Random Cards for Comprehensive Exam Flashcards
What’s a way to get an idea of BP if no a-line and cuff is taking forever?
Look at EtCO2.
A sudden drop in EtCO2 would indicated a sudden drop in BP.
S/S of Parkinson’s treatments (Carbidopa/Levodopa)
Overall, think about effects of increased DA
Motor (Dyskinesias)
Psychiatric (mania, agitation, hallucunations, paranoia)
CV effects (increased contractility and HR, orthostatic hypotension)
GI (N/V d/t stimulation of CRTZ by DA)
Autonomic dysreflexia
1) Cutaneous or visceral stimulation below level of lesion
2) This activates preganglionic SNS nerves
3) Vasoconstriction below injury
4) SEVERE HTN
5) Bradycardia and vasodilation above injury
When is the peak risk for hyperkalemia with sux after spinal cord injury?
3-6 months
After acute head injury, the pt may experience a hyperdynamic circulatory response. S/S and tx of this
S/S: Increased HR, BP, and CO
Arrhythmia secondary to epi surge
Labetolol and esmolol are useful to treat this.
Monitors for crani for head trauma
All standard monitors
Probs art-line but don’t delay crani for placement!!
May or may not need CVP (to monitor hemodynamics and for VAE risk)
Monitoring best able to detect VAE
1) TEE (best)
2) Doppler
3) EtCO2
Isthmus of the thyroid is located over these trachial rings
2nd to 4th tracheal rings
Causes of hypoaldosteronism
1) Congenital deficiency
2) Hyporeninemia
- May happen in long-standing DM, renal failure, or treatment with ACE-inhibitors (causes loss of angiotensin stimulation)
3) NSAIDs
- May inhibit renin release and exacerbate existing renal insufficiency
S/S of Hypoaldosteronism
Severe hyperkalemia
Hyperkalemic acidosis
Hyponatremia
Defects in cardiac conduction
Treatment for hypoaldosteronism
Mineralcorticoids (Fludrocortisone)
Liberal salt intake
Nucleoside Reverse Transcriptase Inhibitors
N/V/D, myalgia, increased LFTs, renal toxicity, pancreatitis, peripheral neuropathies, BM suppression, anemia, lactic acidosis, and CYP450 inhibition
Zidovudine + corticosteroids = severe myopathy, including resp. muscle inpairment
Non-Nucleoside Reverse Transcriptase Inhibitors
Delavirdine= Inhibition of CYP450 and causes increased concentration of sedatives, antiarrhythmics, warfarin, and CCBs
Nevirapine induces CYP450 by 98%!
Protease Inhibitors
Ritonavir
HLD, glucose intolerance, abnormal fat distribution, altered LFTs, and CYP450 inhibition!!
HIV Med CYP450 Inducers and Inhibitors
Inhibitors:
- Ritonavir
- Delavirdine
- Zidovudine
Inducer:
Nevirapine
Considerations for the patient on Ritonavir
They will have more pronounced effects with Midaz and Fentanyl (start on low end of dosing)
Ritonavir is a CYP450 inhibitor.
Avoid MAD:
Meperidine
Amiodarone
Most frequent S/S of TB
Non-productive cough Weight loss Fever and night sweats Malaise Hemoptysis and chest pain (late s/s)
TB treatments and their effects
Most can cause hepatotoxicity (INH, rifampin, and pyrazinamide)
Rifampin is a CYP450 inducer
SBE Prophylaxis is Recommended in these Heart Conditions
1) Damaged heart valves
2) Artificial heart valves
3) Cardiac transplant pt who develops problems with heart valves
4) Hx of endocarditis
5) HCM
6) Certain congenital malformations
- Cyanotic congenital heart disease
- Congenital defect that has been repaired with artificial material for the first 6 months after the procedure
- A congenital problem that has been repaired, but has residual effects (persisting leak, etc)
SBE Prophylaxis is recommended in these surgical procedures
1) Dental or oral surgery, where perforation of the oral mucosa is likely
2) Respiratory tract surgery, where the resp. mucosa will likely be perforated
3) Procedures to treat infection of GI/GU tract, skin, or musculoskeletal tissue
4) Cardiac surgery
5) Hepatobiliary procedures with high risk of bacteremia
Antibiotics used for SBE prophylaxis
ACCC
Ampicillin, Cefazolin, Ceftriaxone, and Clindamycin
What is an anaphylactoid reaction?
A reaction that isn’t antibody-mediated
The drug itself causes histamine release from basophils. Size of reaction depends on how much of the agent was given and how rapidly.
NMBs (sux, atra, curare, and miva), opioids (morphine and demerol), and protamine can all cause this type of reaction.
Medications that can be used to prevent anaphylactoid reactions
H1 and H2 antagonists.
Corticosteroids (these cause transcription of anti-inflammatory proteins, and decrease the transcription of pro-inflammatory proteins)
Basically all anesthetics we give cause allergic reactions except
Ketamine and benzos
S/S of Anaphylaxis
- CV collapse is often the first sign (accompanied by MI and dysrhythmias)
- Hypotension (50% of intravascular fluid may be lost)
- Flushing
- Increased PIPs or difficulty ventilating (bronchospasm)
- Difficulty intubating d/t laryngeal edema
Overall, think anaphylaxis with sudden hypotension and bronchoconstriction following drug administration
What should you do if your patient has an LMA in place and you suspect anaphylaxis?
Remove that shit and intubate!!
They will have bronchoconstriction and need assistance ventilating. If you wait, they can develop laryngeal edema and cause a difficult intubation.
Volume replacement in anaphylaxis
Colloids preferred d/t leaky capillaries
Colloid replacement: 10mL/kg
Crystalloid: 10-25mL/kg
Basic interventions in anaphylaxis
Stop offending drug
Communicate to the surgeon what is happening
Administer 100% O2
Intubate if haven’t done so already
Elevate legs
Give fluids (10-25mL/kg)
Give epinephrine (10mcg-1mg –> start low if just suspecting anaphylaxis, and see how they respond)
- If resistant to epi, try Glucagon, Norepi, or Vasopressin
Second-line pharmacology:
- B2 agonists (albuterol and terbutaline)
- H1&2 antagonists (better for prevention than actual treatment)
- Corticosteroids (hydrocortisone 250mg IV)
- -> corticosteroids work by enhancing the B effect of other agents and inhibiting arachidonic acid release
What is the best regional technique in the septic patient?
PSYCH! Regional anesthesia is contraindicated in sepsis.
This is the only anesthetic gas that is consistently teratogenic
N2O. Increases the rate of spontaneous abortions and causes birth defects.
(remember that it inhibits enzymes responsible for DNA synthesis and myelin formation)
Effect of gases other than N2O
Studies are inconclusive
Gas concentration standards set by NIOSH and OSHA
N2O less than 25ppm
Anesthetic gases
When are you at greatest risk of VA exposure?
Filling the vaporizers
Air turns over in the OR ____ times per hour
15-20
When are you at greatest risk of HIV?
Deep cutaneous needle-stick injury with a large, hollow needle
Can also occur with small breaks in skin or splatters in mouth
When is post-exposure anti-retroviral therapy begun after exposure?
This virus is the most serious occupational health danger facing anesthesia providers
Hep B
20-50% of providers have markers of previous Heb-B exposure
Risk of infection after exposure is 37-62%
Virus can remain active up to 1 week in dried blood
Hep C infections occur mostly due to
blood transfusions
You have a ___% chance of developing TB after exposure
10%
Who is most at risk of developing a latex allergy?
Those with chronic exposure
Spina bifida, urologic patients, and healthcare providers
Latex allergy is often associated with these food allergies
Avocado, potato, banana, tomato, chestbuts, kiwi, and papaya
WTF is methylmethacrylate?
Acrylic cement used for prostheses
Supplied as separate powder and liquid components that are then mixed together.
Can release toxic vapors and causes heat production.
Risks of methylmathacrylate
Patient:
- Hypotension
Providers:
- Dyspnea, wheezing, caughing, and rhinorrea
- HTN
- Erythema
- HA
- Unknown effects in pregnancy
NIOSH recommends that 8 hour exposure to methylmethacrylate should be limited to
100ppm
although levels may reach 300ppm during mixing
Effects of Sarin Gas
Inhibits acetylcholinesterses and butyrylcholinesterases, causing an increase in Ach in muscarinic and nitotinic receptors (effects similar to neostigmine).
Excessive secretions, bradycardia, HB, bronchospasm, sz, resp depression, and paralysis.
Treatment for sarin gas exposure
1) Atropine (b/c anticholinergics are given with anticholinesterases).
2) Oximes
Vesicant Agents (Mustard Gas)
These are blistering agents
Treatment: Respiratory and fluid support
Choking agents (Chlorine gas / Phosgene)
Causes laryngospasm and pulmonary edema
Treatment: Respiratory support and to limit inflammation
Cyanide. What does it do and what is the treatment?
It inhibits cytochrome oxidase enzymes (CYP450) and causes hypoxia.
Treatment: Sodium thiosulfate
Botulinum Toxin. What does it do and what is the treatment?
Inhibits the release of Ach.
Treatment: Antiserums
Anthrax. What does it do and what is the treatment?
Bacterium that causes pulmonary edema and a widened mediastinum.
Treatment: Vaccination and antibiotics (Cipro)
Greatest risk of radiation is during
Fluroscopy
Max yearly radiation exposure
When an x-ray is taken you should be a minimum of ___ feet away
3
6 feet of air space provides the same protection from radiation as
9 inches of concrete or 2.5mm of lead
Order of things to do in the event of a fire
ERASE
Evacuate, rescue, activate, shut doors, evaluate
Steps in an airway fire
Remove the ETT
Turn off all gasses
Extinguish the fire by pouring saline down the airway
Remove any burning materials
Mask ventilate. Assess, and re-intubate.
Bronchoscopy if pieces of ETT left behind.
Macroshocks
Large shocks of electricity
1mA = perception threshold 5mA = maximal harmless current 10-20mA = let-go threshold 50-100mA = pain 100-300 = Vfib, resp failure, and apnea > 6000mA = sustained myocardial contraction, temporary resp paralysis, and burns
Microshock
Direct application of a very small amount of electrical current to someone who has an external conduit that is in direct contact with the heart
(cardiac pacing wires, or invasive monitoring catheters)
- Maximum leakage allowed is 10 micro-amprs
- A current as low as 100 micro-amps can cause v-fib
- A ground wire is the most important factor in preventing microshock**
What is the line isolation monitor (LIM)?
A monitor that continually evaluates the integrity of the isolate power system.
It alarms at 2-5mA or resistance of 60,000 ohms.
If it detects a faulty piece of equipment, it converts to a grounded system to prevent shocks.
If it alarms, check the gauge:
2-5 means there are too many pieces of equipment plugged in
>5 means there is a faulty piece of equipment
Type of electrocautery recommended for those with pacemakers
Bipolar
Hazardous noise is considered to be
> 90 decibels for 8 hours/day
Electrical power is usually (grounded/ungrounded) in the hospital
Ungrounded
___% of providers will have at least one medication error or near miss in their career
85%
The most common error is giving relaxant instead of reversal at the end of a case.
__% of medication errors result in death
1.8%
Addiction
Primary, chronic disease characterized by:
- Lack of control over drug use
- Compulsion and craving
- Continued use despite adverse consequences
What is a covered entity?
Hospitals, dentist offices, pharmacies, health care plans, providers, clearing houses, billing services, business associates, etc.
What is protected health information?
Patient health information in any form (oral, paper, electronic, or recorded).
Demographic information is also included in PHI (name, DOB, etc.)
What is disclosed PHI?
PHI that is released, transferred, or accessed by anyone outside of the covered entity. Even to billing companies.
The patient must sign a release contract prior to ANY disclosure happening.
This is included in authorization forms
- Description of the PHI that will be disclosed.
- Who the PHI is being disclosed to and why
- If the covered entity will get financial gain from release of the info
- Letting the pt know that they have the right to refuse authorization
- Date and signature
When is written authorization not required during sharing of PHI?
- For the pt directory within the facility
- When informing appropriate agencies during disasters
- For public health issues related to disease control
- In reporting abuse or neglect
- For health oversight activities
- To coroners, medical examiners, and funeral directors (b/c these people have a right to know what they’re dealing with)
- Organ and tissue donations
- In research, public health, or healthcare operations as a limited data set (any identifying info is removed)
Patient rights
- Patients can exercise rights over their PHI
- Patients will receive a privacy notice at first delivery of service
- PHI will be communicated in a way to protect confidentiality
- Pt can inspect, amend, correct, and obtain copies of their PHI
- Request a history of disclosures for the last 6 years (be able to see who your health info was divulged to and why)
- Pt can contact ppl within the facility regarding concerns or breaches of confidentiality
Parents have control over PHI of minors except when it comes to
- HIV testing
- Abuse
- If parents agree to give control to the minor
- If the state takes over control of the child
These meds should be avoided in parkinson’s
- Anti-emetics that are DA antagonists
- Fentanyl and alfentanil (may have some anti-DA activity)
Loss of diaphragm functioning if injury above
C4
Loss of cardiac accelerators if injury above
T6
Methylprednisolone dosing within 8 hours of spinal cord injury
30mg/kg IV bolus, then
Infusion at 5.4mg/kg/hr for 24-48 hours
Blood loss is greater in these areas of the spine
Lumbar and thoracic > cervical
