ICU and Emergency

Question 0

What are the steps of a rapid primary survey?

Answer 0

Airway maintenance with cervical C spine control
Breathing and Ventilation
Circulation (pulses, haemorrhage control)
Disability (neurological status)
Exposure (complete) and. Environment ( temperature control)
A primary survey should be continually reassessed during the secondary survey, and you should always watch for signs of shock during the secondary survey)

Question 1

What is the total body water weight of the average male? Water makes up what percentage of total weight? How much of this is intracellular? How much of this is extra cellular? How much is interstitial fluid? How much is intravascular fluid?

Answer 1

42L in the average male which is ~60% of total body weight.
Two thirds is intracellular and one third is extra cellular. Two thirds of ECF is interstitial fluid which baths cells and tissues, and 1/3 is intravascular fluid.

Question 2

What are the basic airway measures?

Answer 2

Protect the c spine ( use cervical collar)
Head tilt and jaw thrust to open airway if c spine not suspected
Sweep and suction to clear mouth of foreign material

Question 3

What are the steps of definitive airway management?

Answer 3

ETT intubation with inline stabilisation of the spine
Orotraceal with rapid sequence induction or nasotracheal may be better tolerated in a conscious patient
Cricothyrodotomy if unable to intubate using oral/nasal route and unable to ventilate

Question 4

What are the steps for breathing in the rapid primary survey?

Answer 4

Look: mental status (anxiety, agitation, decreased LOC), colour, chest movement, (bilateral vs asymmetrical) , respiratory, rate/effort, nasal flaring
Listen: sounds of obstruction (eg stridor), breath sounds, symmetry of air entry, air escaping.
Feel: flow of air, tracheal shift, chest wall for crepitus, flail segments, sucking chest wounds, subcutaneous emphysema
Breathing assessment rate pulse oximetry, arterial blood gas, aa gradient
Manage breathing via nasal prongs >simple face mask>non rebreather mask> CPAP/BiPAP. A Venturi mask is used to precisely control O2 delivery,

Question 5

What are the signs of fluid depletion?

Answer 5

Increased heart rate, postural changes in vital signs, decreased urine output, hypotension, decreased skin turgor, sunken eyes, dry mucous membranes, decreased cap refil

Question 6

What are the causes of shock?

Answer 6

Septic, spinal/neurogenic
Hemorrhagic
Obstructive (tension pneumo, cardiac tamponade, pulmonary embolism)
Cardiogenic ( arrhythmia, MI)
AnaphylactiK
Endocrine (addisons, myxoedema)
Drugs

Question 7

What are the clinical signs of shock?

Answer 7

Tachypnoea, tachycardia, narrow pulse pressure, reduced capillary refil, cool extremities, reduced central venous pressure, hypotension, altered mental status, reduced urine output.

Question 8

If you are giving crystalloids to replace blood loss, how much should you give?

Answer 8

You should give three times the estimated blood loss as only 30%of the fluid will re,aim in the intravascular space.

Question 9

What does AVPU stand for?

Answer 9

Alert
Responds to Verbal stimuli
Responds to Painful stimuli
Unresponsive

Question 10

What is the history taken during a secondary survey?

Answer 10

Sample
Signs and symptoms
Allergies
Medications
Past medical history
Last meal
Events related to injury

Question 11

What is an arterial line?

Answer 11

An arterial line is used to monitor beat to beat pressure variation and obtain blood for routine ABGs. Common sites are the radial and femoral arteries.

Question 12

What is a central line?

Answer 12

A central line is a central venous catheter. A central line is used to administer fluids, monitor CVP, and insert pulmonary artery catheters. Central lines are also used to administer TPN and agents too irritating for the peripheral line.
Common sites include the jugular vein, the subclavian vein, and the femoral veins.

Question 14

What is a pulmonary arterial catheter?

Answer 14

A pulmonary arterial catheter is when a ballon guides the catheter from a major vein to the right heart. It measures pulmonary capillary wedge pressure (PCWP) via a Cather wedged in the distal pulmonary artery. The PCWP reflects the LA and LV diastolic pressure (barring pulmonary venous or mitral valve disease).

Question 15

What is the half life of thiopentone?

Answer 15

Thiopentone is a rapid onset general barbiturate that is used as an induction agent. It has a long half life of 12 hours and is associated with a hang over effect. Consequently it has largely been replaced by Propofol.

Question 16

What is the half life of propofol?

Answer 16

Propofol is a short acting IV administered aneasthetic. It is used for both induction and maintenance of general aneasthesia. It has a half life of four hours, and is therefore suitable for day procedures. The use of propofol has largely replaced thiopentone.

Question 17

What are the common side effects of opiates?

Answer 17

• Nausea and vomiting
• Constipation
• Decreased heart rate
• Respiratory depression
• decreased cough reflex

Question 18

What is the definition of hypothermia?

Answer 18

Hypothermia occurs in people who have a body temperature of less then 35 degrees.Alcohol and anaesthetic gases cause vasodilatation, thus increase heat loss. As the core temperature continues to fall the cardiac rhythm becomes increasingly unstable, sinus bradycardia tends to give way to atrial fibrillation followed by ventricular fibrillation and finally asystole. In hypothermic patients, J waves are frequently seen on the ECG.

Question 19

What is the mechanism of action of prochlorperazine and droperidol?

Answer 19

Prochlorperazine and droperidol are both dopamine antagonists that function as antiemetics.

Question 20

What are the changes on ECG seen in hypomagnesia or hypokalaemia?

Answer 20

The changes on ECG are the same for hypomagnesia and hypokalaemia.
-U
-Long PR
-Long QT
-Small flattened T waves
In hypokalaemia, U got no Pot and no T, but a long PR and a long QT.

Question 21

What are the changes seen on ECG in pericarditis?

Answer 21

In pericarditis there is a concave upward elevated ST segment, which is different to the convex upward ST elevation seen in MI.

Question 22

What is ASA grading?

Answer 22

The American Society of Anesthesiologists introduced a grading score (one to five) to classify patients according to risk. Roman numeral are used and ‘E’ is added to indicate emergency surgery.
I- No illness/healthy patient
II- Mild illness, no functional restrictions
III-Severe systemic illness causing functional restrictions
IV- Severe systemic illness that poses a constant threat to life
V- Moribund patient, unlikely to survive 24 hours.

Question 23

What are the contents of Hartmann’s Solution?

Answer 23

A litre of Hartmann’s solution (compound sodium lactate or lactated Ringer’s solution) contains:
Sodium 131 mmol
Chloride 111 mmol
Potassium 5 mmol
Calcium 2 mmol
Lactate 29 mmol.
It is an isotonic crystalloid intravenous fluid. The lactate is metabolised by the liver to release bicarbonate, which would otherwise precipitate with the calcium to form calcium carbonate.

Question 24

How do you treat hyperkaleamia?

Answer 24

Hyperkalceamia is potassium greater than 5mmol/L. It can be treated a number of ways.
1) Give IV calcium (calcium chloride or calcium gluconate 5-10mmol IV). Calcium acts as a physiological antagonist against potassium and protects against arrythmias.
Sodium bicarbonate results in an exchange of potassium ions for hyrogen ions across membranes and can also be used.
Insulin will drive potassium back into cells over a minimum of 30 minutes.
Oral or rectal calcium resonium or dialysis are also accepted methods.

Question 25

What is the importance of the thyromental distance?

Answer 25

thyromental distance (the distance of the lower mandible in the midline from the mentum to
the thyroid notch)
• with the adult patient’s neck fully extended, <6 em) is associated with
difficult intubation

Question 26

What is the Mallampati score?

Answer 26

The Mallampati Index is used to rate people on their ease of being intubated.
1- full view of Uvula and tonsilar pillars
2- full view of uvula, but tonsillar pillars obstructed
3- Base of uvula obstructed
4-Only hard palate and tongue able to be seen.

Question 27

What are the fasting guidelines for surgery?

Answer 27

8 Hours after a heavy meal
6 hours after a light meal
4 hours after jelly or infant formula
2 hours after clear fluids

Question 28

Where are beta-1 adrenergic receptors primarily located?

Answer 28

Beta 1 receptors are primarily located in the heart and kidneys.Beta 1 receptors act on the heart to increase heart rate and contractility, and act on the kidneys to increase the release of renin from juxtaglomerular cells. Dobutamine is a beta 1 agonist that is used to increase cardiac contractility.

Question 29

Where are beta-2 adrenergic receptors primarily located?

Answer 29

Beta-2 adrenergic receptors are located in the lungs, and smooth muscle. Activation of beta-2 adrenergic receptors causes relaxation of smooth muscle (such as dilation of the bronchi, stopping contractions of the uterus, decreased motility of the GI tract, and dilatation of blood vessels). It also causes increased production of the aqueous humour by the ciliary bodies.

Question 30

What are the actions of alpha-1 adrenergic receptors?

Answer 30

Activation of alpha-1 adrenergic receptors cause vasoconstriction of the coronary arteries, and venoconstriction (thereby raising blood pressure). Meteraminol is an alpha1 adrenergic agonist. It also causes smooth muscle constriction (bronchoconstriction), and has a positive inotropic affect on the heart.

Question 31

What are the IV induction agents?

Answer 31

IV induction agents are non opioid agents that are used to provide amnesia and blunt reflexes,. They include Ketamine, Propofol, and sodium thiopental. Ketamine and propofol are also used as maintenance agents.

Question 32

What are the volatile induction agents?

Answer 32

Volatile induction agents include sevoflurane, isoflurane, desflurane, enflurane, halothane, and nitrous oxide.

Question 33

What is the MAC?

Answer 33

the alveolar concentration of an agent at one atmosphere (atm) of pressure that will
prevent movement in 50% of patients in response to a surgical stimulus (e.g. abdominal incision)
• often 1.2-1.3 times MAC will ablate response to stimuli in the general population
• potency of inhalational agents is compared using MAC

Question 34

What is a depolarising muscle relaxant?

Answer 34

Succinylcholine is a depolarising muscle relaxant.

Question 35

What are the non depolarising muscle relaxants?

Answer 35

The non depolarising muscle relaxants are rocuronium, mivacurium, vercuronium, cistracurium, pancuronium.