Memorize

Question 1

What is the Glasgow Coma Score and it’s significance?

Answer 1

Scale relating to severity of TBI that correlates with mortality.

Eyes : 4 spontaneous opening, 3 open to voice, 2 open to pain, 1 none

Voice: 5 oriented 4 confused 3 inappropriate 2 incomprehensible 1 none

Motor: 6 obeys commands, 5 localizes pain, 4 withdraws, 3 flexion, 2 extension, 1 none

< 8 severe (need immediate resuscitation)
9-12 moderate (emergent CT)
13-15 mild (may need head ct)

Question 2

Treatment of Pre E?

Answer 2

Delivery of the fetus

Magnesium infusion for seizure px

Blood pressure control usually with labetalol or hydralazine (to prevent end organ damage and ICH)

Question 3

Magnesium levels and PE findings?

Answer 3

Mag tox should always be on ddx of unresponsive pregnant pt

2 normal
5-9 therapeutic
6-12 ecg changes (long PR, wide QRS)
>12 weakness, loss of DTRs
15-20 resp arrest, heart block, cardiac arrest

Question 4

MOA of methergine

Answer 4

Partial Ag/antagonist at 5HT (serotonin) rec on uterine smooth muscle causing contraction, also DA and alpha activity

Avoid in HTN

Dose 200mcg IM for uterine atony

Question 5

MOA oxytocin

Answer 5

Acts at oxytocin rec on uterus - G protein coupled rec that increases intra-cellular Ca causing smooth muscle contraction

produced by posterior pituitary during labor and after birth for uterine contraction. Also involved in bonding and lactation

Has ADH activity and can cause vasodilation

Question 6

MOA carbaprost

Answer 6

Synthetic prostaglandin F2? Stimulates uterine myometrial contraction. Also stim GI smooth muscle leading to diarrhea

Can cz bronchospasm

Question 7

MOA Misoprostol

Answer 7

Cytotec

Synthetic PGE1 that stimulates uterine smooth muscle contraction

Given PR

S/e: diarrhea, fever

Question 8

Massive transfusion
vs
Massive Transfusion Protocol

Answer 8

Massive transfusion: any situation where patient receives many transfusions (traditionally 10units or more in 24h)

MTP: rapid admin of large amounts of blood (> 6u) in a balanced manner (usually in a fixed 1:1:1) in an attempt to avoid dilutional coagulopathy for the treatment of hemorrhagic shock. Institution specific

Question 9

Maximal surgical blood ordering schedule

Answer 9

List of commonly performed procedures and corresponding T&C units recommended.

Hospital specific.

Used to avoid unnecessary T&C

Question 10

Target Pre Ductal SpO2 after birth

Answer 10

1 min   60-65%
2 min   65-70%
3 min   70-75%
4 min   75-80%
5 min   80-85%
10 min 85-95%

Question 11

Neonatal Resuscitation (NALS)

Answer 11

APGAR 8-10 - stimulate and dry
5-7 - stimulate and dry
3-4 - bag mask (start room air)
0-2 - bag mask consider ETT, vent and CPR

0-30sec Of HR < 100 - bag mask (start RA and titrate FiO2)

30-60sec if HR < 60 - CPR 3:1 comp/breaths

60-90sec if:
HR < 60 - epi (10mcg/kg IV or 100mcg/kg ETT)
HR 60-99 continue supported ventilation
HR > 100 you’re good

Very rarely shock neonate but: 2J/kg

Post resuscitation consider hypothermia (33-34deg x 24h)

Question 12

APGAR

Answer 12

Quick way to assess how well neonate is adjusting to birthing process and extrauterine life

Appearance (color):
pink(2), peripheral cyanosis (1), cyanotic (0)

Pulse: >100 (2), < 100(1), absent (0)

Grimace (reflex to stim):
Strong response (grimace, cough, sneeze) (2), 
Weak grimace (1), none (0)

Activity (muscle tone): 
Active movement (2), flexed extremities (1), floppy (0)

Respirations:
Strong crying(2), weak (1), none (0)

HR is the last thing to go (so if APGAR 1-2 all they have is a HR)

Question 13

What are the different targets for anti coagulation drugs?

Answer 13

Platelet inhibitors:
Inhibition of COX2 (TxA2 and PG)
ADP rec antagonist
GIIBIIIA rec antagonist

10a inhibitors

Thrombin inhibitors

Enhance ATIII activity

Vit K antagonist (decrease 2,7,9,10)

Herbs (4Gs) may impair plt fx

Question 14

Platelet inhibitors

Answer 14

(-) COX2 and thus TXA2 and PG:
ASA and NSAIDS

ADP rec (-):
Clopidogrel (Plavix)
Pasugrel (Effient)
Ticlodipine (Ticlid)
Ticagrelor (Brillinta)

GIIbIIIa (-):
Eptifibatide (integrilin)
Tirofiban (aggrastat)
Abciximab (rheopro)

Question 15

10a inhibitors

Answer 15

LMWH enoxaparin (Lovenox)
Fondaparinux (Arixtra)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)

All have X so block factor X

Renal elimination

Question 16

Thrombin inhibitors

Answer 16

2 is “da big” guy in coagulation so

Dabigatran (Pradaxa)
Argatroban
Desrudin
Lepirudin
Bivalirudin (gtt for CPB in prot sens pt or HIT)

Question 17

ASRA and LMWH

Answer 17

Pt on LMWH:
Place cath - 12h low dose, 24 high
Pull cath - 12h low dose, 24 high (but shouldn’t have a cath if on high dose)

Want to start LMWH after neuraxial:
Can only start 40 QD low dose LMWH with in-dwelling cath. Wait 6-8h from end of surgery. Second dose not before 24h.

Question 18

ASRA and Warfarin

Answer 18

Place cath:
5d plus INR 1.5

Pull cath:
When INR 1.5

Question 19

ASRA and fibrinolytic therapy

Answer 19

Contraindicated

If pt comes to ED with stroke and had bloody neuraxial recently, ideally should wait 10 days for tpa

If cath in place when tpa started, check fibrinogen before d/c

Question 20

ASRA and IV Heparin

Answer 20

Place cath: Hold 4-6h

Give Heparin in case:
1h after neuraxial
(Controversial if bloody tap, may want to cancel if case is CPB)

Pull cath: 4-6h

Question 21

ASRA and SQ Heparin

Answer 21

5000 BID: 4-6h to place and to pull

TID dosing and 7500 dosing wait longer?, maybe don’t do it, maybe check ptt?

Is therapeutic (>10000) : wait 24h

Question 22

LMWH dosing

Answer 22

High dose 1mg/kg

Low dose 40QD or 30 BID

Question 23

ASRA and anti platelets

Answer 23

NSAIDs ok

ADP rec (-): 
7d (clopidogrel, prasugrel, ticagrilor)
10d (ticlodipine)

GIIbIIIa (-):
8h (eptifibitide, tirofiban)
24-48h (abciximab)

Question 24

ASRA and thrombin (-)

Answer 24

Dabigatran
Place or pull : 5d

Bivalirudin and argatroban - normal coagulation or avoid

Question 25

ASRA and 10a (-)

Answer 25

Fondaparinux, Rivaroxaban (Xarelto), Apixiban (Eliquis) - 72h

Longer if renal impairment