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EDIC Part (1) Course Notes > Physiology > Flashcards

Physiology Flashcards

1
Q

Scoring system which is part of the current international consensus definition for sepsis and septic shock?

A
  • SOFA
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2
Q

qSOFA?

A
  • Quick Systemic Organ Failure
  • Components: RR, GCS and SBP < 100mmHg
  • qSofa > 2 is 10% mortality
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3
Q

Surviving sepsis campaign, compnents? Hour-1 bundle?

A
  • Measure lactate and check again if > 2
  • Blood culture before antibiotics
  • Broad spectrum abx
  • 30ml/kg crystalloid for hypotension or lact > 4
  • Vasopressor to aim MAP > 65
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4
Q

Bugs responsible for necrotising fascitis?
- Type (1) - Polymicrobial?

A
  • Staphylococci
  • Anaerobes
  • Gram negative
  • Immunocompromised
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5
Q

Bugs responsible for necrotising fascitis?
- Type (2) - Monomicrobial?

A
  • Beta-haemolytic streptococci group A (S. pyogenes)
  • Co-infection with S. Aureus
  • Trauma
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6
Q

Options for diagnosis & management of Necrotising Fascitis?

A
  • Fascia biopsy
  • Immediate surgery
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7
Q

Pharmacokinetics of antibiotics?

A
  • Dose given reaches Cmax (maximum concentration)
  • Distribution & elimination occurs
  • MIC reached (Minimal inhibitory concentration).
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8
Q

Minimal inhibitory concentration, properties?

A
  • Concentration must be above MIC
  • All beta-lactams work by duration above MIC
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9
Q

Antibiotics of choice in Necrotising fasciitis?

A
  • Vancomycin if MRSA is a concern
  • flucloxacillin for staph. Aureus
  • clindamycin for streptococci (Good tissue penetration)
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10
Q

Coverage of Clindamycin?

A
  • Anaerobic cover
  • Streptococcus
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11
Q

Immunoglobulin as adjunctive therapy in sepsis?

A

Effective for necrotising fasciitis. InStinct trial (Scandinavian)

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12
Q

AF and SVV?

A

There is a decrease in SVV with AF

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13
Q

Tricyclic antidepressant overdose and ECG changes?

A
  • Prolonged QRS / QTc
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14
Q

Timing of inflation of intra-aortic balloon should be timed with which portion of the ECG?

A

Middle of T-wave

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15
Q

Mechanical assist cardiac device, indication?

A
  • Intractable arrhythmias in severe LV dysfunction
  • Chronic HF causing renal & hepatic dysfunction
  • Intractable angina with poor LV function despite medical & revascularization treatment
  • Post-cardiotomy shock
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16
Q

What is the commonest cause of pulmonary HTN?

A
  • Left heart disease
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16
Q

What is the commonest cause of pulmonary HTN?

A
  • Left heart disease
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17
Q

Effect of high respiratory rate on RV and LV?

A
  • This will increase the pre-load of the RV
  • It increases LV afterload
  • Increased transmural pressures
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18
Q

PEEP & cardiovascular response?

A
  • Decreases transmural pressures
  • Reduces RV pre-load
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19
Q

What contributes most to ventilator-induced lung injury?

A

Plateau airway pressure

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20
Q

Peak airway pressure is related more to ?

A

Airway resistance

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21
Q

Airway driving pressures will decrease with increasing what ventilator setting?

A

PEEP

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22
Q

How to calculate driving pressures?

A

Driving pressures = Plateau pressures - PEEP

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23
Q

Calculation of compliance ?

A

Compliance = Volume / Driving pressure

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24
Q

Calculation of CO2 gap?

A

CO2 gap = PaCO2 - ETCO2

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25
Q

Conditions causing increased CO2 gap?

A
  • PE
  • Dead-space ventilation
  • Low filling status - Needs fluid resuscitation
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26
Q

Uses of Esophageal pressure monitoring?

A
  • Used to assess whether ventilation is lung-protective
  • Measures estimated pleural pressure
  • It can measure patient’s work of breathing
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27
Q

NAVA (Neurally-Adjusted Ventilator Assist)? Functions & uses?

A
  • Measures the electrical activity of the coastal diaphragm
  • Allows for proportional ventilation
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28
Q

Wasted effort can be illustrated using what diagram?

A

The campbell diagram

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29
Q

Improve patient - ventilator interaction?

A
  • Increasing trigger sensitivity
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30
Q

Factors affecting cardiac output?

A
  • Pressure within the venous system
  • Capacitance of the venous reservoir
  • The resistance to venous return
  • Peripheral distribution of the blood flow
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31
Q

What is Cardiac output?

A

CO = HR x SV

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32
Q

Factors influencing SV?

A

Preload, contractility & afterload

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32
Q

Factors influencing SV?

A

Preload, contractility & afterload

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32
Q

Factors influencing SV?

A

Preload, contractility & afterload

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33
Q

Preload dependent on ?

A

Venous return

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34
Q

Afterload dependent on?

A

Arterial pressure

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35
Q

What is CVP?

A
  • Equivalent to the RA pressure
  • Filling pressure of the right side of the heart
  • Determinant of cardiac function
  • It is a key determinant of venous return
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36
Q

Venous valves in the thorax?

A

There are no venous valves in the thorax

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37
Q

Factors increasing CVP?

A
  • Increased circulating volume
  • Decreased venous capacitance
  • Increased venous tone (vasopressors)
  • Decreased cardiac function (HF/Obstructive acute HF - PE/Tamponade)
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38
Q

Etiology of shockable rhythms?

A
  • IHD/ AMI
  • Electrolyte abnormalities
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39
Q

Etiology non-shockable rhythms?

A
  • Hypovolaemia
  • Hypoxia
  • Hypothermia
  • Electrolyte abnormality
  • PE
  • Tamponade
  • Tension PTX
  • Trauma & Toxins
  • AMI
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39
Q

Etiology non-shockable rhythms?

A
  • Hypovolaemia
  • Hypoxia
  • Hypothermia
  • Electrolyte abnormality
  • PE
  • Tamponade
  • Tension PTX
  • Trauma & Toxins
  • AMI
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40
Q

Factors causing falsely elevated oxymetry readings?

A
  • Carboxy-haemoglobin
  • Met-haemoglobin
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41
Q

Factors causing falsely low oxymetry readings?

A
  • Ambient light
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42
Q

Location of the respiratory centre?

A

Medulla oblongata

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43
Q

Location of the respiratory centre?

A

Medulla oblongata

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44
Q

Functions of the central chemoreceptors?

A
  • ## Directly senses CO2 changes (conc. of hydrogen ions in the CSF)
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45
Q

Location of peripheral chemoreceptors?

A
  • Carotid
  • Aortic arch
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46
Q

Function of peripheral chemoreceptors?

A
  • Sense PO2
  • Sense change in pH of blood
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47
Q

Calculation of PaCO2?

A

PaCO2 = CO2 production / Minute volume

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48
Q

Calculation of alveolar ventilation?

A

Alveolar ventilation = RR x (Tidal volume - Dead-space)

Effective tidal volume diminishes with increased RR

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49
Q

What is dead-space ?

A
  • Volume not participating in gas exchange
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50
Q

What are the different components of dead-space?

A
  • Anatomical dead-space (2ml/kg)
  • Alveolar dead-space
  • Instrumental dead-space
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51
Q

Physiology of alveolar dead-space?

A
  • Ventilated but not perfused
  • Increased arterial CO2 due to lack of excretion via the lungs
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52
Q

Causes of alveolar dead-space?

A
  • PE
  • Hypoperfusion
  • Intrinsic PEEP
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53
Q

Calculation for measuring dead-space?

A

VD/VT = PaCO2 - PeCO2 / PaCO2

PeCO2 - Mixed expired CO2

54
Q

Causes of hypercapnia ?

A
  • Low minute volume
  • Increased dead-space
  • High CO2 production
55
Q

Potential systems which could be affected that causes hypercapnia?

A
  • CNS
  • PNS
  • Respiratory muscles
  • Chest wall and pleura
  • Upper airway
  • Lungs
56
Q

What is the alveolar gas equation?

A

PAO2 = FiO2 x (P.atm - P. H2O) - PaCO2 / RQ

Ex;
PAO2 = 0.21 x (760 mmHg - 47) - 40 / 0.8 = 100 mmHg

PACO2 = Alveolar O2

57
Q

gases and vapors in the alveolar?

A
  • Nitrogen
  • Oxygen
  • CO2
  • Water vapor
58
Q

Hypoxia & altitude ?

A

The atmospheric pressure is lower at higher altitude hence low amount of FiO2

58
Q

Hypoxia & altitude ?

A

The atmospheric pressure is lower at higher altitude hence low amount of FiO2

59
Q

Causes of hypoxia?

A

Elevated A-a gradient
- Shunt (A-a gradient elevated)
- V/Q mismatch (A-a gradient elevated)

Low A-a gradient
- Altitude (A-a gradient low)
- Hypoventilation (A-a gradient low)

  • High CO2
  • Diffusion limitations ( Rare ) - Chronic lung disease / COPD
60
Q

What is shunting ?

A

This is volume of blood not taking part in gas exchange

61
Q

Anatomic shunt?

A
  • Normally < 5% in healthy individuals
  • No response to increased FiO2
62
Q

Venous admixture or low V/Q (Shunt)?

A
  • Improves with increase FiO2
  • Chemo-sensors prevent admixture by Hypoxic vasoconstriction
63
Q

Physiology of hypoxic vasoconstriction?

A
  • Low Oxygen levels detected inside the alveolar
  • Capillary vasoconstriction occurs
  • Blood diverted to more well oxygenated capillaries
64
Q

Calculation of A-a gradient ?

A
  • It should normally be very low

A-a gradient = PAO2 - PaO2 = FiO2 x (P.atm - P.H2O) - PaCO2 -PaO2 / RQ

65
Q

Shunt equation?

A

See EDIC notes

66
Q

Shunt equation?

A

See EDIC notes

67
Q

Treatment for MH?

A

Dantrolene

68
Q

Temperature is higher in pyrexia or hyperthermia?

A

Higher in hyperthermia

69
Q

Hyperthermia?

A
  • Temperatures higher than pyrexia
  • Thermoregulatory mechanisms are lost
  • Temperatures usually > 41.3 degrees Celsius
70
Q

Where is thermoregulation processed ?

A

At the hypothalamus

71
Q

Definition of fever ?

A

Core temperature > 38.3 degrees Celsius

72
Q

Pyrexia and thermoregulatory mechanisms?

A

Thermoregulatory mechanisms are preserved

73
Q

What chemical results in an elevated temperature setpoint in the brain?

A

PGE2 in the CNS

74
Q

Total body mass constitution?

A
  • Made up of 60% of water
75
Q

Total body fluid is divided into ?

A
  • 2/3 intracellular fluid
  • 1/3 Extracellular fluid
76
Q

The ECF is divided into?

A
  • Interstitial fluid = 80%
  • Plasma = 20%
77
Q

Intracellular compartment volume?

A

25 litres

78
Q

Extracellular compartment volume?

A

17L

79
Q

What are the intracellular electrolytes ?

A
  • Potassium = 140mEq/L
80
Q

What are the extracellular electrolytes ?

A
  • Sodium = 140mEq/L
81
Q

Osmolality of the fluid compartment?

A

280 mOsm/kg

82
Q

Units of hydrogen ion concentration ?

A

nmol/L (Nano-moles / Litre)

83
Q

Normal hydrogen ion concentration ?

A

40 nmol/L

84
Q

Acuity of liver failure?

A

Hyper-acute = < 7 days (Drugs induced or hypoxia)
Acute = 7 - 28 days ( Autoimmune or drug related)
Sub-acute = > 28 days (Unknown cause)

85
Q

KCH criteria to identify patient’s at risk of death from liver failure?

A
  • PT > 100s & INR > 6.6 ( + Encephalopathy)
86
Q

KCH criteria to identify patient’s at risk of death from liver failure? Any three out of 5 criterias? (+ Encephalopathy)

A
  • Age: < 10 or > 40
  • Bilirubin > 300
  • Duration of jaundice before the onset of encephalopathy > 7 days
  • PT > 50s or INR > 3.5
  • Non-hepatitis A or B / drug induced
87
Q

Scoring systems in liver failure?

A
  • MELD
  • APACHE II
  • CLIF-SOFA
  • Child-Pugh Score
88
Q

Scoring systems in liver failure?

A
  • MELD
  • APACHE II
  • CLIF-SOFA
  • Child-Pugh Score
89
Q

Primary (hepatic) causes of acute liver failure?

A
  • Drug related
  • Viral hepatitis
  • Toxin induced ALF
  • Budd-Chiari syndrome
  • Autoimmune
  • Pregnancy related
90
Q

Secondary (extra-hepatic) causes of ALF?

A
  • Ishcaemic hepatitis
  • Haemophagocytic syndrome
  • Metabolic disease
  • Infiltrative disease
  • Lymphoma
  • Infections (e.g malaria)
91
Q

Primary causes of chronic liver disease?

A
  • Wilson’s disease
  • Autoimmune
  • Budd-Chiari
92
Q

Seconadary causes of chronic liver disease ?

A
  • Liver cancer
  • Alcoholic hepatitis
93
Q

Hypoxamia mechanisms ?

A
  • inadequate fio2
  • inadequate delivery to target organ
94
Q

What is the oxygen cascade?

A

Transfer of oxygen from the environment to the alveoli and subsequently arterial blood.

95
Q

Oxygen cascade & oxygen content?

A

Reduction in oxygen tension from the environment to arterial blood.

96
Q

Main factors causing hypoxia ? See individual breakdown of the below points ……

A
  • low fio2 (altitude, hypoxic gas mixture)
  • Alveolar hypoventilation
  • diffusion impairment
  • V/Q mismatch & shunt
97
Q

Consequence of alveolar hypoventilation?

A
  • decrease in V/Q
  • A-a gradient is usually normal
98
Q

Causes of pulmonary diffusion impairment?

A
  • Increased thickness of alveolar membrane (fibrosis)
  • Decrease in capillary transit time ( severe sepsis)
  • Decrease in capillary blood volume (hypotension)
99
Q

Variation of V/Q from base to apex?

A

0.6 - 3.0

100
Q

V/Q mismatch causing hypoxia?

A
  • Reduction of ventilation relative to perfusion (low V/Q).
101
Q

Hypoxic pulmonary vasoconstriction?

A

Physiological pulmonary vasoconstriction will reduce blood flow to poorly ventilated alveolar units, thus a shunt

102
Q

Atmospheric pressure at sea level?

A

101.3 kPa

103
Q

Calculation of atmospheric PO2?

A

PO2 = FiO2 x Atmospheric pressure

104
Q

Outline processes of the oxygen cascade ?

A
  • inspired oxygen
  • Trachea - humidification
105
Q

What is hypoxaemia?

A

This is low arterial oxygen tension occuring due to pathology in transfer of oxygen from the atmosphere to the left side of the heart.

106
Q

Hypoxia is a consequence of either ?

A
  • Inadequate arterial oxygen tension
  • Inadequate delivery of oxygen to the end organ
107
Q

Inspired oxygen within the oxygen cascade?

A
  • FiO2 is 21% in RA
  • Atm pressure 101.3 kPa at see level
  • PO2 = FiO2 x Atm pressure
  • Pathologies - Altitude , hypoxic gas mixture
108
Q

Trachea in the oxygen cascade?

A
  • Humidification
  • Saturated vapour pressure of water - 6.3 kPa @ 37 degrees
  • PO2 = FiO2 (Atm pressure - SVP H2O)
  • Normal PO2 19%
109
Q

Alveoli in the oxygen cascade?

A
  • Ventilation
  • Normal PACO2 5.3 kPa
  • Alveolar gas equation is used to calculate PO2 (Google it)
  • Hypoventilation will cause hypoxia
110
Q

Pulmonary capillary in the oxygen cascade?

A
  • Diffusion
  • The rate of diffusion across the alveolar member determined by Fick’s law
  • A - a gradient = PAO2 - PaO2
  • Pathologies; Emphysema, fibrosis & Oedema
111
Q

Artery in oxygen cascase?

A
  • Admixture / shunt
  • Oxygenated blood from the lungs mixes with deoxygenated blood in the left heart (<3%)
  • Admixure arises physiologically from Thebesian and bronchial veins.
  • Pathologies; Intra-cardiac or intra-pulmonary shunts, ARDS, effusion, PTX
  • Oxygen content = (SPO2 x Hb x 1.34) + 0.003 x PO2
112
Q

Hypoxia corrected with increasing FiO2?

A
  • V/Q mismatch
  • Diffusion impairment
  • Alveolar hypoventilation
  • Low inspired oxygen
113
Q

Hypoxia with normal A-a gradient?

A
  • Alveolar hypoventilation
  • Low inspired oxygen
114
Q

Hypoxia with normal shunt fraction?

A
  • Diffusion impariment
  • Alveolar hypoventilation
  • Low inspired oxygen
115
Q

The P50?

A

Represents the PaO2 at which Hb is 50% saturated

116
Q

Properties of oxygen?

A
  • ## Low solubility in plasma
117
Q

Haemoglobin and ODC?

A
  • Affinity for oxygen increases with every molecule of oxygen it binds
  • Left shift of the curve - Increases Hb affinity for oxygen
118
Q

Factors determining left-ward shift of the ODC?

A
  • Decreased temperature
  • Decreased CO2
  • Decreased 2,3-DPG
  • Increased pH
119
Q

Factors determining right shift of ODC?

A
  • Increased temperature
  • Increased arterial CO2
  • Increased 2,3-DPG
  • Decreased pH
120
Q

Determinants of oxygen delivery (DO2)?

A
  • Transfer of oxygen from atmosphere to blood
  • Carriage of oxygen in blood bound to Hb
  • Systemic blood flow (Cardiac output)
121
Q

Oxygen delivery flux equation?

A

DO2 = CO (SaO2 x Hb x 1.34) + 0.003 x PO2

122
Q

Classification of hypoxia?

A
  • Hypoxaemic hypoxia - Low arterial oxygen tension
  • Anaemic hypoxia - Low Hb or impaired (Methaemoglobinaemia, carbonmonoxide poisoning)
  • Stagnant hypoxia - Low cardiac output
  • Cytotoxic hypoxia - Abnormal cellular utilization of oxygen. Failure of aerobic respiration (Cyanide poisoning)
123
Q

Properties of carbondioxide?

A
  • About 22 times more soluble than oxygen
  • Affected only by ventilation - Alveolar CO2 and minute ventilation are directly related
124
Q

Components of dead-space?

A
  • Anatomical dead-space
  • Alveolar dead-space
  • Physiological dead-space
125
Q

Anatomical dead-space?

A
  • Consists of the conducting airways
  • Do not contribute to gas exchange
  • Its approximately 2ml/kg
  • Reduced by ETT
  • Fowler’s method is used to measure anatomical dead-space
126
Q

Alveolar dead-space?

A
  • Proportion of tidal volume entering the alveolar - Not perfused
  • Increased in disease
  • Present in PE & low cardiac output state
127
Q

Physiological dead-space?

A
  • Combination of anatomical and alveolar dead-space
  • Calculated using the Bohr’s equation
128
Q

What is the Bohr’s equation?

A
  • Used to calculate physiological dead-space
  • VD/VT = PaCO2 - PeCO2 / PaCO2
129
Q

Lung volumes?

A
  • IRV = 2500mls
  • TV = 500mls
  • ERV = 1500mls
  • RV = 1500mls
  • TLC = 6000mls
  • VC = 4500mls
130
Q

Calculation of alveolar MV?

A
  • (TV - dead-space) x RR =
  • Main determinant of Mv is arterial CO2
  • Central chemoreceptors in the medulla detect changes in pH associated with changing CO2
  • PO2 becomes a determinant of MV only in hypoxia
131
Q

Barriers to infection and percentage of protection?

A
  • Physical barriers (99%)
  • Innate immune response (0.9%)
  • Adaptive immune response (0.1%)
132
Q

Components of physical barriers to infection?

A
  • Skin
  • Cilia
  • Acidity
  • Lysozomes
  • Normal bacterial flora
133
Q

Components of innate immune response?

A
  • Neutrophils
  • Mast cells
  • Macrophages
  • NK cells
  • Complements
  • Acute phase
134
Q

Components of Adaptive immune response?

A
  • B-lymphocytes
  • T-lymphocytes
135
Q

Causes of dynsfunction to physical barriers? skin

A
  • Burns
  • Trauma
  • Steven-Johnson’s Syndrome
  • Kartagener’s
  • Prolonged antibiotics
136
Q

Causes of dysfunction to innate immune response?

A
  • Wiscott-Aldrich
  • Leucocyte adhesion defect
  • Complement defect
  • Steroids
  • TNF-alpha inhibitors
  • Chemotherapy
  • Diabetes
  • SLE
  • Liver failure
  • Malignancy
137
Q

Causes of dysfunction to adaptive immune system?

A
  • Hypogammaglobinaemia
  • DiGeoge’s syndrome
  • Common variable immunodeficiency
  • Lymphoma
  • HIV
  • Chemotherapy

EDIC Part (1) Course Notes (8 decks)

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