Oral Board Flashcards
PFTs- which would you order and why?
FEV1, FVC, MEFR (max epiratory flow rate), MMEF (max mid expiratory flow 25-75%. FEV1/FVC - restrictive vs obstr dz, MEFR helps identify large airway obstr assoc with asthma and MMEF give an effort independent eval of small airways
Tachycardia- causes
primary or secondary
primary- svt, vent arrythm
second- hypoxemia, hypercapnia, decr perfusion (anemia, low C.O.), pain (somatic, visceral, sympathetic), hypovolemia (absolute [volume] or relative [obstructive shock]), extraneous work related variables
Will you proceed with lung surgery for patient with lung disease?
The worst case scenario for the case is catastrophic bleeding requiring total pneumonectomy. If this occurs I would need to refer to a split lung test to evaluate if the patient will become ventillator dependent afterwards.
Go through the difficult airway algorithm…
Step 1: global assessment which includes identifiying difficulty (ventillation, DL, cooperation, trach), locating material and staff resources
Step 2: assess for feasibility of avoiding intubation; topicalized sedated vs. intubation under GA; need for preserving spont vent
Important points for GA with ablate spont breathing-
—confirm preoxygenation- use cpap
—always use short acting drugs if need to abort or at least confirm ability to mask ventilate
—always find multiple ways to deliver O2
—use techniques most comfortable
If cannot intubate/ventillate:
1) call for help
2) non invasive emergency vent adjuncts- lma, jet vent, rigid bronch, combitube
3) perc / surgical airway
Go over NALS
No intervention needed- crying, good color, good tone, spontaneous breathing, HR >100bpm. Focus on temperature reg.
If non-vigorous baby- place pulse ox
While waiting for signal-> stimulate baby, observe airway, lay supine, neutral head position, suction if see secretions
Evaluate for meconium staining (may require ETT suctioning)
If Remains non vigorous->PPV (titate FiO2 to sat and HR)
IF HR 60-100bpm revealutate after 30 seconds and continue PPV
IF HR chest compressions
Intubate if chest compressions, cant mask vent
compression rate 90 per minute
breath rate 30 per minute
Epi late addition, 100-300 mcg/kg 0.1-0.3 mL/kg of 1:100,000
give volume
no naloxone, no bicarb
What are the considerations prior to intubating (crossing the line)
ABCD
Airway- evaluate the specific source of dificulty
Belly- full stomach precautions
Conduit- types of equipment, monitors
Drugs/delivery- what drugs are available and IV access
What are the procedure risk stratification descriptions:
Emergent- <6 hours needed- no work up avail
Urgent- 6-24hrs limited work up avail
Time sensitive- 1-6 weeks for delay
Elective-
What are considerations of HOCM?
C.O. impaired with decreased SVR (arterial vasodilators), reduction in preload. This may may increase the degree of dynamic obstruction. Inotropic agents like Epi are usually not used in these patients because of increased LV outflow gradient.
Describe peripartum cardiomyopathy
It is typically a dilated CM that occurs in the last timester or atleast 6 months post, must consider volume status
Concerns for cardiac implantable device
Need to know underlying rhythm and indications, ICD versus ppm, when last interrogated, action if magnet, location of surgery, ability to use bipolar cautery
What are risk factors that factor into a risk assessment cardiac score?
Cr >2, insulin dependent DM, HF, h/o CVA, CAD
Must evaluate functional METS >4-> (flight of stairs, brisk walk)
When to do a cath? When to do a stress test?
Cath- active ACS or post stress
Stress- risk factors and/or <4 MET activity
Helps determine if need particularization or initiation of beta blockade in higher risk
How many days should you wait for elective surgery after balloon angio? BMS? DES?
14 days- baloom, 30 days- BMS, 365 days- DES
Elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosi
What are the features of the CVP waves?
a-atrial contraction c-ventricular contraction V- venous return x- decent from downward displacement of ventricle during systole y- passive ventricular filling
What is a normal CVP? PAP? PCWP?
CVP 0-8, PAP 15-30/6-12, PCWP= 5-15
How to calculate SVR (nml value)? PVR (nml value)?
SVR = 80 x(MAP - CVP) / CO (1200-1500 dyne-sec/cmsqr)
PVR = 80x (PAP - PCWP)/CO (100-300)
What is the orientation of the brachial plexus branches when performing an axillary block?
musculocutaneos- corocbrachealis musc
median- superficial/lateral to ax artery
radial- deep to ax artery
ulnar medial to ax artert
what nerves need to be blocked to prevent tourniquet pain?
intrercostalbrachial (T2) and medial brachial cutaneous (C8,T1) field block at the humerus head
Discuss management of total spinal
early recognition is key- brady, hypotenstion, resp distress, anxiety.
Reverse T
Atropine/ephedrine to treat brady
IVF bolus, phenylephrine to treat hypotension
mask ventillation for oxygenation
supportive verbalization to talk patient through temporary block
Discuss ASRA guidlines for UFH, LMWH, warfarin, Plavix, new anticoagulants
UFH- 2 hr weight, no evidence of increased risk
LMWH- ppx dose or single daily- 12h, therapeutic dose or twice daily is 24h,warfarin 4-5 days and inr <1.5 (inr may be nml but other factors may still be abn), plavix 7 days based on labeling
What is the management of LAST
Call for help airway- ventilate seizure suppression- use benzos avoid prop if cv collapse Call for ECMO available ACLS Intralipid
What are the hallmarks of MH and treatment?
Hypermetabolic state- hyperthermia, hypercarbia despite nml to hight tv, musc rigidity, metabolic acidosis, incr lactate, incr CK, myoglobinuria, rhabdo
Stop volatile agents, call for help, hyperventillate, initiate TIVA, high flows and either mask vent with ambubag or get filter, establish large bore IV and give dantrolene, treat hyperK, MHAUS recomends na-bicarb for acidosis
What are the causes of non amion gap acidosis
Hardup Hyperalimentation Acetizolimide Rta Diarrhea Uterosigmoid fistula Pancreatic fistula
How to prepare for and detect sitting crani?
Ga, Aline, central line with subclavian or ac access- use multi orifice catheter positioned in ra detected by iv ecg showing biphasic p wave
Avoid nitrous
Precordial Doppler - right of sternum between 3rd and 6th rib
