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The OSCE in anaesthesia - book > OSCE 1 > Flashcards

OSCE 1 Flashcards

1
Q

1.1 a Check the breathing system on machine circle absorber

A
  1. Visual inspection
  2. Ensure soda lime present not used up
  3. Identify blockages
  4. Leak test
    - Flow 0, Close APL, Occlude Y, pressure bag to 30cmh20 w/ flush, ensure remains fixed >10s, open apl - ensure decreased
  5. Leaks?
  6. 1 way valves - connecting bags

second bag - sim lung on Y, fill with flush + manually ventilate - ensure inflate and deflation lung connected y - watch movement unidrectional

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2
Q

1.1 b What are the benefits of the system circle absorber

A
  1. Economy - FGF reduced - <1lmin, reduced consumption volatiles
  2. Humidification - inspired gas saturated w/ water vapour from expire gas
  3. Reduce heat loss - conservation of heat - exothermic reaction co2 absorption assists maint body temp
  4. Reduced pollution - using low FGF - escaped volatile minimised
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3
Q

1.1 c What happens if a unidirectional valve malfunctions

A

Mixing of inspired gas with expired gas - Co2 = hypercapnia

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4
Q

1.1 d What is the mesh size of granules
what’s that in mm

What do you understand by x-y mesh

A

4-8 mesh or 3-4 mm spheres

Strainers w/ 4-8 mesh - 4 equal strands per linear inch both vertical + horizontal axes
8 mesh = 8 = strands per linear inch
granules of 4-8 mesh size pass thru strainers w/ 4-8 mesh

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5
Q

1.1 e What constitutes soda lime

What are contaminants produced w/ soda ime

A

NaOH, CaOH, KOH, Water, Silica

Compound A - sevo
CO - des iso enflurane

methane + acetone also produced

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6
Q

1.1 f Chemical reactions soda lime

A

Co2 reacts w/ water = carbonic acid - reacts cal hydrox - calc carb and water

co2 also reacts w/ naoh -> sodium bic - reacts calcium hydroxide to regenerate sodium hydroxide

CO2 + H20 -> H2C03 & H+ & HCO3-

CaOH2 & ++ & HCO3- -> CaCO3 + 2 H2O

CO2 + 2 NaOH -> Na2CO3 & H2O & Heat

Na2CO3 & CaOH2 -> 2NaOH & CaCO3

water required for absorption
moisture already present
more added patient

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7
Q

1.1 g Unidirectional valve - how does it function

A

Inspiration -
FG & CO2 free gas from reservoir bag passes thru inspiratory unidirectional vavle & inspiratory limb to patient

During expiration
inspiratory undirect valve closed and expire gas from exp limb pass thru expiratory unidirectional valve to soda lime canister

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8
Q

1.2 ECG

A

Trop T - greatest sensitivity and specificity detecting Acute Mi
norally not serum

Aspirin decrease mortaility

Delta wave - WPW

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9
Q

1.3 Haemodynamics

Cardiac index calculation
Normal ranges

SVR calc
normal range
SVRI

DO2
CaO2

PVR

A

CI = CO / BSA
2.8-3.5

Stroke index = SV/BSA

SVR = MAP - CVP / CO x 80
900-1200
SVRI = SVR/CI -

Fluid guidance - BP, CVP, Wedge

DO2 = CaO2 x 10 x CO
CaO2 Hb x SaO2 x 1.34/100
1
PVR PAP - PAWP / CP x 80

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10
Q

1.4 Stats

Correlation coefficient is denoted by
what is it

Regression involve

R ranges from

Independent variable

Independent variable plot on

complete absence

A

Correlation coefficient is denoted by letter R
denotes association between 2 quant variables

Regression involves estimating best straight line to summarise association

R ranges from 1 -> -1

When 1 vary increase w/ other - positive

Independent variable plot on X axis

Assoc strength
0.2 very weak .4 weak .6 mod .8 strong 1 strong

complete absence represented by 0

correlation =/= causation

Significance of data tested using t-test for parametric data or a non paratmetic test - spearman rank correlation

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11
Q

1.5 Anatomy IJV

label pg 19

Describe course

Tributaries

A 
Originates @ jugular foramen
-continues w. sigmoid sinus
runs down neck terminate 
between sternoclavicular joint
join subclavian vein form brachiocephalic

Common facial Vein

Lingual Vein

Superior and middle thyroid veins

Pharyngeal venous plexus

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12
Q

1.5 Anatomy IJV

Relations

ant x3

post x 3

med x3

A

Anterior
1 ICA

2 Vagus between V+A

3 SCM lower part b

Posterior

1 Symp Chain

2 Dome pleura

3 Thoracic duct

medial

1 Carotid Artery

2 CN IX-XII

3 Deep cervical LN close to vein

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13
Q

1.5 b Describe CVC insertion

A

1 Sterile + head down

2 LA to skin

3 US + use

4 approiate skin punc + direction needle

5 aspiration blood + insert guidewire

6 Passes dilo and railroad cvc catheter

7 Aspirates lumens + suture

8 CXR

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14
Q

1.5 c CVC complications

group

A

A Mechanical

Needling / Introduction catheter

1 Haemorrhage
2 PTX
3 Haemothroax
4 Air embolism
5 Nerve damge
6 exvasc catheter placement
7 chylothorax

B Infective
C Thrombotic

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15
Q

1.5 d Veins of head and neck on page 19

A 
1 Supficial temporal vein
2 facial vein
3 retromandibular v
4 IJV
5 Ant jug v
6 post auricular V
7 EJV
8 Vertebral
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16
Q

1.5 e

Tributaries of IJV

A 
1 Inferior petrosal vein
2 Pharyngeal veins
3 Facial vein
4 Superior thyroid vein 
5 Middle thyroid vein
6 EJV
7 IJV
8 Ant jug v
9 Brachiocephalic V
10 Subclavian V
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17
Q

1.6 F

Major veins of head and neck describe

A

Ijv contin of sigmoid sinus

Runs down neck vertrical
lateral to interal carotid artery
then lateral to CCA

Glossopharyngeal + hypogloassal N
-forward between IJ and CCA
Vagus descend between and behind v + a in same sehath

Many tributaries within neck
Inferior petrosal sinus, common facial, lungual pharygneal super midldle thyroid veins
sometimes occip

EJV commences sub of partoid gland @ level mandilbe
passes down to midpoint of clav and enter subclav vein
crosses SCM

RIJ is straighter - more common for canullation
NICE - US

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18
Q

1.7 ATI
a
Awake tracheal intubation explain to pt
14 points on marking sheet

A

1 Introduce

2 Understanding previous problem

3 Explain why intubate

4 Normally done

5 Why different

6 Other methods - VL after induction

7 Disadvantage
failure intubvate
further danger d/t difficulty BMV

8 Adv / benef
Maint airway = safer

9 May use sedation

10 monitoring

11 LA tech

12 Compare to camera test

13 simple terms

14 clarity

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19
Q 
1.7 ATI
b
indication
C/I
Procedure

how

why nose

A

Indi - known / suspected difficult airway
aspiration risk + difficult intubate antic
cervical cord instabiltiy

c/i  rel
upper airway bleeding
bleeding tendency
stridor
uncoop patient

full monit
iv acces

supplement o2 thr
sedation + reversal

head end / operator in front

Nasal - Alignment / uncomfortable

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20
Q

1.7 ATI
C
Techniques airway anaesthesia

Nose

Oropharynx

Lower airway

A

1 Nose
Cocaine 1.5mg kg or
lidocaine 5% w/ phenyl 0.5%

Oropharynx Lido 4%
gargle 4-5ml solution
3-4 spray of 10% lidocaine (spray 10mg)

Neb also a technique

Lower airway
Spray as you go
4% lido - thru scope w/ epidural catheter down scope
direct visualisation

scope adv to base 2ml 4% sprayed
another 1-2,ml sprayed glottis and vocal cord
scope advance & 1ml thru vocal cords

Total 3-6ml 4% required

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21
Q

1.7 ATI

Internal laryngeal N

A

Int laryngeal nerve
branch superior laryngeal
block internal / external approach

hyoid bone located directly above thyroid
greater horn - located lateral most part none
SLN block walking 25g needle off greater horn inject 2ml 2%
accident art inject into CCA possible complication

internal laryngeal run under muc membrane covering piriform fossa

Trans laryngeal 
skin cricothyroid infiltrate w/ LA
needle / cannula attach to syringe - n saline thru cric
direct bac and caudal avoid vc trauma
aspiration air
4ml 4% lido inject end inspiration
cough - spread above below
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22
Q

1.7 Surgical cricothyroidotomy ? NOT RECOMMENDED PRACTICE NO MORE? - LOOK UP

A

FONA das algorithim

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23
Q

1.7
b
Cricothyroid membrane

A

subcutaenous midline structure

between strap muscles of neck

8mm deep below skin
rang 3-14mm
adults 9mm high 22-30mm wide
wargest tube <9mm outer diam

Identify
feel thyroid notch & follow down
identify stabilise catilage thumb and middle using index locate membrane in midline
not pro pal trachea and follow up

24
Q

1.8 Trauma patient assessment

A 
A
B
C
D
Rapid prim survey
resus vital fxnions
detailed assessment and initiation dfinitice care
25
Q

1.8
b
Indication for CTB in head injury x7

RFactors to warrant further look x 3

A

1 GCS < 13 on initial assessment ·
2 GCS < 15 at 2 hours after injury on assessment in
the emergency department ·
3 Suspected open or depressed skull fracture ·
4 Any sign of basal skull fracture ·
5 Post-traumatic seizure ·
6 Focal neurological deficit ·
7 More than one episode of vomiting since the head
injury

risk factors
1. Age > 65 years ·
2. A history of bleeding or clotting disorder · Dangerous mechanism of injury (a pedestrian
or cyclist struck by a motor vehicle, an
occupant ejected from a motor vehicle or a fall
from height of > than 1 metre or 5 stairs) ·
3.More than 30 minutes’ retrograde amnesia of
events immediately before the head injury

On assessment can the patient actively rotate the neck to 45 degrees to the left and right? if Y - no need for further

26
Q

1.8 c

Neurosurgical r/f

A
  1. Persisting coma GCS 8< after initial resus
  2. Confusion >h

3 Deterioration in LOC after admin

4 Progressive FND

27
Q

1.9 PA Catheter

dNormal PCWP

where does prox lumen open
where from tip

how much volume in baloon

draw traces

wheres the thermistor

4 uses

4 complications

measured values

derived values

A

4-12

Prox lumen - open 25cm tip in RA
measure cvp

1.5ml

Draw traces as inserted and wedges thru
diagram page 35
scaler of 40mmhg, RA 0-4, RV 25 -2 PA

Resembles trace CVP in RA

Thermistor situated?
4cm prox tip

1 assessment of volume status CVP unreliable
2 Sampling mixed venous blood calc shunt fraction
3 Measure CO using thermodilution
4 Derivation of CV indices such PVR DO2 and uptake

Arrhythmia on insert
knotting in rv
balloon rupture
Pulmonary infarction

Measured
CVP PAP PCWP CO SVO2

Derived
CI SV SVI SVR SVRI PVR PVRI

28
Q

1.9 b PAC other

A

PAFC swan and ganz in 970
7 or 7.5G and 110cm long

Balloon tip capacity 1.5ml

Before insert - traducer and zero - wave up down appear monitor - ensure corrected to correct

advamced 20cm before inflate baloon

RA - CVP mon rv systol 25

29
Q

1.10 Paeds resus

Compressions

Doses

A

5 rescue breaths
Compressions 15:2

Doses

Adren
10mcg kg .1ml/kg of 1:10000
IO dose 10ug

Amiodarone 5mg / kg
Atropine 20mcg / kg

Dose DCCV 4 J Kg

Weight 2x age + 4

Fluids 20ml kg

IO after 3 attempts

30
Q

1.10
b
Hs
Ts

A

Hypoxia
hypovolaemia
hypo / hyper kalaemia
hyothermia

Tension PTX
Tamponade
Toxins
Thromboembolism

31
Q

1.13 a
Anaphylaxis
Sim station 10 points

A
  1. Checks vitals + calls critical incident
  2. call 4 help
  3. 100% O2
  4. Check ETT
  5. Auscultate
  6. Ask for adrenaline
  7. Check drip give floods
  8. look cutaneous signs
  9. Admin Anaphylaxis adjuncts
  10. Reassess vitals + repeat adren prn
32
Q

1.13 b
recognising anaphlylaxis
6 features

A

1 Tachycardia

2 Hypotension

3 Severe bronchospasm

4 Low sats - im gas exchange & reduced peripheral perfusion

5 low etco2 reduced pumonary perfusion

6 Unresponsiveness to ephedrine metaraminol

33
Q

1.13 Anaphylaxis QRH steps

A

❶ Call for help. Note the time. Stop or do not start non-essential surgery.

❷ Call for cardiac arrest trolley, anaphylaxis treatment pack and investigation pack.

❸ Remove all potential causative agents and maintain anaesthesia.
• Important culprits: antibiotics, neuromuscular blocking agents, patent blue.
• Consider chlorhexidine as cause (impregnated catheters, lubricants, cleansing agents).
• Consider i.v. colloids as a possible cause.
• Change to inhalational anaesthetic agent (if not already).
❹ Give 100% oxygen and ensure adequate ventilation:
• Maintain the airway and, if necessary, secure it with tracheal tube.

❺ Elevate patient’s legs if there is hypotension.

❻ If systolic blood pressure < 50 mmHg or cardiac arrest, start CPR immediately.

❼ Give drugs to treat hypotension (Box A):
• Hypotension may be resistant and may require prolonged treatment.
• Give adrenaline bolus and repeat as necessary.
• Consider starting an adrenaline infusion after three boluses.
• If hypotension resistant, give alternate vasopressor (e.g. metaraminol, noradrenaline
infusion +/- vasopressin)
• Give glucagon in ß-blocked patient unresponsive to adrenaline.

❽ Give rapid i.v. crystalloid: 20 ml.kg-1 initial bolus, repeated until hypotension resolved.

❾ Give hydrocortisone as part of resuscitation (Box B).

❿ If bronchospasm is persistent, consider → 3-4

⓫ Take 5-10 ml clotted blood sample for serum tryptase as soon as patient is stable.

• Plan for repeat sample at 1-2 hours and >24 hours.

⓬ Give chlorphenamine when feasible (Box B).

⓭ Plan transfer of the patient to an appropriate critical care area. Note tasks in Box D.

⓮ Prevent re-administration of possible trigger agents (allergy band, annotate notes/drug chart)

34
Q

Drugs as per QRH for hypotension

A

Box A: DRUGS TO TREAT HYPOTENSION IF CARDIAC ARREST → 2-1
• Adult adrenaline: i.v. 50 μg (= 0.5 ml of 1:10 000)
i.m. 0.5 mg (= 0.5 ml of 1:1000) if i.v. not possible
• Paediatric adrenaline: i.v. 1.0 μg.kg-1 (0.1 ml.kg-1 of 1:100 000)
[1:100 000 solution made by diluting 1 ml of 1:10 000 up to 10 ml]
• If no i.v. access, intraosseous adrenaline dose same as i.v.
• Suggested adrenaline infusion regimes (adult):
5 mg in 500 mL dextrose = 1:100 000, titrate to effect
3 mg in 50 mL saline. Start at 3 ml.h-1 (= 3 μg.min-1), titrate to
maximum 40 ml.h-1 (= 40 μg.min-1)

  • Glucagon (adult): 1 mg, repeat as necessary
  • Vasopressin (adult): 2 units, repeat necessary (consider infusion)
35
Q

1.13 Anaphylaxis

C Other drugs

A 
Box B: OTHER DRUGS
• Hydrocortisone i.v. doses:
  • Adult: 200 mg
  • Child 6-12 years: 100 mg
  • Child 6 months-6 years: 50 mg
  • Child <6 months: 25 mg
• Chlorphenamine i.v. doses:
  • Adult: 10 mg
  • Child 6-12 years: 5 mg
  • Child 6 months-6 years: 2.5 mg
  • Child <6 months: 250 μg.kg
36
Q

1.13 Anaphlyaxis

D Dont forgets from QRH

A

Box D: DON’T FORGET
• Repeat testing for serum tryptase at 1-2 hours and >24 hours.
Store at 4 degrees
• Liaise with hospital laboratory about analysis of samples.

  • Liaise with department anaphylaxis lead regarding referral to a specialist allergy or immunology centre to identify the causative agent
  • Inform the patient, surgeon and general practitioner.

Report

Inform patient

37
Q

1.13 e
Physiology of anaphylaxis from Kerry B

Diff Anaphylactic vs anaphlyactoid reaction

A

Anaphylactic - acute hypersensitivity rxn - previously sensiteised to antigen

Immune med Ige mast cell

med His + LK released mast cell

Not relate to dose

type 1 or immed hypersensitivity

Anaphylactoid - no prior exposure, can occur on 1st exposure, not IgE med, less severe (can be fatal) related to dose of agent

Similar symptoms = sim causative agents rel from mast cell
difficult different clinc

38
Q

1.13 f
Physiology of anaphylaxis

Acute reaction

A

1st exposure no symp
ige atnibod develop over 14 days
attached to mast cell

mast cell may have 500000 IgE attach membrane

second and subseq exposure - severe reaction
combines with cell bound IgE
mast cell release contents

severeal mediator rel - symp can produce his alone

symptoms vary mild to severe depending amt histamine rel

anaphylaxis - without protection - old theory 1st exposure used body protection / defences against toxic agent
body without defences for subsequent exposures.

39
Q

1.14 Monitoring - capnography
a
ID it

Main stream
what is
advantage

Factors affecting response time

A

Main stream
Cuvette Co2 sesnor - between ett and system
No need sampling
vapour condense on sensor - can result fals high
sense heated 39C
heavier and cumbersome

Adv
No delay,
no loss in gass
no mixing sample w/ inspired

40
Q

1.14 b

side stream

A

Side stream
Sensor located main unit
gas aspirated - small pump via sampling tube at rate of 50-150ml min
gas also contain anaes - should be scavenged / return system

Factors affecting response time
1 Response time depend on transit + rise time
2 Transit time depends on length of sample tube
3 rise time depends on optimum flow and size of chamber
- very low flow and large chamber increase rise time

41
Q

1.14 C

Capnography phases

A

1 Inspiratory baseline -
should be at 0 as elevated means rebreathing

2
Expiratory upslope
shallow - obstruction

3
Plateau
representing mixing of alveolar gas
if sloped not flat - uneven mixing - COPD

4
Inspiration
Fall to 0
downstroke

42
Q

1.14 Patterns of capnography on page 57

A

page 57

43
Q

1.14 E
Measurement of CO2
Capnometry vs capnography

plotted how

A

Capnometry measure of Co2 conc during resp cycle

Capnography graphic representation CO2 conc - waveform

plot as EtCO2 vs time
CO2 plot y
Time - X

44
Q

1.14 F

How does it work

A

Capnography uses IR absorption Co2
gases molecules 2/= diff atoms absorb rad in IR spec
Co2 strong absorption at 4.26
Spec scope page 58

Amt IR absorb proport to CO2 conc
Electrical output photodetector present partial pressure Co2 in sample chamber

45
Q

1.14 G
Changes in trace

sudden decrease to 0

sudden decrease low

exponential drop

gradual decrease

A

Sudden decrease in etco2 to near 0 =
airway disconnection
totally obstructed airway or vent malfunction

Sudden decrease to low level
reduced CO or leak

Exponential drop due to reduced pulmonary perfusion - low CO / PE

Gradual decrease hypervent / hypothermia

gradual increase - hypervent or increase body temp

46
Q

1.15 a
1 Diathermy uses

2 Physical principle

3 current

4 Why plate large area

5 What happens if plate disconnected + diathermy activated

6 Other problems with diathermy

7
Mono vs Bi

A

1 High freq A/C
cut or coag tissue during surgery

cutting - sine wave
coag - damped or pulse sine wave

2 High frequency current
(min fx on cardiac and skel muscle)

localised high density current
(current per unit area)
High at forceps at low at earth plates
depending equipment - accetpable level leakage determ

3 0.5- 1Mhz

4 Large plate reduce current density

5 Current flow thru patient and earther thru any metal - attach patient

6 Fire and explosion
pacemaker dysfxn

7 monopolar needs neutral plate

bipolar forceps travels one limb and leaves other other
bipolar - lower power

47
Q

1.15 b
Safety features

Precautions prevent hazards to patient

A

1 Outer case is earthed

2 Isolating capacitor - high impedance to low frequency current

3 Floating circuit
active electrode and neutral electrodes are isolated from earth connection
‘earth free circuit’

1 Good connection to neutral plate to patient

2 not activating diathermy until active electrode contact with tissues

3 Regular servicing

48
Q

1.15 C

Pictures

A

CF - leakage current <10amperes

BF Higher protection vs shcok than provided w/ B

LIKE cf - FLOATING RESPECT TO EARTH

B type = non cardiac grounded applied parts
come into contact with patient

C type = heart
f floating - isolating

CF is for cardiac application - higher degree protection vs shock than BF

49
Q

1.16 A Radiology CXR

CT ratio

And heart borders in page 66

A

Normal cardiothoracic ratio

50
Q

1.18 Awarenss communication station

a marking sheet

15 points

A

1 introduce

2 Discuss in presence of witness

3 confirms facts
listens to hix find out what does recollect

4 apology

5 advise precaution measure taken

6 unstable - stabilised careful drug - possible during that had awareness

7 any pain during it

8 rare, complcation with trauma patients

9 interview senior consultant

10 Follow up

11 Psychological support

12 Ressures future ga safe

13 advise documented and write gp

14 want to know anything more

15 polite rapport

51
Q

1.18 b

Memory

A

Explicit memory - concsiou awarenss w/ recall +/- pain

implicit - perception during anaes w/out recall or concious awareness

poss confused ketamine

high
obs and trauma
tiva

human error judgement or faults

52
Q

1.18 C

Key points

A

See patient early

ward nurse / reposible

apology not guilt - helps patient

get facts right

find out what recall

explanation and conduct and safety

special interest boss

reassure

53
Q

1.19 a
Anatomy - intercostal nerve block

Anatomy of chest on page 72

A

page 72 1-8

54
Q

1.19 b

3 structures passing thru IC space
how aranged

i 3 strctures
how arranged

ii
how many veins in each space

iii Indications

iv which 2 muscles are IC nerves and vessels found

V
Complications

vi what type of nerve is IC

A

i

V
A
N
above down

ii

1 posterior
2 anterior

iii

Thoracic surgery 
breast
upper abdo procedures - chole
rib #
IC drain

iv
NV bundle between internal IC + Inner IC muscle

v 
PTX
intravasc injection
Bleeding
nerve damage
LAST

vi
Mixed spinal

55
Q

1.19 c
Intercostal nerves
emmerge where

divsions?
what they do

connect what

where does ant division pass

Where doe t1 t2 etc provide

Prob with block?

A

t1-t12 Spinal nerves
emerging intervertebral foramina divide into anterior post div

post - sens and motor to parvert region

connect symp chain
anterolat to vert body and comm thru rami communicantes

ant division
ic space - ICN
runs costal groove 
inner surf
inf border of body rib
= protection

T1 - UL
T2 Intercostbrachail

T3-6 thorax
t7 down - abdominal wall

t11 t12 - subcostal

Block - no viscera cover
D/T vascularity - high propensity for LAST
Higher peak plasma vs other blocks

56
Q

Cranial Nerves and how to test

A

1 Olfactory - smell

2 Optic

Pocket acuity chart - seperately
visual fields 
Diam pupils
Direct + Consensual
Accom reflex
3 4 6
Oculomotor Trochlear Abducens
Ex ox muscle
SO4 LR6
3 - levetor palpebrae - eye elevator - 
PS fibre w/ 3rd - a/w disrupt ps activit - pupil dilate

5
trigeminal -
mastication + sensory innervation
feel masseter bulk - clench teeth

sense
Opthalmic 
max 
mandib
pin prick fine touch cold + warm

corneal reflex V + VII
Cotton bud touching cornea - observe reflex blinking

7 Facial
look creases
raise eyebrows, shut eyes tight, show teeth bloow air out
lesion peripheral - entire half face
central - upper half spare - dual innervation

8 Vestbicoc
hearing and balance - hearing tested
bilat connect precise diagnosis difficult
whisper
webber rinne 
audiogram
9 + 10
Glossopharyngeal + Vagus
Test together
hoarseness swall dific
aa look palate - 
uvula reamains midline
soft palate rises symett
unilat - uvula drawn to normal side
gag sens ix motor x - stim back throat

11 Accessory
trapezius + SCM
wwasting muscle
shrug shoulder and turn head

12 hypogloassoal
tongue muscle - ask prtude - wasting fasic deviation
unilat lesion - towards affect side

The OSCE in anaesthesia - book (5 decks)

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