OSCE 2 Flashcards
2.1 Humphrey ADE
pg 81
i Componenets
ii what pressure does relief valve open at
iii advantage
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
2.1
iv
What are the changes with lever position
v
Explain how it functions as each
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
2.2
ECG basics
standardisation
Normal recording speed
RBBB
LBBB
RAD
LAD
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
2.2 PM Insertion indications
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
2.3 Data interpretation
Aspirin
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
2.4 Cushing reflex
features
what happens
whats the response to the initial defence mechanism
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
2.4 Diabetes insipidus in Ischaemia
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
2.5 Stellate ganglion block
anatomy pic page 95
where is stellate ganglion
describe techniqu 5 points
Anatomy page 95
C7-T1
Vertebral + subclavian close
- Informed consent
- Drugs / equipment check
- Aseptic technique
- supine + neck extended
5 Between trachea + carotid sheath
@ cricoid - chassaignacs tubercle of c6
- neg aspiration + inject LA
2.5 b
Indicatios for stellate ganglion block
1 Pain syndrome
CRPS 1+2
Refractory angina
phatnom limb pain
2 Vascular insufficiency
Raynauds
frostbite
oblit vascular disease
2.5 c
Features of successful block
Fetaures horners
Horners
Increase temp ipsi UL
Ptosis miosis anhydrosis enopthalmos loss ciliospinal reflex
2.5 d
Name 4 complications of stellate ganglion block
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
2.6 Communication of brain stem testing
a marking scheme for osce station
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
2.6 b
Principles of communication
- Introduce + explain role and purpose
- Establish understanding + knowledge of person
3 Honest + Provide correct info and facts
- Explain in simple language
- Actively listen
- Respond to verbal and non verbal
- Summarise and clarify - provide opportunity clarification
2.6
Brain stem testing
3 preconditions
- Apnoea + MV
- Establish cause coma = reversible injury
- 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
2.7
Tech skill
a LP -> spinal anaesthesia
Surface landmarks - spine
Describe procedure
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
- Consent, resus, equipment
- IV access establish
- Monitoring ecg spo2 nibp
- strelity
5 back prep -> antiseptic soln + sterile draping - LA infiltration
2.7 Needles for spinal
a
types
gauge
procedure
what if its bloody?
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
2.7 Spinal
1 How much LA for each segment to be blocked
2 What affect spread of LA
- Contraindications to Spinal
- Blood supply to spinal cord
- 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
2.8 Cardiac exam
IPPA
Radiofemoral delay - coarct
2.9 Wrights respirometer
1
what measure
2 How does it work
3 Uni or bidirectional flow
4 Advantages?
5 disadvantages
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
2.9 Wrights respirometer
b
whats the resistance to flow#
2 other devices measuring flow
Principle behind pneumotachograph
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
2.10 BLS Pregnants mother
- Seen is safe
- Check signs of life?
feel pulse and open airway - Call cardiac arrest, trolley, senior help
obstetrician + paediatrician - Insert wedge under right side / manual displacement
- relieve aortocaval compression - Chest compression 30:2
- BMV/ Intubate
- Arrest trolley arrives - get pads on
8. Hs hypoxia hypovolaemia hypothermia hyper/po kalaemia
T tension ptx toxin tamponade thrombembolism
2.10 b
Pads are on
see a bradycaria - hr 38
how manage?
Rx
Rf for asystole
Adverse signs rate <40 bp <90 Heart faiulre vent arrythymia
Rx
Iv Atropine 500ug
max dose 3mg atropine
in 500ug doses
RF asys
- Recent asystole
- Mobitz 2
- CHB w/ broad QRS vent pause >3s
2.10 c
challenges resus preg
causes of maternal death
Challenges in preg anaes
- CO. Blood vol / oxyge consumption increase
- Consider baby
- Gravid uterus - compression iliac / abdo vessels
Causes mat death: Thromboembolism hypertensive disorder preg haemorrhage amniotic fluid embolism
- 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
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
1 Vagus 2 SupLN 3 IntLN 4 ExtLN 5.RecLN
Medulla oblongata
- Dorsal nucleus
- Nucleus ambiguus
- Nucleus tractus solitarius
Jugular foramen
- Accessory N
- Glossopharyngeal
- IJV
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
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
2.12 Lap chole hx taking
previous awareness
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
2.13 Failed intubation
DAS algorithm PDF
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
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
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
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
2.15 Defibrillator
safe use of defib
- checks leads - position + monitor on patient
- confirms rhythm
- applies pads correctly
a - right upper sternum below clavivle
b - 5th IC left any axillary line - charge safe energy level
- 150-360 biphasic - Visual sweep before shocking - stand clear
- Remove oxygen
- Deliver shock while looking at monitor
- Resume CPR
2.15 Defib
a what would do if patient has PM
what about symbols
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
2.16 CXR - reporting a CXR
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
2.17 Hx of VV patient -
ICU admission
nut allergy
seizures
2.18 Communication - sux apneoa
Points to hit in comms w/ a parent of a kid i+v
1 Introduce self
2 Confirm talking right person
- Explain reason for admission icu
4 avoid jargon
- reassure sedated, pain free and will wake up
- Sux correct drug and why
- recognisnsed complication
- why not able to breathe
- blood tests
- anaes safe in future
- write gp
- family undergo blood tests
- sympathetic
2.18 b
Sux apneoa
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
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
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
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
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
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
- Superficial peroneal
- Deep peroneal
- Saphenous
- Tibial
- Sural
iv Saph not branch sciatic
v tib divides medial and lateral plantar nerves
2.20 b tech skills
ankle block
vi how block tibial nerve @ ankle
how block deep peroneal N
Where local to block sural
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
