned or entrampment of nerve, is their visual field limited because of the entrapment

193
Q

Exophthalmoses

A

bulging eyes

194
Q

Strabismus

A

Think about endocrine disorders or trauma. Funny looking kids (FLK) often have challenging airways

195
Q

ectropion

A

(eversion, lid margin turn out)

196
Q

entropion

A

(inversion, lid margin turns inwards)

197
Q

ptosis

A

(abnormal drooping of lid over pupil)

198
Q

(miosis)

A

A persistently small pupil

consider opiod use

199
Q

(anisocoria)

A

A notable difference in pupil size between the two eyes

200
Q

upside-down ptosis

A

Slight elevation of the lower lid

201
Q

(anhidrosis)

A

Little or no sweating (anhidrosis) either on the entire side of the face or an isolated patch of skin on the affected side

202
Q

Horners syndrome

A

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
Q

Treatment for a sty?

A

Warm moist towel, helps increase perfusion and unclog the duct.

204
Q

Stage 2 of anesthesia eye features

A

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
Q

Stage 3 anesthesia eye features

A

pupils are back to midline

206
Q

Arcus senilis

A

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.

207
Q

PERRLA

A

Pupils Equal Round and Reactive to Light Accommodation

208
Q

Accommodation

A

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
Q

EXTRA OCULAR MOVEMENTS

A

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
Q

Basic causes of peripheral vision loss include

A

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

211
Q

Otoscope

A

is used to see internal ear structure

212
Q

Weber’s test

A

Tuning fork placed on top of head

213
Q

Rinne test

A

tuning fork measures
air vs bone conduction

214
Q

What can cause air trapping

A

N2O -> lungs -> Blood stream-> diffuses out, if in fluid or air trapped space = pressure.

if concerned about barotrauma or air trappid avoud N2O

215
Q

meds for hemorrhagic control for nasal intubation

A

phenylephrine/ afrin/

cocaine- vasoconstrictor and anesthetic agent

216
Q

THE MOUTH, PHARYNX AND NECK

A

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
Q

bright red tongue seen in

A

deficiency of iron b12 or niacin,

218
Q

Which nair is usually the largest?

A

Right

219
Q

Causes of epistaxis

A

anticoagulations, chronic htn, cocaine

220
Q

Cherry lips

A

carbon-monoxide poisoning

221
Q

Pallor lips

A

anemia/ hypoperfused

222
Q

Cyanosis

A

Hypoxia or Hypoperfusion

223
Q

Halitosis

A

bad breath

224
Q

Discoloration of enamel may be?

A

Dental caries

225
Q

Spongy gums bleed easily

A

(Vit-C deficiency)
liver issues
on anticoags

226
Q

Leukoplakia

A

thick white patches because of smoking and alcohol

227
Q

Pharynx assessment

A

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
Q

Dysphagia

A

difficulty swallowing

229
Q

Thyroid gland anterior assessment

A

using the pads of the index and middle finger, palpate the left lobe with the right hand and right lobe with left hand.

230
Q

Thyroid gland posterior part

A

Both hands are kept around the neck with two finger of each hand on the side of trachea

231
Q

Thyroid gland general assessment

A

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
Q

Common sign of COPD

A

Barrel chest

233
Q

Butterfly rashes are associated with what autoimmune disorder

A

systemic lupus erthyematous

234
Q

Clubbing of the fingers is associated with what congenital heart defects

A

ventricular septal defect
pulmonary stenosis
overriding the aorta
right ventricular hypertrophy

235
Q

Pill rolling tremors are associated with what neurologic disorder

A

Parkinsons

236
Q

Pill rolling tremors are associated with what neurologic disorder

A

Parkinsons

237
Q

What sign, also known as RUQ pain accompanies cholecystitis

A

Murphys sign

238
Q

What vision change accompanies glaucoma

A

Tunnel vision

239
Q

1 inch is how many cm

A

2.54 cm
25.4mm
0.0254m

240
Q

1 cm is how many inches

A

0.393

241
Q

Apical pulse

A

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
Q

difference of radial pulses

A

Aortic aneurysm
subclavian steal syndrome
devices- migration of port
clavicle fractures

243
Q

Ominous sign for aortic stenosis

A

fatigue and syncope

244
Q

Common urinary complication with OB patients

A

slicing Ureter with C section - pay attention to baseline urine

245
Q

Hypospadias

A

penile opening being some place different

246
Q

Most common nerve injury in anesthesia

A

peroneal nerve injury from bad positioning
cant dorsiflexion
have permanent plantar flexion

247
Q

Lordosis

A

Increased lumber curvature
increase abd pressure
difficult to get epidural
consider coming in from the side

248
Q

Kyphosis

A

Exaggeration of posterior curvature of thoracic spine

increased pressure on lung and not ventilating well

249
Q

Romberg test

A

evaluate proprioception

250
Q

Van positive

A

Vision, aphasia, neglect

+ pronator drift

high risk for LVO (large vessel occlusion) needs thrombectomy

251
Q

Bicep reflex

A

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
Q

Triceps reflex

A

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
Q

Patellar reflex

A

Have client sit with leg hanging freely over side of table.
Tap patellar tendon just below patella.
Reflex : Extension of lower leg.

254
Q

Achilles reflex

A

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
Q

Plantar reflex

A

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
Q

Gluteal reflex

A

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
Q

Ultrasounds is defined by….

A

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
Q

range of audible sound

A

20Hz and 20,000Hz.

259
Q

Linear probe

A

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
Q

Phased Probe (medium to low frequency)

A

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
Q

Curved probe (medium to low frequency)

A

Broad range of frequencies to image anatomy needing a wider and deeper field of view

262
Q

Focal Zone and Focal Point

A

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
Q

Field (Fraunhofer Zone):

A

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
Q

Near Field (Fresnel Zone):

A

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
Q

Impedance equation

A

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
Q

Reflection coefficient

A

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
Q

mirror artifact

A

occurs due to the reflection of sound waves after they propagate through a medium

268
Q

Refraction

A

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
Q

Attenuation

A

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
Q

Absorption

A

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
Q

Echogenicity

A

refers to the ability to reflect or transmit ultrasound waves in the context of surrounding tissues

272
Q

Anechoic

A

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
Q

Why do we ultrasound eyes?

A

difference of pressure/ loss of symmetry
open globe
retinal detachement

274
Q

Hypoechoic

A

structures appear darker than surrounding structures; gives off fewer echoes. Often seen in tissues with increased density such as fibrous masses

275
Q

Hyperechoic

A

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
Q

Isoechoic

A

is used to describe a structure that gives off similar echoes relative to another structure in the same image.

277
Q

Reverberation

A

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
Q

Gain

A

Gain is a feature of ultrasound machines to compensate for sound wave attenuation.
contrast

279
Q

Color doppler

A

Red towards probe, blue away from probe

280
Q

Sliding

A

Moving the transducer along its long axis.

281
Q

Sweeping

A

Moving the transducer along its short axis.

282
Q

Tilting or Fanning

A

While maintaining a fixed position on the body, the transducer is moved along its short axis to change the angle of incidence < 90°.

283
Q

Rocking or Heeling

A

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
Q

Rotating

A

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
Q

short axis view

A

transverse plane
out of plane view

286
Q

long axis view

A

longitudinal plane
in plane

287
Q

Anohter name for leprosy

A

Hansen’s disease

288
Q

chipmunk face is associated with what eating disorder?

A

bulimia nervosa

289
Q

spider angioma is associated with what liver disorder

A

Cirrhosis

290
Q

Pyloric stenosis is associated with what shape of mass

A

olive

291
Q

Hyperthyroidism is associated with what ophthalmic change?

A

exopthalmus

292
Q

what physical feature is commonly associated with Cushing syndrome

A

Buffalo hump

293
Q

Rice water stool is commonly found with what illness

A

Cholera

294
Q

Contractile Cells

A

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
Q

Smallest box on ekg strip

A

0.04

296
Q

1st degree heart block

A

pr longer than .2

297
Q

normal PR

A

0.10-0.2
Atrial depolarization/ ventricle filling

298
Q

normal qrs

A

<0.12 seconds
represents ventricular depolarization

299
Q

normal p wave

A

Duration < 0.12 seconds

+ in; 1,2 ,avf, V4-6.

300
Q

ST segment elevation significance

A

Elevation/depression > 1mm significant

301
Q

T wave

A

Ventricular repolarization
Positive in I, II, V3-V6

302
Q

PSVT

A

Starts and stop svt

303
Q

normal v tach rate

A

150-180

304
Q

Halothane/enflurane causes what dysrhythmia?

A

sensitive myocardium

305
Q

Sevoflurane triggers what dysrhthmia?

A

bradycardia in infants
five and dime reflex when holding mask. oculcardiac reflex.

306
Q

Desflurane causes what dsyrhythmia?

A

Prolonged QT during induction
risk of r on T

307
Q

Local anesthetics given iv can cause?

A

severe bradycardia/ asystole
treat with lipid rescue

308
Q

Causes of bradycardia

A

abnormal ABG with hypoventilation
lytes/ hyperkalemia
Intubation
Vagal, peritoneum or cervix reflex

309
Q

Correct diagnosis can be made in_____ % of cases on the basis of history alone

A

56

310
Q

Test the Function of sternocleidomastoid muscle

A

As the patient to flex the neck with the chin to the chest

311
Q

Test the function of the trapezius muscle

A

Movement of the head sideway so that the head moves towards the shoulder

312
Q

How long does the av node delay conduction for?

A

0.1 seconds

313
Q

Bundle of his intrinsic rate

A

40-60bmp
Also known as the atrioventricular bundle

314
Q

Purkinje Fiber intrinsic rate

A

20-40bpm

315
Q

Normal Junctional rate

A

40-60
Retrograde p wave

316
Q

IBW MALE

A

Height in cm minus 100= kg IBW

317
Q

IBW FEMALE

A

Ht in cm minus 105= kg IBW

HA (15 decks)

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