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A1 > Random APEX > Flashcards

Random APEX Flashcards

1
Q

Normal anatomical shunt

A

-Thesbian (drain left heart)
-Bronchiolar (drain bronchial circulation)
-Pleural (drain bronchial circulation)

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2
Q

What increases zone 1 in the lungs?

A

Hypotension (no blood thru lungs)
PE (blocks blood from coming in contact with alveoli)
Excessive airway pressure (too much V not enough Q)

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3
Q

How does the body combat west zone 1?

A

Bronchioles constrict in OVER? perfused alveoli

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4
Q

How does the body combat west zone 3?

A

Hypoxic Pulmonary Vasoconstriction reduces blood flow to under ventilated alveoli

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5
Q

What causes west zone 4?

A
  • increased volume: mitral stenosis, fluid overload
  • Fluid is pulled d/t a decrease in pleural pressure: laryngospasm, mullers maneuver (bite tube and breathe in)
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6
Q

What causes Increased Aa gradient? O2 or CO2?

A

O2
Aging (higher closing capacity)
Vasodilators (prevent HPV which hinders VQ match)
RL shunt (from atelectasis, pna, bronchial intubation, intercardiac defect)
Diffusion limitation

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7
Q

Alveolar gas equation (partial pressure of alveolar oxygen)

A

[fio2-(ATM-H20)]-(PCO2/RQ)

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8
Q

Estimation of shunt % per Aa gradient

A

1% for ever 20mmHg of Aa

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9
Q

What increases FRC

A

OLD- asthma, copd
Older age- longer sigh bc wisdom, sighing
Prone/ sitting
PEEP

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10
Q

What decreases FRC

A

RLD- obesity, pregnancy, pulmonary edema
General anesthesia
Supine
Fluid overload

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11
Q

Normal FRC value

A

35ml/kg

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12
Q

How can we measure FRC

A

Nitrogen washout
Helium wash in
Body pleth

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13
Q

How to determine time to desaturation?

A

FRC/ VO2
Where FRC is (100% O2= 2300x1.0)- 2300
Where FRC is (21%O2= 2300x.21)
Where VO is 250
In the first- 9.2 minutes
In the latter is 1.9 minutes

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14
Q

Do you want a high or low FRC?
How do you do it?

A

High! Gives more time before desaturation
To increase- PEEP, prone/sitting/lateral, old age, sigh, fio2 <.8, asthma, COPD

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15
Q

Do we want closing volume high or low?

A

LOW!!!!

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16
Q

What increases closing volume?

A

CLOSE-P
COPD
LV failure
Obesity
Surgery
Extremes of age (young or old)
Pregnancy

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17
Q

Normal relation between FRC and CC

A

FRC should always be bigger!
If CC is bigger than FRC, alveoli will collapse during normal Vt
CC>FRC-> shunting, hypoxemia

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18
Q

How would you increase FRC in relation to CC?

A

PEEP

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19
Q

How does age effect CC/FRC?

A

30-CC=FRC during anesthesia
44-CC=FRC when supine
66- CC=FRC when standing
So, CC increases as we age, making it easier for airway to collapse

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20
Q

What decreases SvO2

A

Shivering
Fever
Pain
Thyroid storm
Anemia

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21
Q

What increases SvO2

A

Hypothermia
Sepsis (makes CO2, cant accept O2)
Increased CO, HGB, PaO2
Cyanide toxicity binds HGB up

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22
Q

How does hypercapnea affect the body

A

Myocardial depressant
PVR increased
K, CA increased
Increased IOP/ ICP

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23
Q

What drug, action, and clinical situation increase minute ventilation?

A

Aspirin
Surgical stimulation
Hypoxemia

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24
Q

Peripheral vs central chemoreceptors locations

A

Central- medulla- primary detector of CO2
Peripheral- carotid bodies, transverse aortic arch- secondary detector of CO2

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25
Q

Can increased CO2 ever depress breathing?

A

Yes
80-100mmHg

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26
Q

Which drugs cause left shift on CO2 ventilatory response?

A

L shift- makes u breathe more
Aspirin
Norepi
Aminophylline
Doxapram

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27
Q

Which drugs cause right shift on CO2 ventilatory response?

A

R shift- stops u from breathing
Opioids
Paralytics
Volatile anesthetics

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28
Q

CO2 ventilatory response- surgical stimulation vs carotid endarectomy

A

SS L shift- makes u breathe!
Except for carotid endarectomy, blunts baroreceptors in carotid, prevents u from breathing

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29
Q

Apneustic vs Pneumotaxic center

A

Apneustic- stimulates DRG to inspire
Pneumotaxic- Inhibits the DRG (stimulates the end of inspiration)
Pneumotaxic- strong signal-> shallow but rapid breaths, weak signal-> slow deep breaths (normal)

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30
Q

DRG vs VRG

A

DRG- inspiration rate and rhythm
VRG- expiration, but also inspiration to a lesser degree

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31
Q

Location of DRG and VRG

A

DRG- Medulla (nucleus tractus solitarius)
VRG- Medulla (nucleus ambiguous/retroambiguus)

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32
Q

Location of Pneumotaxic and apneustic?

A

“PA” = PONS
Upper pons
Lower pons

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33
Q

Can CO2 of H+ cross the BBB?

A

Only CO2

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34
Q

Primary stimulus at the central chemoreceptor

A

H+
Hypercarbia and hypoxemia to a lesser extent

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35
Q

Peripherl chemoreceptor job and location

A

Transverse aortic arch, carotid body
Respond to PaO2 <60

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36
Q

How do volatile anesthetics influence peripheral chemoreceptors?

A

.1 MAC-> decreased hypoxemic ventilatory drive

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37
Q

What stimulates J receptor?

A

PE
CHF

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38
Q

What inhibits HPV?

A

Volatile anesthetics 1-1.5 MAC
Dobutamine
Vasodilators
Vasoconstrictors may constrict well ventilated units and cause shunt
PDE inhibitors
Excessive PEEP
Large Vts

NOT INHIBITED FROM TIVA

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39
Q

Will shunt respond to O2?

A

NO

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40
Q

5 types of hypoxemia and their Aa gradient

A

Normal Aa- reduced fio2, hypoventilation
Increased Aa- shunt, VQ mismatch, diffusion limitation

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41
Q

What impairs hypoxemic respiratory drive?

A

Anemia and CO poisoning
Normal enough PaO2

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42
Q

COPD and dead space relationship

A

Direct positive

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43
Q

“venous admixture” ??

A

SHUNT

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44
Q

“small airway diseases”??

A

Obstructive

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45
Q

What things increase risk for PPC?

A

Old age >60
COPD
CHF
ASA >2
Ciagrette >40 pack yrs
Aortic>thoracic>upper abdominal
GA
Duration >2H
Albumin <3.5

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46
Q

What does NOT increase risk of PPC?

A

mild/moderate asthma
PFT
ABG

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47
Q

Absorption atelectasis

A

Keep fio2 under .8
Causes shunt

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48
Q

Drugs bad for asthma pts

A

-Histamine releasing drugs- Sux, Atracurium, Morphine, Meperdine
-Ketamine causes bronchodilation BUT increases secretions
-Ketorolac increases airway resistance
-Antiholinesterases
-Nonselective BB

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49
Q

Drugs good for asthmatics

A

All volatile agents reduce airway resistance/ dilate the airway, sevo can also reduce coughing
Sevo best, then iso, des
Propofol surpresses airway reflexes
Lidocaine surpresses airway reflexes
IV hydration to thin secretions

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50
Q

How to treat bronchospasm

A

Fio2 1.0
Deepen anesthetic (volatile agent, propofol, ketamine, lidocaine)
Albuterol
Ipratropium (anticholinergic)
EPI 1mcg/kg IV
Hydrocortisone 2-4mcg/kg IV
Aminophylline (methylxanthine, theophylline cant work acutely)

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51
Q

Some causes of COPD

A

Aplha 1 antitrypsin deficiency (emphysema only)
Smoking (bronchitis mostly)
Environmental pollutants
Respiratory infections

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52
Q

Bronchitis vs emphysema

A

Bronchitis- hypertrophied bronchioles
Emphysema- damaged airway distal to terminal bronchioles- alveoli?

53
Q

Spirometry in COPD

A

Increased: RV, FRC, TLC
Decreases: Fev1, Fev:FRC, FEF 25-75

54
Q

HPV and volatile agents

A

Volatiles inhibit HPV at 1-1.5 MAC, although fio2 might help if shunt isnt severe
Volatiles do, however, cause bronchodilation

55
Q

No neuraxial anesthesia if it is above what spinal level?

A

T6
This would impair

56
Q

1 Nitrous oxide risk

A

Pneumo d/t rupture of pulmonary blebs

57
Q

1 critical drug for anesthesia in pt with severe aortic stenosis

A

Phenyl!
Maintain high SVR to perfuse tissues
Low afterload, hypotension, will cause feinting, and maybe even rebound tachycardia, bad!

58
Q

How does a systolic vs diastolic murmur sound?

A

Systolic- Lub murmur dub
Diastolic- Lub dub murmur

59
Q

Aortic regurg conditions

A

Anklyosing spond
Marfans
Ehler danlos

60
Q

“Mitral prolapse”

A

Mitral regurg

61
Q

Worst drug for mitral prolapse

A

Ketamine

62
Q

What drug is worst for pneumo

A

N2O
Increases size of pneumo d/t BG coefficient

63
Q

What positions are safest for PE

A

Left lateral (durant maneuver traps air in upper R lung)
prone
supine
sitting

64
Q

Treatment for PE

A

Fio2
NS
DC insufflation
Durant maneuver
Aspirate air
Hemodynamic support until air is absorbed

65
Q

PE diagnostic tools

A

TEE
Doppler
ETCO2
CO

66
Q

Drugs that increase PVR

A

Ketamine
N2O
DES

67
Q

Mallampati pneumonic

A

PUSH
Pillars (tonsillar)
Uvula
Soft palate
Hard palate

68
Q

Normal incisor gap

A

3 fingers- 4cm

69
Q

What can restrict incisor gap?

A

arthritis
scar tissue
TMJ disease
prior surgery

70
Q

Why would a thryomental distance be small?

A

Tumor
radiation
submandibular abscess

70
Q

Mandibular protrusion test failure

A

Class 3- very underbite

71
Q

What can impair AO mobility

A

Anklyosing spondylitis
RA
Down syndrome
Klippel feil
DM
DJD
Surgical fixation

72
Q

Cormach lehane score pneumonic

A

Glottic (complete) (to include anterior commissure)
Glottic (partial)
Epiglottis and soft palate (no glottis at all)
Soft palate only (no larynx at all)

73
Q

Cormack 2a vs 2b

A

2a partial cords
2b only corniculates and posterior cords (no opening of glottis)

74
Q

BONES

A

Mask
Beard
Obesity
No teeth
Eldelry
Sleep apnea

75
Q

LEMON

A

intubation
Look at external airway
Evaluate 332
Mallampatie
Obstruction
Neck mobility

76
Q

RODS

A

LMA
Restrictive mouth opening
Obstruction
Distorted airway
Stiff lungs/ c spine

77
Q

SHORT

A

Surgical airway
Surgery/previous scar
Hematoma
Obesity
Radiation
Tumor

78
Q

What pressure for cricoid pressure

A

20Newtons before LOC
40N after LOC

79
Q

Complications of cricoid pressure

A

Lower esophageal sphincter tone
Difficult intubation
Airway obstruction
Esophageal rupture

80
Q

Conditions associated with c spine abnormalities

A

Trisomy 21
goldenhar
Klippel-feil

81
Q

3 key causes of angioedema

A

anaphylaxis
ACE inhibitors
C1 esterase deficiency

82
Q

Congenital conditions that affect airway management pneumonics

A

(Large tongue) Big Tongue- beckwith, trisomy 21
(small mandible) Please get that chin- pierre robin, goldenhar, tracher collins, cri du chat
(c spine anomaly) Kids Try Gold- klippel feil, trisomy 21, goldenharr

83
Q

How to treat heredity angioedema

A

same as ace inhibitor
C1 esterase concentrate
FFP
Ecallantide
Icatibant

84
Q

How to treat anaphylaxis

A

epi
steroids
antihistamines

85
Q

Sniffing position is described as ___

A

Cervical flexion (use pillow will pull neck towards chin towards chest)
AO extension (look up)

86
Q

What axes does sniffing position align?

A

Not tracheal
Oral
Pharyngeal
Laryngeal

87
Q

HELP

A

For obese patients to intubate
Head
Elevated
Laryngoscopy
Position
Also, reverse trendelenburg

88
Q

Nerve affected when ETT is laying on pt face, symptoms

A

Supraorbital nerve (5- branch of v1, the opthalmic nerve)
Forehead numbness, eye pain, photophobia

89
Q

Nerve affected when face mask is too tight and symptoms

A

buccal branch (7 facial, but also cn5v3 mandibular)
Difficulty opening and closing lips

90
Q

Nerve affected when aggressive jaw thrust, symptoms

A

CN7 facial
Affected side may sag, drool, and chew will be affected

91
Q

In obese pt, what 2 structures should be aligned for HELP/ optimal position?

A

Sternum and external auditory meatus

92
Q

Contraindications for naso airway

A

Coagulopathy
Cribiform plate injury (many)
Nasal fracture
Caldwell Luc previous procedure
Transsphenoidal hypophysectomy prev procedure

93
Q

Dangers of the wrong size oral airway

A

Too small- pushes tongue to top of mouth
Too big- pushes epiglottis towards glottis

94
Q

Cribiform plate injuries

A

Lefort 2/3
Basal skull fracture
CSF rhinorrhea
Raccoon eyes
Periorbital edema

95
Q

Max pressure for ETT balloon

A

25 cm H2o

96
Q

Predictors of difficult VAL

A

LetsThinkClass,ShittyNeck?
Limited cervical motion
Thick neck
Class 3 upper lip bite test
Short TMD
Neck pathology (radiation, tumor, surgical scar)
NOT mallampati and obesity

97
Q

MAP formulas (2)

A

1/3 PP + DBP
(COxSVR)/80 +CVP

97
Q

LMA max PPV pressure and cuff pressure

A

20cm H2O
60cm H2O (goal 40-60)

98
Q

Nerves at risk for injury with LMA

A

Lingual
Hypoglossal
RLN

99
Q

LMA size and cuff inflation

A

1 <5kg 4
1.5 5-10 7
2 10-20 10
2.5 20-30 14
3 30-50 20
4 50-70 30
5 70-100kg 40

100
Q

Most common cause of nerve injury with LMA

A

Overinflation

101
Q

LMA contraindications

A

gastroparesis/ hiatal hernia/ full stomach/ sbo/ GERD
obstruction at or below glottis (tumor)
Poor lung compliance (not asthma/ reactive airway disease)
Tracheomalacia/externl tracheal compression
restricted,obstruction,distorted airway, stiff lungs, full stomach

102
Q

CN5 branches, location, motor

A

V1 opthalmic ethmoidal nares/ ant septum
V2 maxillary sphenopaltine turbinates/ septum
V3 mandibular lingual anterior 2/3 tongue mastication

103
Q

CN9 sensory and motor

A

posterior tongue to anterior epiglottis
swallowing phonation

104
Q

CN5 vs CN7 branches

A

Trigeminal- opthalmic, maxillary, mandibular
Facial- temporal, zygomatic, BUCCAL, (but also is connected to cn5v3), mandubula (but also connected to cn5v3), cervical

105
Q

Best, next best, worst time for bougie

A

3,2b,4

106
Q

How far to put bougie in, how far for hold up sign

A

25cm, 35-40cm

107
Q

Poiselles law

A

q=pi x r^4 x chg P/ (8nl)
flow
pi
radius
AV pressure gradient
viscosity (hct)
length of tube

108
Q

Radius to flow (2r, 3r, 4r = _ flow)

A

2r- 16x increase in flow (q)
3r- 81x Q
4r- 256x Q

109
Q

Another way to write sv formula

A

co=hrxsv
so, co/hr=sv
OR, sv= co x (1000/hr)
to get right units, you have to do hrx sv and then divide by 1000

110
Q

What does pcwp equal?

A

LVEDP
CVP
PAD
LAP
LVEDV

111
Q

Things that increase contractility

A

SNS/ catecholamines/
Calcium
dig
PDE inhibitors

112
Q

Things that decrease contractility

A

Hypoxia/ hypercarbia
Hyperkalemia- induced cardiac arrest/ hypocalemia-low contractility!(opposite of dig toxicity risks)
acidosis/ ischemia
Prop/ BB/ CCB/ volatile anesthetics

113
Q

B1 MOA as far as enzymes

A

B1 stimulates AC
AC converts ATP to CAMP
CAMP increases iCA and PKA
PKA-> 1) Ca enters via L type 2) Ca enters via ryanodine 2 receptor 3) Stimulate SERCA 2 to increase reuptake and release of Ca

114
Q

Where do the SA, AV, bundle of his, and bundle branches get blood supply?

A

RCA 70%
RCA 80%
LCA 75%
LCA ~100%

115
Q

What part of the heart is most susceptible to ischemia?

A

LV (sub but later no sub)endocardium- it squezes the hardest
Thats why LCA pressure waveform drops as compared to regular arterial line waveform

115
Q

RCA arterial waveform

A

Small A line
Stays relatively the same, no major squeeze drops it

116
Q

3 things that increase myocardial O2 demand

A

tachycardia
HTN
SNS stimulation

117
Q

What effect does increasing preload have on myocardial O2 supply and demand

A

Decreases supply
Increases demand
Cause it causes hardy inotropy

118
Q

cAMP and PKA in cardiac myocyte vs vascular muscle cellg protein cAMP

A

Cardiac- contraction
Muscle cell- opposite

119
Q

PLC pathway

A

AgII-> agII receptor-> g protein->PLC->increased Ca-> vasoconstriction
1st messenger->g protein coupled receptor-> effector->second msger -> cellular response

120
Q

s1 s2 s3 s4

A

s1 av valves closing (step 2)
s2 ap valves closing (step 5)
s3 rapid filling of ventricle suggestove of heart failure (step 6)
s4 atrial kick- poor ventricular compliance (step 1)

121
Q

First messenger -> second messenger

A

First messenger
G protein receptor
Effector
Second messenger
Response

122
Q

What to do in emergency

A

fio2 100%
Open fluids wide open
Turn off agent
Call for help

123
Q

HIESD

A

HI, ever suck d?
MAC of gasses
Halothane .75%
Isoflurane 1.15%
Enflurane 1.6&
Sevoflurane 2%
Desflurane 6%

124
Q
A
125
Q
A

A1 (122 decks)

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