NCE Prep Flashcards
Damage to the ulnar nerve presents how?
as a claw hand
- digit affected- 4th and 5th
- inability to extend pinky and ring finger
- inability to abduct pinky finger
Motor innervation of tibial nerve is?
Plantar flexion and inversion
Fail Safe-something about adding a 3rd gas
?
What risk is it to the patient if the positive pressure relief valve dosnet work?
can cause barotrauma
What innervates the Biceps?
Musculocutaneous
What innervates the Triceps?
Radial
What drugs should not be given to Parkinson’s patients?
-Antidopaminergic drugs such as metoclopramide. butyrophenones(haloperidol & •droperidol), and phenothiazines(promethazine) may exacerbate extrapyramidal s/sx. These drugs are contraindicated.
•aspiration. Levodopa has a half-life of 6-12 hours. It must be given the morning of surgery to prevent •worsening of symptoms such as rigidity, which can impact ventilation. For longer procedures, levodopa may be administered via an OG tube. Anticholinergics may be used to treat acute exacerbation of Parkinsonian symptoms. •Diphenhydramine has anticholinergic properties and is useful for sedation and reduction of •tremor. Hypotension should be treated with intravascular volume expansion and direct-acting •agents, such as phenylephrine. Alfentanil may cause an acute dystonic reaction due to interruption of central •dopaminergic neurotransmission. Ketamine is controversial due to its effects on the SNS. •There is no contraindication to succinylcholine or non-depolarizers. •Monitor for postoperative ventilatory failure
In the patient with Parkinson’s disease, the dopaminergic neurons in the basal ganglia are destroyed. This favors a relative increase in cholinergic activity. 1.Increased Ach in the basal ganglia increases GABA activity in the thalamus. 2.Recall that GABA is an inhibitor neurotransmitter, so increased GABA suppresses the thalamus. Thalamic inhibition suppresses the cortical motor system and motor areas in the 3.brainstem. The end result is an over activity of the extrapyramidal system
WPW can be recognized by this wave on an EKG and what Ca Channel blocker should not be given?
Delta Wave
Verapamil
Order of decreased SVR/MAP? “SVR is down” of the volatile agents?
- Iso
- Sevo
- Des
(Apex) Sevoflurane causes the least reduction in SVR
N2O and B12-aplastic anemia??
?
Why might patients with Treacher Colins/VSD have a difficult AW?
Treacher Collins-small underdeveloped maniple
VSD-Trisomoy 21?-large tongue/C-spine(C1/C2 possible subluxation!) abnormaliites
Diaphragmatic hernia
Congenital diaphragmatic hernia is a diaphragmatic defect that allows the abdominal contents to enter the thoracic cavity. The formation of Bochdalek is the most common site of herniation(usually •on the left side). Other sites of herniation include the foramen of Morgagni and around the •esophagus
Pathophysiology and Anesthetic Management The mass effect of abdominal contents within the chest impairs lung development, leading to pulmonary hypoplasia. One or both lungs can be affected. Consequences include poor pulmonary vascular development, •increased pulmonary vascular resistance, pulmonary hypertension, impaired airway development and airway reactivity. Keep PIP < 25 - 30 cm H2O to minimize barotrauma and the risk of •pneumothorax of the “good” lung. This may require permissive hypercapnia; and while it will increase PVR, it’s the lesser of two evils in this situation. Avoid other conditions that increase PVR(hypoxia, acidosis, •hypothermia). Abdominal closure may increase PIP. The surgeon can create a •temporary ventral hernia to increase the abdominal volume. A pulse oximeter placed on a lower extremity can warn of increased •intra-abdominal pressure. Right-to-left shunting through the ductus arteriousus leads to hypoxemia and cyanosis, and this gives rise to a positive feedback loop where PVR increases even further. Use the right upper extremity to monitor pre ductal SpO2 and BP. •Pre ductal SpO2 should be > 90% •Surgery is delayed 5 - 15 days to allow for stabilization of the pulmonary, cardiac, and metabolic status.
TEF—–>
Esophageal atresia is the most common congenital defect of the esophagus, and most of these children also have a tracheoesophageal fistula. Esophageal atresia prevents the fetus from swallowing amniotic fluid, this maternal polyhydramnios is a key diagnostic indicator for TEF. Diagnosis is confirmed by the inability to pass a gastric tube into the stomach. Other symptoms include: choking, coughing, and cyanosis during oral feeding.
Discuss the anesthetic management of TEF.Head up position and frequent suctioning minimize the •risk of gastric aspiration. Awake intubation or inhalation induction with •spontaneous ventilation. Positive-pressure ventilation -> Gastric distention -> •decreased Thoracic compliance -> increased PIP required to ventilate -> repeat Placement of g-tube allows for gastric decompression. If •the patient already has a g-tube, open it to atmosphere before induction. Place the endotracheal tube below the fistula but above •the carina. If placed too high, respiratory gas is delivered to the •stomach. If placed too low, endobronchial intubation is likely. •A precordial stethoscope placed on the left chest will •immediately detect a right mainstem intubation. Right lung compression during surgical repair is •common. Right mainstem intubation will cause rapid desaturation.
Epiglottis vs Croup
Epiglottis: age2-6 Rapid onset supra glottis structures CXRAY: thumb sign High fever tripoding drooling
Croup: age <2 gradual onset laryngeal structures CXRAY: steeple sign mild fever mild stridor barking cough
Phase 2 block hotspot?
?
What are the ingredients of EMLA cream?
- 5 lido
2. 5 prilocaine
What are the dangers of sevo in the presence of desiccated soda lime?
fire
What is the osmolarity of CSF?
295…the osmolarity of plasma also is295
What type of bond is the strongest?
Covalent bond
What tendons is the ulnar nerve block between?
flexor carpi lunaris tendon
palmaris longus tendon
Block of the ulnar nerve is achieved by abducting the arm and flexing the elbow to 90°. The needle is inserted 1–2 cm proximal to the ulnar sulcus and directed 45° cephalad. When optimal needle position has been achieved, 5–10 ml of LA should be injected. Injection into the tight ulnar sulcus should be avoided as this can cause pressure-induced neuropraxia. Within the ulnar sulcus, the nerve is relatively immobile and is at risk of needle trauma.
What tendons is the median nerve block between?
flexor carpi radius tendon
palmaris longus tendon
The median nerve is found approximately 1 cm medial to the brachial artery on the elbow crease, lying at a depth of 1–2 cm. The needle is advanced at 45° cephalad to the skin, and a click may be felt as it passes through the bicipital aponeurosis. When optimal motor stimulation is achieved, 5–10 ml of LA is injected. The needle is then redirected subcutaneously along the medial border of the biceps tendon where the medial cutaneous nerve of the forearm is blocked by injecting a further 5–10 ml of LA.
What tendons is close to the radial nerve block
extensor pollicus longus
extensor pollicus brevis
What are the T3, T4, TSH differences between hypothyroid and hyperthyroid?
Hyperthyroidism: low TSH, High T3 and T4
Hypothyroidism: high TSH, low T3 and T4
What abnormal laboratory values are seen with Addison’s disease?
hyponatremia
hyperkalemia
normal glucose
I present with:
Hypertension(Na+ and water retention)
Hypokalemia(K+ wasting)
Metabolic alkalosis(H+ wasting)
Etiology is:
Primary hyperaldosteronism
-increased aldosterone release from adrenal glands(renin activity is normal)
Causes: aldosteronoma, pheochromocytoma, primary hyperthryoidism
What am I
Conn’s Sydrome
I present with- Glucocorticoid effects: -hyperglycemia -weight gain -increases risk of infection -osteoporosis -muscle weakness -mood disorder
Mineralocorticoid effects:
-HTN
hypokalemia
-metabolic alkalosis
Adrongenic effects:
- women become masculine
- men become feminized
etiology: the result of cortisol excess either from overproduction or exogenous administration.
what am I?
Cushing’s Syndrome
Cushing’s disease is a result of excess ACTH
I present with- Adrenal insufficiency: -muscle weakness/fatigue -hypotension -hypoglycemia -hyponatremia/hyperkalemia/metabolic acidosis -anorexia/weight loss -n/v -hyperpigmenation of the knees, elbows, knuckles, lips
what am I?
Addison’s disease
Decreased ACTH
What’s the treatment for Addison’s disease?
Adrenal insufficiency:
-steroid replacement therapy
Acute adrenal crisis:
- steroid replacement therapy
- ECF volume expansion
- hemodynamic support
What is the treatment for Conn’s Syndrome?
Anesthetic Implications?
Removal of aldosterone secreting tumor
Aldosterone antagonist-spironolactone/eplerenone
Potassium supplemenatation
Na+ restriction
Anesthetic implication:
Hypokalemia
Hypertension
What is the treatment and anesthetic implications for Cushing’s Syndrome?
Treatment:
Transsphenoidal resection of anterior pituitary gland
Pituitary radiation
Adrenalectomy(if adrenal tumor)
Anesthetic Implications:
In addition to considerations for hyperaldosteronism covered on last page:
-special attention to aseptic technique
-careful positioning to reduce akin and bone injury
-consider postop steroid supplementation
-diabetes insidious may develop after removal of anterior pituitary gland
What is peripheral edema a sign of?
right sided heart failure
What drug is toxic to the lungs?
Bleomycin
