Medicine Quick Knows Flashcards
ASA Classification I
Class I – normal healthy patient (non-smoker; no or minimal alcohol use)
ASA Class II
patient with mild systemic disease (well-controlled and no functional limitation. Examples: Current
smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well controlled DM/HTN, mild lung disease)
ASA Class III
patient with severe systemic diseases (moderately controlled and definite functional limitation.
Examples: poorly controlled DM or HTN, COPD, morbid obesity BMI >40), active hepatitis, alcohol
dependence or abuse, implanted pacemaker, moderately reduced EF, ESRD undergoing regularly scheduled
dialysis, history (>3 months) of MI, CVA, TIA, of CAD/stents.)
ASA Class IV
Severe systemic disease that is a constant threat to life (Examples: recent (<3 mos.) MI, CVA, TIA,
or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of EF, sepsis, DIC,
ARD, or ESRD not undergoing regular dialysis)
ASA Class V
Moribund patient unlikely to survive without operation (Examples: ruptured abdominal/thoracic
aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant
cardiac pathology or multiple system organ dysfunction.
How many ASA classifications are there
I-VI
Mallampati Classification I
visualization of the soft palate, fauces, uvula, anterior and posterior pillars
Mallampati Classification II
visualization of soft palate, fauces and uvula
Mallampati Classification III
visualization of soft palate and base of uvula
Mallampati Classification IV
soft palate is not visible at all
Pediatric Airway Differences (17 Points)
Small Nares
▸ Large Tongue
▸ Head Large, Neck Small
▸ Limited Cervical Extension
▸ Adenoids/Tonsils – Largest
ages 4-10
▸ Long, Narrow, Higher
Epiglottis
▸ Higher, Funnel Shaped
Larynx
▸ Vocal Cords Inclined
▸ Compliant, Shorter Trachea
▸ Lower Airway Anatomy
▸ Narrower Airway
▸ Diaphragmatic Breathing
▸ Horizontal Ribs
▸ Poorly developed Accessory Muscles
▸ Decreased Alveoli
▸ Decreased FRC – lung size increases rapidly until age 6, then more slowly
▸ Lack of elastin causes collapse of terminal airways to occur earlier, decrease in
Noted difference with heart on pediatric patient due to intubation.
Increased vagal tone, prone to bradycardia on intubation
Diameter for pediatric patient
Diameter: (age + 16)/4 i.e 4y.o. = size 5
Length: (age/2) = 12
Bagging a pediatric patient
Bag valve mask – tidal volume 10-15cc/kg
3 important points about pediatric physiology
-Blood pressure mainly dependent on HR (vs adults where controlled by HR, SV, SVR)
-Cardiac output needs to be twice as high as adults due to increased metabolic rate and oxygen consumption
*Major determinant is Heart rate
*Bradycardia leads to sharp decrease in cardiac output and BP
-Decreased FRC – one of the reasons they desaturate faster than adults
Laryngospasm - 1 Liner
Protective reflex to prevent foreign matter from entering the larynx, trachea, or lungs.
Algorithm to break laryngospasm
-100% Oxygen
-Suction all blood and foreign/pack surgical site to prevent further bleeding into the hypopharynx
-Depress patient’s chest and listen for a rush of air to indicate patency
-If obstruction persists, break spasm with positive pressure via 100% O2 and full-face mask with good seal (appropriately sized for child vs. adult patient.)
-If obstruction persists - Succinylcholine (where is it kept in your office?)
Adults 0.1-0.2mg/kg IV for adults (small dose 10-20mg IV for partial obstruction).
Pediatric dose 0.25-0.50mg/kg IV
In a complete spasm where smaller dose fails to break spasm, use 20-40mg IV
Complications of succinylcholine (4)
▸ Myalgias
▸ Malignant hyperthermia
▸ Hyperkalemic cardiac arrest (in susceptible patients with myopathies)
▸ Masseter muscle spasm in pediatric patients (potential indicator of MH)
Post-treatment concerns of succinylcholine after laryngospasm
Cardiac rhythm changes in response to hypoxia and hypercarbia in prolonged spasm
-NPPE
Bronchospasm - 1 Liner
Constriction of the walls of the bronchioles often
caused by mast cell degranulation that can occur in response to allergic triggers or physical stimuli (secretions or ETT).
-Airway diameter decreases due to mucosa thickening and increased production of thick, viscous mucous.
Signs and symptoms of bronchospasm: (4)
▸ Wheezing
▸ Diminished breath sounds
▸ Prolonged expiration
▸ Increase airway pressures (in ventilated patients)
▸ Predisposing factors to Bronchospasm
▸ History of asthma
▸ Recent symptoms of Asthma
▸ Recent respiratory infection: wait several weeks for airway edema to resolve
▸ Anesthetic technique
▸ Treatment of bronchospasm
Awake/cooperative patient
▸ Inhaled beta agonist via inhaler of nebulizer
▸ Oxygen
Treatment of bronchospasm
Obtunded/Unconscious patient (without ETT)
▸ 100% Oxygen
▸ Epinephrine (1:1,000) 0.3 to 0.5mg SC/IM [Peds= 0.01mg/kg]
▸ 10 to 20 mcg of 1:10,000 solution in response to anaphylaxis
▸ Airway support
▸ Consider corticosteroids
▸ If situation deteriorates -> intubation
NPO guidelines
▸ Clear liquids = 2 hours
▸ Light solids = 6 hours
▸ Fatty solids = >6 hours
▸ Prolonged gastric emptying seen with apprehension, pain, narcotics, analgesics and opiate sedatives
High aspiration risk groups (8)
▸ Pregnant
▸ Diabetics
▸ Anxious
▸ Geriatric
▸ Obese
▸ Smokers
▸ GERD
▸ Hiatal Hernia
Signs/Symptoms of aspiration – may set-in rapidly (6)
▸ Rales
▸ Dyspnea
▸ Tachycardia
▸ Bronchospasm
▸ Cyanosis
▸ Progressive hypotension
Treatment in emerging aspiration patient
▸ Encourage coughing to clear airway
▸ Put chair in Trendelenburg (head down 15 degrees) with patient onto right side (stomach empties more rapidly in this position.
▸ Suction airway – remove any foreign material
▸ 100% oxygen
If patient fails to clear lungs from aspiration, what do you do?
▸ Activate EMS
▸ Clear airway again
▸ Intubate and manage bronchospasm with beta agonist
▸ Small volume tracheobronchial lavage
▸ No antibiotics and no steroids
Appropriate management of patient with airway complication
▸ Observe at least 2 hours in office
▸ Discharge criteria
▸ SpO2 > 94% on room air
▸ No wheezing, shortness of breath and minimal cough
▸ Consider hospital transfer if
▸ Aspiration of particulate matter
▸ Supplemental O2 needed to keep SpO2 in 90’s
Explain the capnograph to me?
Describe Asthma - 1 Liner
A chronic inflammatory disorder of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and cough particularly at night or in early morning.
These symptoms are usually associated with widespread but variable airflow limitation that is at least partially reversible either spontaneously or with treatment.
Asthma-Classic triad of symptoms
▸ Wheeze (high-pitched upon expiration)
▸ Cough – may be dry of productive (mucoid or pale yellow sputum)
▸ Shortness of breath or difficulty breathing
Triggers of Asthma
▸ Exercise – 5-15 minutes after brief exertion
▸ Cold air
▸ Exposure to allergens (dust, mold, pollen)
Classifications of Asthma (4)
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Intermittent Asthma
▸ Symptoms 2 or fewer days per week
▸ No interference of normal activity
▸ FEV1 between exacerbations are normal range
Mild Persistent Asthma
▸ Symptoms more than 2x weekly
▸ Minor interference with normal activity
▸ FEV1 within normal range
Moderate Persistent Asthma
▸ Daily symptoms and need for short acting beta agonist
▸ Some limitation of normal activity
▸ FEV1 60-80% of predicted
Severe Persistent Asthma
▸ Symptoms throughout the day
▸ Extreme limitation of normal activity
▸ Nocturnal wakening nightly
▸ FEV1<60% of predicted
▸ Perioperative Management of Asthma
▸ Peak Flow rate (PEFR)
▸ Reduce exposure to triggers
▸ Prophylactic use of bronchodilator
Drugs used to treat Asthma
▸ Short –acting beta-2-selective adrenergic agonist
▸ Low dose inhaled glucocorticoid
▸ Alternatives – Leukotiene receptor agonists, theophylline, and
cromoglycates
What should you expect an asthmatic patient to have post-operatively
Expect patient to have bronchospasm intra-op and follow management guidelines
Angina-1 Liner
Chest pain that Presents due to inadequate coronary blood flow to the myocardium
Most common sign of an acute coronary syndrome (70-80% of affected patients)
CONGESTIVE HEART FAILUIRE - 1 Liner
Complex clinical syndrome that can result from any structural or functional CV disorder causing systemic perfusion inadequate to meet the body’s metabolic demands without excessively increasing the left ventricular filling pressures
What is CHF characterized by. ( 3 symptoms)
fatigue, dyspnea and fluid retention
CONGESTIVE HEART FAILUIRE common causes (4)
Ischemic heart disease;
valvular heart disease;
idiopathic dilated cardiomyopathy;
chronic HTN
What helps determine severity of CHF?
Exercise tolerance (distance traveled on level ground before SOB);
ability to climb flights of stairs without stopping;
sleep position
(supine?);
lower extremity edema?;
most recent hospitalization
Cardiomyopathy - 1 Liner
Enlargement, thickening or increasing rigidity of heart muscle
Type of Cardiomyopathy and causes (6)
Dilated; hypertrophic; restrictive; arrhythmogenic; right ventricular
Ischemia;
EtOH;
viral illness;
atrial fibrillation/SVT;
ESRD;
poorly controlled HTN
Angina -
Classic Angina
Angina -
Anginal Equivalent
No pain or discomfort, but sudden or decompensated ventricular
failure (dyspnea) or ventricular arrhythmias.
Angina
▸ Atypical chest pain:
Pain and discomfort that is localized to the precordial area and has
positional, musculoskeletal, or pleuritic features.
How is angina classified?
-Stable
Unstable-
Prinzmetal
Stable Angina - 1 Liner
poorly localized deep chest pain that is associated with physical exertion and relieved by rest or sublingual nitro
HTN Stages and Classifications
