key words Flashcards
succinylcholine in strabismus surgery
interferes with the “forced duction test” that the opthalmic surgeons use. interference can last up to 20 minutes
MMR
masseter muscle rigiditiy –> when severe i.e. jaws of steel, high risk of progression to malignant hyperthermia or rhabdo.
cancel case!
if mild and transient –> cancel if elective but continue with non-triggering anesthetic if emergent/urgent
bradycardia during strabismus surgery
this is most likely the
“oculocardiac reflex”
check if patient is HD stable
ask surgeon to stop manipulation of the eye
DEEPEN anesthetic
if it persists, give atropine 20 mcg/kg
local anesthetic
this reflex is subject to fatigue with repeated stimulation
limbs of the oculocardiac reflex?
afferent: trigeminal nerve
efferent: vagus nerve
concerns with tachycardia in the PACU
poorly controlled pain vs. low volume status
assess at bedside, look at vitals, and quick chart review
pain meds if poor pain control
fluids if low volume status
treatment for MH?
Call for help and MH cart.
STOP TRIGGER, change circuit and soda lime
Hyperventilate with 100% oxygen
dantrolene 2.5 mg/kg every 5-10 minutes PRN and sodium bicarb 1-2 mEq/kg
get a-line +/- CVP to SUPPORT CIRCULATION with vasopressors/antiarrhythmics
aggressive COOLING(lavage, cooling blanket, ice packs, cold IV fluids, cold dialysis) –> stop when temp drops to 38 degrees
fluids plus mannitol/lasix to maintain UOP
ABGs, electrolytes, CK-MB, coags – treat acidosis, treat hyperkalemia
Continue dantrolene 1 mg/kg q 6 hours x 24-48 hours to prevent relapse
low urine output in setting of rhabdo?
myoglobinuria – improve urine output and alkanize urine to prevent cast formation
pathophys of MH?
hypermetabolism and lactic acidosis from uncontrolled muscle contractions due to an abnormal ryanodine receptor that leads to a dysregulated release of calcium from sarcoplasmic reticulum
early signs of MH?
MMR
tachycardia
hypercarbia
hyperthermia is a late sign
general muscle rigidity is NOT always present
the different types of shock
distributive shock = low SVR state
cardiogenic shock = low CO state
hypovolemic shock = low intravascular state
common distributive shocks: sepsis, SIRS, neurogenic, anaphylaxis
common cardiogenic shocks: arrhythmias, cardiomyopathy from MI/valvular origin, RV failure (from PHTN or embolism), OR
extracardiac (aka obstructive shock) such as tamponade/PTX
common hypovolemic causes: hemorrhage, third spacing, insensible losses
Cushings Triad
Sign of increased ICP:
bradycardia
irregular respirations
widened pulse
Do things to decr ICP:
mannitol/lasix
raise head of bed 30 degrees
hyperventilate
insert drain
deepen anesthetic
Causes of hypoxia?
Causes are classified into 5 groups:
1. Low FiO2
2. Alveolar hypoventilation - RR, TV, tube malposition, tube obstruction
3. Impaired diffusion across blood-gas membrane - bronchospasm, pulmonary edema
4. Shunt
5. Ventilation-perfusion mismatch
increased peak AW pressure - what to do?
feel, look, listen
hand ventilate to assess compliance
look at machine, monitors, circuit, valves, tube, chest
listen to chest
How to block SLN for awake airway?
lidocaine soaked swabs in piriform sinuses
-OR- 1-2 mL lido injected just inferior to the greater cornu of the hyoid bone
supplies sensation from epiglottis to level of cords
how to block glossopharyngeal nerve for awake airway?
inject at the
‘
adjuvant medications in setting of nerve injury?
gabapentin, TCAs, SSRIs, anticonvulsants
NSAIDs, tramadol
TENS units
Rheumatoid Arthritis
airway: cervical instability, narrow glottis, limited TMJ; Evaluate ROM preop. Consider AFOI. Consider lateral films.
cardiac: pericarditis, tamponade, AI, condxn abnormalities
pulm: restrictive dz
renal: insuff 2/2 NSAIDs
GI: bleeding 2/2 NSAIDS
Immune: prone to infections 2/2 DMDs
primary survey
A: airway
B: breathing
C: circulation
D: disability - FAST, other imaging
E: exposure: ABG, labs, other studies
signs of cholinergic crisis? and treatment?
DDUMBBELLS
diarrhea
diaphoresis
urination
miosis
bronchospasm
bronchorrhea
emesis
lacrimation
lethargy
salivation
hypotension
tachycardia
confusion
shock
treat with atropine!! endpoint is adequate oxygenation!! (do not stop bc of tachycardia/mydriasis).
What to do in myasthenic crisis?
Presents with weakness:
secure AW if critical hypoxia
tensilon test improves weakness in 2 min
give pyridostigmine or neostigmine
consult neurology (IVIG, steroids, immune modulators, plasmapheresis)
Ddx for fever, hypotension, tachycardia in setting of bowel surgery?
Anastomotic leak, bowel ischemia, sepsis, drug reaction
