Ortho lecture

Question 1

Early indicators of BCIS

Answer 1

Bradycardia
HOTN
Decreased ETCO2 (first under anesthesia)
Dyspnea & AMS (first in the awake patient)
Hypoxia as measured by spo2
Other indicators: dysrhytmias, decreased CO, p HTN,

Question 2

BCIS treatment

Answer 2

Early: fio2 1.0, Aggressive fluid resuscitation, Pressors (phenyl)/ CVC

Question 3

What procedure has the highest risk for BCIS?

Answer 3

Hip arhtroplasty
But also of note: knee, vertebra, kyphoplasty

Question 4

Tourniquet pressure

Answer 4

Upper: 250
Lower: 350

Question 5

Releasing the tourniquet can cause:

Answer 5

Increased ETCO2
Decrease in core body temp
Decreased BP, SVR, SvO2
Met acidosis

Question 6

Tourniquet pain is usually transmitted by ____

Answer 6

C fibers (slow)

Question 7

Triad of symptoms for fat embolism

Answer 7

Dyspnea
Confusion
Petechiae
but also: drop in etco2 and spo2

Question 8

Fat embolism is seen with what procedures?

Answer 8

Long bone fractures (pelvic, femoral)
but also: CPR, lipo, iv lipids

Question 9

Fat embolism greatest risk is within how soon?

Answer 9

The first 72 hours

Question 10

Risk factors for DVT and PE

Answer 10

Age >60
Obesity
Tourniwuet
>30 min surgery
Fx lower extremities
Immobilization >4 days

Question 11

How would neuraxial anesthesia affect DVT/ PE?

Answer 11

Reduction in events
Sympathectomy
Anti inflammatory
Decreased platelet activity

Question 12

Placement or removal of epidural should NOT be undertaken within ___h of (what) dosing

Answer 12

6-8 hours of mini dose of heparin or 12-24 hours of LMWH

Question 13

True of false: spinal anesthesia is associated with a lower risk of hematoma formation than epidural

Answer 13

True

Question 14

Predictors of peri op mortality following a hip fracture

Answer 14

> 85 yo
Cx
Post op chest or wound infection

Question 15

For arthroscopy, which procedures require LMA, which require ETT?

Answer 15

LMA- knee, wrist
ETT- shoulder

Question 16

What is IVRA, and what is the highest risk?

Answer 16

Double cuff TQ
LAST from wash out after TQ release- cuff MUST remain inflated for 20MINUTES after injecting LA

Question 17

Common upper extremity blocks

Answer 17

Interscalene- upper arm and shoulder
Supraclavicular- upper and lower arm
Infraclavicular- elbow and lower arm
Axillary- lower arm

Question 18

When working with blocks, and pt gets regression of block (tingling, movement), what should you do?

Answer 18

Treat for pain before its too late

Question 19

Explain the brachial plexus

Answer 19

RTDCB
R5 (c5, c6, c7, c8, t1)
T30 superior, middle, inferior
D 5?
C3- lateral, posterior, medial
B5- MARMU (musculocutaneous, axillary, radial, medial, ulnar)

Question 20

Lower extremity blocks

Answer 20

Femoral
Sciatic
Popliteal
Ankle

Question 21

The most frequent symptom of LAST is __

Answer 21

seizure
Except for bupivicaine- cardiac arrest before seizure

Question 22

Last is more common with ___ than with epidurals

Answer 22

Peripheral nerve blocks

Question 23

Signs and progression of LAST from lidocaine

Answer 23

CNS- analgesia (1-5), tinnitus, SM twitching, blurry vision, numbness (5-10), seizure/ LOC(10-15), coma (15-25)
CP- HOTN/ myocardial depression (5-10), Respiratory arrest (15-25), CV collapse (>25)

Question 24

What factors can increase the risk of CNS toxicity? (last)

Answer 24

hypercarbia , hyperkalemia, met acidosis (increases RBF)

Question 25

What factors decrease the risk of SCNS toxicity/ last?

Answer 25

hypocarbia (reduces CBF), hypokalemia, cns depressants raise seizure threshold

Question 26

Difficulty of cardiac resusciation last

Answer 26

Hardest- bupi, levo bupi, ropiv, lido

Question 27

The risk of bupi toxicity is increased with;

Answer 27

pregnancy
BBs
CCBs
Digitalis

Question 28

Treatment of LAST

Answer 28

1- airway fio2 1.0
2- seizures with benzos (avoid propodol bc myocardial depressant)
3- ACLS modifications good: amio avoid: epi, phenyl, bb, ccb
(try to void epi bc it reduces lipid emulsion therapy, but if necessary, keep epi low dose 1mcg/kg),
4- lipids over 70 kg- 100ml over 2 min followed by 250ml over 20 minutes
lipids under 70kg- 1.5ml/kf of LEAN bw over 2 min, then 0.25ml/kg/min
both can be repeated
Continue infusion for 15 minutes after cardiac stability
MAX dose 12ml/kg

Question 29

Max dose for lipid emulsion

Answer 29

12ml/kg