ICU, Anaesthetics and Emergency Medicine Flashcards
Thrombolysis for ischaemic stroke can be considered up to how many hours after onset of symptoms?
4.5hours
If exact Sx onset not known, go back to when patient was last known to be well
What are the criteria included in the Canadian CTHead Rules
1) GCS <15 2hrs post-injury
2) AGE >65yo
3) Vomiting 2+
4) Amnesia ≥30mins
5) Suspected open/ depressed/ basal skull #
6) Dangerous mechanism
A stroke in the ACA territory will cause_______
Contralateral leg weakness, personality changes (if frontal lobe injury)
What components make up the ABCD^2 rule for TIA risk stratification?
Age >60yo - 1pt
BP >140 (systolic) - 1pt
Clinical features: unilateral weakness (2pt), speech impairment (1pt)
Duration >60mins (2pts), 10-59mins (1pt)
Diabetes (1pt)
What are the 3 grades of TBI (as defined by GCS)?
Mild: GCS 13-15
Moderate: GCS 9-12
Severe: GCS <9
Blood (aka haemorrhage) is white on a CT head scan for ____ week/s
One (1) week
Hypocapnia causes cerebral vaso(dilation/constriction)
Vasoconstriction
What is the qSOFA score components?
Need 2+ of the following
- Altered mental status
- RR >22 / min
- SBP <100mmHg
How long can CVL and PICC lines be left in
1 week and 6 weeks, respectively
What is the target ICPafter TBI?
<20mmHg
Which of the following vasopressors does NOT have any inotropic effect? Dopamine, metaraminol, noradrenaline, adrenaline
Metaraminol
What are the 5 elements in the ‘chain of survival’ with regards to resuscitation
1) Early recognition of arrest & activation of emergency services
2) BLS
3) Early defib
4) ALS
5) Post-arrest cares
What 3 measures have been shown to have survival benefit in resuscitation?
1) competent BLS
2) Early defib for VT/VF
3) Post-arrest cooling
Failure of circulation for ____ mins can lead to irreversible brain damage
3-4 mins
List 3 risk factors for aspiration under anaesthesia
1) GORD
2) Delayed gastric emptying
3) Unfasted patient
In anaesthetics, how is pre-oxygenation achieved?
100% O2 is delivered for 2-6minutes until end-tidal CO2 is >80
Which inhalational agent can be used for induction of anaesthesia? Which cannot?
Can - sevoflurane
Cannot - desflurane, isoflurane
What does TIVA stand for in anaesthetics?
Total intravenous anaesthesia
What is the normal level of ETCO2?
35-45mmHg
The waveform of ETCO2 reflects the amount of a) time or b) volume of CO2 the monitor is exposed to
a) time
List 4 factors causing hypothermia during anaesthesia
1) Vasodilatory effects of anaesthetic agents
2) Anaesthetic effects on hypothalamus
3) Exposure of viscera to environment
4) Reduced heat production
List 5 complications of hypothermia related to anaesthesia
1) Impaired coagulation
2) Increased risk post-op infection
3) Prolonged drug action -> slow waking
4) Confusion
5) post-op shivering & increased O2 demand
What is the max safe dose for lignocaine? Lignocaine + adrenaline?
Lignocaine alone: 3mg/kg
Lignocaine + adrenaline: 7mg/kg
What are the initial CNS and CVS effects of local anaesthetic toxicity?
CNS - circumoral tingling, dizziness, tinnitus, restlessness
CVS - tachycardia, HTN
What analgesic medications can be delivered via a PCA?
Morphine, fentanyl, oxycodone, tramadol ± ketamine
With a laryngoscope the posterior aspects of the glottis can be seen, but not the anterior commissure. What grade view is this?
Grade II
(grade I = full glottis i.e. ant + post commissures
grade II = post glottis but not ant commissure
grade III = epiglottis only
grade IV = hard palate only (glottis/ epiglottis not seen)
What are the aims of pre-oxygenation?
To create a high concentration oxygen reservoir in the functional residual capacity and delay desaturation during apnoeas during airway manipulation
What are the 4 types of hypoxia?
1) Hypoxic hypoxia
2) Anaemic hypoxia
3) Ischaemic hypoxia
4) Histotoxic hypoxia
A Swan-Ganz catheter is also known as _____
Pulmonary artery catheter
Hypothermia intra-operatively leads to (increased/ decreased) O2 consumption and increases the risk for ____ and ____?
Increased O2 consumption
Infection and post-op bleeding
ETCO2 is generally ____ mmHg (lower/ higher) than arterial CO2
2-3mmHg LOWER
What are the causes of hypocarbia (low ETCO2)?
Hyperventilation Hypothermia Deep anaesthesia Decreased CO2 production: poor perfusion Leak from system
PEEP should not exceed __cm H2O. Higher settings increase the risk of ___, ____ and ____
20cm H20
Severe lung damage, subcutaneous emphysema and pneumothorax
What are the daily requirements for a) water b) sodium c) potassium d) glucose?
a) 25-30mL/kg/day H2O
b) 1-2mmol/kg/day Na+
c) 1mmol/kg/day K+
d) 50-100g/day glucose
What is the Apfel score?
Assessing risk of post-op nausea & vomiting (PONV). It gives 1 point for each of
- Female
- Non-smoker
- Hx of motion sickness or PONV
- Use of post-op opioids
A score of 4 = 79% risk of PONV within 24hrs
What are the 6 life-threatening injuries considered with trauma?
ATOM-FC Airway obstruction Tension PTX Open PTX Massive haemothorax Flail chest Cardiac tamponade
What is Beck’s triad? What is it a sign of?
Distended neck veins + Muffled heart sounds + hypoTN
It’s a sign of cardiac tamponade
Opioids should be dosed by (age / weight)
Age
What is the alveolar gas equation?
P(A)O2 = (FiO2x(PB-PH20)) - (PaCO2/0.8)
Where PB = barometric pressure (760mmHg)
PH2) = water vapour pressure (47mmHg)
i.e. P(A)O2 = (FiO2 x 713) + (PaCO2/0.8)
What is the formula for minute ventilation?
Tidal volume x resp rate
Normal = ~450mL/breath x 10 breaths/ min = 4500mL/min
What are the causes for high anion gap metabolic acidosis (HAGMA)?
'L TKR' Lactic acidosis Toxins (methanol, ethylene glycol, salicylates) Ketoacidosis (diabetic, starvation) Renal failure
Distinguish type 1 and type 2 respiratory failure
Type 1 = hypoxaemic resp failure i.e. low PaO2 (but normal PaCO2). Due to problems with O2 getting into blood e.g. low FiO2, shunt, VQ mismatch, impaired diffusion
Type2 = hypercapnic resp failure i.e. low PaO2 AND low PaCO2. Due to impaired ventilation, e.g. reduced resp drive, neuromuscular weakness, structural deformity (kyphoscoliosis), increased dead space
How much volume and FiO2 can be delivered via Hudson mask? High-flow nasal cannulae?
Hudson mask = 6-10L/min, FiO2 40-60%
HFNC = up to 70L/min, FiO2 30-90%
A patient presents with an acute asthma attack. They are speaking in few words, their RR is 26, HR 90 and O2 sats 93%. What is the severity of their attack?
Severe (only need 1 of the features)
- in favour: speaking in words, RR>25, O2 90-94%
- HR of 90 fits under mild/ moderate, however if any of above features are present, the attack automatically becomes severe
What are the components of the PSI (pneumonia severity index)?
Low-risk if ALL of the following <50yo No malignancy, CCF, cerebrovascular, renal or hepatic impairment Normal mental state Normal vitals
What does SMART-COP stand for?
Assessment of pneumonia severity & likelihood of needing ICU support SBP <90 Multilobar involvement on CXR Albumin <35g/L RR >25 Tachycardia >125 Confusion O2 <93% or PaO2 <70 pH <7.35 (i.e. acidaemic)
What is the recommended treatment for a small PTX <2cm and patient who is clinically stable
No intervention - observe
Catheter aspiration is recommended if a) there are Sx or b) large PTX
With respect to managing acute pulmonary oedema, what does the acronym ‘POND’ stand for?
Position: sit patient up
Oxygen: high-flow to target sats
Nitrates: GTN
Diuresis: frusemide
Which analgesic medication should be avoided in APO?
Morphine
What are the 3 criteria for ARDS?
1) Resp failure (PaO2/FiO2 <300) w’in 1wk of respiratory or systemic insult
2) Bilateral infiltrates on CXR
3) Increased alveolar and/or interstitial fluid, not caused by cardiac failure
A patient with ARDS has a PaO2/FiO2 ratio or 150. What severity is this?
Moderate
Mild 200-300
Moderate 100-200
Severe <100
What are the best settings for mechanical ventilation for a patient with ARDS?
Low tidal volumes, limited inspiratory pressures, high levels of PEEP
What are the 3 pillars of anaesthetics?
1) Hypnosis/ unconsciousness
2) Analgesia
3) Muscle relaxation
A patient with severe systemic illness that is a constant threat to life has an ASA of ___
4
Smoking should be ceased at least ___ hrs before surgery
48 hours
Pre-operatively, patients should fast from solids for at least ___ hrs and from clear fluids at least __ hrs in advance
Solids - 6hrs
Clear fluids - 2hrs
What are the 5 key features included in a surgical safety checklist?
1) Patient identity: name, DOB, URN
2) Consent
3) Surgical procedure & site
4) Fasting status
5) Allergies
In positioning a patient for induction, the ear should be aligned with the ____
Sternal notch
Define MAC
the alveolar concentration of an agent (or agent + N2O) at 1 atmosphere absolute that prevents movement of 50% of the population in response to a standard noxious stimuli
What is the maximum safe dose of ropivacaine?
3mg/kg
How long does lignocaine last for? With adrenaline?
2-3 hrs.
With adrenaline, up to 8hrs
In a regional block, the dose of local anaesthetic injected influences the
a) density of block
b) duration of block
c) number of spinal nerves affected
b) duration
The volume determines c)
The strength determines a)
What is a Bier’s block?
Injection of local anaesthetic directly into the venous system (with application of tourniquet distally)
When considering a nerve block for a hip operation, what are the dermatomes you want to block?
T12-L2
A patient comes in with hypovolaemic shock. Their pulse rate is 110, BP 125/85, RR 25 and they have mild anxiety. What class of haemorrhage is this? What is the estimated blood loss?
Class II
750-1500mL blood loss
Factors in favour
- PR 100-120
- BP normal
- RR 20-30
- Mild anxiety
In an emergency situation, what is the process of pre-oxygenation?
100% O2 via mask for 4 vital capacity breaths
What is the ideal position for extubation?
Left lateral
True or false: it is recommended to give an IV PPI pre-operatively to patients with symptomatic GORD undergoing anaesthesia?
FALSE
IV PPIs are NOT recommended
Can gie 30mL sodium 20mins prior to induction or 150mg ranitidine PO a few hours in advance
As per the ALS algorithm, when should adrenaline be given? In what dose?
Non-shockable rhythm: Immediately and every 2nd cycle
Shockable rhythm: after 2nd shock then every 2nd cycle
Dose = 1mg
(either 10mL of 1:10000 or 1mL of 1:1000)
When should amiodarone be given in an arrest? What dose?
After the 3rd shock of a shockable rhythm.
Dose = 300mg bolus (in 20mL 5% dextrose, given over 2min with large flush)
What are the 4 H’s and T’s of reversible causes of an arrest
Hypovolaemia
Hypoxia
Hypo/hyperthermia
Hypo/hyperK+ (or other metabolic disturbance)
Tension PTX
Tamponade
Thrombosis
Toxins
What is the dose of atropine for severe bradycardia?
0.5-1mg in repeated doses to max 3mg
Troponin levels peak at a)___ post-MI and remain elevated for b)___
a) 6-12hrs
b) 7 days
A patient is low-risk for ACS if they have ALL of the following factors (5): ______
1) No ongoing Sx
2) Normal serial Tn
3) Normal ECG
4) Sx not typical for angina
5) <40yo
If all are present, no further Ix is required & pt can be discharged once other serious pathology is excluded
What is the Stanford classification?
Classifies thoracic aortic dissections as
Type A: involvement of ascending aorta
Type B: NO involvement of ascending aorta
A patient has ?PE. They have haemoptysis, SOB and HR 115, BP 140/90. There are no signs/ Sx of DVT, there is no Hx of DVT/PE, no recent immobilization or surgery and no malignancy. They take the COCP. PE is not necessarily the primary diagnosis. What is their Well’s score and what is their subsequent management?
Well’s score 2.5
- 1.5 for tachycardia
- 1 for haemoptysis
Score ≤4 = PE unlikely -> should perform a D-dimer test
SOB, BP and COCP are not components of the Well’s score.
The mnemonic HAD CLOTS can be used to remember the components of the PERC score. What does this stand for?
Haemoptysis Age >50yo DVT/ PE Hx COCP or hormone use Leg swelling/ signs of DVT O2 ≤95% Tachy >100 Surgery/ trauma in past 4/52
What are the criteria for an AKI?
Increase SCr >26µmol (>0.3mg/dL) in 48hrs OR >1.5X baseline OR
UO <0.5mL/kg/hr for >6hrs
Which of these is NOT considered one of the best markers of tissue perfusion?
a) Level of consciousness
b) UO
c) lactate
d) heart rate
e) cap refill and skin temp
d) heart rate
The other 4 options are all good markers
The following can all be surrogate decision makers for someone who is incapable of making a decision. Order them from first to last resort
EPoA, statutory health attorney, AHD, adult guardian
1) AHD
2) EPoA
3) Statutory health attorney (spouse if close, continuing relationship > adult carer > close friend or adult relationship
4) Adult guardian
Which of the following would not (yet) prompt you to call a MET call?
a) RR 37
b) HR 120
c) BP 89/60
d) O2 92%
e) RR 4
b) HR 120 Criteria for calling rapid response team - Threatened airway - RR <5 or >36 - PR <40 or >140 - SBP <90 - Sudden decline in LOC - Unresponsive - Resp/ cardiac arrest - Repeated or extended seizures - Significant concern regardless of above
What is the most sensitive vital sign for impending arrest?
Resp rate
What is the target BSL for a patient with sepsis?
8-10mmol
hypo or hyperglycaemia can worsen outcomes
Tissues can be donated after a death in hospital or community < ____ (time)
<24hrs
What tissue/ organs can be donated from living donors? (4)
Blood, bone marrow, stem cells, kidney
Pancreatic or bowel tissue can be donated after (circulatory/ brain) death
Brain death
Organs that can be donated after circulatory death (and also brain death) are kidneys, lungs, liver and heart
A patient triaged as cat 2 should be seen within ___ (time)
10 minutes
[Cat 1 immediately; cat 3 in 30mins; cat 4 in 60mins; cat 5 in 120mins]
Anaphylaxis is likely if any of 3 criterion are met. What are these criterion?
1) Acute onset (mins-hrs) of skin/ mucosal involvement PLUS either resp compromise or hypoTN/ other sign of end-organ dysfunction
2) After exposure to likely allergen, 2+ of
skin/ mucosal involvement
resp compromise
reduced BP
persistent GI Sx
3) SBP <90 or >30% decrease from baseline after exposure to known allergen
What is the recommended dose of adrenaline in anaphylaxis?
0.3-0.5mg IM q5-15mins
What is the most common substance involved in an intentional overdose?
Paracetamol
Then antidepressants, BZDs
( ± alcohol)
What is the most common substance involved in an accidental overdose?
Opioids
Hyperthermia can sometimes indicate a toxidrome. Name 3 possible toxidromes/ syndromes
Anticholinergic toxicity
Amphetamine toxicity
Serotonin syndrome
In an overdose, activated charcoal should ideally be given within __ hr of ingestion and should be avoided if the patient is _____
Within 1hr
Avoid if the patient is drowsy/ altered level of consciousness
A relatively common complication of NAC infusion for a paracetamol overdose is?
Anaphylactoid reaction (occurs in ~10%)
What is the antidote for TCA overdose?
Bicarbonate
Which of the following drugs would NOT produce an anti-cholinergic toxidrome?
a) TCAs
b) anti-histamines
c) organophosphates
d) atropine
e) Parkinson’s treatment
c) organophosphates
- this will produce a cholinergic toxidrome (opposite)
The other drugs listed can cause anti-cholinergic side effects
With regard to trauma deaths, there is a trimodal distribution. Which deaths can most likely be prevented?
The 2nd peak: 1-6hrs after injury
Despite possibly being preventable, these deaths account for ~30% of all trauma deaths
What is the most common cause of trauma in QLD?
Transport accidents (closely followed by falls)
Which 2 imaging investigations are performed as part of the primary survey in trauma?
CXR and pelvic XR
What are the 4 complications of radial artery puncture?
Pain
Vasospasm
Haematoma
Neurovascular compromise
True or false: Allen’s test has good predictive value for Cx following arterial puncture
FALSE
Allen’s test has LITTLE predictive value for Cx following arterial puncture
How long must firm pressure be applied to a radial artery puncture site?
3 minutes
What are the indications for inserting an IDC?
1) Drain bladder for obstruction/ retention
2) Monitor UO
3) Collect sterile urine specimen
4) Neurogenic bladder e.g. epidural
What are 3 signs that may suggest urethral injury from pelvic trauma and should be examined when considering inserting an IDC?
Blood at meatus
Scrotal haematoma
High-riding prostate
The ___ (type of NGT) is wide-bore with 2 lumens
Salem sump
The clinifeed is narrow with a single lumen and used for feeding only, not drainage
What are 4 complications of NGT insertion?
1) Discomfort
2) Epistaxis
3) Aspiration pneumonia (either from endobronchial insertion or impaired swallow with regurg of gastric feeds)
4) Sinusitis
CSF opening pressure can only be measured when an LP is performed in what position?
Lateral
In an LP, how much CSF should be collected?
10 drops each in 3 bottles i.e. 30 drops total
What is the normal central venous pressure in ventilated patients?
5-10 mmHg
What is the formula for cerebral perfusion pressure (CPP) and what is the target?
CPP = MAP - ICP
Target is 60 mmHg
(Target ICP is <20 mmHg, and MAP 65-70mmHg)
What does LEMON stand for with regards to airway assessment?
Look externally (face anatomy, beard, teeth, habitus)
Evaluate 3-3-2: MO >3cm, >3cm mandible-to-hyoid, 2cm thyrohyoid distance
Mallampati
Obstruction
Neck mobility
What are 5 causes of delayed gastric emptying
Pyloric stenosis Shock Autonomic: fear, pain, anxiety Late pregnancy opiates
What is the preferred opioid for someone with renal failure?
Fentanyl
What are the contraindications (4) for guedel airway?
Awake patient (cause laryngospasm)
Facial/ oral trauma
Epiglottitis
Seizing
How is a nasopharyngeal airway sized?
Tip of the nose to the tragus of the ear + 2.5cm
How are ETTs sized in children? (Formula)
(Age/4) + 4
Perioperatively, a stress response to significant surgery results in _________ (3 things)
1) Fluid retention
2) K+ loss -> Hypokalaemia
3) Dilutional hyponatraemia
Due to autonomic & hormonal changes (ADH, aldosterone, cortisone, cytokines, catecholamines)
