Medicine / Anesthesia Flashcards
1
Q
Pre-Surgical Recs to Diabetic
A
- NPO for 12 h (delay gastric emptying)
- AM appointments
- Hold oral hypoglycemics day of surgery
- Hold metformin for IV contrast or renal hypoperfusion
- D5 gtt ready
- Hold fast acting insulin, 50% of slow
2
Q
Diabetic Ketoacidosis
A
- BG > 500 + metabolic acidosis + ketonemia
Tx:
- IV 0.9% NS
- insulin regular
- Replace K (insulin pushes K inracellularly)
- Bicarb if ph <7
3
Q
Hypoglycemia
A
Sx: fatigue, malaise, trembling, cold sweats, confusion, coma
Tx:
- oral glucose if conscious
- if unconscious - IV D5W (up to 500 ml), D50 (up to 50 ml), or glucagon (0.1mg/kg)
4
Q
Hypertension
A
- > 2 BP readings >140/90 on > 2 occasions OR BP >200/100
Classification
- Normal <120/80
- Elevated <130/80
- Stage 1 <140/90
- Stage 2 > 140/90
5
Q
Causes of Hypertension
A
Essential HTN
- Stress
- Smoking
- Obesity
- EtOH
- Aging
Secondary
- Pheochromocytoma
- Cushing Syndrome
- Renal disease
- Pre-eclampsia
6
Q
Perioperative Management of Hypertension
A
- Defer tx if BP > 180/110
- Chronic HTN patients keep taking meds
7
Q
Alzheimers
A
- Disease of dementia
- 2/2 accumulation of neurofibrilary tangles and plaques
8
Q
Parkinsons
A
- Disease of tremors, rigidity, coordination, and impairment due to decrease in dopamine neurons
9
Q
Hypertensive Crisis Treatment
A
- Hospital / Activate EMS
Tx - nitroprusside
- propranolol
- nitroglycerin
- nicardipine
10
Q
Hypotension
A
- decrease in arterial pressure > 20%
- bradycardia seen early
- tachycardia seen late
- decrease cardiac output and organ perfusion
11
Q
Hypotension Treatment
A
- supine/trendelenburg, elevate legs
- 100% O2
- ASA monitors - NIBP, EKG, pulse ox
IV
- atropine - .01 mg/kg up to 0.5mg (if bradycardic)
- ephedrine 5-10mg q5mins
- phenylephrine 0.1 mg if tachycardic
Treat cause:
- syncope/anxiety
- CAD/MI
- Drugs
- Hypercarbia
- Hypoxia
- decrease volume
12
Q
Bleeding Disorders
A
- Von Willebrands
- Hemophilia A and B
- Sickle Cell
13
Q
Von Willebrands
A
- Most common bleeding disorder - Factor VIII and vWF deficiency
- Type 1 - AD, 85%, quantitative
- Type 2 - AD, 15%, qualitative
- Type 3 - AR, rare, vWF absent
Tx:
- DDAVP - increases vWF release from endothelium
- Severe - cryoprecipitate (VIII, XII, vWF + fibrinogen) + post operative amicar (inhibits fibrinolysis)
14
Q
Hemophilia A
A
- Sex linked deficiency in Factor VIII
- Clinical manifestations when less than 80% factor
- 80% most common hemophilia
Tx:
- mild - DDAVP - increases vWF release from endothelium + VIII
- Severe - cryoprecipitate (VIII, XII, vWF + fibrinogen) + post operative amicar (inhibits fibrinolysis)
15
Q
Hemophilia B (Christmas Disease)
A
- Sex linked deficiency in Factor IX
- 20% most common hemophilia
Tx:
- FFP (II, VII, IX, X)
- Severe - IV Proplex (II, VII, IX, X in concentration)
16
Q
Sickle Cell Anemia
A
- AR in Hb where deoxygenated Hb polymerizes and precipitates in conditions of decreased O2 or dehydration and results in painful occlusive crises
-Shortened life span of RBCs causes sequestration by spleen -> splenic infarction -> immune compromised to encapsulated organisms (S. pneumo, H influenza)
Tx:
- folic acid increase RBC production
- hydroxyurea drives HbF formation
17
Q
Transfusion Reactions
A
- cross agglutination of blood by Ab’s in plasma
- 1/3000 due to clerical errors
Signs/Symptoms
- fever
- hypotension
- sweats/chills
- hives
- anapylaxis/dyspnea
- rigors
- vomiting
- flank pain
- headache
18
Q
Transfusion Reaction Types
A
- Acute hemolytic - immune mediated
- Hemolytic - non-immune mediated
- Non-hemolytic
- Allergic reactions - IgE meditated
- Ag contamination
- Delayed reactions
19
Q
Initial Therapy of Transfusion Reactions
A
- Maintain BP and renal perfusion
- IVF - NS
- Strict I/Os - monitor urine output
- Nephrology consult early
- Initial diuresis - 40-80 mg lasix - want urine output > 100ml/hr
- Mannitol for osmotic diuresis
- Dialysis - monitor for K from hemolysis
- Benadryl/steroids
- Dialysis
20
Q
Epilepsy and Seizures
A
- Epilepsy = 2 or more unprovoked seizures in a lifetime
- General - LOC with/without contractions
- Partial - no LOC
- Status epilepticus - on/off seizures for 30 mins
21
Q
Seizure Treatment
A
- control airway
- Supplemental oxygen and monitors
- Activate EMS
- Midazolam - 2mg IV -> 1mg/min IV (.05 mg/kg adults, .025mg/kg peds)
- Glucose check
- Glucose and thiamine prn
22
Q
Multiple Sclerosis
A
- Disease resulting in inflammation, demyelination, and degeneration
Symptoms
-vertigo
-nystagmus
-pain, dysesthesia
-optic issues
-heat sensitivity
-Trigeminal neuralgia
23
Q
Multiple Sclerosis
A
- Disease resulting in inflammation, demyelination, and degeneration
Symptoms
-vertigo
-nystagmus
-pain, dysesthesia
-optic issues
-heat sensitivity
-fatigue
-weakness
24
Q
Myasthenia Gravis
A
Autoimmune disease where acetylcholine receptors attacked resulting in:
- muscular weakness - ocular, face, neck/limbs, respiratory
- fatigue
Beware of drugs that may unmask such as: K, benzos, antibioitcs, muscles relaxants
25
Pscychiatric Patient Concerns
Drug Interactions
- lower seizure threshold
- increase response to epi
- exaggerated CNS depression
- anticholinergic effects
Liver dysfunction
EKG changes
Serotonin syndrome
Neuroleptic malignant syndrome
26
MAOIs
- inhibits MAO
- decreases metabolism of serotonin and catecholamines
-caution with ketamine and meperidine
27
TCAs
- Inhibits reputake of NE/serotonin
- increase response to sympathomimetics, excessive sedation, possible arrhythmias
28
SSRIs
- Prevents serotonin reuptake
-Caution with MAOIs, tramadol, zofran
Serotonin syndrome:
- tachycardia
- tachypnea
- sweating
- diarrhea
- hyperthermia
- hyperreflexia
Tx:
- lorazepam, cyproheptadine, methylsergide, propranolol
29
Bipolar Disorder
Mood disorder resulting in episodes of mania and depression
Tx:
- neuroleptics (1st - typical, 2nd - atypical) - inhibit dopamine -> extrapyramidal effects
Neuroleptic Malignant Syndrome -
fever, rigidity, respiratory distress
-Lithium
-Anticonvulsants -valproate, carbamazepine
30
Concerns in Alcoholic Patient
- Liver dysfunction (decrease in factors II, VII, IX, X, A, D, E, K)
- AST/ALT > 2:1
- decrease in K, Mg, Ph
- EKG anomolies
- DTs: severe aggitation, confusion,
nightmares, tachycardia,
hypertension, sweating
-Tx: benzos
31
Concerns in Opioid Addicted Patients
- increased anesthetic doses
- use benzos and ketamine
- communicate with pain specialist
32
Concerns in Alcoholic Patient
- Liver dysfunction (decrease in factors II, VII, IX, X, A, D, E, K)
- AST/ALT > 2:1
- decrease in K, Mg, Ph
- EKG anomalies
- DTs: severe agitation, confusion,
nightmares, tachycardia,
hypertension, sweating
-Tx: benzos
33
Concerns in Cocaine Abuser
- closely monitor cardiopulmonary system -> high risk of arrhythmia
- no tx within 24 hours of last use
- use caution with local anesthesia
34
Duchennes's Muscular Dystrophy
- X linked disorder in dystrophin protein resulting in weakness, waddling gait, kyphosis, and respiratory difficulties
-Avoid depolarizing muscle relaxer and volatile anesthetics - can increase K and increased risk for MH
35
Marfans Disease
- AD disorder of fibrillin
Signs:
- tall, lanky
- hypermobile joints
- micrognathia
- dislocation of lens
- cardiovascular anomalies - aortic root dilation, aortic regurgitation, MVP, aortic aneurysm)
- Tx: lower heart rate with beta blockers
36
Rheumatoid Arthritis
- Chronic inflammatory condition via autoimmune attack on synovial lining of joints
- Concerns: cardiac valve abnormalities, sjogrens and salivary flow, pulmonary effusions
- Chronic NSAID use increase risk of platelet dysfunction
- Potential for C-spine and TMJ instablity/dysfunction
37
Changes in Pregnancy
- increase cardiac output 30-40%
- increase blood volume 25-50%
- increase in clotting factors -> increase risk of DVT
- increase compression of IVC - L lateral position
- increase respiratory difficult, increase in GERD
38
Dental Treatment in Pregnancy
- 1st trimester - emergency only
- 2nd trimeseter - urgent/semi-elective
- 3rd timester - emergency only
39
Medications in Pregnancy
- Opioids - IV ok but caution with respiratory depression, hydrocodone ok
- propofol ok
- ambien ok
- ketamine ok
- zofran ok
- tylenol ok
- midazolam ok
40
PE/DVT
- blockage of pulmonary vessels
- increased risk from prior DVT, age
- S/S: chest pain, SOB, dyspnea,
41
Gestational Hypertension
SBP >139 w/o proteinuria after 20 weeks
42
Pre-eclampsia & HELLP Syndrome
- SBP > 140
- Proteinuria after 20 weeks
- End organ dysfunction
- Tx: bedrest
- Hemolysis, elevated liver enzymes, low platelets
43
Eclampsia
- Seizures
- end organ dysfunction
- Tx: Magnesium
44
Fetal Alcohol Syndrome Features
hypoplastic philtrum
broad upper lip
micrognathia
hypoplastic vermillion
45
Naloxone
- Opioid antagonist
- side effects: increase in pain, monitor for renarcitization
- Dose: .01 mg/kg q3min IV
46
Flumazenil
- Benzo antagonist
- side effects: PONV, seizures
-Dose: .01mg/kg, .2mg over 15-30 secs, can repeat q3 mins to max 1mg per hour
47
Angina
- Stable: poorly localized chest pain, relieved by rest or sublingual nitro
- Unstable: random, appears at rest
- Prinzmetal's: cyclic coronary artery vasospasm
48
Angina Treatment
- Morphine
- O2
- Nitro - 0.4 mg SL if SBP>90. if no response to 3 doses in 10 mins (q5) activate EMS for MI
- ASA 325 mg
49
Acute MI
- sudden severe crushing chest pain even at rest
Diagnosis:
- 12 lead EKG -> ST elevation in leads 2, 3, aVF
- Q waves represent prior MI
- Troponins : most specific
- CK-MB
- Angiogram
- Tx: MONA, take BP first, activate EMS, institute ACLS
50
Management of STEMI vs NSTEMI
- MONA
- IV access
- CXR - rule out aortic dissection and pleuritis)
- cardiac enzymes
- EKG
STEMI:
- <90 mins PCI, <30 mins fibrinolysis
NSTEMI:
- ASA, evaluation by cardiologist for: stress test, angiography w/wo PCI
51
CVA/Stroke
- Ischemic: thrombus/embolus from A-fib
- Hemorrhagic
- S/S: unilateral face droop, limb droop, slurred speech
Tx:
- activate EMS
- head CT within 25 mins, if ischemic then rTPA/fibrinolysis within 60 mins
52
Lovenox Bridging
- Coumadin takes 4-6 days to exit system
- Thrombin half-life is days so take 6-10 days to ramp up
- Lovenox 80 mg 3 days before procedure, last dose 24 hours prior, then resume 24 hours after
53
Ca Channel Blockers
Dihydropyridines (propensity to vasodilate)
- Amlodipine
Non-DHPs(minimal vasodilation)
- varapimil
-diltiazem
54
Treatment of Bradycardia
- Airway, Breathing, Circulation
- Atropine 0.5 mg q3 mg to max 3mg
- Transcutaneous pacing if heart block
55
Treatment of Bronchospasm
- albuterol if awake
- airway support and positive pressure if sedated
- Epi (1:1000) 0.3mg-0.5 mg Subq
- Corticosteroids
- intubate if worsening
56
Treatment of Laryngospasm
- recognize stridor w/wo retractions
- suction/pack site
- extend neck and jaw thrust to open airway
- Deepen sedation
- Positive pressure ventilation
- Succinylcholine - 0.1-0.2mg/kg
- Intubate
57
Treatment of Acute Hypertension
- Esmolol IV: 10-30mg, only use if tachycardic and normotensive
- Labetolol IV: 5-20mg, only use if tachcardic and hypertensive
- Hydralizine: 5-10mg if bradycardic
58
Succinylcholine Dose
- Depolarizing muscle relaxant
- 0.1-0.2 mg/kg IV, 4mg/kg IM
- 30-90sec onset
- 5-10 min half life
59
COPD/Emphysema
- Loss of elasticity of alveoli, obstructive
- Pink puffer: barrel-chest, dysnpea, cachexia, distant breath sounds
- Blue bloater: obese, chronic cough, cor pulmonale RHF 2/2 pulmonary vasocontriction
- ipratropium inhaler first line, albuterol second line
60
Pneumothorax
- S/S: shortness of breath, tachypnea, cyanosis, hypotension
- CXR: trachea deviated towards in normal, deviated away in tension
Tx:
- depends on size and symptoms
- observation and O2
- needle decompression (midclavicular, 2nd/3rd intercostal)
- Chest tube (anterior axilla, 5th intercostal)
61
Cystic Fibrosis
- AR disease affecting lungs, pancreas, decrease in CFTR protein
- 1:3000
- Dx: genetics, sweat Cl test
- Tx: supplement ADEK, dornase alpha, inhaled corticosteroid, chest PT
- Chronic infections: pseudomonas aeruginosa. Tx: inhaled levofloxacin
62
OSA
HPI, STOP-BANG
Lab based polysomnogrpahy to measure AHI/RDI
- mild 5-15
- moderate 15-30
- severe >30
Nasopharyngoscopy to observe airway obstruction
-DISE or mueller
- fujita scale
Ask for history of CPAP, UPPP, etc...
63
Treatment of OSA
- Nonsurgical: weight loss, CPAP, oral devices, modafinil
- Surgical: genioglossal advancement, UPPP, MMA, bariatric surgery, tracheostomy, tonsils, hypoglossal nerve stimulation
64
Anesthesia Considerations and Management in OSA
- Optimize comorbidities
- avoid sedating premeds
- optimize head position
- be prepared for airway adjuncts
- short acting agents
- optimize pain control
- low threshold for OR setting
65
Hypernatremia
- Na > 145 + headache, lethargy, nausea, thirst, coma
- usually caused by free water loss
- Extrarenal causes: vomiting, osmotic diarrhea, NGT suction, fever, exercise
- Renal - diuresis, DI
66
Treatment of Hypernatremia
- Free H2O repletion
- Don't increase > 10-12mEq daily due to cerebral edema
- Postpone surgery if >150
67
Hyponatremia
- Na < 135
- Acute: cerebral overhydration, N/V, lethargy, seizure, coma
- Chronic: gait disturbance, dizzy, confusion, muscle cramps
-Causes: vomiting diarrhea, third spacing, diuretics, steroids, SIADH, CHF, primary polydipsia
68
Hyponatremia Treatment
- Replete Na slowly due to risk of central pontine mylenolysis
69
Treatment of Tachycardia
Stable:
- Vagal maneuvers, O2,
- Adenosine 6mg ->12mg
- If it doesn't convert get consult and consider procainamide or amiodarone 300mg -> 150 mg
Unstable (hypotension, decreased LOC, shock, chest pain):
- synchronized cardioversion 50-200J
70
Malignant Hyperthermia
- Increased Ca in myoplasm due to ryanodine receptor mutation
- Risk Factors: Family hx of MH, NM disorders, dark urine after prior anesthesia or exercise
- Agents - Depolarizing muscle relaxants (succinylcholine), inhalation agents
- S/S: increases in CO2, HR, RR, temp, muscle rigidity, acidosis
Tx:
- 100% O2, discontinue inhalation agents
- cold saline
- Dantrolene: 10 mg/kg. Prep: 20mg dantrolene, 3g mannitol, 60mL sterile water
- treat hyperkalemia - glucose and insulin + Ca Cl
- Bicarb for acidosis
- ICU - 24 hours minimum
71
Asthma
- inflammatory disease of upper airway resulting in wheezing cough, shortness of breath from various environmental triggers
- As disease increases in severity FEV1 decreases
Types (inhaler need)
- mild intermittent - <2x week
- mild persistent - >2x week
- moderate persistent- daily
- severe - wakes up at night
Tx: Beta 2 agonist, inhaled gluccocorticoid, leukotriene, theophylline
72
Acute Intermittent Porphyria
- Defect in Hb metabolism
- S/S: abdominal pain, constipation, psychiatric symptoms, hyesteria, motor neuropathies, labs show increase in porphobilinogen
- Tx: Hb synthesis, porphon precursors, glucose, narcos, hematin, neurotin
73
Subacute Bacterial Endocarditis
- 2/2 strep viridians on a damaged valve
- Can be fatal if untreated within 6 weeks-1 year
- S/S: fever, cough, SOB, joint pain, diarrhea, flank pain
- audible murmur
- Osler nodes - raised tender lumps on fingers/toes
- Janeway lesions - palms soles septic emboli
- splinter hemorrhages
74
Differences in Pediatric Airway vs Adult
Upper Airway:
- higher position of chords
- limited neck flexibility
- large tongue
- long, narrow, higher epiglottis
- enlarged tonsils
Lower Airway:
- diaphragmatic breathing
- decreased FRC
- increased metabolic demand
- HR main determinant of cardiac output
75
Ketamine
- NMDA antagonist, dissociative, analgesic
- IV dose: 0.5-1.5mg/kg
- IM dose: 2-4 mg/kg
- Increase in HR/BP - use with caution with cardiac patients
76
Midazolam
- Benzodiazepine - anxiolysis and amnesia
- IV dose: 0.1 mg/kg
- PO dose: 0.5 mg/kg
- Causes mild decrease in RR, HR, BP
- Reversal - flumazenil 0.2mg IV (1mg max in 60 mins)
77
Fentanyl
- Fast acting opioid
- IV dose: 2ug/kg
- major decrease in RR, HR, BP
- Reversal - naloxone .01-.03mg/kg
78
Propofol
- general sedative, hypnotic, short-acting, potentiated GABA
- major decrease BP and apnea
- Induction: 2-2.5mg/kg
- Maintenance: 100-150 ug/kg/min
79
Hyperkalemia
- > 5.5
- Causes: ESRD/CKD, hyperglycemia, tissue injury, extracellular shift
- S/S: arrhythmia, weakness, peaked T waves, wide QRS
80
Treatment of Hyperkalemia
- Insulin (w/glucose) /albuterol - drives K into cells
- Lasix if intact renal function
- Ca gluconate - stabilizes cardiac membranes
- Kayexelate - GI elimination
- Dialysis in severe cases
81
Hypokalemia
- <3.5
- Causes: GI/GU losses
- S/S when <3.0: weakness, arrhythmias, flat T waves, U waves
- Tx: replete orally (IV in severe of intolerance of PO), K-sparring diuretics
82
Hyperthyroidism
- Over production of thyroid hormone results in hypermetabolic state, tremors, and increased reflexes
- Causes: Graves disease, goiter, TSH secreting tumor/adenoma, overdose of thyroid hormone
- Dx: TFT showing increase in T4, T3. Decrease in TSH
- Tx: propylthiouracil/methimazole inhibit TH
83
Anesthesia Concerns Hyperthyroidism
- delay case until controlled
- avoid sympathomimetics
Monitor for thyroid storm
- Tx: propranolol, cooling, IVF
84
Hypothyroidism
- Hypometabolic state from decrease in thyroid hormone due to autoimmune disease, thyroidectomy, iodine deficiency
- S/S: weight gain, cold intolerance, fatigue, lethargy, dull facial expression, constipation
- Dx: decrease T4
- Tx: replace thyroid hormone
- Anesthesia - slow recovery
85
Hyperparathyroidism
- Primary - carcinoma, adenoma
- Secondary - response to disease that lowers calcium levels
- Causes increase in calcium results in weak bones, stones, psychiatric undertones, HTN, EKG changes
- Anesthetic considerations - NS and lasix to control Ca
86
Link Between Diabetes and Hypertension
Diabetes increases risk of atherosclerosis which causes damaged endothelium/hardening of arterial walls which causes hypertension
87
Congestive Heart Failure
- Inability of the heart to meet metabolic needs of the body with decreased cardiac output and O2 during exertion
Classes NYHA
1. symptomatic with greater than normal activity
2. symptomatic with ordinary activity
3. symptomatic with minimal activity
4. symptomatic at rest
Tx: diuretics, ACEi, Digoxin, beta blocker
88
Reading CXR
Airway - overall quality, exposure, angulation
Bones - clavicle, ribs, vertebrae
Cardiac - silhoutte slightly enlarged, aortic/pulm vessels visible, pericardial effusions
Diaphragm - R/L hemidiaphragm
Effusions and costophrenic angle
Fields- Lung fields
89
Liver Disease
- Categorize hepatocellular (hepatitis, EtOH) vs cholestatic
- LFTs before surgery and consult with internist
- Caution regarding propensity for bleeding due to factor deficiencies (besides VIII)
90
Diabetes
- glucose regulation disorder
- Type 1: insulin dependent, juvenile, autoimmune
- Type 2: insulin resistant
- Secondary: gestational, steroids, tumor, pancreatic resection, cystic fibrosis
Dx:
- fasting BG > 120 2x
- BG > 200 after 2hrs
- HbA1c > 7
91
Insulin Types
- Fast - regular, semilente
- Intermediate - NPH and lente
- Prolonged - protamine, ultralente, glargine
- Hold fast forms the am before surgey; 1/2 prolonged the nigh before
92
Metformin
- glucophage
- decreased hepatic gluconeogenesis and intestinal glucose absorption
- Side effects: lactic acidosis
- Contraindications: renal or liver failure
93
Glipizide/Glyburide
- sulfonylurea that increases insulin release from beta cells of pancreas
94
Pioglitazone
increase insulin sensitivity
95
Exenatide
- GCP-1 Agonist
- increases insulin secretion
96
Alpha-Glucosidase Inhibitor
Decreases intestinal glucose absorption
97
Pramlintide
- Decreases gastric emptying
- Decreases glucagon
98
Complications of Type 1 Diabetes
- hypo/hyper-glycemia
- acidosis
- ketosis
- microvascular occlusion resulting in end organ damage: CAD, retinopathy, hypertension, neuropathy, gastroparesis
- predisposition to infections and oral disease
- fungal infections
99
AHA/ADA Indications for Prophylaxis
