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What are the clinical presenting signs of venous air embolism?
Dysrhythmias: either tachy or brady Myocardial Ischemia Circulatory/Cardiovascular collapse Hypotension rales, wheezing hemoptysis tachypnea pulmonary edema Mill WHEEL murmur: constant machine like sound, late sign, heard over precordium
What is the ABG finding in air embolism?
ABG can show metabolic ACIDOSIS as a result of hypoxemia
What is the Durant Maneuver
treatment for air embolism: place pt in L Lat decubitus and T-berg (may be effective by allowing air to move toward the right ventricular apex, thereby relieving the obstruction of the pulmonary outflow tract
How much is MAC decreased over the age of 40?
MAC decreased by 4% per decade over 40 yrs
List some age related changes in pulmonary physiology
Age-Related Changes
- Elasticity decreased (Over distention of alveoli- Decreases alveolar surface area and decreases gas exchange efficiency.)
- Collapse of smaller airways resulting in increased residual volume and closing capacity.
- Increase anatomical dead space
- Increased physiological dead space
- Increased chest wall rigidity
- Decreased cough response
- Decreased maximal breathing capacity
- Blunted response to hypercapnia/ hypoxia
- Decreased arterial oxygen tension by 0.35 mm Hg per year- As closing capacity increases small airways start closing at normal tidal breathing causing ventilation perfusion mismatch and decreases PaO2.
Which anesthetic drugs INCREASEintraocular pressure?
Succinylcholine (peak at 2-4 mins, resolves by 6 mins)
Ketamine
Nitrous Oxide
Which anesthetic drugs DECREASE intraocular pressure?
Opioids Volatile Anesthetics barbiturates, lidocaine Nondepolarizing NMB
What are four compensatory mechanisms in CHRONIC anemia?
- increased cardiac output: (in isovolemic hemodilution from chronic anemia, the hematocrit decreases and reduces SVR through decreased viscosity of blood)
- Redistribution of cardiac output: (blood flow is redistributed to the tissues with higher extraction ratios (brain and heart), (in a healthy heart coronary blood flow can increase up to 600% of baseline)
- Increased oxygen extraction: (in times when the hematocrit reaches less than 25%) (The brain and heart already have a high extraction ratio and are unable to increase oxygen delivery by this mechanism)
- Changes in oxygen-hemoglobin affinity: the oxyhemoglobin dissociation curve is shifted to the righ
Describe the innervation of the LARYNX:
Sensation:
- superior laryngeal nerve (supplies sensation to mucosa from the epiglottis to the level of the cords through the internal branch)
- recurrent laryngeal nerve (supplies sensation to mucosa below the cords)
Motor:
The recurrent laryngeal nerves supply all of the intrinsic muscles of the larynx except for the cricothyroid muscle. The cricothyroid muscle is innervated by the external branch of the superior laryngeal nerve.
What nerves need to be anesthetized for awake fiberoptic intubation?
- Superior laryngeal nerve- (supplies sensation to mucosa from the epiglottis to the level of the cords through the internal branch)
- recurrent laryngeal nerve (supplies sensation to mucosa below the cords)
- maxillary branch of the trigeminal nerve which supplies sensory innervations to the nasopharynx
- glossopharyngeal nerve which supplies sensory innervations to the posterior 1/3 of the tongue, pharynx, and areas above the epiglottis/vallecula.
What are the autonomic nervous system changes that result from ECT (electroconvulsive therapy)?
The initial reaction following application of the electric current is a parasympathetic response resulting in bradydysrhythmias and possibly sinus pause. The parasympathetic response is followed by a sympathetic response associated with tachycardia and hypertension.
How does Lidocaine effect ECT management?
Lidocaine, an amide local anesthetic, has been shown to be ineffective in ameliorating the robust sympathetic response associated with ECT. In addition, pre-treatment with lidocaine is also associated with decreased seizure duration and a higher likelihood of patients requiring multiple applications of electric current during a single ECT session to achieve a therapeutic seizure.
Which drugs increase and decrease seizure threshold in ECT?
Increases duration: Etomidate
NO change in duration:
Methohexital (Induction agent of choice)
Ketamine
Decreases duration:
Thiopental
Midazolam
Propofol
What are the three manifestations of amniotic fluid embolism?
1) acute pulmonary embolism, (2) DIC, and (3) uterine atony.
What is the most commonly abused narcotic by Anesthesiologists?
Fentanyl was the most commonly abused narcotic, followed by sufentanil, meperidine, morphine, and oral drugs
What is the “fire triad”?
an oxidizer (O2, N2O), ignition source, and fuel (ett, sponges, etoh prep, drapes, masks, nc)
Describe the management of an airway fire:
In the case of an airway fire immediately, without hesitation, halt the procedure and remove the tracheal tube. Stop the flow of all airway gases. Remove sponges or any other flammable material from the airway, and pour saline into the airway. Once the fire is extinguished, re-establish ventilation either with the circuit or a self-inflating resuscitation bag. If possible, ventilate with room air. Examine the integrity of tracheal tube to make sure no fragments may have been left in the airway. Consider bronchoscopy (preferably rigid) to assess injury and, especially, to locate and remove tracheal tube fragments and other debris. Assess the patient and then devise a management plan.
How is pain mediated in the first stage of labor?
sympathetic nerve fibers (going through the inferior hypogastric plexus on the way to the sympathetic chain) that originate from the T10-L1 segments of the spinal cord (referred to the back as well as abdominal wall).
What is the Effect of Intracardiac Shunts on Anesthetic Induction with IV/Volatile Right to Left and Left to Right?
Right to Left (IV): rapid induction (easy to remember - blood bypasses lungs, straight to brain)
Right to Left (volatile): slower induction
Left to Right (IV): slower effect (little)
Left to Right (volatile): faster induction with soluble agents (less pronounced with insoluble agents)
What are the clinical concerns when taking care of a patient with ankylosing spondylitis?
Systemic Considerations: uveitis, vasculitis, aortic insufficiency, pulmonary fibrosis, restrictive lung disease
General Anesthesia: reduced cervical and TMJ mobility
Regional Anesthesia: osseous ligaments, reduced intravertebral spaces (consider caudal)
How to you treat organophosphate poisoning?
Termination of the exposure including removing all soiled clothing. Gently cleanse with soap and water to hydrolyze organophosphate solutions. Irrigate eyes (may help with Morgan lens)
Abc- Airway control (Intubation may be necessary due to laryngospasm, bronchospasm, bronchorrhea, or seizures) atropine may eliminate the need for intubation. Succinylcholine should be avoided because it is may result in prolonged paralysis. Torsades de Pointes should be treated in the standard manner.
Pharmacologic Treatment
Atropine - The endpoint for atropine is dried pulmonary secretions and adequate oxygenation. Tachycardia and mydriasis must not be used to limit or to stop subsequent doses of atropine. The main concern with OP toxicity is respiratory failure from excessive airway secretions.
Pralidoxime - Nucleophilic agent that reactivates the phosphorylated AChE by binding to the OP molecule. Used as an antidote to reverse muscle paralysis resulting from OP AChE pesticide poisoning but is not effective once the OP compound has bound AChE irreversibly (aged). Current recommendation is administration within 48 h of OP poisoning.
A patient with anti phospholipid syndrome should have what lab abnormalities? Are they candidates for epidurals?
Increased ptt and positive testing for lupus anticoagulant or anticardiolipin.
Patients have antibodies that interfere with testing but are at increased risk of thrombosis, not bleeding. As long as they are not on anticoagulant therapy, they can receive epidurals
