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The OSCE in anaesthesia - book > OSCE 2 > Flashcards

OSCE 2 Flashcards

1
Q

2.1 Humphrey ADE
pg 81

i Componenets

ii what pressure does relief valve open at

iii advantage

A

Inspiratory + expiratory tubing

Humphrey block

  • apl valve
  • indicator
  • reservoir bag

Lever - spont / cv

vent port / saftey pressure relief valve
(opens at 60)

Adv
1 Effic Sv + CV
2 Single system adult / children
3 Choice - semi closed w/out soda lime or circle w canister
4 Easy scavenge
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2
Q

2.1
iv
What are the changes with lever position

v
Explain how it functions as each

A

mapleson A when lever up - SV
FGF 50-60

lever down - mapleson E CV
70ml kg min

Level up - A
resevoir bag -> inspiratory limb

Expire - thru expire limb to APL- scavenge connected
end expiration - mix alveolar and dead space thru apl
inspiratory - gas breathed inspiratory limb + resevor bag

Lever down
reservoir bag isolated inspiratory limb 
\+
APL valve isolated from expiratory limb
acts as a t piece - 
insp limb gas delivery tube to patient end of T piece and expiratory limb acts as a reservoir limb of t piece

attach reservoir bag and apl converted to D
exp limb reservoir of t piece can be connected to ventilator

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3
Q

2.2
ECG basics

standardisation

Normal recording speed

RBBB

LBBB

RAD

LAD

A

5mm = 1mv

Normal recording speed 25mm/sec

RBBB
QRS >120ms -
rSR’ / rsR’ V1
Wide Term S in lead 1 and V6

LBBB
QRs >120
upright QRS I + V6
Predom neg qrs in V1

RAD
neg I
Pos III

LAD
III neg

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4
Q

2.2 PM Insertion indications

A

1 Sinus node -
sick sinus syndrome
recurrent stoke adams
SN dyfxn

2 CHB
Symp 2nd hb
symp bifasic
trifascic hb

3 Chronic AF

4 Persistent / symp 2nd or 3rd hblock w. MI

5 Atribeicent pacing in mod to severe hf

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5
Q

2.3 Data interpretation

Aspirin

A

Act charcoal + lavage may be useful for 24hr

Acidic drugs - elim alkaline urine
achieve 1.26 soium bic
increase elim - plasma level 3.6>

HDial - considered >5.1 / lower w/ fetaures
aspirin 90% prot bound - OD >25% removed by HD

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6
Q

2.4 Cushing reflex
features

what happens

whats the response to the initial defence mechanism

A

HTN
Bradycardia
Increased intracranial HTN

Ischaemia of hypothalamus -
activates SNS
increase Contractility , HR, VCON

Increase bp maint CPP

Raised BP increased baroreceptor d.c
= inhibition of vasomotor centre
increase PS d/c
= bradycardia

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7
Q

2.4 Diabetes insipidus in Ischaemia

A

High urine output
low urine osmolality 50-200
high serum osmolality
norma to elevated serum sodium

U out >90ml kg day ~4ml kg hour
spec gravity < 1.101

Trauma surgery pit / hyptohal
Rx DDAVP

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8
Q

2.5 Stellate ganglion block

anatomy pic page 95

where is stellate ganglion

describe techniqu 5 points

A

Anatomy page 95

C7-T1
Vertebral + subclavian close

  1. Informed consent
  2. Drugs / equipment check
  3. Aseptic technique
  4. supine + neck extended
    5 Between trachea + carotid sheath
    @ cricoid
  5. chassaignacs tubercle of c6
  6. neg aspiration + inject LA
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9
Q

2.5 b

Indicatios for stellate ganglion block

A

1 Pain syndrome
CRPS 1+2
Refractory angina
phatnom limb pain

2 Vascular insufficiency
Raynauds
frostbite
oblit vascular disease

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10
Q

2.5 c
Features of successful block

Fetaures horners

A

Horners
Increase temp ipsi UL

Ptosis
miosis
anhydrosis
enopthalmos
loss ciliospinal reflex
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11
Q

2.5 d

Name 4 complications of stellate ganglion block

A

Needle in wrong place
1 vascular injury
haematoma trauma to carotid

2 Neural injury - vagus / brachail plexu

3 Pulmonary injury - PTX haemotx

4 Oesophageal perf

Spread LA

1 IV inject

2 Epidural block

BP injury

Infection

Soft tissue / neuraxial

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12
Q

2.6 Communication of brain stem testing

a marking scheme for osce station

A

1 Introduce self

2 Confirm talking to right person

3 asks what understand so far

4 explains breathing machine on life support

5 explains scan findings

6 Neurosurgical r/v + opinion

7 Explains procedures of bs test

8 respeated again

9 signifcance of brains stem testing / breathing machine off

10 organ donation

11 reassure explain

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13
Q

2.6 b

Principles of communication

A
  1. Introduce + explain role and purpose
  2. Establish understanding + knowledge of person

3 Honest + Provide correct info and facts

  1. Explain in simple language
  2. Actively listen
  3. Respond to verbal and non verbal
  4. Summarise and clarify - provide opportunity clarification
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14
Q

2.6
Brain stem testing
3 preconditions

A
  1. Apnoea + MV
  2. Establish cause coma = reversible injury
  3. Exclude reversible causes

Brian stops working not send mentions to unconcoius fxn + cant recieve info back
= No chance of recovery and by law has passed away

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15
Q

2.7
Tech skill
a LP -> spinal anaesthesia

Surface landmarks - spine

Describe procedure

A

C7 - Most prominent Spinous process

T7 - Inferior scapula tip

L3-4 - ASIS TUFFIERS LINE

Locate - asis / iliac crest sitting / lateral
not higher LP / spinal

Procedure

  1. Consent, resus, equipment
  2. IV access establish
  3. Monitoring ecg spo2 nibp
  4. strelity
    5 back prep -> antiseptic soln + sterile draping
  5. LA infiltration
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16
Q

2.7 Needles for spinal
a
types

gauge

procedure

what if its bloody?

A

Quincke - cutting

Sprote / Whitacre - pencil point

<24g generally

Introducer inserted into space
Spianl introduced - LOR when Dura pierced
Free CSF flow

if bloody -wait CSF clear - then inject
bloody - resite

17
Q

2.7 Spinal

1 How much LA for each segment to be blocked

2 What affect spread of LA

  1. Contraindications to Spinal
  2. Blood supply to spinal cord
A
  1. 0.2ml

In avg 70kg man
1-1.5ml 0.5% bupivacaine = saddle block
2-2.5 T10
2.5-3ml - T4-T6

2 Baricity
patient position

3 
Patient refusal
System / Local infection
Abnormal clotting
Raised ICP

1 anterior
@ magnum: join vertebral
join radiular - 1 arteria radicularis magna - / artery adamkiewicz (aorta low thoracic / lumbar)
damage = ant spinal artery syndrome

2 posterior spinal artery
Post inferior cerebellar artery
-supplement spinal branch vertebral, deep cervical intercostal

18
Q

2.8 Cardiac exam

A

IPPA

Radiofemoral delay - coarct

19
Q

2.9 Wrights respirometer

1
what measure

2 How does it work

3 Uni or bidirectional flow

4 Advantages?

5 disadvantages

A

TV + MV

direct gast hru oblique slot in small cylinder

enclosing vane - made to rotate
spindle mounted connected pointer - moves over a dial indicating amt gas passed

Unidirectional flow
dont register gases flow back thru device reverse direction inpinges on bottom edge vane = not rotate

small
portable tv measurer
Not require electrical supply

5 -
Min flow 2L/min
over read at high and under at low
water condensation can cause it to stick
no diplay of measured volume - no elec output
20
Q

2.9 Wrights respirometer

b

whats the resistance to flow#

2 other devices measuring flow

Principle behind pneumotachograph

A

Low

2 cmH2O @100l min

Pneumotachograph
Rotameter

Constant orifice
variable pressure flow meter

Gas flow thru fixed resitsance = drop pressure

differential pressure transucer senses pressure gradient accross restance
change pressure proprtional flow

advantages -
high accuracy
display reading

21
Q

2.10 BLS Pregnants mother

A
  1. Seen is safe
  2. Check signs of life?
    feel pulse and open airway
  3. Call cardiac arrest, trolley, senior help
    obstetrician + paediatrician
  4. Insert wedge under right side / manual displacement
    - relieve aortocaval compression
  5. Chest compression 30:2
  6. BMV/ Intubate
  7. Arrest trolley arrives - get pads on
8. Hs 
hypoxia
hypovolaemia
hypothermia
hyper/po kalaemia
T
tension ptx
toxin
tamponade
thrombembolism
22
Q

2.10 b
Pads are on
see a bradycaria - hr 38
how manage?

Rx

Rf for asystole

A 
Adverse signs
rate <40
bp <90
Heart faiulre
vent arrythymia

Rx
Iv Atropine 500ug

max dose 3mg atropine
in 500ug doses

RF asys

  1. Recent asystole
  2. Mobitz 2
  3. CHB w/ broad QRS vent pause >3s
23
Q

2.10 c
challenges resus preg

causes of maternal death

Challenges in preg anaes

A
  1. CO. Blood vol / oxyge consumption increase
  2. Consider baby
  3. Gravid uterus - compression iliac / abdo vessels
Causes mat death:
Thromboembolism
hypertensive disorder preg
haemorrhage
amniotic fluid embolism
  1. Increase risk aspiration
    tracheal intubation more diff - changes anatomy

ectopic preg
abruption
rupture - massive haemorrhage

immed resus fail - consider emergency section
better change survival if 5m of arrest

24
Q

2.11 Anatomy
a
i Vagus nerve diagr pg 115

ii Origin of vagus

iii how many nuclei

iv
what foramen does it leave

v
what other structures leave with it

A 
1 Vagus
2 SupLN
3 IntLN
4 ExtLN
5.RecLN

Medulla oblongata

  1. Dorsal nucleus
  2. Nucleus ambiguus
  3. Nucleus tractus solitarius

Jugular foramen

  • Accessory N
  • Glossopharyngeal
  • IJV
25
Q

2.11 Anatomy Vagus nerve
b

i What are the relations of the vagus nerve

ii course Right vagus

iii course left vagus

iv

other branches of vagus

A

Neck - passes in carotid sheath
between IJV + Internal carotid artery

beyond border thyroid cartilage - between IJV and common carotid

ii R
passes subclavian between innominate vein
descends side trachea to back root of lung - spread pulonary plexus

L
Thorax between l carotid and subclav - behind l innominate -
crosses left side archa aorta
descend beind root of left lung - posterior pulm plexus

iv

Jug foramen - meningeal + auricular

Neck
pharyngeal

Thorax - inferior cardiac
post bronchial

abdomen
gastric coeliac hepatic

26
Q

2.12 Lap chole hx taking

previous awareness

A

Types awareness

Explicit awareness

  • > recalls event
  • rare

1/1000 - no cardiac surgery GA
Risk - cardiac csection trauma emergency

Implicit awarenss
brain retains abilitiy take information into subconscious part brain - no spont recollection

  • conscious recall
  • unpleasant dram
RF awareness
Impaired CVS status
anticipated difficult airway
hx awareness
heavy alcohol intake
bzd opiod chronic use
asa 4/5
27
Q

2.13 Failed intubation

A

DAS algorithm PDF

28
Q

2.14 PNS
i function

ii 2 factors determine energy requirement propagate impulse

iii Why supramax stim

iv where ulnar

v where neg and pos

A

Monitor depth of NM fxn
Induction - assess depth
maintenance - titrate repeat does
recovery - assess adequacy reversal

Stimulus strength mA
Duration of stimulus m/s

Ensure all motor fibres of nerve stimulated
~60mA - acheive most
(increase above pointless - not produce stronger response

Distal -
1cm proximal to flexion crease wrist

2-3cm prox to distal one

Negative - distally - on nerve
Positive proximally

29
Q

2.14 PNS
What muscle contraction - observe when ulnar stim

Methods of assessing

whats a dbs

whats a ptc

whats mech of ptc

whats signif ptc

A

Adductor pollicis brevis

Visual
Tactile
EMG
Accelomyography

Two bursts of
50hz tetanic stimulation
sep 750ms

Single twitch stim following tetanic stim - count response

Increase mobilisation of ach
subseq single twitch release supernormal ach

ptc<5 profound block
>15 = 2 TOFs twitch’s

30
Q

2.15 Defibrillator

safe use of defib

A
  1. checks leads - position + monitor on patient
  2. confirms rhythm
  3. applies pads correctly
    a - right upper sternum below clavivle
    b - 5th IC left any axillary line
  4. charge safe energy level
    - 150-360 biphasic
  5. Visual sweep before shocking - stand clear
  6. Remove oxygen
  7. Deliver shock while looking at monitor
  8. Resume CPR
31
Q

2.15 Defib

a what would do if patient has PM

what about symbols

A

Place electrode 12-15cm from PM unit
If has pacemaker - current travel along wire - causing burn where tip contact w/ myocardium
AP placement

BF - body floating defib proof

CF - cardiac floating - defib prrof

if equip does not demonstrate them they should be removed from patient before defibbing

32
Q

2.16 CXR - reporting a CXR

A

Date / Patient

Projection
Penetration
rotation
adequate

A- Airway -
mid/dev
Patent

B - Bones
Defects clavicles
ribs sternum
scapulae / vertebrae

C - Cardiac silhouette / shape/ CT ratui

D Diaphragm r diaph high left costophrenic margins
air

E - Effusion empty space

F - fields - infiltrates, interstitial markings, masses, air bronchograms, increase vascularity, discrete / gen shadow

G - Gastric bubble

H - Hilar region
left high right
shadowing

I - inspiration
6 rib anteriorly
10 post

33
Q

2.17 Hx of VV patient -

A

ICU admission
nut allergy
seizures

34
Q

2.18 Communication - sux apneoa

Points to hit in comms w/ a parent of a kid i+v

A

1 Introduce self

2 Confirm talking right person

  1. Explain reason for admission icu

4 avoid jargon

  1. reassure sedated, pain free and will wake up
  2. Sux correct drug and why
  3. recognisnsed complication
  4. why not able to breathe
  5. blood tests
  6. anaes safe in future
  7. write gp
  8. family undergo blood tests
  9. sympathetic
35
Q

2.18 b

Sux apneoa

A

Normal cholinesterase - 4-6min

Prolonged block- acquired / genetic factors

Clear FH
difficult identify

Delay cause recovery excluded -
NM TOF - Reduced all 4 twtich
no fade to teatnus
no PTC

Delay test if blood transfusion given (8/52)

Blood taken -
dibucaine no
plasma cholinesterase

Normal pl chol
1000-3500u/L

Dibuc no - % inhib of pl cholin
by amide LA dibuc

Normal ~80

60 heterozygous
block up to 20m

<20 homozygous
block 4-8 h

Most acq - drug induced

MTX
Neostigmine
Organophosphates

36
Q

2.19 ACF anatomy Diagr 1

ii Diagram 2 nerve supply sensoryh

iii How block LCN of forearm

iv
What movements by stimulating median nerve at axilla

A

diagram page 143
Page 144

LCN - Continuation Musculocutaneous N

Innervates skin lateral aspec forearm

Block Subcut infiltration LA / inject LA between brachioradial + biceps

iv
Flexion wrist
abduction thumb

37
Q

V
How block median N @ elbow

vi
How block ulnar nerve at elbow

vii
How find Radial N in acf
how block

viii
response if radial nerve stim at elbow

A

v
medial to brachial artery - elbow crease

vi
Ulnar groove - medial epi - posterior

consent
equip drugs

elbow flexed, arm abducted, supine
3-4ml LA inject 2-3 prox to epicondyle

vii
Radial N - deep between biceps tendon and brachioradiais
2cm above crease line between 2 structures

viii
Wrist and finger extension

38
Q

2.20 Tech skill - LOOK AT THIS IN BOOK AGAIN

i ankle block for hallux valgus removal

ii other nerves for complete ankle block

iii which is not a branch of sciatic

iv structures page 149

v terminal branches of tibial

A
  1. Superficial peroneal
  2. Deep peroneal
  3. Saphenous
  4. Tibial
  5. Sural

iv Saph not branch sciatic

v tib divides medial and lateral plantar nerves

39
Q

2.20 b tech skills

ankle block
vi how block tibial nerve @ ankle

how block deep peroneal N

Where local to block sural

A

vi Tibial block inject LA behind medial malleolus
anterior to tibial artery pulsation

vii deep peroneal:
Lies medial dorsalis pedis a

block inject LA medial side of artery
between A + EX hall long
1st metatarsal

Subcut infiltration of LA behind lateral malleolus

subcut infiltration 5-10cm above medial malleolus
along course of long saphenous V

The OSCE in anaesthesia - book (5 decks)

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