LIVE VALLEY REVIEW DAY 1 Flashcards
1
Q
The only fused vertebrae is the
A
Sacral
2
Q
C8 nerve runs under
A
T1
3
Q
A Caudal block is an
A
Epidural
4
Q
When you do caudal block the ligament you cross is the
A
Saccrococcygeal Ligament
5
Q
Adults Spinal cord ends at
A
L1
6
Q
Pediatric spinal cord ends at
A
L3
7
Q
SIFEDSASP
A
Skin Subcutaneous Supraspinous ligament Interspinous ligament ligamentum Flavum Epidural Dura Arachnoid Subarachnoid Pia
8
Q
Other names spinal
A
SAB
9
Q
Other names spinal
A
SAB, intrathecal
10
Q
When does the infant SC ends at L1?
A
20-24 months
11
Q
Toughest layer is the
A
Dura mater
12
Q
Offer the most protection
A
Dura mater
13
Q
Spinal web is the
A
Arachnoid mater
14
Q
Spinal cord Layer that is tightly attached to the spinal cord
A
Pia
15
Q
Delicate and highly vascular
A
Pia
16
Q
At any time how much CSF in the body
A
100-150 ml
17
Q
Per day how much CSF is produced
A
500 ml per day
18
Q
Normal pressure of the CSF
A
10-20 cm H2O
19
Q
Is the CSF high or low pressure
A
Low pressure (in healthy individuals)
20
Q
Where is the CSF produced?
A
Choroid plexus third and fourth ventricle
21
Q
Where is the CSF produced?
A
Choroid plexus third and fourth ventricles
22
Q
***** Principle site of action of neuraxial blockade (SPINAL OR EPIDURAL) is the
A
Nerve root (Branch that sticks out of the picture)
23
Q
Last ligament when you’re doing midline paramedian approach?
A
Ligamentum Flavum
24
Q
Action of epinephrine with LA
A
Vasoconstriction, decreases absorption leading to a LONGER DURATION
25
Anatomical shape that can affect spinal/epidural?
Kyphosis or scoliosis
26
Angulation of needle can affect
Distribution
27
In a pregnancy , do you increase or decrease dose of LA
Decrease the dose
28
In a pregnant or morbidly obese, you decrease the dose why?
Increase abdominal mass which decreases the space.
29
If you don't think the spinal is enough for a pregnant person, you think you underdose
Underdose redose can lead to TOTAL SPINAL
| Do an epidural instead
30
To change density of the block you can change the
Change the concentration of the block
31
What can differentiate a Sensory vs motor block with choosing the local anesthetics?
Is the concentration .
32
SG of the CSF
1.004 - 1.009 (just remember 1.007)
33
Hyperbaric to CSF
Heavier than CSF (Sink)
34
Hypobaric to CSF
Lighter than CSF (Float)
35
To make hyperbaric mix with
Dextrose 5% to 8%
36
To make hypobaric mix with
STERILE water
37
To make isobaric mix with
CSF
38
Hypobaric laying down going
Cephalad
39
Hyperbaric laying down going
Caudal
40
If patient laying on affected side
use hyperbaric
41
Best for patient with hip fracture
HYPOBARIC
42
The most important factor affect SPINAL
Position
43
The most important fact for EPIDURAL
VOLUME
44
After spinal what do you get dilation vs constriction
Venous and arterial vasodilation
45
CV effect of sympathetic blockade
```
Massive vasodilation
Decrease preload
Decrease Venous return
Decrease CO
Decrease BP
```
46
CV effect of sympathetic blockade treatment necessary
BEST treatment with hypotension to spinal is PHYSIOLOGIC not pharmacological .
47
Maternal hypotension associated with
Late Decelerations
48
Late decelerations is associated with
maternal hypotension
49
If not normovolemic use
Fluids
50
If normovolemic use
EPHEDRINE
51
Before fluid loading, need to know
EF (heart pumping status)
52
If LV not functioning you will get
pulmonary edema
53
Cardiac changes occur to
Sick, very young, and elderly
| THEY LACK RESERVE
54
Cardiac reserve decrease
1% every year after the age of 30.
55
High spinal vs Total spina
High spinal: Greater than T4
| Total spinal :
56
High spinal vs Total spina
High spinal: Greater than T4
| Total spinal : ALL THE WAY PAST T
57
Common reason of total spinal
Epidural dose for a spinal dose
58
Respiratory changes with neuraxial techniques
Severe chronic lung disease OR use of accessory muscles.
59
Interscalene block (ISB) for patients with respiratory issues?
No because of ISB possible adverse effects phrenic nerve palsy
60
High points
C3 and L3
61
Low points
T6 and S2
62
Widest level of spine
L2
63
Narrowest level of spine
C5
64
Cutting needle disadvantages
Bigger cut of dura
| More at risk for PDPH
65
How long epidural set up
about 20 minutes
66
Spotte vs whitacre
Sprotte takes longer to setup
67
Cutting needle perpendicular to the fibers
Takes out lot of fibers.
68
Cutting needle bevel towards the
Flank
69
Aspirin and Neuraxial
NON issues
70
SC heparin or LMW, loo
ACT or PTT
71
Coumadin therapy
PT/INR
72
INR level for neuraxial
< 1.5 ok
| >1.5 NO PROBLEM
73
Pulling a catheter , what to ask
Why is it in?
| Anticoagulation reason
74
Fibrinolytics or thrombolytics therapy , about to have surgery, can they have neuraxial
NO , none for 10 days
75
Patient receive this should not receive neuraxial for 10 days
Fibrinolytics or thrombolytics therapy
76
Generic of plavix
Clopidogrel
77
Generic of eliquis
Apixaban
78
Generic of Pradaxa
Dabigatran
79
Aside from stopping AC , should know when to
Restart the medication
80
Xiphoid level
T6
81
L4 is the
illiac crest
Tuffiers line
intercristal lie
82
Absolute contraindications of neuraxialL: CHIP
```
CHIP
Coagulation
Hemodynamic instability
Infection at site
Patient refusal.
```
83
Assault vs battery
Verbal ASSAULT
| Physical BATTERY
84
No absolute __________ for Neuraxial
Indications
85
Considerations that support using subarachnoid block- FATO
Full stomach
Anatomic distortions of the upper airway
TURP
Obstetrics.
86
Meningitis or increased ICP
Possible herniation , No neuraxial
87
Only aortic stenosis not to do neuraxial
Severe Aortic stenosis
88
Reason of the tight fitting styelet
27ga,
| Enough body to bounce through tissue. Solid needle when stylet needle, and hollow without it
89
Predisposing factors to infections
```
3 AAAs CD
Advanced age]
Alcoholism
AIDS
Cancer
Diabeters
```
90
3 main signs of Meningitis
High fever
Nuchal rigidity
Headaches
91
Laying down, headaches gets better with
PDPH
92
Definitive symptoms that differentiate PDPH from meningitis
High fever
93
Risk factors to know for PDPH
```
Perpendicular needles
Large cutting needles
Female > men
Young > Elderly
Pregnant women
```
94
Epidural anesthesia can be done at
ANY LEVELS
95
Epidural anesthesia at the sacral
Caudal
96
Safest entry point into epidural space is the
Midline lumbar region
97
Binds the epidural space
dural posterior
| and ligamentum flavum ANTERIOR
98
Why is epidural needle curve and noncutting?
A potential space
| Loss of resistance -> thread the catheter
99
Crawford needle of the Epidural is the
STRAIGHT NEEDLE
| and CUTTING
100
Tuohy needle of the epidural is
CURVE needle
| non-cutting
101
Increase risk of epidural puncture is the
Crawford needle
102
Most epidural catheter is
Multi port or orifice
103
Agents for epidural ONSET FAST TO SLOW (2-2-2)
```
Chloroprocaine
Prilocaine
Lidocaine
Mepivacaine
Bupivacaine
Ropivacaine
```
104
WEISS has
WINGS
105
During an epidural if you get a blood return?
Remove and start it over.
106
Epidural air vs saline
use either .
107
How much catheter you want in the epidural space?
4 cm
108
How do you fix a one sided epidural )
Take tegaderm off
Withdraw catheter about 1 cm
inject extra medication .
109
Neuraxial acts on the
Nerve rootlets, nerve roots and spinal
110
Easiest to block : myelinated vs unmyelinated
Myelinated nerve
111
The order in which nerves are blocked following epidural
BC ADGBA
112
Sensory order: Myelinated and unmyelinated
Large myelinated
Small myelinated
Unmyelinated
113
Why do B fibers get blocked first.
B fibers gets blocked first because of their location
114
Sensitivity of LA vs order of Blockade
Page 400.
115
Sensory block most sensitive to
Alcohol swab to assess loss of temperature
116
Epidural hematoma most important issue
PARALYSIS
117
Incidence of epidural hematoma
1 : 150,000 blocks
118
Majority of epidural hematoma occur in patients with
ABNORMAL COAGULOPATHY
119
ABNORMAL COAGULOPATHY patients at risk for epidural hematoma
```
Disease state ( Factor VIII deficiency)
Pharmacological therapy
```
120
S/s of epidural hematoma
SHARP BACK and leg pain
Numbness
Motor weakness
SPHINCTER dysfunction .
121
Only way to diagnose EPIDURAL HEMATOMA
Imaging (CT, MRI) It 's an emergency you need it.
122
Definitive treatment is EPIDURAL HEMATOMA
Surgery
123
2 main complications of Epidural
Penetration of a blood vessel
| Epidural hematoma
124
Signs and symptom of PDPH
```
Headches
Double vision (Diplopia) because of traction on the cranial nerve.
```
125
Headache with PDPH why
When the lay down medulla and brainstem to drop into the foramen magnum, stretching the menin
126
Differential diagnoses for PDPH:
```
SAH
Subdural hematoma
Meningitis
Anxiety
Dehydration
Hypoglycemia
Lack of caffeine
Loss of resistance with air (pneumocephalus)
```
127
Definitive treatment for PDPH
Epidural blood patch
128
PDPH is
Self limiting
129
Epidural blood patch process
10-30 cc of aseptically drawn blood
blood is injected into epidural space until the patient can feel pressure in the back
After the epidural blood patch, bed rest 1-2 hours before ambulating
130
Caffeine is a ______in the cerebral bed
Vasoconstrictor
131
First blood patch injecting resolves : (success rate)
89-95% of headaches may repeat in 24 hours.
132
How much blood to inject
14-18 ml OR when patient say feel pressure
133
What does the blood do when injected?
Compressing SAH with the injected blood.
134
Most common regional anesthetic in children
Caudal
135
Caudal can be done
Awake or sleeping
136
You don't want to get
CSF
137
Brachial plexus blocks
Interscalene
Supraclavicular
Infraclaviular
Axillary
138
Supraclavicular/ infraclavicular
Pneumothorax
139
Interscalene block best for
Shoulder
140
Nerve roots of Brachial Plexus
C5-T1
141
Branches of Brachial Plexus
```
MARMU
Musculocutaneous
Axillary
Radial
Median
Ulnar
```
142
Cords and divisions of brachial plexus.
3 cords
| 6 Divisions
143
Appears black of image
LIQUID (anechoic)
144
Appears white of image
BONE (hyperechoic)
145
Safer to work (in plane or out of plane)
In plane
146
Commit to memory pg.
409
147
Pain to pinky finger, what dermatome?
C8
148
Radial nerve stick gives you ______when stimulated everything else______
EXTENSION : FLEXION
149
Radial nerve stick gives you ______when stimulated everything else______
EXTENSION ; FLEXION
150
Cervical plexus block
Unilateral procedure of the neck
151
Complications of Cervical plexus block
Unilateral phrenic nerve paralysis (ONLY see with DEEP)
Horner's syndrome
Hoarseness
Accidental subarachnoid or epidural injection .
152
Complication, Only seen with DEEP cervical block
Unilateral phrenic nerve paralysis
153
How much to inject for Cervical plexus block ?
4 ML (think C2-C4)
154
Interscalene is between
Between 2 scalene muscles
155
Level of C6
Cricoid Cartilage
156
Where it crosses interscalene groove
Level of C6
157
Best way to prevent intravascular injection
Aspirate first
158
Occurs in 100% patients undergoing interscalene block
Ipsilateral phrenic nerve block resulting in diaphragmatic paresis.
159
ISB is a ____volume block? how much ?
Large ; 40
160
Most inferior part of the interscalene groove
2 cm from MidPoint of clavicle on the medial side.
161
Landmarks to know Interscalene Groove
Anterior scalene
Middle scalene
Clavicle
1st rib
162
Complications of Supraclavicular
Pneumothorax. (hemothorax as well)
Horner's syndrome
Phrenic nerve block
163
Supraclavicular volume
20-30 mL
164
Axillary bundle, nerve missing (muscle associated)
Musculocutaneous nerve (Costcobrachialis muscle)
165
Injection site for axillary block
Find axillary pulse as high as possible
| Move to rope of muscle.
166
Most popular of the ISB
Axillary block
167
For axillary block, do this to the arm
90 deg out and 90 degrees up
168
Lies outside of axillary sheath
MCTN
169
For axillary block, what can cause incomplete spread.
Fascial septa result in INCOMPLETE SPREAD of LA
170
Median and radial nerve inject
3-4 cm
171
Radial where do you inject your LA.
Radial flexor muscle and extending to the dorsal surface of the ulna styloid
172
NO epi where with the elbow
Below elbow
173
NO epineprhine in 4 areas
Nose , toes, fingers, penis
174
Median and radial nerve blocks at elbows
Insert B bevel needle slighly medial to the brachial artery .
175
Radial nerve at elbow
Inject
176
Femoral nerve becomes the
Saphenous nerve
177
Lumbar plexus levels
L1 - L4 an some T12
178
Ulnar block of the elbow
Insert between the medial condyle of the humerus and the olecranon of the ulna
179
Ulnar block at the wrist
Insert B bevel needle slighly adjacent to the ulnar artery
180
Median nerve block at the wrist
Between long palmar muscle and the radial flexor muscle of the wrist.
181
Popliteal is a
Sciatic nerve block
182
Ankle block vs popliteal interchangeable
Saphenous is missing
183
Most difficult to block
Posterior tibialis
184
Superficial nerve of lumbar
All that starts with S
185
Radial nerve block at the wrist
Inject beginning at the radial flexor muscle and exendin to the dorsal surface of the ulnar styloid.
186
Webspace between 1st great toe and 2nd toe
DEEP peroneal nerve.
187
BLOCK REVIEW
421` 423
188
Retrobulbar
Up and away or down an dway s
189
Bier block , need to stay up for at least
20 minutes
190
Ilioinguinal and iliohypogastric nerve block
Inject 8-10 ccc
| Most common complication
191
Most common complication of Ilioinguinal and iliohypogastric nerve block
Patient discomfort.
192
Maternal changes : lungs parameters unchanged
TLC, VC, IC unchanged
193
Maternal changes: decreased lung
Decreased FRC
194
What makes maternal desaturation fast?
Increase in Alveolar ventilation, and a decreased in FRC, desaturation quick
195
Makes maternal at risk for bleeding
Airway engogement
| mucosal friable
196
Do not do this with maternal
no nasal instrumentation
197
Term changes of maternal : CO2 and PaO2
PaO2 increases
| PaCo2 decreases
198
O2 consumption produces a
70% increase in alveolar ventilation at term.
199
Term and MAC
Decreased
200
Alveolar vs minute ventilation (difference between)
Dead space
201
Closing volume and capacity
Unchanged
202
Oxygen consumption at rest for maternal
20-30%
203
Oxygen consumption at Labor
2nd stage 100%
204
Uterine vasculature % of Co
10%
205
Blood volume and plasma volume
Dilutional anemia because plasma volume goes up greater than blood volume
206
Increase in Blood volume no increase in BP because
drop in SVR.
207
Increase in Blood volume no increase in BP because
drop in SVR and PVR
208
Maternal At risk for this because of an increase in blood volume
Thromboembolic events
209
CO =
HR x SV
210
Blood volume is
Up 25-40 %
211
Aortal caval compression aka
Maternal supine hypotensive syndrome
212
Best position for maternal
Left lateral tilt
213
Explains Aortal caval compression
Compression of IVC decrease VR and results in decrease SV and hypotension
214
What is the maternal response to Aortal caval compression?
TACHYCARDIA
| VASOCONSTRICTION
215
CO increase in pregnant women is due to
Increase is SV
216
Stages of labor : First (four dermatomes)
Begins onset of contraction , result in complete dilation of the cervix
217
Stages of Labor: seconds (Sacral)
Sacral included.
218
Signs of fetal distress
Fetal scalp ph< 7.20
Meconium stained amniotic cluids
Oligohydramnios
219
Normal placental implantation
Top of the uterus
220
Placenta previa
Painless preterm bleeding
Plan
Pass on pushing (C-section needed)
221
Non-reassuring fetal heart rate pattern
Repetitive late decelerations
Late decelerations due to prolonged cord compression
Loss of beat-to beat variability associated with late or deep decelerations
Sustained fetal heart rate < 80bpm
222
Placenta previa ultimate goal
Keep fetus inside to as close to 37 weeks as possible
223
Expected management is terminated when
Active labor
documented lung maturity
Excessive bleeding
Gestational age reaches 37 weeks.
224
Most common cause of neonatal morbidity and mortality
Before 20 weeks
225
Incidence of accreta for normal
3%
226
Antibody serum
2- 4 hours for exact match blood
227
Emergency bleeding volume for labor and delivery
VOLUME, VOLUME, VOLUME
| ACCESS
228
What to prepare for possible increase bleeding.
Large bore IV
4 PRBC
FLUID/BLOOD WARMERS (possible DIC)
229
Placental abruptio is the
loss of area for maternal fetal gas exchange
230
Known risk factors
```
HTN
Age
Parity
Tobacco
Trauma
History of
```
231
What to order for Placenta abruptio :
RBCs
Platelets
FFPs
Cryopreciptate
232
Any concenrst with volume or coagulation status
No epidural
233
Abnormal placental implantation, worst is
percreta
234
Placenta Accreta
Adheres to the
235
Placenta Increase
INvades and is confined the myometrium
236
Placental Percreta
PEN"etrate the myometrium
237
Hemabate don't use with
ASTHMA
238
Methergine don't use with
Hypertension (High blood pressure)
239
If mom has had a placenta previa, previous C-section or had uterine trauma she is at risk for
developing PLACENTA ACCRETA.
240
The more C section the greater the incidence of
ACCRETA
241
Amniotic Fluid embolism
High mortality rate 50% in the first hour
242
Amniotic fluid embolism (A- OK)
A OK
Atropine
Ondansetron
ketorolac
243
MAternal heart Group I
Regional ok
244
Maternal heart Group II
NO regional
245
DIC fibrinogen
< 150
246
DIC platelets
Decrease
247
DIC times all
increase
248
Pre-eclampsia DEFINITIVE TREATMENT
DELIVERY of the fetus.
249
Maternal Heart problems Group I
MVP, AI, L to R shunts
| Everything else group 2
250
Hemodynamically Magnesium does the
OPPOSITE OF CALCIUM
251
Loss of DTRs, magnesium level mg/dL
7-12
252
During laryngoscope , see fluid, next action
Suction
253
Does the risk of preeclampsia ends with delivery
NO
254
Normal Mag mg/dl, mEq/L
1. 8-2.5
| 1. 5-2.1
255
Treat which decelerations with priority
Late
256
Agent with lower pka
more ionized
257
Nonionized form is
Lipid soluble.
258
3% chlorprocaine does
Not follow the rule,
| VERY HIGH CONCENTRATION
259
The lower pKA the
the faster the onset
260
Speed of onset is dependent on
Degree of ionization
261
Lipid solubility is a measure of
potency
262
Duration of action is more important for
Protein binding and LIPID SOLUBILITY
| But MAINLY protein binding
263
Oil water partition coefficient
Highest potency
264
The higher the Oil water partition coefficient
The higher the potency and lipid solubility
265
Low albumin
Increase action of highly bound drug.
266
What determines blood cocentration
Wheter
267
The only vasoconstrictor LA
Cocaine
268
LA goes away from site from
Absorption
269
What form do you need to have an effect for a conduction
BOTH (one to cross one to bind)
270
2 forms of esters
Procaine
| Chlorprocaine
271
Dibucaine is an
Amide local anesthetics
272
80% suppression with dibucaine
Normal
273
Dose of Lipid
1.5 mg/kg followed 0.25 ml/kg/min
274
Succinylcholine to vecuronium
Make sure you check twitches before giving NDNMB
275
No propofol in the
Context of cardiovascular instability
276
ECF Liter
14 L (1/3)
277
ICF Liter
28 L (2/3)
278
Other name for ICF
Cytosol and cytoplasm
279
Cell membrane has a
Phospholipid bilayer
280
What is the role of the phospholipid bilatery
prevent things from crossing
281
Cell membrane
50% proteins
| 50% of fatty acids.
282
For substance to cross you need
Channel
283
You need Amino acids to create
proteins
284
Amino acids are made from
DNA
285
Proteins 3 main functions
1. receptor
2. transporter
3. enzymes
286
Receptor with 7 seven branches in and out of the cell
GPCR
287
Transporter receptor is a type of
bring products in an out depending on the concentration gradient
288
Major ions in extracellular and concentration
Sodium (135-145}
Chloride 98-108
Calcium (8-10.2)g/dL
Bicarbonate (22-27)
289
Major ions in INTRACELLULAR and level
K
| 135-150
290
All Major ions in INTRACELLULAR and level
K, Mag, and phosphate and PROTEINS
291
Phosphate INside is
100
292
Proteins levels inside the cell
65
293
Na+ inside the cell
10-15
294
Any ionized gets inside cell you get
Neurotransmitter release
295
BICARBONATE inside the cell is
18-22
296
K+ outside of cells level
3.5 - 5
297
Phosphate and Mag outside of the cell lvels
2 and 2
298
Protein outside of the cell level
16
299
Ficks law of diffusion
Concentration gradient
Size
thickness
Surface of the molecule
300
NA-K pump move Na+
Against concentration gradient, so OUT , 3 NA+
301
NA-K pump move K+
Against concentration gradient, soIN, 2 K+
302
ATP broken down to ADP
Releases a phosphate
303
Na-K ATPase uses
ENERGY
304
Calcium attaches to the
RECEPTOR*(which is a protein)
305
When calcium or ions attach to a receptor is.
A LIGAND-GATED ION CHANNEL._
306
Examples of ligand
Drugs, chemical , neurotransmitter, hormones
307
1st messenger is the
ligand
308
2nd messenger is the
GPCR
309
Signal transduction is
RELAY of message, (tweet , retweet).
310
G-Protein (i)
Inhibitory
311
G-Protein (s)
Stimulatory
312
Beta adrenergic agonist would be a
Stimulatory (Gs) (stimulates production of adenylate cyclase producing cAMP)
313
AcH binds to
Inhibitory muscarinic , prevent production of adenylate cyclase
314
2nd messengers are all
TISSUE SPECIFIC
315
Bronchial smooth muscle : Terbutaline":
Ligand and first messenger
316
Terbutaline binds to
Beta -2 receptor, activate G protein
317
Enzymes are generally located on the
inside
318
Adenylate cyclase is an
Enzyme
319
Substrate is
ATP
320
The first messenger is where?
Outside the cell
321
The second messenger is where
inside
322
Cyclic AMP
active protein kinase (all kinase add a phosphate)
323
Calcium and bronchial
Bronchial constriction
324
ATP substrate create
Cyclic AMP
325
Signal transduction steps 1-6
1. ligand
2. activates recepot
3. binds to protein
4. Enzyme (adenylate cyclase)
5. 2nd messenger cyclic AMP
6. Physiological response
326
Nitric oxide is not a ____why?
LIGAND; Way to small travels in the body
327
Nitrous oxide is not a ligand but it is
STILL a 1st messenger
328
Nitrous oxide is still a first messenger because
It still sends a signal from outside to the inside of the cell
329
Nitric oxide inside the cell
Nitric oxide synthase (NOS) , convert the substrate GTP to cyclic GMP
330
cGMP works on
protein kinase G and we get physiological response--> BRONCHODILATION
331
Cyclic GMP PDE5
Cialis , viagra
332
PDE 3
milrinone
333
Sildenafil is
viagra which is a PDE5
334
Phospholipase C action
Phospholipase C remove the head of the phopholipids then it becomes IP3, cut head off.
335
IP3 acts on ER because calcium
2nd messenger
336
2nd messenger with IP3
2nd , second messenger is CALCIUM
337
Peripheral nervous system
Efferent NS (motor)
338
VEM mnemonic for
Ventral
Efferent (away central to peripheral)
MOTOR
339
Going in or towards
Afferent
340
The predominant neurotransmitter in the periphery is
AcH
341
Cell bodies --> Axons terminal then
Dendrites, Ganglion , organ
342
What is a ganglion?
Peripheral collection of nerve cell bodies
343
Neurotransmitters list
```
Ach
Histamine
Serotonin
Glutamate
GABA
Etc..
```
344
Neurotransmitters list
```
Ach
Histamine
Dopamine
Serotonin
Glutamate
GABA
Epinephrine
Norepinephrine
Glycine
```
345
A-alpha most of the work done with what neurotransmitter
Ach
346
Dopamine neurons are called
Dopaminergic neurons
347
Autonomic divisions
Visceral : heart , gut ,stomach,
348
Long pre-ganglionic and short post ganglionic neurons
parasympathetics neurons
349
Short pre-ganglionic and Long post ganglionic neurons
Sympathetic neurons
350
All preganglionic neurons release
ACH
351
Release of NE are called
Adrenergic nerve
352
Preganglionic neurons act on adrenal medulla
ACH
353
Because NE is release into the adrenal medulla it is a
HORMONE
354
Muscarinic is a
GPCR
355
Muscarinic is a _____receptor
GPCR
356
All Adrenergic receptors are
GPCR
357
SAME for remembering afferent vs efferetn
Sensory --> Afferent
| Motor- EFFERENT
358
To know where you are look for the
Ganglion (it is the posterior)
359
Where does the action potential start
Dendrites , send signal --> Dorsal root ganglion =--> goes to dorsal horn --> axon collaterals
360
Axon collaterals stay on the same
Side (ipsilateral pathWAYS)
361
90%
PSEUDOpolar
362
SAD to remember
SENSORY
AFFERENT
DORSAL
363
Dorsal horn has what ?
Bunch of layers called REXED LAMINAE
364
A-delta travel ? which lamina
Travel pass dorsal root ganglion, will synapse as fast as they can REXED LAMINAE I or REXED LAMINA V
365
How many rexed laminae
10 (I-X)
366
Fast and sharp pain fibers go up to the brain using
LATERAL SPINOTHALAMIC PATHWAYS
367
Slow and chronic pain travel using
VENTRAL spinothalamic pathways.
368
Lamina for slow and chronic pain
Lamina II and III
369
Slow and fast pain
Anterior and lateral pathway
370
C fibers
Slower burning throbbing pain pathway
371
Substantia Gelatinosa found in
Rexed lamina II and /or III
372
Neurotransmitter release from A delta is
GLUTAMATE which binds to AMPA and NMDA receptors on the receptors on the postsynaptic membrane
373
Neurotransmitter released from C fibers is
Substance P which binds to NK-1 neurokinin 1 receptors on the postsynaptic membrane.
374
Anterolateral system
Lateral spinothalamic tract
| Ventral spinothalamic tract
375
Tracts looking lines are on the
DORSAL
376
SSEPs
Dorsalateral fasciculus
377
Slower pathway is the
Ventral Spinothalamic tract
378
Crude touch and pressure
Ventral spinothalamic (spinal to thalamic)
379
Where are pain impulses attenuated?
Susbstantia Gelatinosa
380
Pain in the body
Endorphins
Enkaphelins
Dynorphins
381
Opiods receptors
Mu-1
Mu-2
Kappa
Delta
382
****The predominant opioid receptor is
Mu-2
383
Mu-2 receptor action
Pain transmission/sensation is decreased
384
Mu-2 creates ____Analgesis
SPINAL
385
Supraspinal analgesia
you feel it but you dont care
386
Spinal analgesia
Mu-1
387
Spinal analgesia
Perception of pain is diminished
388
Opioids acts on the
Periventricular gray or Periaqueductal gray ,
389
Spinal analgesia results fromthe action of opioids in the
Substantia Gelatinosa or in the periventricular (after epidural or intrathecal administation) /periaqueductal gray (after IV admnistration )
390
Nuclei
Central bodies collection
391
Ganglia
Peripheral nerve bodies collection
392
Key term for Vd is
Theoretical volume
393
Elimination Half Life
TOTAL AMOUNT of the drug
394
Elimination half time
T 1/2 beta
395
Vd =
Quantity / plasma concentration (at time =0)
396
Large volume of distribution
Induction agent like propofol
397
Charged and ionized
Water soluble.
398
Drugs with small Vd
Muscle relaxants
399
MR are water soluble due to their
POLAR nature.
| CHARGED NATURE>
400
Induction agents are
Lipid soluble because NONPOLAR and UNCHARGED NATURE
401
Neonates need more succinylcholine ____why?
MORE; IMMATURE NMJ
402
Neonates and NDNMA
Less , immature NMJ
403
Zero order kinetics aka
Michaelis Menses
404
Linear order kinetics
Linear (constant)
405
First order kinetics
LOG (constant FRACTION)
406
Most drug eliminated through
FIRST ORDER KINETICS
407
Distribution is
Alpha
408
Elimination is
B"e"ta
409
Contraindicated in patients receiving dandrolene therapy
CCBs
410
Weak acids and weak bases important concept
pKa
411
Weak bases LA when is pka/pH relevant
Patient is septic
412
If pH < Pka for WA
Nonionized
413
If pH > Pka for WA
Ionized
414
If pH < Pka for WB
Ionized
415
If pH > Pka for WB
Nonionized
416
Follow 3 steps for acids bases questions
- WA or WB
- Look at pKa
- pH of the target solution
417
Renal effects of nitrous oxide include:
decreased renal blood flow secondary to increased renal vascular resistance
418
Nitrous oxide appears to decrease renal blood flow by increasing renal vascular resistance. This results in
decreased glomerular filtration and decreased urine output.
419
Most drugs are
Neither weak acids or weak bases
420
Barbiturates are
Weak acids
421
Weak acids is an
molecule that give up hydrogen ions incompletely
422
HBarb examples of weak acids breakdown
[H+] + [Barb - ]
423
SA node location
Posterior Right atrium
424
Internodal pathway : Anterior
Bachmann RA to Left atriuj
425
Internodal pathway : Middle
Wenckeback tract
426
Internodal pathway: Posterior
Thorel tract
427
AV node located on
Floor of the right atrium , near tricuspid valve.
428
Triangle of Koch is in the
heart
429
AV node delay allows
Proper conduction of action potential
| allow the heart to be synchronous
430
Right and Left bundle branches small branches called
Fascicle
431
Action potential sequence of propagation
SA node, AV node,s Bundle of HIs, R+L BB , purkinje fibers.
432
Nodal action vs ventricular myocytes action potential
No phase 1
| No phase 2 in nodal
433
RMP for the nodal is (stable vs unstable)
Not stable
434
What ECG represents
Electrical activity
435
P wave
Atrial depolarization
436
QRS complex
Ventricular depolarization
437
U wave may represents
hypokalemia
438
RMP ventricular myocytes
-90 mV
439
RMP SA nodal cells
-70 mV
440
RMP is maintained by
Potassium Efflux (Leaky channels)
441
Depolarization is caused what ions
sodium influx
442
Ventricular myocytes Phase 0
Sodium influx
443
Ventricular myocytes Phase 1
```
Transient repolarization (Chloride influx)
Inactivation of the fast sodium channels
```
444
Plateau phase is
Phase 2
445
PHase 2 of ventricular myocytes
Calcium L-types channels open , and calcium influx
446
Phase 3 of ventricular myocytes
Late/ delayed repolarization
| Delayed rectifier potassium channels
447
Phase 4 of ventricular myoctyes
Back to RMP
448
Na-K pump only responsible for about
6 mV
449
Helps maintain and restore RMP
Na-K- ATPase
450
Ohm's law states
Voltage = Current / Resistance
451
V = (voltage)
IR (current x resistance)
452
For nodal phase 4 , what channels are responsible to maintain
Funny sodium channels
453
What type of Calcium channels for nodal phase 0
T-type calcium channels (transient)
454
For phase 3 what is the channel working
L-type calcium channels
| Delayed rectifier potassium efflux
455
With release of ACH, it binds to
muscarinic receptor M2
456
Excitatory M receptors are
M1, M3, M5
457
Inhibitory M receptors are
M2, M4
458
NE binds to
B1, GPCR
459
Transplanted heart: parasympathetic innervation
no parasympathetic innervation
460
SA node beating at
110 for transplanted heart because of a lack of parasympathetic stimulation .
461
Potassium leaky channel is a
2 port
462
Primary cause of negative charge is
Protein
463
Phase 2 also has a
conformational change to sodium channels, shuts the H-gates
464
The conformational changes that occurs to the sodium channels is responsible for the
Absolute Refractory period (plateau phase)
465
Repolarization phase 3 , the
Relative Refractory period (strong enough stimulus can cause an action potential).
466
SV will be determined
EDV- ESV
467
EDV is primarily determined by
Preload (volume)
468
Ejection fraction formula
EF = SV/ EDV x 100
469
EF =
EF = EDV- ESV/ EDV
470
Lusitropy meaning
myocardial relaxation
471
Preload is dependent on
Compliance
venous tone
Venous return
Blood volume
472
Extravascular volume determined by
Sodium
473
3 types of reflex
Baroreceptors
Bain bridge
Bezold -Jarisch
474
Angiotensinogen is made in the
LIVER
475
ACE is in the
lung
476
Precursor of angiotensin I
Angiotensinogen
477
Force at end diastole, right before contraction is
Preload
478
The more filling the more
Preload
479
Contractility is determined by the
CHEMICAL environment of the cardiac cell
480
Atrial kick
20-30%
481
Frank Starling mechanism
Increase preload
482
Decrease Venous return states all the hemodynamic changes
```
Decrease Preload
Decrease filling
Decrease EDV
Decrease SV
Sam
```
483
After fluids administration , what parameter is increased?
Increased preload
EDV increase
ESV unchanged.
484
When you give a loop diuretic, what parameter is increased?
Decreased preload
EDV increase
SV decrease
ESV unchanged.
485
Cardiac tamponade : filling
Decrease ability to fill the heart.
486
Afterload is associated with
pressure.
487
Can increase SVR
Alpha 1 agonist
488
If you increase afterload what happens to EDV, ESV, SV, BP and HR
```
EDV increase
ESV increase
SV decrease
BP increase
HR decrease due to reflex. (which reflex?)
```
489
What happens after you give nitroprusside?
```
EDV decrease
ESV decrease
SV increase
BP decrease
HR increase due to reflex. (Baroreceptor? )
```
490
After given a vasopressor, what happens to EDV, ESV, SV, BP and HR
Afterload increase
SV decreases
BP increase
491
Phosphodiesterase Inhibitors OR DIGITALIS administration: EDV, ESV, SV, BP and HR
```
Increase in contractility
Decrease EDV
Decrease ESV
Increase SV
BP increase
HR decrease (BaroReflex)
LV decrease
```
492
CHF what happens ?
```
EDV increased
ESV increased
SV decreased
BP decrease
and HR increase ( Baroreceptor reflex)
```
493
Bezold Jarisch in response to
(hypotension) Low HR
494
Concentric remodeling is associated with
Pressure overload. (AS)
495
Eccentric remodeling is associated with
Volume Overload
496
Wall stress / wall tension on questions think
LAPLACE's law
497
Hypertrophic cardiomyopathy is associated with
LV outflow tract obstruction .
498
Hypertrophic cardiomyopathy is inherited in the
Autosomal dominant pattern
499
Most common cause CARDIAC death for young adults and peds
Hypertrophic cardiomyopathy
500
Hypertrophic cardiomyopathy is not a result of
HTN
CAD
Valvular disease
Pericardial disease.
501
Hypertrophic cardiomyopathy dysfunction
Asymmetrical septal hypertrophy (ASH)
502
Hypertrophic cardiomyopathy motion
Systolic anterior motion (SAM)
503
Dilated LA associated with
Atrial fibrillation
504
Hypertrophic cardiomyopathy may have atrium
LA enlargement
505
Management of patient with Hypertrophic cardiomyopathy: HR
Maintain HR, not slow not fast
506
Management of patient with Hypertrophic cardiomyopathy: RHYTHM
Keep it sinus
507
Regurgitant management FFF
Fast, Full, forward
508
Management of patient with Hypertrophic cardiomyopathy: Preload
Increase
509
Management of patient with Hypertrophic cardiomyopathy: Afterload
iNcrease, Pure vasoconstrictor is the 2nd line of defense for hypotension
510
***Management of patient with Hypertrophic cardiomyopathy: CONTRACTILITY you want
DECREASE
511
Blood going trough LVOT is , what effect?
Venturi effect
512
LVOT with Hypertrophic cardiomyopathy
Increased contract
Decrease preload
Decrease LV ventricular afterload (hypotension, vasodilation)
513
Do not give with Hypertrophic cardiomyopathy
Lasix, NTG, PEEP nitroprusside.
514
Medications to decrease contractility with Hypertrophic cardiomyopathy
Beta blockers
| CCBs
515
OLD CATs PEE Alot
Obstruction
Contractility
Preload
After loading
516
Hypertrophic cardiomyopathy patient have this
AICD (if you disactivating you need the external defibrillator)
517
Venturi effects draws the anterior leaflet of the mitral valve out as blood rushes by whose principles is this
Bernoulli's principle.
518
If the patient goes to a funny rhythm
Take the magnet off
519
Magnet put pacemaker mode
Asynchronous mode ;
520
Hypertrophic cardiomyopathy S/S (SAD)
Syncope
Angina
Dyspnea
521
Notched P waves
Atrial enlargment
522
Main.Goal intraoperative Hypertrophic cardiomyopathy
Prevent release of Catecholamines
523
Hypertrophic cardiomyopathy prevents
Stimulation that can cause an increase in the HR and sympathetic stimulation
524
No spinal or epidural with this condition
Hypertrophic cardiomyopathy
525
A line with Hypertrophic cardiomyopathy shows
Biferiens pulse
526
Vasopressor of choice for Hypertrophic cardiomyopathy
Phenylephrine
527
If they ask about a valvular lesion in doubt pick
Rheumatic fever
528
Severe Coronary artery disease
You want MORE TIME in diastole
| Decrease HR
529
Most prominent end point of severe cardiac issue
PULMONARY EDEMA
530
Why fast HR with regurgitation?
Because diastole time you want lower for less regurgitation.
531
Can cause regurgiation
Aortic annulus dilation
532
Acute aortic regurgitation triad:
Severe dyspnea
Hypotension
weakness
533
Acute AR LV has not
Compensate
534
AR presents as
Sudden onset of pulmonary edema and HYPOTENSION
535
Aortic regurgitation minimal vs severe
When regurgitnat volume remains < 40% SV
| But severe if it > 60% SV
536
Aortic regurgitation SPINAL and EPIDURAL
OK
537
Aortic regurgitation Best vasopressor
EPHEDRINE
538
RRRE
Regarding Regurgitation Reach Ephedrine.
539
PCWP estimation of LV
Indirect
540
Chronic MR is usually due to
Rheumatic fever
| incompetent fever
541
Acute MR cause
Acute MI ,
| Papillary muscle rupture
542
As much as ________% of the SV may be regurgitant with MR
50%
543
LV compensates in MR by
Dilating and increasing EDV
544
Filling to a greater volume emptying in the same
Frank Starling law
545
In MR End Systolic volume remains
normal but eventually increases as the disease process progresses.
546
In mild MR
regurgitant factors < 30 %
547
Valvular lesion of MR radiates to the
Axilla
548
In moderate MR
regurgitant factors 30-60 %
549
In severe MR
> 60%
550
Regurgitant disease is AR, and MR tolerates spinal or epidural
YES
551
AS ventricles gets thicker what happens
There is subendocardial ischemia.
552
Rhythm for AS wanted VERY IMPORTANT
NSR (b/c atrial kick)
553
From least to most invasive to restore
Meds
EP labs
Atrial ablation
554
Important to Aortic stenosis
NEED ATRIAL KICK (without it , 40% decrease in CO)
555
Aortic Stenosis and afterload
maintain normal
556
Aortic Stenosis and Contractility
Maintain
557
Most common valvular disease in the US
AS
558
Most common cause of AS
Calcification
559
Aortic valve is a (bi/tricuspid)
TRICUSPID VALVE
560
Normal size of Aortic Area
2.5 - 3.5 cm
561
Severe stenosis , and surface area
75 % of decrease surface area
562
Criticial AS
< 0.8 cm^2
563
Concentric hypertrophy its because trying to decrease
WALL TENSION (La place law)
564
La place law formula
(2 x Thickness x Tension)/Radius
565
Epidural vs spinal for AS
Epidural, raise level of LA
566
The higher the pressure gradient
The worst the patient
567
Mean transvalvular pressure gradient : mild to mod
Mild to moderate , < 20
568
Mean transvalvular pressure gradient : severe
20-50
569
Mean transvalvular pressure gradient critical
> 50
570
Peak transvalvular pressure gradient : mild to mod
< 36
571
Peak transvalvular pressure gradient severe
>50
572
Peak transvalvular pressure gradient critical
>80
573
Aortic valve area, Mild to mod
1 - 1.5
574
Aortic valve area, severe
0.8-1
575
Aortic valve area,critical
<0.8
576
Once angina from Aortic stenosis
Angina 5 years
Syncope 3 years
Dyspnea 2 years
577
RV failure
Cor pulmonale
578
The elimination half-time of a drug: related to clearance
is inversely proportional to the clearance
579
The elimination half-timeof a drug is proportional to the v
Volume of distribution
580
Delayed complication of rheumatic fever
mitral stenosis
581
Mitral normal size
4-6 cm
582
Most common cause of right side HR
Left side HF
583
ARDS
Aortic regurgitation Diastolic sternal border
584
MRSA
Mitral regurgitiaton systolic Apex
585
MSDA
Mitral stenosis Diastolic Apex
586
ASS ARCh
Aortic Stenosis systolic Aortic Arch
587
Anesthesia Risks: GREATER DETERMINANT of postop complication
co- morbidities are the best prediction
588
Surgical risk and outcome in patients 65 years and older primarily on 4 factors (APET)
Age
Patients status and coexisting
Emergency or elective
Type of procedure.
589
Can decrease incidence of VAP
Subglottic suctioning
590
Decline in organ function -->
1% decline per year in organ function after age 30 years . For example 70 year old has a 40% decline in general function
591
DNA/RNA changes
Change in DNA/RNA replication, decrease in function.
592
Elderly and thermoregulation
They shiver at 35C
593
Young adults and thermoregulation
They shiver at 36.1
594
Elderly and body fat
Increase body fat
595
Elderly and total body water
Decrease body fat.
596
Blood volume and Elderly
Decrease
597
Collagen and skin elasticity is
Decrease
598
Increase SVR in elderly cause
reduce arterial compliance
599
Circulation time and elderly
Reduced myocardial pump function leads to reduced CO which prolong circulation time.
600
Adrenergic receptors and elderly
A decrease in adrenergic receptor response.
601
Decrease all drugs doses EXCEPT : why?
Atropine and beta agonist (like isoproterenol) because of a decrease adrenergic response.
602
Increase risk of aspiration in elderly why?
Due to vocal cord stimulation being elevated.
603
Sensitivity of need to clear secretion in the elderly is
Decreased
604
FB close to carina , elderly response
Low stimulus to cough , more likely to aspirate
605
Work of breathing in elderly is _____why?
Because of skeletal calcification and increased airway increase the work of breathing, predisposes them to ACUTE POSTOP VENTILATORY FAILURE
606
What can put the elderly patient at risk for Acute postop ventilatory failure?
Increase WOB due to skeletal calcifications.
607
Chest wall compliance for the elderly patient?Pulmonary compliance?
Decrease: Increase
608
Respiratory changes in elderly mimics (obstructive/restricvie)
Restrictive
609
Most sensitive indicator for renal function in the elderly
CrCl
610
With decreased albumin
Give less
611
MAC decrease is reduced by
4-6% decade of age over 40 years
612
Summary box pg 507
507
613
Elderly and Decrease vascular volume anesthetic consequence
Results in high initial plasma concentration
614
Dose to stay the same for the elderly, 2 medications:
Neogstimine, Edrophonium
615
Elderly and Decrease protein binding anesthetic consequence
increase availability of free drug
616
Elderly and Increase body lipid storage sites
Prolonged action of lipid soluble drugs
617
Decrease renal and hepatic blood flow
Prolonged actions of drugs dependent on kidneys and liver for elimination
618
Pediatric larynx level
C2-C4
619
Adult larynx level
C3-C6
620
Narrowest function location for adult vs pediatric
Adult Vocal
| Pediatric cricoid
621
Pediatric emergency know when it is a
Medical vs surgical emergency
622
V shaped epiglottis
Adult
623
Omega shaped epiglottis
Pediatric
624
ETT tube ID UNCUFFED
Age (years) / 4 + 4
625
ETT tube ID for CUFFED
Uncuffed minus 3.5
626
Defining hypotension in kids: at Term:
<60 mmHg
627
Defining hypotension in kids: 1- 12 months
<70 mmHg
628
Defining hypotension in kids:1-10 years
< 70 mmHg + (2x age in years)
629
Ducturs arteriorsus shunt is
RIGHT to LEFT
630
Syndrome think of -->
Craniofacial anomalies.
631
Greatest risk of apnea
<46-60 weeks
632
Diaphragmatic herniation highest occurrence on the
LEFT foramen of Bochdalek.
633
CHD you can cause a
CONTRALETERAL PNEUMOTHORAX (small underdeveloped lung)
634
First apgar in CHD
usually fine
635
Between first and 2nd apgar, what happens to the baby
transitioning from high PVR, low SVR to low pVR high SVR
636
CHD issues what preop information we need
ECHO, Heart disease, and conditions?
637
CHD abdomen
SCAPHOID ABDOMEN ,
| BOWEL IN THE THORAX
638
CHD hallmark signs
Profound arterial hypoxia due to Right to left shunt
Barrel-shaped chest,
SEVERE RESTRATIONS
639
CHD treatment goal
Preductal saturation over 85% using peak inspiratory pressure below 25 cm H2O and allowing PCo2 to rise to 45-55 mmHg
640
CHD concern Respiratory
RIGHT SIDED PNEUMOTHORAX
641
Increase PVR 3 things:
Hypothermia
Hypoxia
Acidosis
642
Sings of TEF Feeding leads to
CCC
Choking
coughing
Cyanosis
643
Most common variation is the form that ends in a
BLIND
644
More likely for aspiration : TEF
TEF D
645
Less likely for aspiration TEF
TEF A
646
TEF is associated with what mnemonic
```
VACTERL
Vertebral defect
Anal atresia
CArdiac anomalies
TEF
Esophageal atresia
Renal dysplasia
Limb anomalies
```
647
TEF anesthesia considerations: Key to successful anesthetic management
Correct positioning of the ETT
648
TEF and PPV
Avoid PPV which will distend the stomach, thereby increasing the risk for reflux and ventilatory compromise.
649
What should you avoid in a patient with TEF?
Avoid instrumentation of the esophagus.
650
What should you avoid in a patient with TEF?
Avoid instrumentation of the esophagus increase the risk for reflux and ventilatory compromise.
651
Describe the most common TEF
Noncommunicated blind pouch and a lower esophageal connection to the trachea
652
How do you suction a patient with pyloric stenosis
Suction supine, left decubitus, and right decubitus
653
CHD more at risk for pneumothorax
Lung is small can't carry normal tidal volume.
654
Most common cause of acute airway obstruction in otherwise healthy kids
CROUP
655
With croup , what problem becomes evident and requires the patient to be intubated ?
Increase PaCO2.
656
Treatment croup
2.25% epi in 3 ml of NS 0.05 ml.kg up to 0.5 ml/kg repet 1-4
657
Edema of supraglottic structures (croup vs epiglottidis)
ACUTE EPIGLOTTIDIS
658
Inspiratory stridor associated with
Epiglottidis
659
Signs of Epiglottitis
Sitting forward and upright, , chin up, mouth open , drooling.
660
Epiglottitis what vaccine to prevent?
Hemophillus influenza type B
661
DO NOT ATTEMPT to do this with epiglottidis
Not attempt to visualize glottis
662
Tube size with Epiglottidis
1-3 mm smaller
663
Epiglottitis extubation usually
2-3 days
664
Epiglottidis extubation, readiness?
Do an AIR leak
Use Glidescope.
Pediatric fiberscope
665
Omphalocele covered?
Covered
666
Gastrochisisis covered?
Sausage (not covered)
667
Mortality Gastrochisis vs omphalocele
Mortalitiy related to cardiac and chromosomal abnormalities.
668
Worst combination.
Macroglossia and MICROGNATHIA
669
Survival omphalocele vs gastrochisis
Gastrochisis > 90 %
| Omphalocele > 70-90
670
Pierre Robin and treacher collins syndrome Anesthesi
Intubation very difficult
use awake technique
Fully awake before extubation
671
Pierre Robin and treacher collins syndrome
ASD
VSD
PDA
Tetralogy of fallot.
672
Pierre Robin and treacher collins syndrome : glottis
ASSOCIATED WITH SUBGLOTTIC STENOSIS
673
Trisomy 21 most common issues.
Macroglossia and MICROGNATHIA
674
Trisomy 21 associated anomalies
CHD
| SUBGLOTTIC STENOSIS
675
Right to left shunt you need to
NO AIR BUBBLES IN IV LINE
| SHORT IV TUBING< WITH FEWEST CONNECTIONS>
676
Malignant Hyperthermia triggers
All VA (halogenated) and succinylcholine
677
Early MH signs
Masseter spasm
Tachypnea
Tachycardia
678
Early MH SYMPTOMS
Masseter spasm
Tachypnea
Tachycardia
679
Intermediate MH SYMPTOMS
CLASSIC MOTTLED CYANOSIS
680
EARLY SIGNS of MH
Increased ETCO2
| Peaked t waves
681
Exhausted CO2
Not going back to baseline
682
CO2 increase with MH is
Abrupt and very high
683
Incidence of MH
1: 50,000
684
MH increase in temperature
Increase 1C every 5 minutes
685
MH is associated with increase
CO2
686
Leading cause of death with MH
Vib
Renal failure
DIC
687
Interventions:
Cooling pads
688
Dandrolene will cause
Diuresis because of the mannitol
689
Why do you need foley?
because dandrolene has mannitol
690
Ryanodex mixing vs Dandrolene
Dandrolene: 20 mg in 60 ml; 3000mg manniotr
Ryanodex: 250mg in 5 ml . 125 mg mannitol each vial
691
Testing for MH
Genetic
| muscle biopsy: CAFFEINE (Caffeine Halothane contracutre test)
692
First step in coagulation is
Endothelial damage
693
Platelets: What promotes platelet adhesion
Von willebrand's factor.
694
Platelet binds to von willebrands via
Glycoprotein Ib (GP Ib)
695
Problem with glycoprotein Ib
Platelet adhesion does not occur
696
Most common inherited coagulation defect.
Von willebrand's disease
697
Type I von willebrand' disease
insufficient amount of von willebrands production
698
Most common von willebrand's type is
Type I
699
Increase in bleeding time with normal platelets and others
Von willebrand's disease.
700
Standard treatment for von willebrand's disease
DDVAP (work 80% of the cases) if doesn't work CRYOPRECIPITATE
701
Platelet adhesion to VWF via GPIB now we need activation how?
Thrombin receptor --> located on the platelet, Precusor of thrombin is
702
Platelet adhesion to VWF via GPIB now we need activation how?
Thrombin receptor --> located on the platelet, Precusor of thrombin is prothrombin, activated by thrombin (activate self)
703
When platelet activated,
It changes shape, allows aggregation
704
Thromboxane A2 and ADP
Signaling molecules that are released by platelets.
705
Thromboxane A2 and ADP
Signaling molecules that are released by platelets,
| Promotes Platelet aggregation
706
2 that promotes platelet aggregation
Thromboxane A2 and ADP
707
Thrombin role
thrombin activates self to promote more thrombin.
708
Platelet aggregation feedback loop.
Positive feedback loop
709
When platelet start aggregated , a platelet plug is formed, which is called
A white thrombus.
710
How does the platelet plug formed? what is used
Fibrinogen is used.
711
Prevent fibrinogen from sticking to platelets
Fibrinogen receptor GLYCOPROTEIN IIB/IIIa
712
Fibrinogen receptor GLYCOPROTEIN IIB/IIIa is capped to prevent fibrinogen from sticking to it, which can remove the cap
ADP and Thromboxane A2.
713
Most effective way to protect from coagulation
Intact endothelium
714
Once platelets activated,we use
Phospholipase A2
715
Phospholipase A2 (easy to remember)
Amputates leg (remove lipids)
716
Phospholipase A2 after legs removes turns into
Arachidonic Acid
717
The most common acquired blood clotting defect is due to
Inhibition of Cyclooxygenase production by ASA or NSAIDS.
718
Common antiplatelet
ASA
719
ASA is (reversible/irreversible)
Irrreversible for lifetime of the platelets.
720
NSAIDS recommendation no more than
5 days
721
3 antiplatelets other ASA or NSAIDS
Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brillinta)
722
Dipyridamole (persantine) increase
cAMP in platelets
723
Dipyridamole (persantine) acts
by prevents aggregation of platelet via cyclic AMP (cAMP)
724
Antifibrinogen receptor drugs are
GIIb and IIIa
| CAP and BLOCK fibrinogen receptor.
725
GIIb and IIIa drugs
Eptifibatide (intergrillin)
abciximab (Reopro)
Tirofiban (Aggrastat)
726
Stimulates creation of platelets
Thrombopoietin.
727
Tissue factor aka
Thromboplastin
728
Fibrin what do you use
Intrinsic
Extrinsic
Final common pathways
729
Fibrinogen to fibrin conversion done by
Thrombin
730
Fibrin stabilizing factor (Factor XIII)
Secure clots
731
Factor XIII bond is a
Covalent
732
Activates factors XIII to XIIIa
Thrombin
733
When in doubt think
Thombin for activation.
734
Thombin impacts
```
Itself (Factor II)
Helps activate factor XIII
Fibrinogen to fibrin
Factor V
Factor VIII
Factor XI
```
735
Final common pathway factors
1, 2, 5, 10, 13.
736
Extrinsic pathway (extrinsic
3, 7
737
Intrinsic pathway
Cant buy for 12 but for 11.98
738
Glue
Fibrin
Activator
13
I
II
739
Activated C is an
anticoagulant
740
Activated protein S
stabilizes it.
741
Direct thrombin inhibitors
Dabigatran
Argatroban
Bivalirudin
742
Determinant of osmolality: Primarily
Sodium
743
Concentration is
Amount/ volume
744
Determinant of how much sodium we have
Aldosterone.
745
Hormone that deal with water
ADH (vasopressin) arginine vasopresor. (AVP
746
Volume determinant
ADH
747
Normal Osmolality
270-310
748
End products of metabolism is
Excreted
749
End products of metabolism is
Excreted by kidneys
750
OTher name for VITAMIN D
1,25 dihydroxycholecalciferol
751
Calcium is involved in homeostasis
Vitamin D3
752
Functional unit of nephron
nephron
753
Kidney location
retroperitoneal space
754
Nephron per kidney
about 1 Million
755
Lose how much of nephron
65% of nephron before needing therapy
756
Afferent arteriole
Toward the kidney
757
Efferent arteriole
away from the kidney
758
Efferent arteriole is associated
Peritubular capillaries
759
Vasa recta is responsible for the
Hyperosmotic concentration
760
Kidney receive CO
25%
761
Pressure in the kidney
HIGH PRESSURE 80 mmHg
762
Glomerular capillaries pressure is about
60 mmgh
763
High pressure in glomerular capillaries and low pressure of bowman's capsule favor
Filtration
764
Fitration rate
125 ml/min then rest to efferent arteriole
765
Filtration amount
180 L/ day
766
Aldosterone acts on the
collecting duct
767
Aldosterone acts on the
collecting duct (think AC)
768
Reabsorbed most of the ions in
Proximal tubule
769
Proximal tubule absorption of
Mag, Chloride, water, Glucose
770
% of water absorbed in Proximal tubule
65%
771
Majority of ions absorbed where?
Proximal tubule.
772
Impermeable to sodium
Descending loop of Henle
773
Thick ascending loop of henle
Sodium , Potassium - 2Chloride pump
774
The juxtaglomerular apparatus
Juxtaglomerular apparatus
775
In tubules, structure that sense fluid, sodium concentration
Macula densa
776
Juxtaglomerular cells can communicate with
Macula densa
777
Renin leads to the production on
Aldosterone
778
Aldosterone role at the collecting tubule.
Sodium reabsorped
| Potassium excretion
779
PTH deals with
Calcium, Mag and Phosphate
780
PTH acts on
Distal convoluted tubule.
781
From distal nephron
Distal nephron-->Cortical collecting ducts -->
782
Medullary nephron have
Aquaporin-2 channels.
783
Aquaporin-2 channels need this hormone to function
ADH
784
Aquaporin-2 helps with the
reabsorption of water
785
Medications for blood pressure : HCTZ works where in the nephron ?
Early part of the distal tubule
786
Loop diuretics work where do they work in nephron ?
Thick ASCENDING LOOP of HENLE
787
Potassium sparing where do they work in nephron?
LATE PART OF THE DISTAL TUBULE
788
Potassium sparing agents most common agent
Spironolactone
789
Carbonic anhydrase inhibitors work where in the nephron?
Proximal tubule
790
Osmotic diuretic(mannitol) work where in the nephron?
Proximal tubule or anywhere water is involved
791
Ventricular Myocytes
Leaky K+ RMP
792
-60MV set
Ca++ outside threshold
793
RMP move from -90mV to -100mv cell is
HYPERPOLARIZED (further from threshold potential)
794
Hyperpolarized K level
HypOkalemia
795
When cell is hyperpolarized distance further from
RMP
796
Hypokalemia cell is hyperpolarized, arrhythmia why
Reduction in potassium channel conduction, delay and increase in action potential duration. PURKINJE FIBERS MORE LIKELY TO FIRE> (Torsade, vtach)
797
Threshold potential set by ____at __mV
Calcium ; -60 mV
798
RMP becomes LESS negative (hypopolarized) what happens?
Due to HYPERkalemia
799
Excitability with HYPERKALEMIA
VERY HIGH because RMP is close to threshold
800
RMP close to threshold makes cell more
EXCITABLE (more likely for VFIB, Torsades)
801
When the RMP is move UP past threshold ____what happens
(-40 for example) RMP move over the threshold
802
Cardioplegia K level
15-40 K + mEq/L
803
Cardioplegia puts the cardiac cells
Put in Absolute Refractory period( cannot fire)
804
Threshold potential increase with
HyperCALCEMIA
805
RMP Increase and Threshold potential increase
HyperKALEMIA and HYPERCALCEMIA (after treatment of hyperkalemia)
Cells is hyperpolarized, calcium stabilizes, LESS EXCITABLE , it raises the threshold potential level.
806
RMP of nerve cell
normal at -70 mV
807
Decrease threshold potential of nerve cell
HYPOCALCEMIA
808
Hypocalcemia increases
Excitability
809
Acute hyperkalemia treatment FIRST
Calcium chloride (works in 1-2 min)
810
Acute hyperkalemia BICARB (work in how long)
Reduction in plasma concentration of K+ (3-5min)
811
Hyperventilation and acute hyperkalemia (work in how long)
15 minutes
812
Each 10 mmhg decrease in PaCo2 , serum K+
decrease 0.5 mEq
813
Loop diuretics for hyperkalemia how does in
Work on distal nephron to increase K+ excretion
814
Insulin, glucose and hyperkalemia
Acts on Na-K pump and drives potassium into the cells.
815
Administer B2 agonist for hyperkalemia does what
Stimulates the Na-K pump
816
The law of place states
For cylindrical shaped structures with an infinitely thin wall
817
Law of Laplace formula
T= wall tension, P = pressure of liquid R= radius
818
As structure expands, the radius _______, the tension in the wall of the structure ____. This law applies to
Increases; Increases; blood vessels and the left ventricle which also may be considered a cylinder.
819
The law of Laplace has two applications to alveoli
Normal alveoli and alveoli deficient in normal surfactan.
820
The smaller the radius of the bubble,
The greater the pressure inside of the bubble.
821
No normal surfactant what happens to wall tension?
wall tension becomes constant and independent of the radius
822
Smaller radius ____pressure
Higher pressure.
823
Smaller alveoli empties into the
LARGER ALVEOLI.
824
What causes atelectasis with ARDS?
Smaller alveoli empties into larger alveoli causing atelectasis.
825
Flow 2 types
laminar / turbulent
826
Flow is
Concentric ring of fluid.
827
Flow is __________ to the fourth power of the radius
Directly proportional
828
What has the most dramatic effect on floww?
Changing radius
829
Flow is ____________to the hydrostatic pressure gradient
Directly proportional
830
Flow and fluid viscosity
FLow is inversely proportional to fluid viscosity
831
Property of a fluid that largely determines flow when flow is Laminar is
VISCOSITY .
832
Trippling the radius increases flow to
81 times.
833
What is more difficult when flow is turbulent
Ventilating patients.
834
Resistance is _________to fluid viscosity
Directly proportional
835
The greater the blood viscosity the greater the
Resistance.
836
O2 dissociation curve x axis is
PO2
837
O2 dissociation curve y axis is
Hgb Saturation.
838
PaO2 clinical meaning of less than 60 mmhg
Hypoxemia
839
CADET MS RIGHT
```
Increased Co2
Acidosis
2,3 DPG
Exercise
Increase in temperature
Maternal hemoglobin
Sickle cell.
```
840
BOhr effect deals with
Unloading and loading to O2 from tissues
841
Bohr effect shifts curve to the
Rightt
842
IN pulmonary capillary , BOhr effect
CO2 moves up and the dissociation curve shifts to the left and facilitates loading of O2.
843
Total oxygen carrying capacity of the blood
(O2 Bound to hgb) + (O2 Dissolved in blood
844
How to find how much Hgb bound to O2
1.34 x 15g / hg x100 ml of blood X % O2
845
How to find O2 content that is DISSOLVED in blood?
0.003 x 90
846
The solubility coefficient of O2 is
0.003
847
The solubility coefficient of CO2
0.67
848
Gas inversely related to
Temperature
849
More gas will be given if patient is
Hypothermic , dissolves quicker/
850
How much (%) of CO2 is transported in blood as HCO3- (bicarb) in WHOLE BLOOD
90% (whole blood)
851
How much (%) of CO2 is transported in blood as HCO3- (bicarb) in WHOLE BLOOD
90% (whole blood) general accepted
852
Hydrate CO2 you get
Carbonic Acid (H2CO3)
853
CO+ H2O to get --
Carbonic acid
854
Enzyme that convert the reaction of CO2 + H2O to carbonic acid
Carbonic anhydrase.
855
Le Chatelier principle
Law of mass action
856
More reactant will facilitate more reaction as per the law of
Mass action
857
H2CO3 will lead to
HCO3 + H+
858
O2 unloading is favored by an _______in Co2
Increase
859
Major muscle for inspiration of
Diaphrgam
860
Diaphragm is a
Skeletal muscle.
861
Internal intercostal muscles from rib 1-7 help
INSPIRATION MOve ribs up and up
862
Internal intercostal muscles from Ribs 8-12 they are located in a way that they help with
EXPIRATION
863
VRG deal both with
Inspiration and expiration
864
Everything originates in the
DORSAL RESP GROUP
865
Everything originates in the
DORSAL RESP GROUP and goes to the DRG
866
DRG is the
Inspiratory pacemaker.
867
Apneustic Center + Pontine respiratory ROLE
Fine tune rate and depth of respiration
868
Pneumatix center now known as the
Pontine respiratory group
869
Pneumataxic center now known as the
Pontine respiratory group
870
Hering Bruer reflex
Lung distention , stretch receptors
871
Hering Bruer reflex more active in
Neonates.
872
By when do people have adult number of alveoli
By 2 years of age.
873
By when do people have adult number of alveoli
By 2 years of age. (though immature)
874
Aortic arch we have
We have chemoreceptors
875
Carotid bifurcation has
Peripheral chemoreceptors.
876
Aortic sends message via
VAGUS NERVE
877
Carotid send message via
GLOSSOPHARYNGEAL Nerve.
878
What drives NORMAL Ventilation
CO2
879
STRONGEST drive for ventilation
O2
880
PaO2 less than 60, hypoxemia
Chemoreceptors will kick in
881
When asked about dependent, vs nondependent.
Upright, normal TV quiet breathing
882
FRC range
2-3L
883
V/Q infinite
Extreme dead space
884
Obstrcutive SLEEP APnea
KNOW EVERYTHING
885
Obesity hyperventilation Syndrome
Know everything
886
Know reversal of opioid
narcan Dose and infusion
887
Know reversal of bnzo
Flumazenil Dose and infusion
888
OHS worst than
OSA
889
Alveoli are windows to the
Brain
890
Lipid solubility is related to
Potency
891
Pathophysiologic changes associated with metabolic alkalosis include: (Select 2)
hypokalemia, reduced tissue oxygen availability
892
Metabolic alkalosis is associated with
hypokalemia, ionized hypocalcemia, secondary ventricular arrhythmias, increased digoxin toxicity, and compensatory hypoventilation (hypercarbia).
893
Alkalemia may reduce tissue oxygen availability by
shifting the oxyhemoglobin dissociation curve to the left and by decreasing cardiac output.
894
The use of long-acting beta-2 agonists without the concomitant use of ______ is associated with fatal and near fatal asthma attacks.
Inhaled Corticosteroids
