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Semester 4 TxWes > Principles of Anesthesia II Unit I > Flashcards

Principles of Anesthesia II Unit I Flashcards

1
Q

Lesions located where are rarely diagnosed/picked up on physical exam?

A

Mediastinum, interstitium and in the center of the lung

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2
Q

What is the relationship of acute vs chronic illness to the effectiveness of a physical exam vs CXR?

A

Physical exam is good for acute illness, CXR is better for chronic illness

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3
Q

What is under vs overexposure in an xray?

A

Over = the film is very dark
Under = the film is very bright

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4
Q

If the film is overexposed, what structures are easier to identify?

A

The T-spine, mediastinal structures and retrocardiac structures

Small nodules and fine structure cannot be seen if the film is overexposed

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5
Q

If the film is underexposed, what structures are easier to identify?

A

The small pulmonary blood vessels are more prominent

The downside here is d/t the underexposure it may give the appearance of there being infiltrates when none are present

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6
Q

Excessive breast tissue can cause what problem during a CXR?

A

The breast tissue absorbs some of the x-ray beam causing underexposure

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7
Q

What is the interpretative difference of a PA vs AP x-ray?

A

The heart will be magnified on an AP projection

This occurs because the heart is farther from the film and the x-ray beam diverges as it goes farther from the tube

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8
Q

When is PA projection of an x-ray commonly done? AP?

A

PA = generally done on ambulatory patients standing up
AP = on patients lying down, what we commonly did in the ICU

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9
Q

Why do we instruct patients to inspire for a CXR?

A

To push the liver and abdominal contents down. If not done, the pulmonary vessels can become crowded and the heart will appear larger

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10
Q

What do you need to be aware of if the domes of the diaphragm are at the seventh posterior ribs on x-ray?

A

The chest should be considered hypo-inflated and the diagnosis of basilar PNA or cardiomegaly should be done with extreme care

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11
Q

What are the 2 acronyms given to help standardize how you read a CXR?

A

ATMIB and Are There Many Lung Lesions

Both guide you to go; Abdomen first, then thorax, mediastinum, the individual lungs, then both lungs

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12
Q

On a CXR, how many anterior ribs are visible? Posterior?

A

A = 10
P = 6

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13
Q

What is the order, per lecture, to systematically read a CXR?

A

Start with the bony framework, then evaluate soft tissues, then the lung fields/Hila, diaphragm and pleural spaces, mediastinum and heart then the abdomen/neck

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14
Q

What structures are you examining when you inspect the bony framework?

A

You should be able to count and number the ribs, inspect the capulae, humeri and shoulders, and clavicles, and see the diaphragms overlying the posterior aspects of the 10th or 11th ribs (in a normal adult)> The spine and sternum are generally difficult to visualize in detail on standard PA films due to overlying shadows.

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15
Q

What are the soft tissues you are examining on CXR?

A

Breast shadows, supraclavicular areas and tissues along the sides of the chest

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16
Q

What creates the hilum (lung root) on a CXR?

A

The shadow of the pulmonary artery and vein that are adjacent to the heart shadow

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17
Q

What borders the right heart/mediastinal border? Left?

A

Right = IVC, RA, ascending aorta and SVC
Left = LV, LA, pulmonary artery, aortic arch and subclavian artery/vein

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18
Q

What are the 3 main pitfalls to x-ray interpretation?

A

Poor inspiration, over/under penetration and rotation

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19
Q

Which view of the lungs has extensive overlap?

A

The PA view

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20
Q

Which lung has more lobes?

A

R = 3 lobes
L = 2 lobes

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21
Q

The RUL is adjacent to what ribs?

A

The first 3 - 5 ribs posteriorly, anteriorly, it can extend as far as the 4th rib (more obvious on a lateral view)

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22
Q

The RLL is adjacent to what internal structures on x-ray?

A

The 6th thoracic vertebral body and extends to the diaphragm

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23
Q

What do the fissures in the R. Lung seperate?

A

Minor fissure (horizontal) separates the the RUL and the RML, the major fissure (oblique) separates the RLL from the others

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24
Q

Why are fissures not a reliable marker to use when examining a CXR?

A

They are not always easily identifiable and in some people they may not be completely formed or may even be completely absent on CXR

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25
Q

What areas are you examining with a lateral view?

A

Oblique fissure, horizontal fissure, thoracic spine, retrocardiac space and retrosternal space

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26
Q

What structures can you identify with a PA view?

A

Aortic arch
Pulmonary trunk
Left atrial appendage
Left ventricle
Right ventricle
Superior vena cava
Right hemidiaphragm
Left hemidiaphragm
Horizontal fissure

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27
Q

What is the silhouette sign?

A

Something is coming into contact with the border of the heart/aorta which obscures the normal border

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28
Q

What is the air bronchogram sign?

A

We can visualize the bronchi now (normally it is obscured by alveoli) which generally indicates some sort of consolidation (this consolidation of non-air material allows us to see the bronchi)

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29
Q

Most disease states replace _____ with a pathological process that creates the visual change on xray?

A

Air

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30
Q

A consolidation radiologically transcribes to what?

A

A density corresponding to a segment or lobe, air bronchogram and no significant loss of lung volume

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31
Q

What are the radiologic criteria for absorptive atelectasis?

A
  1. A density corresponding to a segment or lobe
  2. significant signs of loss of volume
  3. compensatory hyperinflation of normal lung(s)
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32
Q

What are the steps in evaluating an abnormality on CXR?

A
  1. Identification of abnormal shadows
  2. Localization of lesion
  3. Identification of pathological process
  4. Identification of etiology
  5. Confirmation of clinical suspension
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33
Q

Where should a CVC tip lie?

A

lie between the most proximal venous valves of the subclavian or jugular veins and the right atrium

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34
Q

The loss of what generally indicates a pleural effusion/accumulation of fluid outside the lung?

A

Loss of the costo-phrenic angle

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35
Q

How can you differentiate RLL vs RML lobe PNA on CXR?

A

They occupy almost the same position on an CXR, the easy way to identify the difference is RLL PNA will occupy most/all of the costo-phrenic angle, RML should leave that angle intact

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36
Q

What is a Gohn complex?

A

A lesion caused by TB that consists of a calcified focus of infection and an associated lymph node

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37
Q

What type of radiation comes from the motion of atoms and combine electricity and magnetism?

A

Electromagnetic

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38
Q

What type of radiation only travels through substances?

A

Mechanical

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39
Q

What type of radiation is the result of unstable atomic nuclei?

A

Nuclear

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40
Q

What type of radiation is composed of electrons only and is frequently emitted from the sun?

A

Cosmic (beta) waves

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41
Q

What type of radiation does a CXR utilize?

A

Electromagnetic

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42
Q

What category of radiation does not knock off electrons, doesn’t break molecular bonds and is only harmful from it’s ability to produce heat?

A

Non-ionizing

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43
Q

What process creates ionizing radiation?

A

Some stimulus (the exact stimulus is not important for this class) causes a particle to lose an electron, as the ion is created energy/radiation is produced

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44
Q

What category of radiation are you most likely to encounter in patient care areas?

A

Ionizing

non-ionizing dominates the break room though

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45
Q

Of the EMS spectrum, what rays are not part of the visible spectrum?

A

Radio waves and gamma rays

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46
Q

X-rays are most similar to what other ray?

A

Light rays

both are electromagnetic energy and carried by photons

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47
Q

What is the relationship of wavelength to energy of a ray?

A

As wavelength shortens, energy drastically increases

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48
Q

Describe how light is emitted (same process as creating a photon)?

A

An external stimulus causes an electron to become excited and jump to a higher orbital. This state is energetically unfavorable; and so the electron will eventually go back to a lower energy orbital. When this occurs, energy is released as a photon

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49
Q

What type of tissue is more likely to be made of small atoms? Large atoms?

A

Small = soft tissue
Large = bones

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50
Q

Why are bones bright on an x-ray?

A

Because they are larger atoms they absorb more photons making them appear brighter. Smaller atoms, like soft tissue, absorb less making them grey. Since air has very little to no capability to absorb photons the pulmonary space has a tendency to appear black

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51
Q

Describe the basics of how an x-ray machine works

A

A filament in a cathode heats up, this energy causes electrons to leave the filament. An anode made of tungsten is positively charged and attracts the photons across the tube. As the photons leave this tube, they hit tissues and reflect to create the image.

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52
Q

What environmental factor can alter a CXR’s appearance?

A

Ambient light

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53
Q

What is the basic difference between a CT and a CXR?

A

Both use x-rays to create an image, a CT however uses x-rays along with computer processing to create a 3D image

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54
Q

What is a non-image related use for medical x-rays?

A

Radiation therapy for cancer

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55
Q

What s/e of radiation therapy is common across all anatomic locations?

A

Fatigue

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56
Q

What is the most common s/e of radiation therapy above the abdomen? Most common s/e of the abdomen and below?

A

Above = hair loss
Abdomen and below = diarrhea

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57
Q

What areas of the body when exposed to radiation therapy can cause N/V?

A

Brain, pelvis and abdomen

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58
Q

What anatomic areas when exposed to radiation therapy can cause urinary changes?

A

Abdomen, rectum and pelvis

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59
Q

What is the allowable radiation dose for the whole body?

A

5,000 mrem

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60
Q

What is the allowable radiation dose for the extremities?

A

50,000 mrem

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61
Q

What is the allowable radiation dose for lens of the eye?

A

15,000 mrem

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61
Q

What is the allowable radiation dose for pregnancy?

A

500 mrem

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62
Q

How many mrem’s are released from a CXR?

A

5-10 mrem

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63
Q

How many mrem’s are released during a coronary angiogram?

A

1,500 mrem

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64
Q

How many mrem’s are released during an angioplasty?

A

5,700 mrem

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65
Q

How many mrem’s are released from a CT?

A

5,000 mrem

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66
Q

What 3 factors can affect radiation scatter?

A

Collimation - the “size” of the window that radiation is allowed to escape

Object thickness - the thicker the object, the more the radiation will scatter (this is partially why imaging on obese patients can be of poor quality)

Air gap - fairly straightforward; the longer the distance to travel, the more opportunity there is for scatter to occur

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67
Q

At what dose of mrem does transient erythema occur?

A

200,000 mrem

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68
Q

What dose of mrem is unlikely to cause fetal s/e after 20 weeks of gestation?

A

Less than 10,000 mrem

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69
Q

With a direct source of radiation, what is the relationship of distance to exposure rate?

A

For every doubling of distance (or factor increase by 2) you will decrease exposure rate by 1/4

(if you go from 2 to 8 feet, and starting mrem is say 100 mrem/min, you have doubled your starting distance 3 times, 2 -> 4 -> 6 -> 8, be VERY careful when doing this math and be comfortable with the difference between factor increases, which is what this is, and standard multiplication. So, you have 3 factor increases of distance, so you will multiply 100 by 0.25 3 times) -> 100 x 0.25 = 25 mrem/minute (first factor), 25 x 0.25 = 6.25 mrem/minute (2nd factor), 6.25 x 0.25 = 1.5626 mrem/minute (3rd factor). This illustrates why distance is so valuable in reducing radiation exposure

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70
Q

You are 3 feet away from a radiation source and receiving 750 mrem/min of radiation, you move away from the radiation source to 15 feet. What is your new exposure rate?

A

2.93 mrem/minute (remember, this is factor multiplication, for each doubling of the distance you reduce radiation exposure by 1/4 and in this scenario you have doubled the distance 4 times)

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71
Q

What occurs is you leave a dosimeter on your car dashboard?

A

Because it is being exposed to cosmic (beta) radiation it can falsely elevate/trip the dosimeter

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72
Q

The interactions between what create the images of an MRI?

A

The interactions between the static magnetic field and the individual atom nuclei

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73
Q

Why is MRI, in general, a safer option than a CT?

A

Because an MRI does not use ionizing radiation there are less cell death/damage risks

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74
Q

Describe how an MRI orients molecules/atoms to create images

A

The magnetic field orients the nuclei of hydrogen molecules to north/south poles and radio wave pulses change the orientation of specific atoms which radiates energy

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75
Q

What property allows MRI to create detailed pictures?

A

Each atom/molecule “resonates” at a unique frequency, and when exposed to the properties used in an MRI machine, each atom creates an image unique to that atom. So hydrogen will look different than iron

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76
Q

What is a T1 MRI image most useful in identifying?

A

Due to the good grey-white matter contrast, it is good to examine anatomy.

fat appears bright, water appears dark in T1

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77
Q

What is a T2 MRI image most useful in identifying?

A

Because of it’s ability to identify tissue edema, it is very useful in identifying tissue pathologies

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78
Q

How does fat and water appear on T1 vs T2 MRI images?

A

T1 = Fat is bright, water is dark
T2 = Fat is darker than water

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79
Q

What is the most common contrast medium used in MRI?

A

Gadolinium

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80
Q

How does gadolinium work?

A

It Alters the magnetic properties of nearby water molecules which enhances the quality of MRI images.

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81
Q

What pieces of equipment, in general, should not be introduced in a room with MRI?

A

Oxygen/nitrous oxide tanks
Anesthesia machine
Monitors
Infusion pumps
Stretchers
Crash carts

Most of these items are generally located just outside

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82
Q

What is the primary danger/risk of MRI?

A

Projectile risk. Another concern is heating, particularly of metal components that have been implanted in someone

Dr. Mordecai gave an example of how she had the LINX procedure for acid reflux, and because of that she isn’t safe in an MRI room

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83
Q

Do the AANA standards of care have any changes/accommodations for a patient in MRI?

A

No, these standards apply regardless of the patient care setting

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84
Q

What type of MRI scans (think region of the body being scanned) have a high incidence rate of brachial plexus injury?

A

Abdominal scans - because you have to place the arms over the head to get them out of the way of the scan

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85
Q

What s/sx can occur if you approach the MRI field rapidly?

A

dizziness, HA, light flashes, nausea

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86
Q

What implantable devices should warrant caution before being exposed to an MRI? Which are generally safe?

A

Caution/may not be safe = Pacemakers, AICDs and insulin pumps

Generally safe = Heart valves, endovascular and biliary stents after the 8 week mark, coronary stents, vascular ports, IVC filters and most orthopedic implants

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87
Q

What type of stent is immediately safe for MRI (no waiting period necessary to allow for healing/attachment to native vessel)?

A

Coronary stents

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88
Q

What differences are present between normal light vs a laser?

A

A laser has a specific wavelength, a focused narrow beam and high intensity

Normal light = many/varying wavelengths and spreads out in many directions

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89
Q

What type of radiation does a laser make use of?

A

Electromagnetic

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90
Q

What are the 3 properties listed on the powerpoint that describe the behavior of lasers?

A

Monochromatic - all photons of a laser are of the same wavelength

Coherence - the travel of the photons is synchronous; they do NOT move randomly

Collimation - the laser beam photons are nearly perfectly parallel which allows for a very focused beam

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91
Q

What are the 3 primary lasers used in medicene?

A

Argon, CO2 and Nd:YAG lasers

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92
Q

What laser has minimal scatter/minimal damage to surrounding tissue making it preferable for vocal cord/oropharynx surgery?

A

CO2 laser

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93
Q

What laser has modest penetration (0.05 - 2mm) and is commonly used for dermatology?

A

Argon lasers

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94
Q

Why does a CO2 laser cause minimal to no to surrounding tissue?

A

The CO2 laser is well absorbed by water, meaning it disperses very little heat

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95
Q

What is the most powerful laser with deeper penetration of 2 - 6mm and useful in tumor debulking?

A

Nd:YAG lasers

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96
Q

What are the 2 primary risks we are concerned with when lasers are in use?

A

Atmospheric contamination (think condyloma surgery) and airway fire

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97
Q

What are the 5 hazards listed in lecture of laser use?

A

Atmospheric contamination, perforation of a vessel/structure, embolism (think air embolism from a hole in a vessel), inappropriate energy transfer and airway fire

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98
Q

Why are we so concerned about atmospheric contamination from laser procedures?

A

The plume of smoke can transmit particulates that can be carcinogenic in nature

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99
Q

What are the basic/generic safety considerations with laser use?

A

Laser glasses for provider

Laser glasses for patient with eyes taped

Windows covered

Laser plume masks for vaporized viruses and particulates

Appropriate suction

Water/saline irrigation on back table

Don’t tent drapes/have pockets of oxygen

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100
Q

What is the fire triad?

A

An ignition source, fuel (oxygen) and an oxidizer

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101
Q

What are the 2 major sources of OR fires?

A

ESU (electrical surgical units, think cautery devices) and lasers

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102
Q

What are some interventions you can use to help maintain airway fire safety?

A

Laser-resistant ETTs

Low-inspired (21% if possible) O2

Wet pledgets around the ETT

Methylene blue in the ETT cuff

Use scissors to cut into trachea instead of bouvie

Remove ETT during laser procedure and reinsert ETT prn sats

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103
Q

Why must TIVA be a backup if there are planned apneic periods during surgery due to airway fire concerns?

A

If you are apneic, you aren’t breathing in any volatile; you want to prevent surgical awareness, so you can use TIVA to help maintain anesthesia

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104
Q

What should be included in the anesthesia care plan if airway fire is of concern?

A

Methylene blue ETT cuff, saline gauze protection of face/airway, try to convince the surgeon that short repeated pulses of a laser is better instead of long/continuous, avoid O2 concentration of greater than 30%, avoid nitrous and communicate

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105
Q

What type of radiation does not travel through the air?

A

Mechanical

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106
Q

What generates contrast in an MRI?

A

The time until tissue relaxation when the radiofrequency is turned off (this is determined by the various densities of hydrogen nuclei in tissues and different chemical/physical properties)

107
Q

What MRI image occurs when the magnetic vector relaxes?

A

T1

108
Q

What MRI image occurs when the axial spin relaxes?

A

T2

109
Q

What does the bat wing pattern on a CXR indicate?

A

Fulminant pulmonary edema from CHF

110
Q

What condition occurs due to transposition of a loop of large intestine in between the diaphragm and the liver without pain?

A

Chilaiditi sign

Chilaiditi sign is the anatomic variant without s/sx like pain, SOB or torsion. Once the extra s/sx occur, it becomes Chilaiditi syndrome

111
Q

The anatomical variant of Chilaiditi sign/syndrome mimics what medical emergency on CXR?

A

Bowel perforation

112
Q

What 3 factors contribute to the depth of a thermal injury?

A

Contact temperature
Duration of contact
Thickness of skin

113
Q

What layers of the skin are generally involved in heat burns?

A

The epidermis and dermis

114
Q

What is the primary concern at the cellular level with an electrical burn?

A

Disruption of membrane potential

115
Q

A friction burn is a combination of what 2 types of burns?

A

Mechanical and heat

116
Q

The magnitude of an electrical burn depends on what 3 factors?

A

Pathway of current
Resistance to current flow
Strength and duration of current flow

117
Q

What caustic reactions can be caused by a chemical burn?

A

pH alteration
Disruption of cell membranes
Direct toxic effect on metabolic process

118
Q

The magnitude of a chemical burn is related to what 2 factors?

A

The duration of exposure
Nature of the agent

119
Q

Acidic agents cause necrosis by using what?

A

Necrosis by coagulation

120
Q

Alkali agents cause necrosis by using what?

A

Necrosis by liquefaction

121
Q

What burn type is most likely to have weird/irregular injury patterns?

A

Chemical burn (think splash pattern from a liquid or aerosolized spread from a powder)

122
Q

The magnitude of a radiation burn relies on what 2 factors?

A

Dose and time of exposure
Types of particles

123
Q

________causes damage from radiation burns

A

Ionization

124
Q

What are the examples from lecture of radiation burns?

A

Sunburns
Therapeutic radiation
Diagnostic procedures
Nuclear industry workers

125
Q

What type of burn is not included in TBSA?

A

1st degree burns

126
Q

What populations tend to have deeper burns related to thin skin?

A

Adults over 55 and kids under 5

127
Q

Due to burns ability to evolve/change in the early period, when does true staging of a burn occur?

A

24 - 72 hours after the initial burn

128
Q

What is the primary difference between superficial and deep partial thickness burns?

A

Deep extend more deeply into the dermis with less pain, have a longer healing period of 21 - 28 days and require skin grafting

129
Q

What type of burn has a surface that is dry and inelastic?

A

3rd degree burns

1st degree burns are dry with/without small blisters

130
Q

List the rule of 9’s for each body region for an adult

A

Head = 9%
Each arm = 9%
Each leg = 18%
Trunk = 36% total
Perineum = 1%

for each above except perineum, they account for TOTAL area of each region, anterior and posterior account for half of that total. So anterior trunk would be 18%, posterior left arm would be 4.5%

131
Q

The palmar method of estimating burns account for how much TBSA measured?

A

The palm of the patient is approximately 1% BSA

132
Q

How does being obese change burn estimation?

A

Underestimate torso burns
Overestimate extremity burns
Android (fat accumulates in the upper part of body mainly abdomen/chest) vs gynecoid (pear shape) shape important

133
Q

At what TBSA do patients develop severe enough burn shock to warrant IV resuscitation and admission to the ICU?

A

Greater than 20% TBSA

134
Q

Why are we starting to become more cautious about fluid resuscitation in burn patients?

A

Over resuscitation can cause abdominal compartment syndrome, pulmonary edema/ARDS

135
Q

What are the general metabolic responses to trauma/burns?

A

Auto-cannibalism - leading to loss of fat, loss of lean body mass (proteolysis), gluconeogenesis, lipolysis, hyper-metabolism and insulin resistance

136
Q

What metabolic effects occur with a greater than 40% BSA burn?

A

Metabolic rate doubles
Cannibalism for months
Immunodepression, recurrent infections, poor wound healing

137
Q

Increases in cortisol, catecholamines, and glucagon lead to what changes in carbohydrate metabolism in a burn patient?

A

Accelerated hepatic gluconeogenesis

Peripheral insulin resistance (50-70%) -> (causes post-receptor defect hindering uptake related to the extent of the burn which can last up to 3 years)

Impaired intracellular glucose transport

138
Q

Accelerated lipolysis is caused by what in a burn patient?

A

Excessive B2/3 adrenergic stimulation (this in turn is stimulated by elevated glucagon, TNF and IL)

treat with beta blockade to reduce lipid oxidation and therefore decrease metabolic rate

139
Q

The loss of muscle mass in a burn patient is proportional to what?

A

The degree of stress, or rather the severity of the burn. In severe burns the loss of skeletal muscle can be doubled

140
Q

What are the secondary priorities after burn stabilization?

A

Pain control
Thromboprophylaxis
Wound closure
Nutritional support
Control of hyper-metabolism
Prevention of infection

141
Q

What administration route is generally contraindicated in burn patients?

A

IM route

142
Q

What 3 factors from a burn lead to copious loss of fluid?

A

Impaired endothelial barrier
Increased capillary permeability
Loss of intravascular oncotic pressure

143
Q

Aggressive fluid resuscitation is generally indicated for what BSA?

A

Greater than 15% BSA

144
Q

What should be considered on day 2 after fluid resuscitation?

A

Colloid administration

145
Q

How does the parkland formula calculate fluid needs?

A

4 ml/kg/%BSA (2 ml/kg/BSA in the first 8 hours, the other 2 ml/kg/BSA in the next 16 hours)

146
Q

What is the army rule of 10 for adult burns?

A

10 ml/hr x TBSA, if over 80 kg add 100 ml per 10 kg to the hourly rate (so if you are 100 kg, you would add 200 ml/hr to the calculated rate)

147
Q

Based on the parkland formula, how much fluid resuscitation is needed for a 60% TBSA for a 80 kg patient?

A

4 x 80 x 60 = 19,200 mL

148
Q

Base on the army formula, how much fluid resuscitation per hour is needed for a 115 kg patient with a 35% TBSA?

A

10 x 35 + (35 x 10) = 700 ml/hr

*Some math was simplified here, you add 100 ml per 10 kg, which can be simplified to 10 ml per kg over 80 kg. In this case, it’s 35 kg over 80, so 35 x 10 = 350 ml)

149
Q

What findings upon an assessment of a burn warrant transfer to a certified burn center?

A

Full thickness > 10% BSA
High voltage electrical burns
Chemical burns
Associated inhalation injury
Face, hands, feet, perineum, major joint burn(s)

150
Q

What is the goal UOP with burn fluid resuscitation?

A

1 cc/kg of UOP (the slide does NOT specify a timeframe, I’m assuming it’s hourly)

151
Q

Why is LR the crystalloid of choice rather than NS?

A

Large volume administration of NS can cause hyper-natremic hyperchloremic acidosis

152
Q

What is the max fluid rate/hour in burn resuscitation? Max total volume in 24 hours?

A

Hourly = 1500 ml/hr
Total in 24 = 250 ml/kg

153
Q

If children are under 20 kg, what maintenance fluid is added?

A

D5LR

154
Q

If under 14 years old and under 40 kg, what fluid resuscitation formula do you use?

A

2 - 4 ml (of LR) per kg x kg x %TBSA

goal UOP of 0.5 - 1 ml/kg/hr

155
Q

What is the albumin infusion rate for a 30 - 49% TBSA for less than 70 kg? 70 - 90? Over 90?

A

<70 = 30 ml/hr
70 - 90 = 40 ml/hr
>90 = 50 ml/hr

156
Q

What is the albumin infusion rate for a 50 - 69% TBSA for less than 70 kg? 70 - 90? Over 90?

A

<70 = 70 ml/hr
70 - 90 = 80 ml/hr
>90 = 90 ml/hr

157
Q

What is the albumin infusion rate for a 70% or greater TBSA for less than 70 kg? 70 - 90? Over 90?

A

<70 = 110 ml/hr
70 - 90 = 140 ml/hr
>90 = 160 ml/hr

158
Q

What is the pediatric colloid infusion rate?

A

4 - 7 ml/kg at the rate of 0.5 ml/minute

159
Q

What are the 2 cardiac “phases” during a burn?

A

The resuscitative phase or the ebb state (simple version is, CO is low, SVR is high)

The post-initial burn or flow state (CO is high, heart is hyperdynamic and SVR is decreased -> give beta blockers)

160
Q

With a circumferential burn, what procedure can help alleviate the restrictive lung defect?

A

Escharotomy

161
Q

What pulmonary effects begin immediately after a burn?

A

Pulmonary hypertension
Pulmonary capillary alveolar membrane disruption
Decreased plasma oncotic pressure
Increased extravascular lung water…impaired gas exchange
Bronchospasm is common -> bronchodilator therapy

162
Q

What carboxyhemoglobin level would you expect after an inhalation injury?

A

Greater than 10%

163
Q

What topical antibiotic is contraindicated in facial burns?

A

Silvadene cream

164
Q

What antibiotic would you use for the eye lids? The eyes?

A

Lids = bacitracin
Eyes = erythromycin

165
Q

What type of poisoning would you be concerned about from an inhalation injury from a car fire? Tx?

A

Cyanide poisoning, treat with vitamin B-12 (cyanocobalamin)

166
Q

What route of entereal nutrition administration is ideal for burn patients?

A

J-tube (jejunum) -> allows for continuous tube feed with minimal aspiration risk. Advantageous, especially with the high liklihood of multiple OR trips

167
Q

What factors greatly alter the pharmacokinetics/dynamics of drugs after a burn?

A

Plasma protein concentration is changed d/t loss of albumin and increases in free fractions/VD, alterations in ACh receptors (they are upregulated after a burn) and changes in CO (ebb/flow)

168
Q

Why must Sux be used with extreme caution in burn patients?

A

D/t upregulation of nACh receptors, they are very sensitive to Sux

169
Q

What paralytic are burn (greater than 25% BSA) patients resistant to?

A

Non-depolarizers

170
Q

T/F: The severity of a burn correlates to the patients sensitivity to a depolarizer?

A

False

171
Q

Do AANA standards of care make changes/accommodations for burn patients?

A

No; however it may be harder to keep devices attached. You may need to suture devices or place electrodes in weird places

172
Q

What airway assessment findings indicate an inhalational injury?

A

Hoarseness, wheezing, SOB
Carbonaceous sputum
Singed nasal & facial hairs
Deep facial burns
Comatose patient
>40% TBSA

173
Q

When is propofol a good choice for burn induction?

A

During the flow phase (the heart is hyperdynamic here)

174
Q

When is ketamine a good choice for a burn patient induction?

A

During the ebb phase (the CO is low, and ketamine will help preserve the CO)

175
Q

Why must etomidate be used with care in burn patients?

A

D/t adrenal insufficiency concerns

176
Q

What is the ratio for blood volume lost per burn excised/autograft harvested?

A

2.6% blood volume lost per 1% burn excised/autograft harvest

177
Q

What are some interventions to help reduce blood loss related to burn injury?

A

Use of topical thrombin, staged procedures, subq vasoconstrictors

178
Q

What are the choice vasopressors in burn related shock?

A

Vaso and Levo

179
Q

If CVP is less than goal, how much do you increase IVF rate?

A

By 20 - 25%

180
Q

What drugs make up tumescent LA?

A

1g of lidocaine + epi + 10 mEq of bicarb per 1000 cc of NaCl

181
Q

What is the max dose of tumescent LA?

A

55 mg/kg

the burn slide says the max is mg/kg, prior anesthesia pharm lecture says its 55 ml/kg, not sure which one to stick with

182
Q

What are the pros/cons of tumescent LA?

A

Pros: Decreased blood loss, easy excision of granulation tissue, shorter surgery and no hematoma/bruising
Cons: The large amounts of lidocaine and epi can have unpredictable effects on the heart

183
Q

What must be done if nebulized heparin is indicated in an inhalation burn injury?

A

You must coadminister it with albuterol, otherwise bronchospasm may occur

184
Q

What are your goal pCO2 and pH for a burn patient (assuming they are mechanically ventilated)?

A

PCO2 of 30 - 35, pH greater than 7.2

185
Q

A bladder pressure of what indicates early intra-abdominal hypertension? What pressure indicates compartment syndrome?

A

IAH = greater than 12 mmHg
Compartment = greater than 20 mmHg (do a stat ex-lap)

186
Q

What are the basic anesthesia post-op management goals in a burn patient?

A

DVT prophylaxis, Beta blocker admin, Nutritional support, Temp control

187
Q

What surgical procedure may be used to alleviate extremity pressure to allow for return of a pulse?

A

Escharotomy

188
Q

Does scrotal swelling require treatment in a burn patient?

A

No, even extreme swelling does not warrant treatment

189
Q

T/F: abx and steroids are indicated in burn resuscitation?

A

False

they may be needed later AFTER resuscitation d/t the patients now immunocompromised state

190
Q

What are the burn dressings listed in lecture?

A

Topical antibiotics  Silvadene and Sulfamylon
Silver dressings
Silverton water or saline every 8 hours
Silver nitrate
Temporary skin substitutes such as Biobrane
No Silvadene to the face

191
Q

What condition could allow for easy visualization of the fissures of the lungs on CXR?

A

Fluid within the pleural space or if the visceral pleura is thickened

192
Q

Fluid losses in a burn patient are a function of what 2 factors?

A

Burn size and patient weight

193
Q

What burns generally require higher volumes of fluid resuscitation?

A

Inhaled burns, electrical burns, or delayed resuscitation

194
Q

At what carboxyHgb level do overt s/sx (HA, N/V) begin to occur?

A

15 - 20%

195
Q

At what carboxyHgb level do s/sx of severe toxicity (seizure, ARF or myocardial ischemia) occur?

A

20 - 25%

196
Q

At what carboxyHgb level do unconsciousness/death occur?

A

Greater than 25%

197
Q

Of the bipolar limb leads, which is +/+, +/- and -/-?

A

+/+ = LL
+/- = LA
-/- = RA

198
Q

What part of the heart do the traditional limb leads monitor?

A

The inferior aspect of the heart

199
Q

What parts of the heart do the precordial leads monitor?

A

The anterolateral aspects of the heart

200
Q

What does V1/2 monitor?

A

The septal wall

201
Q

What does V3/4 monitor?

A

The anterior wall

202
Q

What does V5/6 monitor?

A

The lateral wall

203
Q

In RVH, what EKG changes would you expect to see?

A

Greater depolarization toward V1 and the QRS in V1 gets very positive with small R waves

204
Q

In LVH, what EKG changes would you expect to see?

A

Large S waves in V1, larger R wave in V5

204
Q

What EKG change is indicative of myocardial ischemia?

A

Inverted symmetrical T-waves

205
Q

What EKG change is indicative of myocardial injury?

A

ST changes

206
Q

What EKG change is indicative of myocardial infarction?

A

Q waves - this indicates necrosis of an old infarct (this is the bump after the QRS)

207
Q

What type of pacer lead is more sensitive to EMI (electromagnetic interference)?

A

Unipolar

208
Q

What type of pacer lead has multiple electrodes within 1 lead but accesses multiple chambers of the heart?

A

Multipolar

209
Q

List what each roman numeral in a pacer is meant to identify

A

I = chambers paced
II = chambers sensed
III = response to sensing
IV = rate modulation
V = multi-site pacing

210
Q

What does inhibition of III on a pacer do?

A

This means if the pacer sense a spontaneous depolarization, the pacer won’t activate/pace

211
Q

What type of pacing is most common to see if the patient has dilated cardiomyopathy?

A

Bi-ventricular pacing (you have leads in the RA, and both ventricles) for cardiac resynchronization or CRT

212
Q

What are the basic criteria for a patient to be placed on Bi-V pacing?

A

Moderate/severe CHF (EF less than 35% ish), intraventricular conduction delays (BBB) or a history of cardiac arrest

213
Q

What modes are asynchronous pacing with no rate modulation?

A

DOO and VOO

214
Q

If you place a magnet on a pacer, what mode should the pacer default to?

A

Asynchronous mode with no rate modulation (DOO or VOO)

215
Q

What kind of cautery device must be used with care in the presence of an AICD/BiV?

A

Monopolar cautery (in bipolar, the current is localized to the 2 electrodes making it safer for pacers)

216
Q

What is the primary thing an AICD measures? Secondary measurement?

A

Primary = R-R interval
Secondary = QRS

217
Q

Where is a CVP line supposed to terminate?

A

At the junction of the RA and IVC

218
Q

What 2 factors is CVP highly dependent on?

A

Blood volume and vascular tone

219
Q

Normal CVP range?

A

1 - 7 mmHg

220
Q

How does PPV affect CVP?

A

It artificially increases it

221
Q

How does a pericardial effusion affect CVP?

A

It increases it

222
Q

List the CVP waveforms and what they measure

A

A wave = atrial kick, occurs after the P-wave
C wave = isovolumetric contraction of the ventricle causing the tricuspid to bulge backwards, occurs after the R wave
X descent = decrease in atrial pressure during systole
V wave = venous filling of the atrium, occurs during late systole after the T-wave
Y descent = tricuspid valve opens and blood goes into the ventricle, occurs after the v-wave and also after the T-wave

223
Q

How does A. Fib change the CVP waveform?

A

No A-wave and a larger C-wave (loss of atrial kick means more blood stays behind in the atria)

224
Q

How does tricuspid regurgitation change the CVP waveform?

A

No x-descent because the valve is incompetent (blood flows backwards through the valve)

225
Q

How does tricuspid stenosis change the CVP waveform?

A

You have a tall A wave with a y-descent of longer duration and lower amplitude

226
Q

What does each lumen of the PA catheter do?

A

Distal end monitors PAP, the 30 cm proximal port monitors CVP, the 3rd lumen leads to a balloon at the tip and the 4th lumen houses the temperature thermistor

227
Q

Describe at what point on the PA catheter you would find the: RA, RV, Pa and where you would wedge the catheter

A

RA = 20 - 25 cm
RV = 30 - 35 cm
Pa = 40 - 45 cm
Wedge = 45 - 55 cm

228
Q

What are 2 s/sx from lecture that can indicate Pa rupture?

A

Hemoptysis and hypotension (potentially profound hypotension)

229
Q

What are some treatment options of Pa rupture?

A

Ensure adequate oxygenation (endobronchial intubation, single or double lumen tube), PEEP to tamponade bleeding, reverse anticoagulation (unless on bypass), bronchoscopy to control bleeding, float balloon into the rupture, but surgery at some point must be done

230
Q

PAWP is a measurement of what?

A

Indirect measurement of LAP

231
Q

Where should the PAC tip be?

A

Zone 3

232
Q

LVEDP is a poor estimate of what?

A

Compliance
Aortic regurgitation
PEEP
VSD
Mitral stenosis/regurg

233
Q

Mitral regurg creates what changes on the PAC waveform?

A

Tall V-wave, C wave fuses with the V wave, no x descent

PAC waveform changes have no sensitivity to LA compliance or volume

234
Q

Mitral stenosis creates what changes on the PAC waveform?

A

Slurred early Y-descent and the A-wave may be absent (especially if they are in A. Fib)

235
Q

What PAC changes occur with an acute LV MI?

A

Tall A-waves, LVEDV and LVEDP increase, PAWP increases

236
Q

Assuming Hgb, arterial saturation and oxygen consumption are static, what is the relationship of a mixed Vbg and CO?

A

An indirect indicator of CO; if mVbg decreases then CO is likely decreasing

237
Q

What is the CO equation?

A

CO = SV x HR

238
Q

What is a normal CO?

A

5 L/min

239
Q

What is a normal SV?

A

75 ml

240
Q

What is a normal SVR?

A

1200 dynes/sec/cm^5

241
Q

What is a normal PVR?

A

80 dynes/sec/cm^5

242
Q

What is a normal mixed venous saturation?

A

75%

243
Q

Describe how bolus thermodilution works

A

You inject a cold liquid, and based on the temperature change you measure CO. If CO is high, the fluid doesn’t have time to increase in temperature (or rather, the temperature of the fluid doesn’t change much), if CO is low, the fluid has more time to increase in temperature and CO is low

244
Q

What conditions can make thermodilution inaccurate?

A

Intra-cardiac shunts

Tricuspid/pulmonic regurgitation

Mishandling of the injectate

Fluctuations in temperature

Rapid fluid infusion

245
Q

When is CCO (continuous cardiac output) more accurate?

A

When the patient is under positive pressure ventilation

246
Q

Why is pulse contour not as accurate as CCO?

A

It relies on an algorithm to determine CO and ventricular compliance

247
Q

What are the downsides to using pulse contour to estimate CO?

A

Several conditions can make it inaccurate as it relies on an arterial waveform; atrial fibrillation, site of arterial puncture can change it, quality of arterial trace (this is affected by vasopressors) and requires frequent re-calibration

248
Q

What mode of an echo uses narrow beams to measure tissue planes?

A

M-mode

good to examine something like a ventricular wall mass

249
Q

What echo mode shows real time motion and shows function?

A

2-D

250
Q

What echo mode determines speed/direction?

A

Doppler - it also makes use of color

251
Q

What are the primary windows used for an echo?

A

Parasternal: 3-5 ICS
Apical: @PMI
Subcostal: just below xiphoid

252
Q

What is the great overall echo view?

A

Parasternal Long Axis

253
Q

What echo view is good for LV function/volume assessment?

A

Parasternal short axis

254
Q

What echo view is good to compare the ventricles, tricuspid/mitral valve function and examine the descending aorta?

A

Apical four chamber

255
Q

What echo view allows for examination of all 4 chambers and is the best choice to diagnose a pericardial effusion?

A

Subscostal four chamber view

256
Q

What echo view is best to determine fluid status?

A

Subcostal IVC - allows you to directly examine the IVC

257
Q

Contraindications to a TEE?

A

Esophageal varices or laparoscopic banding

258
Q

What types of burns generally require skin grafting and/or other invasive surgery to fix?

A

Deep partial thickness (2nd degree) and 3rd degree burns

259
Q

What is the relationship of cortisol, TNF, IL-1 and IL-6 to protein metabolism?

A

Cortisol improves it, the rest worsen it

260
Q

What is the pediatric fluid resuscitation rate using the US army ISR rule of 10?

A

3 x TBSA x kg

261
Q

When do you start colloids in a burn patient?

A

If at the 8 - 12 hour mark the hourly fluid rate exceeds 1500 ml/hr or the projected 24 hour total approaches 250 ml/kg start 5% albumin infusion

262
Q

Where would a pericardial effusion most likely be found on an echo?

A

Next to the right heart using a subcostal 4 chamber view

263
Q
A

Semester 4 TxWes (4 decks)

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