RANDOM/ PRODIGY TRIVIA/VALLEY BOOK Flashcards
Parasympathetic does not include fibers of
CN8
What is the opioids with the highest protein binding?
Sufentanil
NDNMB are what kind of compounds?
Quaternary compounds
What type of diuretics can cause hyperKalemia?
Spironolactone (Potassium sparing diuretics)
What amount of hepatic blood flow comes from the portal vein?
70%
70% of hepatic blood flow comes from the
PORTAL VEIN
What % of calcium is in the ionized form?
50%
Serotonin act as a _________in all tissues, except
Vasodilator ; HEART and skeletal muscles
All of the following should be avoided in carcinoid syndrome
Morphine
Atracurium
fentanyl
Apneic oxygenation during bronchoscopy can lead to
HYPERCARBIA
Fenoldopam on BP
Decreases arterial BP
ARDS is defined as
Acute respiratory failure due to pulmonary injury.
Most suitable for inductin controlled hypotension agent
sodium nitroprusside
CHF is usually caused by
Systolic dysfunction
High cardiac output heart failure is associated with
Sepsis
How does midazolam depresses ventilation?
By decreasing the Hypoxic drive.
Butyrephenones drugs classes are
droperinol and haloperidol
Pt taking MAOIs should avoid
Avocado
The most common manifestation of folic acid deficiency of
Megaloblastic anemia
Carbamezepine helps prevent seizures by primarily
blocking Na+ Channels.
Folic acid antagonists
methotrexate
Acetazolamide is used in treatment of
Altitude sickness
Glaucoma.
Clonidine 0.3mg will not decrease plasma catecholamine in patient w/
Pheochromocytoma.
Dopexamine is similar to Dopamine except that it is devoid
alpha-1
Other name for German measles
Rubella
Prions are responsible for what type of encephalopathy?
SPONGIFORM
Pacemaker of the respiratory system
Dorsal Respiratory Group
Bronchospam with what level of Ca2+
Hypocalcemia
Most common blood transfusion is transmitted via
Hep C
Desflurane differs from isoflurane is chemical structure by how many atoms
1
Condition also known as acute idiopathic polyneuritis
GBS
Drug that increases Lower esophagus sphincter tone and lower aspiration risk ? reversal
Edrophonium
ABG associated with asthma is
Respiratory alkalosis
Platelets half life is
1-2 weeks
In the presence of Ca2+ activated factor XI, will activate factor
IX
What is the most significant risk factor for an acute ischemia stroke?
HTN
The most common complication associated with this procedure is stroke caused by
thromboembolism
Cheyne-Stokes respiration
Bilateral dysfunction of cerebral hemispheres
Midbrain and upper pons
Central neurogenic hyperventilation
Low midbrain and upper pons
Increased intracranial pressure with head trauma
Deep, rapid, and regular pattern of breathing
Central neurogenic hyperventilation
Describe Cheyne-Stokes respiration
Regular increase in the rate and depth of breathing that
peaks and is followed by a decreasing rate and depth
of breathing, which progresses to apnea; then
the cycle repeats itself
Apneusis breathing
A pause at full inspiration occurs; may see prolonged
inspiratory pause alternating with prolonged expiratory pause
Ataxic breathing Location of Injury and Other Causes
Medulla
Irregular breathing with shallow, deep respirations
and irregular apneic episodes; usually slow
Ataxic breathing
Acute ischemic stroke BP range for thrombolysis / no thrombolysis
Keep < 180/110 mm Hg if thrombolysis
Treat only BP > 220/120 if no thrombolysis
Intracerebral hemorrhage BP range
Keep SBP < 180 and MAP < 130 mm Hg
ideal SBP < 160 and MAP < 110 mm Hg
Subarachnoid hemorrhage BR range.
Keep SBP < 160 mm Hg before aneurysm treated
Do not lower BP after aneurysm treated
Traumatic brain injury
Keep MAP to maintain CPP > 60 mm Hg
In cell-mediated immunity, the antigen is presented to the
T lymphocyte by infected cells or by antigen-presenting cells such as dendritic cells, macrophages, or B lymphocytes.
Virchow’s triad includes
hypercoagulability, venous stasis, and vessel wall abnormalities.
Virchow’s triad is a set of three factors that predict a
high risk for pulmonary embolism.
Pericardial sac approximately
10 to 25 mL of serous fluid,
Venous drainage ==> What are the 3 major systems?
coronary sinus
the anterior cardiac veins
Thebesian veins
Three major internodal tracts exist:.
the anterior, middle, and posterior
internodal tracts
The anterior internodal tract, or Bachmann bundle,
extends into the LA and then travels downward through the atrial septum to the AV node.
The middle internodal tract, or Wenckebach tract, curves behind the
superior vena cava before descending to
the AV node.
The posterior internodal tract, or Thorel’s pathway,
continues along the terminal crest to enter the
atrial septum and then passes to the AV node.
From anterior to posterior tract
BWT
Proposed mechanism whereby the inhaled anesthetic agents cause depression of myocardial contractilityInhibition of calcium
Influx into cardiac muscle cells is the proposed mechanism whereby the inhaled anesthetic agents cause depression of myocardial contractility
Pericardial tamponade affect what?
Restricts filling of the cardiac chambers during diastole and produces a fixed low cardiac output
Pericardial tamponade IV anesthetic of choice
Ketamine
Connective disease associated with corneal disturbances
Scleroderma
Trisomy 13 aka
Patau’s disease
Ludgwig’s angina is characterized by
Rapidly expanding cellulitis of the mouth, infection of trismus.
Relative contraindication in hypertrophic cardiomyopathy
VASODILATORS
WPW may present as
Paroxysmal SVT
Cocaine effects on HR mainly through
Blockade of Na+ Channels
Bleomycin leads to what kind of toxicity
Pulmonary
Paget’s disease is a disorder that affects
Bone
Largest parenchymal organ is
LIVER
AKI most frequently
ATN
Herbal associated with prolonged sedation
Kava Kava
Decrease pain transmission signal
Enkephalin
Cisatracurium class
Benzoisoquinolinium
Beta Blocker with the highest degree of protein binding
PROPRANOLOL
% of CO goes to the Kidney
25% of CO every minute
3 types of FLOW
Laminar
Turbulent
Transitional
Bernoulli’s principle relates the effect of flow a tube that contains
Constriction
Theoretical temp of absolute zero
0 degree Kelvin
Vapor pressure of liquid solely dependent on
Temperature
Reynold > 2000
Turbulent flow
Reynolds < 2000
Laminar
Nebulizers rely on this effect to deliver medication
Venturi effect
Whose equation corrects the universal gas law
Van der waal
Cell splits into 2 new cells
Mitosis
How many pair of chromosomes
23
Chemical substance that can cause cellular mutation
Carcinogens
Dark areas crossing cardiac muscle fibers
Intercalated discs
Calcium release channels are known as
Ryanodine receptors
Nitroprusside generates
Nitric oxide–> cGMP
Antiarrythmic drugs inhibiting K+ ions
Amiodarone/sotalol
Digitalis toxicity treated with
Phenytoin
Synthetic NONcatecholamine medication
Ephedrine
ALpha adrenergic antagonist used for BPH/HTN
Prazosin
Carbonic anhydrase inhibitor example? What is it used for
Acetazolamide, glaucoma
Upon what receptors does nalbuphine act? (select two)
Mu and Kappa
After intravenous administration of fentanyl, there is an initial rapid increase in plasma concentration of the drug
followed by a rapid decline in plasma administration. This initial, rapid decline is due primarily to
redistribution to highly-perfused organs
Which calcium channel blockers inhibit CYP450? (select two):
Diltiazem &Verapamil
Propofol metabolized by
Partially 3A4 BUT CYP 2B6 main one
Which class of CCBs is verapamil?
Phenylakalanine
Onset of heparin SQ
1-2h
Describe relationship of between LVEDV/SV
Frank Starling.
Coronary Perfusion Pressure formula
Diastolic BP - LVEDP
Most common congenital cardiac abnormality in infants and children
VSD
Most common CYANOTIC congenital heart abnormality
Tetralogy of Fallow
Ebstein anomaly involves what valve
Tricuspid
Normal venous O2 sat
75%
Equation can be used to estimated physiologic-dead space ventilation
Bohr
Vital capacity in elderly
Increased
2 lungs parameters increase with pneumoperitoneum
PIP, Intrathoracic pressure.
First line of defense against unfavorable changes in pH
Buffers
Physiologic dead space =
Anatomic + functional dead space
The administration of epidural steroids can produce an antiinflammatory effect primarily by the inhibition of
Cytokines & Phospholipase A2
sacroiliac joint with radiation to the groin, medial buttocks, and posterior thigh with occasional
radiation below the level of the knee is consistent with what syndrome?
Pyriformis syndrome
How long after a single epidural injection of methylprednisolone 80 mg would you expect the patient’s ability to secrete cortisol to be impaired?
3 weeks
Remifentanil have lower _____and _____clearance when compared to fentanyl
Vd; clearance
What is the most important buffering system in the body
HCO3 (bicarboate system)
What is the enzyme necessary for Prostaglandins synthesis?
Cyclooxygenase
NSAIS on cyclooxygenase
inhibits
Avoid this drugs with porphyria
DILANTIN
Alveolar gas equation is used to estimated
PaO2
Cyclosporine is most likely to cause toxicity to the
kidneys
Drugs with little to no effect on systemic circulation
N2O
H2 receptor antagonists will cause an
Increase in gastric fluid pH
Drugs must likely beneficial to patient with WPW
Droperinol (dopamine antagonist)
Most common cause of Mitral stenosis
Rheumatic fever
Not an ACYNOTIC but a CYANOTIC heart defect
TOF
What medication antagonize the action of ADENOSINE
THEOPHYLLINE
WPW avoid this drug
VERAPAMIL or cardizem
Commotio cordis is
Blunt chest wall impact
Commotio cordis affects what organ
Heart
20% of athletic injury
commotio cordis
Stimulus for the release of arginine vasopressin arises from
osmoreceptors in the hypothalamus that sense an increase in plasma osmolality.
Not an indirect lung injury
Near drowning
Ependymoma can most commonly be found in the floor of what ventrile
Fourth
Normal pressure hydrocephalus TRIAD (DUG)
DEMENTIA
Urinary incontinence.
Gait changes
Obstructive hydrocephalus is when
CSF outflow is blocked at the LEVEL OF THE AQUEDUCT OF SILVIUS in the 4th ventricle
Tuberous sclerosis aka
Bournovilles disease
Erwing’s sarcoma is a malignancy that affects
bone
2 most common symptoms of SLE
Polyarthritis AND Dermatitis
MALAR RASH 1/3 patients
Gitelman’s disease is an inherited
Renal salt wasting disorder
What is the most common neoplasm in infants
NEUROBLASTOMA
Laryngeal Papillomatosis is caused by
HPV types 6 and 11
Crouson’s syndrome is a
Cranial dysostosis
Atrial systole increase CO by
20-30%
Left coronary artery division
LAD and Circumflex
What creates Lead II (NRAPLL)
What creates Lead III (NLAPLL)
Negative Right Arm Positive Left Leg
Negative lead on L arm and positive lead on L leg.
Junction between S wave and ST segment
J-point
Where is lead V2 placed
Left sternal border @ 4th intercostal space
Unipolar limb leads
avF
BLood type with neither A or B Agglutinogen
Type O
Where in AV node located
Right Atrium
What is Stokes-Adams syndrome?
Fainting spells associated with periodic cessation of A-V conduction
Angiotensin II on sodium
Sodium retention
Filtration fraction =
GFR/ RBF
Visual signals terminate in what lobe of the brain?
OCCIPITAL
Syndrome when only ONE site of the SPINAL CORD is TRANSECTED (incomplete)
Brown Sequard syndrome
Concentration of dissolved gas/solubility coefficient equals
Partial pressure.
Mapleson circuits requires the lowest low FGF
Mapleson D
Most commonly used laser for laryngeal surgery
CO2
Blepharospasm (involunteray movement of eyelid) is a
tonic spasm of orbicularis oculi
Sympathetic innervation and insulin
causes a decrease in insulin secretion via ALPHA-2
Which agent causes no change in the LATENCY or amplitude of SEEP waveform
Dexdemetomidine
Larynx levels
C3-C6
How many segments in the RLL
5
Difficulty swallowing would reveal dysfunction of what CN
IX
Diencephalon 2 parts
Thalamus
Hypothalamus
SA Node aka
Keith Flack node
Batman whacked THOR (AMP)
Batman - Bachmann bundle–> anterior tract
Whacked - Wenckebach tract –> middle tract
Thor - Thorel –> posterior tract
Digitalis (digoxin) is a
Cardiac glycosides
Inotropic effect of digitalis is achieved by
Binding to the alpha subunit of the sodium potassium ATPase in cardiac cells.
S/s of digitalis toxicity
Diarreha, n/v, headache, fatigue, colored vision
What is contraindicated in patient taking digitalis
Calcium (may lead to cardiac arrest)
Larynx begins at the ______and extends to the _____-
Epiglottis; Cricoid cartilage
Most common electrolyte abnormality in hospitalized patients?
Hyponatremia
Changes in banked blood : Factors missing
LaCk Factor V and VIII
Resting cardiac cell membrane is relatively permeable to what electrolytes
POTASSIUM
SLE : medications that can be exacerbate SLE are PHID-ME
Procainamide Hydralazine Isoniazid D-Penicilllamine Methyldopa
Heart issues with SLE
Diffuse SEROSITIS leads to PERICARDIAL effusion
Drugs to treat SLE
Antimalarials
Corticosteroids
Immunosuppresants (reduce corticosteroids requirements)
Condition able to precipitate SLE (PIS)
Pregnancy
Infection
Surgical stresses
SLE : on pulmonary : restrictive vs obstructive
Restrictive
SLE prone to
pleural effusion, pneumonitis, alveolar damage, pulmonary HTN.
Cyclophosphamide consideration
inhibits plasma cholinesterase so may prolong ESTER LA and SUCCINYLCHOLINE
Equation of H2O + CO2 –>
H2CO3 –>
Sensory nerve supply to nasal mucosa comes from
Trigeminal nerve
Stimulation of the atrial stretch receptors will produce
Diuresis
Hemodynamic management of Cardiac tamponade
Increased PRELOAD
The ratio of effective beta: alpha-blockade is approximately (BA)
7:1.
Clonidine alpha 2 to alpha 1 ratio
200 : 1
Dexmedetomidine alpha 2 to alpha 1 ratio
1600:1. (about 7 times more than clonidine)
Should clonidine be continued during the perioperative period?
yes, because ABRUPT discontinuation can lead to HTN and tachycardia
What is the hallmark of ASPIRATION PNEUMONITIS?
Arterial Hypoxemia
Beta-2 receptor stimulation on fat cells
lipolysis
CN supplies PNS innervation to the parotid Gland
CN IX
Metabolite of Norepinephrine
Vanillylmandelic acid
Gas with the highest VP
Desflurane
Primary action on clonidine to reduce BP
Primarily on CENTRAL (not peripheral) ALPHA-2 receptors.
Primary indication for dexdemetomidine is
Short sedation in critically ill patients
2 main side effects of dexdemetodimidine
Hypotension , bradycardia
Intended drug effects of dexmedetomidine
SAAS
Sedation
Anxiolysis
Analgesia
Sympatholysis
Clonidine causes analgesia via
SUPRASPINAL and SPINAL adrenergic receptors and DIRECT INHIBITORY effects on PERIPHERAL nerve conduction (A and C nerve fibers)
Gas with low molecular weight
N2O
Is Nitrous flammable
NO
Another name for scopolamine
Hyoscine
Highest pKA among opiods
MEPERIDINE
What is the only corticosteroid amount other administered orally
Prednisone
What are the 3 methyxanthines
Caffeine
Theophylline
Theobromide
Tricuspid stenosis on CVP waveform
Large A wave
Nitrogen mustards drugs
Mechloretamine, CYCLOPHOSPHAMIDE
Pts on MAOIs should avoid
LIVER, AGED CHEESE, FAVA beans.
Blockade of what receptor causes neuroleptic malignant syndrome
DOPAMINE
Amrinone produces dose dependent
decrease in LVEDP
Edinger-westphat nucleus is located in CN
III
Sympathetic NS neurons arise from
T1 to L2
Substituting a butyl group for an amine group of procaine’s benzene ring creates
TETRACAINE
Procaine to tetracaine
Substitute a butyl group for an amine group
Is Glutamate a biogenic amine?
NO
What is the drug with the lowest hepatic Extraction ratio?
DIAZEPAM
Could cause serotonin syndrome in patients taking MAOIs,
Meperidine
What structures are found in transitional airways?
Alveolar ducts
What is the VP of Sevoflurane at ___C
157 mmHg, 20 degrees C
Fentanyl potency relative to morphine
100x
Fournier gangrene affects what parts
Genitalia
Which factor would increase the reabsorption of NA by the renal tubule
Angiotensin II.
Where are the CENTRAL CHEMORECEPTORS LOCAED
MEDULLA
Diuretics exerts its effects on the Proximal tubule
MANNITOL
CREST syndrome presence is used in the diagnosis of what
Scleroderma
CREST Mnemonic stands for
Carcinosis
Raynaud’s phenomenon: spasm of blood vessels in
response to stress
Esophageal dysfunction- Acid reflux, decrease motility in
esophagus
Sclerodactyly- Thickening or tightening
Telangiectasias _dilation of capillaries causing red marks.
A patient is experiencing pruritus from the administration of an opioid for surgical pain. What is the most appropriate treatment for the itching?
Nalbuphine
Which opioid receptor produces diuresis when stimulated?
Kappa
2 opioids that cause the release of histamine from mast cells when administered in high doses
MORPHINE
CODEINE
Which agent has the ability to reverse opioid induced respiratory depression, yet maintain analgesia?
Nalaxone (Narcan)
Which agent is a pure opioid antagonist that reverses opioid induced respiratory depression and analgesia?
Nalbuphine
Which of the following statements is true concerning the effect of opioids on the CO2 response curve?
They shift the curve to the right, which represents a decrease in responsiveness to CO2
Which agent is administered to patients undergoing treatment for substance abuse to prevent the euphoric effect of opioids?
Naltrexone
Repeat stimulation caused by nerve damage or chronic inflammation can cause a condition known as :
Windup
The muscle relaxant cyclobenzaprine is structurally most similar to :
amitriptyline
What is the most common serious complication associated with opioid intrathecal and epidural administration?
RESPIRATORY DEPRESSION
Select two excitatory neurotransmitters
Glutamate & substance P
Anesthetic malpractice claims have decreased over the past two decades in which area of practice?
Obstetric anesthesia.
When is the optimal time to perform an epidural block for the treatment of post-herpetic neuralgia?
Within 2 weeks of the appearance of the rash
Which of the following substances is the principal neurotransmitter in the activation of dorsal horn neurons following painful stimuli?
Glutamate
The dorsal horn of the spinal cord includes
laminae I to VI
The chief danger in performing a cervical transforaminal steroid injection is
vascular injury
Isotonic fluids 2
Plasmalyte
0.9% NS
VA that potentiate NMB the most
Desflurane
Cushing’s syndrome
Trunchal obesity
Osteopenia
HTN
Acidosis is associated with (calcium)
Increased ionized calcium
What substance is physiologically inhibit platelet activation?
Nitric oxide
Perisinusoid space of DISSE can be found where
liver
Hepatocyte produce bile and secrete it into
biliary calculi via CANALS OF HERING
Metabolite of procaine associated with anaphylaxis reactions?
PABA
Conn’s aka
HYPERALDOSTERONISM
Sevoflurane is
FLUORINATED METHYL ISOPROPYL
Not a chiral compound
Propofol
what is the metabolite of Diazepam
Oxazepam.
Meperidine a.k.a
Pethidine
Toxicity of which drug is associated with PULSUS ALTERNANS
DIGOXIN
Triangle of Koch is located in what organ
HEART
What Corticosteroid with the longest duration?
Bethamethasone
Other name for this synthetic opioid is Diacetylmorphine
Heroin
Nerve fibers with the fastest conduction velocities
MOTOR NEURON
Minor Calyx part of the
Kidneys
Thin CT of the liver
Glisson’s capsule
Kuffer cells are
Specialized macrophages.
Majority of blood flow to liver provided by
Portal vein
Sensory deficit to the lateral thigh w.o motor deficit indicates what kind of injury –>
Lateral femoral cutaneous
Brainstem composed of
MMP
Medulla, Midbrain, pons.
Term use to related SV + elasticity of arteries to the arterial pressure waveform
Windkessel effect
Therapeutic index
LD50/ED50
Example of phase II enzyme
N-acetyltransferase
2 major calcium channels
L-type and T-type
Important channel is the role of cardiac pacemaker
Funny current
Type I hypersensitivy
IgE antibodies
ABO blood group reactions are classic examples of what type of hypersensitivy reactions
Type III
The key antigens triggering reaction in transplant recipient’s are the
HLA molecules.
Xenogenic transplants are between
different specied
Most common substance secreted by GLOMUS TUMOR
NE
What are glomus tumors?
Glomus tumors, or paragangliomas, are slow-growing, usually benign tumors in the carotid arteries (major blood vessels in your neck), the middle ear or the area below the middle ear (jugular bulb).
Drugs to be avoided in patient with a hx of Acute porphyric crisis
Pentazocine
Von Gierke’s disease has excess levels
of GLYCOGEN
Chemo agent with cardiotoxicity
Doxorubicin
Most common patter of Fetal HR changes in intrapartum period
Variable decels
Factors decrease the depolarization threshold of a cardiac PM
Hypokalemia
Kartagener’s syndrome consists of which TRIAD
Sinusitis
Sinus inversus
Bronchiectasis
ADministration of a decarboxylase inhibitor will prevent
conversion of levodopa to dopamine
Vitamin D can reveal
Thoracic kyphosis
Mandibulofacial dystosis
Trachear collins
ISOFLURANE is
HALOGENATED METHYL ETHYL ETHER
Propofol has antioxidants to
Vit D
Scopolamine is derived for what plant?
Bella donna
Prilocaine metabolite is
O-toluidine, which is capable of oxidizing hemoglobin to methemoglobin.
AV dissociation seen with
Cannon A waves
Used for Vtach
Fleicanamide
Class 1C
Fleicanamide
Class 1B
Lidocaine
Class 1A
Procainamide, Quinidine
Fast sodium channels blocker Antiarrythmic
Class 1
Class II antiarrythmic :
Beta Blockers
Class III antiarrythmic :
Amiodarone
Sotalol
Ibutilide
Dofetilide
Class IV antiarrythmic :
Calcium Channel Blockers
Verapamil
Diltiazem
Class V antiarrythmic
Adenosine
Digoxin
Magnesium Sulfate
Changes in Co2 Transport because O2 sat describe
Haldane effect (think Chaldane)
Protamine sulfate should be used cautiously with patient with
VASECTOMY
Macrolide ABT
Erythromycin
Origin of pathology of 2nd Degree Type I HB
Wenckebach AV node
High output cardiac failure
Sepsis
AV fistulas
Pregnancy
Anemia
In what position would a patient with Epiglotitis be placed for emergent intubation
SITTING
May exacerbate sx in patient with parkinson’s
Droperinol
Chlorpromazine
Metoclopramide
Electrolyte imbalance that may exacerbate s/s of Myasthenia gravis
HYPONATREMIA
Produce by parietal cells of stomach
INTRINSIC FACTOR
Target site of ADH
Collecting tubules
3am low BS, morning high
SOMGYI (SO MOCH insulin)
3am NORMAL , morning high
DAWN phenomenon
Too rapid administration of DDAVP IV can cause
hypotension.
Sympathetic detrusor and trigone muscles(DRTC)
Detrusor Relax
Trigone Contract
Sympathetic and penis
EJACULATION
Parasympathetic and penis
ERECTION
Parasympathetic on arterioles
NONE
Beta 2 responsilbe for
Glycogenolysis
Lipolysis
Bladder wall relaxation
Sympathetic on gallbladder and bile duct
Relaxation
Action of sympathetic on liver
Tell liver to release glucose.
Sympathetic on renal
Decrease urine output
Sympathetic on renin
INCREASE renin secretion
Sympathetic on skeletal muscle
Glycogenolysis
Parasympathetic on adrenal medulla
None
What is the most common spinal deformity?
SCOLIOSIS
Assess integrity of the unidirectional valve what test?
FLOW TEST
Arteriogram risks
Kidney and vessel damage, allergic reaction
ACidosis and catecholamines
Decreased responsiveness to catecholamines
Barbiturates on CMRO2
Reduce
Barbiturates on CBF
Reduce
What nerve provides motor innervation to the cricothyroid muscle?
The external branch of the superior laryngeal nerve
To determine the outer diameter of the French gauge system, the French gauge is
divided by 3, and the answer will be in millimeters.
Hunsaker tubes.
. They are used primarily for jet ventilation
They are double lumen tubes
Which endotracheal tube stylet allows the stylet angle to be adjusted during laryngoscopy?
Schroeder stylet
ETT LPHV
LPHV
Seward laryngoscope blade? (select two)
It should be used in patients under five years of age
C. It is useful for nasotracheal intubation
The LMA Fastrach will accommodate an
8.5 ID endotracheal tube.
Does barbiturate lower cerebrovascular resistance
NO
Preferred energy source of the brain
Glucose
Mother of Anesthesia
Alice Magaw (St mary’s hospital, Rochester minnesota)
Who first coined term Laughing gas for N2O
Humphry Davy
1st person to use chloroform for labor pain
James young Simpson
Who is credited with developing the first direct video laryngoscope?
ALFRED KIRSTEIN
Who is credited in the development of the cuffed ETT
Arthyr Guedel .
For POGO the clinician describe
The clinician describes the linear percentage of the glottis that is visible from the anterior commissure to the interarytenoid notch.
The retrograde technique is useful for situations where traditional intubation is
not possible, but ventilation is possible.
The retrograde technique is useful for situations where traditional intubation is
not possible, but ventilation is possible. So NOT IDEAL for cannot ventilate and cannot intubate situation
2 LMA contraindications
Intestinal obstruction
Poor lung compliance
Invented IV Regional anesthesia
August BIER
1st synthesize ether
Valerius Cordus
In the neonate, calcium delivery to the cardiac myocytes is primarily reliant upon
diffusion through the sarcolemma
An infant undergoing surgery for necrotizing enterocolitis is in the ICU but not yet intubated. Which induction method would you anticipate being the most appropriate in this patient?
Ketamine induction
Which topical anesthetic does not contain lidocaine?
Ametop
What area of the brain in the micro-preemie is most at risk for damage?
Periventricular white matter
The neonatal response to hypoxia is typically a short period of _____ followed by _____.
Hyperventilation, hypoventilation
Which inhalation agent should be avoided in micro-preemies?
N2O
In pediatric patients, drugs whose termination of action depends upon redistribution into muscle tissue would most likely exhibit a _____ peak plasma concentration and _____ duration of action.
higher; longer
Earliest known nurse anesthetist
Sister Mary Bernard, St vincent’s hospital, ERIE PA, 1887
Who described the 5 stages of narcotism in repsonse to anesthesia using chloroform
John Snow
Adult brain weights
2-3 % body weight
SLE patients are at increased risk of
Dementia, stroke, seizure.
First to serve chief of the army nurse corps
Colonel Mildred Irene Clark
Founder of NANA (then AANA,now)
Agatha (AAnA 3 as) Hodgkins
Most common arrythmia with lithotripsy
PVC, supraventricular premature complexes
Why is quality ECG important during lithotripsy
Shock waves timed with R wave to prevent arrythmias
Anesthesia for lithotripsy what dermatomes level
T4-T6
Contraindications to lithotripsy
Pregnancy
Untreated bleeding disorders.
PM and lithotripsy
Shut off -reactivates after lithotripsy
Parasympathetic nerve fibers from CN IX innervate
Parotid gland
Where are parasympathetic nerve fibers exit?
3, 7,9,10 S2-S3
Where are CELL bodies of SYMPATHETIC PREGANGLIONIC NEURONE FOUND?
IntermedioLATERAL HORN of SC
Spinal cord segment originates from
T1 - L2
75% of all parasympathetic can be found in CN
X
Adrenergic receptors are
Alpha 1, Alpha 2
beta 1, beta 2, beta 3
What beta receptor is responsible for THERMOGENESIS?
Beta 3
Nerve fiber that terminate in ADRENAL MEDULLA are ________and therefore secrete
Preganglionic; ACH
Where are POST ganglionic neurons of parasympathetic
Within wall of effector organ
Majority of sympathetic post ganglionic neurons are
Adrenergic and secrete NE
Sympathetic post ganglionic neurons in ONLY 3 areas are
cholinergic
SWEAT GLANDS, PILOERECTOR MUSCLES OF HAIR< SMALL NUMBER OF BLOOD VESSELS>
Inhibition of neurotransmitter when stimulated which receptor
Alpha-2
What spinal cord tract modulates pain (DDT)
DESCENDING DORSALATERAL TRACT
Delayed respiratory depression occurs after neuraxial injection of which opioid?
MORPHINE
Pain afferent nerve fibers enters the dorsal cord and ____or _______ how many segmentts/ in what tract before entering and synapsing in the dorsal horn?
Ascend or descend 1-3 segments; TRACT of LISSAUER,
Early depression of ventilation after neuraxial opioids result from
Systemic absorption of opioid
Remember SAD
Sensory , Afferent , dorsal
DORSAL Leminiscal system include
Cuneatus and Gracilis tracts in spinal cord.
Effects of NE released from sympathetic postganglionic neurosn are terminated mainly by
REUPTAKE by the nerve terminal
Vasopressors devoid of beta 2 activity
NE
Low levels of epinephrine leads to ___why?
Decrease in SVR, beta dominates
Patient took propranolol preop , be cautious administering
Phenylephrine
Chronically beta Blocked , upregulation or downregulation?
Upregulation
Alpha adrenergic BLOCKADE (pay attention to agonist vs blocking)
Venodilation , and decrease in venous return.
Organophosphate insecticides treat with
Atropine
Pralidoxime
2nd messenger promotes bronchoconstriction
IP3
2 most important stimuli for aldosterone release
Angiotensin II
High Potassium
Why is dopamine a different kind of vasopressors?
It simultaneously increases contractility, GFR, RBF, sodium excretion and urine output.
Pheochromocytoma: Which one is IV which one is PO
Phenoxybenzamine IV 0.5-1 mg/kg
Phentolamine IV 50-70 mcg/Kg IV
Treatment of EXCESS beta blockade
Glucagon 1-10 mg IV f/b 5mg/hr
Atropine incremental doses 7mcg/kg IV
Chronic exposure to agonist
DOWN regulation
OB patient become hypotensive best vasopressor and why?
Ephedrine, does not decrease UBF
CN IX and X arise from the
Medulla
Parasympathetic arises from
CN III, VII, IX, X
CN III arises from the
Midbrain
CN VII fromthe
PONS
MiPoMed
III, VII, IX , X
Midbrain
Pons
Medulla
Chronic therapy with this medication is a contraindication for the use of succinylcholine and mivacurium
Cholinesterase inhibitor ECHOTHIOPHATE (used to treat glaucoma)
Inhibitor of mast cell release
CROMOLYN SODIUM prevents mast cell release and bronchoconstriction.
cAMP on bronchioles
Producs bronchodilation
Insulin receptors contain an
Active tyrosine kinase domain
What is the function of a kinase?
Catalyze the addition of a PHOSPHATE group to a substrate
Not Innervated by a stellate ganglia
Bronchioles
The substrate of phospholipase C is
Phosphatidylinositol 4,5 biphophate
SSEPs are recorded from the electrodes placed over the
LONGITUDINAL SULCUS if the Tibial nerve is stimulated bilaterally. The foot and ankle are represented in the brain in the cortex of the longitudinal fissure
SSEPs are recorded from the electrodes placed
Laterally from the midline if the ulnar and median nerves are stimulated
Peripheral nerve stimulation travel in the
Cuneatus and Gracillis tracts located in the posterior cord.
Pathway of fast sharp pain
SAD-> Lissauer–>Lam 1-5–> Contraleteral STT –> Brain
Pain afferent nerve fibers enters the dorsal cord and ascend or descend 1-3 in the tract of Lissauer before entering and synapsing in the dorsal horn.
After leaving the tract of Lissauer, the axons of the Adelta fibers enter the dorsal horn and terminate in the REXED’s LAMINA I and Lamina V.
2nd order neurons leaving Lamina I and lamina V cross the CONTRALATERAL LATERAL SPINOTHALAMIC TRACT and ascend to the brain
Pathway of fast sharp pain: what fibers
A delta
Pathway of slow - CHRONIC pain
C fibers terminate primarily in Lamina II and III. Interneurones transmit C fibers impulse to LAMINA V from Lamina II and III. NEurons leaving Lamina V CROSS IMMEDIATLY to the contralateral LATERAL Spinothalamic tract and ascend to the brain.
Lamina II is the
Substantia Gelatinosa (some sources say Lamina II and III)
The major neurotransmitter released from A delta fibers is
Glutamate
Glutamate binds to
AMPA and NDMA receptors on the Postsynaptic membrane.
The major neurotransmitter released from C fibers is
Substance P which binds to Neurokinin-1 (NK-1) recepotns on the Post synaptic membrane
Major neurotransmitters release mnemonic
ADeG
C-Sub
What Does Substance P bind to
Neurokinin-1
Receptors responsible for sedation and dysphoria
Kappa
Physical dependence opioid receptors
Mu-2
Respiratory depression opioid receptors
Mu-2
Opioid receptor for these 2 things not yet identifid
Miosis
N/V
Opioid receptor responsible for Bradycardia and euphoria
Mu-1 receptor
Arterial blood is delivered to the spinal cord
One Anterior spinal artery
Two posterior spinal arteries
Small segmental spinal arteries.
Which substance decrease the release of substance P in the spinal cord ?
Enkephalin
What gland is found in the sella turcica of the sphenoid bone?
Pituitary
The brainstem and cerebellum are found in the
Posterior cranial fossa
What fontanelle closes at about 2 “YEARS” of age
POSTEROLATERAL
Another name for CEREBRAL STEAL
Luxury pefusion
Muscles for chewing controlled by CN
VII
What is coma?
Condition of non-arousal due to damage to the RAS
CSF circulation route
Choroid plexus Lateral ventricles Foramina of Munro Third Ventricle Aqueduct of Silvius Fourth Ventricle Foramina of Lushka / Foramen of Magendie Subarachnoid space of spinal cord Brain Arachnoid villi
Site of formation of CSF
Lateral, Third and fourth ventricles
Cyanosis is most likely to be seen in which patients?
Obesity hypoventilation syndrome
Solution that should not be given to the patient undergoing carotid endarderectomy?
D5W
What is the initial dose of Dandrolene ?
2.5 mg/kg
What % of soda lime canister should be air?
50%
Uptake of 5 volatile to bottom
NDSIEH Nitrous Des Sevo Iso Enflurane Halothane
What is the most common complication of mediatinoscopy?
Hemorrhage
Neural pathways that CARRIES (not modulate pain)
ANTEROLATERAL
Best ECG lead for initial assessment is
II
Flat line CO2 waveform
Esophageal intubation
Pneumothorax is most commonly associated with which approach of the brachial plexus.
Supraclavicular
Ophtalmologist plan to inject sulfur hexafluoride into the aqueous humor to treat retinal detachment you should avoid?
Nitrous oxide
Cardiac T-type calcium channels are maximally open during _____of SA node action potential
Phase 2
What MR has antimuscarinic actions?
Pancuronium
The patient who cannot ABDUCT the thumb has had what nerve blocked by LA?
Radial
Therapeutic plasma concentration of magnesium for Pregnancy induced HTN
4-6 mEq/L
The patient with Pregnancy induced HTN, has BP 190/125 you should can give 3 but not 1
Hydralazine
Labetalol
Nitroprusside
NOT ESMOLOL
3 conditions with Thrombocytopenia
Cancer
Liver disease with splenomegaly
Eclampsia
2 agents to avoid if the patient is taking MAOIs?
Ketamine, Meperidine
2nd heart sound is
closure of Aortic and pulmonic
How much of the TOTAL blood volume is in the venous system
65%
The most common cause of death associated with CAROTID ENDARTERECTOMy is
Myocardial infraction
stick his tongue out:
hypoglossal nerve.
shrug shoulders:
spinal accessory nerve
The most common cause of death following abdominal aortic aneurysm repair is
Myocardial infraction
What are the major contributing factors to the development of peripheral vascular disease? (select two)
DM and smoking
CSF passes from the 4th ventricle to the Subarachnoid space through the foramina of
Luschka
Where is tissue damage greatest when using a tourniquet?
Under the tourniquet
What happens during the PHASE 1 of the ventricular muscle action potential
CL- diffuses in , K+ diffuses out
Given to treat prolonged bleeding time?
Platelets
Cause P50 to decrease (left shift) from 27 to 19 mmHg?
Metabolic alkalosis
You are delivering 5% desflurane to your patient, what is the partial pressure of inspired desflurane?
46 mmHg (5x760/100)
PaCo2 of 60 mmHg , how much Co2 is dissolved in each 100 ml of blood?
- 02
0. 067 mL CO2/100 mL blood/mm Hg;
O2 saturation to PaO2 how i remember
- 70%
50 80% - 90%
Normal adult Hb molecule (Hb A) consists of:
4 heme groups (iron portion of the Hb) - the sites to which oxygen binds
100% Saturation occurs when all four heme sites of each molecule are combined with oxygen
4 amino acid chains: 2 alpha and 2 beta (affect hemoglobins affinity for oxygen, alterations in these chains result in abnormal hemoglobin
The concentration of CO2 in solution is given by what law?
Henry’s law, which states that the concentration of CO2 in blood is the partial pressure multiplied by the solubility of CO2.
Henry’s law, which states that the
concentration of CO2 in blood is the partial pressure multiplied by the solubility of CO2.
What is the solubility of CO2?
0.07 mL CO2/100 mL blood/mm Hg;
Henry’s law : dissolved CO2 increases
linearly with increases in PCO2
1 atm = ___kPa=_____Torr = ______mmHg ____psi,= ____pa
101.325 kPa = 760.0 torr = 760 mmHg = 14.696 psi = 101,325 Pa.
In turn, O2 bound to hemoglobin changes its affinity for CO2, such that when less O2 is bound, the affinity of hemoglobin for CO2
increases (the Haldane effect)
Almost all of the CO2 carried in blood is in a chemically modified form,
HCO3−, which accounts for more than 90% of the total CO2.
Methemoglobin:
– Has iron in the
oxidized form (Fe+++).
The bond with carbon monoxide is
250 times stronger than the bond with oxygen.
CO2
transported in the blood:
–HC03- (70%).
–Dissolved C02 (10%).
– Carbaminohemoglobin (20%)
When Hb saturation with oxygen is high, less carbon dioxide is carred in the blood. What is the relationship called
Haldane effect
Carbon dioxide diffuses across the alveolar-capillary membrane about how many times faster than oxygen?
20 times
What is the primary determinant of the PAO2?
PO2 in the inspired gas
Blood carries O2 in w ways
Physically dissolved in plasma
bound to hemoglobin
Compare PAO2 and PaO2 in Zones I and III when the patient is sitting?
PA>Pa>Pv I
Pa>PA>Pv II
Pa>Pv>PA III
Zone 1 PaO2 High Zone 3 PAO2 Low
Zone 3 PaCO2 High Zone 3 PACO2 Low
Sodium concentration is controlled primarily by
ADH
The Virus most EASILY TRANSMITTED BY a BLOOD TRANSFUSION is
CMV (cytomegalovirus)
Most frequently damaged nerve in LE
Common PERONEAL
Physiologic alterations are least when the patient is
Supine
Conus medullaris ends with adults at
L2
Suspect MH first action
Turn of VA/ succinylcholine
Motor innervation to the tongue?
HYPOGLOSSAL
Why are sickle cell patients anemic?
Life span of the Red cell is 12 days (sickled)
Avoid in anemic patients
Hypoxemia
Most common inherited bleeding disorder is
Von willebrand’s disease
MH is inherited in an
autosomal dominant pattern
In excitable tissues, HYPOCALCEMIA generally promotes
DECREASE THRESHOLD
Goal during management of the patient who transected his spinal cord one year ago is to prevent
Autonomic hyperreflexia
What is the problem if SERUM ALKALINE PHOSPHATASE IS ELEVATED FOUR-FOLD
Biiary tract obstruction
Post transcranial resection of a craniopharyngioma. Large volume of dilute urine indicates
DI , give desmopressin
It was decided to perform a pneumonectomy on a patient who has smoked 2 packs of cigarettes per day for 40 years. Which medicaiton should be avoided?
Fentanyl
Hormones of carcinoid tumors generally do not have systemic effects because they
UNDERGO THE FIRST PASS EFFECT (GI)
During cross-clamping of the descending aorta, you would be most concerned about interrupting flow through what blood vessel supplying the spinal cord
Artery of adamkiewicz
Conditions causing incorrect reading with the pulse ox
Hypotension
Carbon monoxide poisoning
Hypothermia
Conditions NOT causing incorrect reading with the pulse ox
Fetal hemoglobin
Z79 on tube means
nontoxic
What Nerves are blocked first after onset of spinal anesthesia?
B fibers
Mnemonic (BC A-DGBA)
Patient is taking aluminum based antacids , sulcrafate and calcium carbonate, these agents were probably used to treat
HYPERPHOSPHATEMIA
YOu woud be most concernd if the patient had an increased in
Bleeding time
Faster onset of action of LA would be a drug with a pka of
7.4
Atelectasis in the patient with ARDS is explained by whose law?
Laplace
At what age is the hgb concentration the lowest?
8- 12 weeks
One reason the neonate needs more succinylcholine than the adult is because
Motor end plate of NMJ is immature
The requirements for manufacturing and transportation of medical gas cylinders are set by the
DOT
Current guidelines for treating SAH induced Cerebral vasospasm?
Maintain EUVOLEMIA
NIMODIPINE (60 mg q4h on the dot for 21 days)
Stepwise augmentation of BP
Which change will most profoundly increase intraocular pressure?
Increase CVP
Instrument that ionizes a gas sample and then passes it through a magnetic field
Mass Spectrometer
Where is the ligamentum flavum located in relation to the epidural space?
posterior
Decreases the seizure threshold?
Hypocarbia (Think about when you hyperventilate for ECT)
For routine intubation of HIV patienes, the CDC requires all but
GoWN
What hemodynamic changes is most likely to result in Myocardial ischemia during surgery if the patient has CAD?
TACHYCARDIA
THE MOST EFFECTIVE method of keeping the adult patient warm is the
Forced air warmer
What drugs should be avoided in the patient with Alzheimer’s disease?
Sedatives
The purpose of unidirectional valves in the circle system is to
Prevent rebreathing of exhaled gases
What chemotherapeutic causes severe injury to the lung?
Bleomycin
The most frequent lawsuit involving the anesthetist relates to
Airway management
During hypotensive anesthesia with sodium nitroprusside , MAP which had been maintained at 55 mmHg begins to increase. BP continues to rise despite an increase in the nitroprusside rate, your next action to turn off the nitroprusside and give all the following
Sodium Nitrate
Amyl Nitrate
Sodium Thiosulfate
DO NOT GIVE CALCIUM GLUCONATE
Whose law explains the 2nd gas effect?
Fick’s
What will disinfect the laryngoscope blade after intubating an HIV infected patients?
Glutaraldehyde
The dilutional effect occurs during which phase of anethesia?
Emergence
Normal umbilical vasculature
2 arteries , one vein
Antilipidemic agnets best describedas a BILE ACID SEQUESTRANT
Cholestyramine
May be detected using a minimum pressure alarm except:
Increase in resistance
The patient with Type A blood has
Anti-B antibodies
Which of the following valvular lesions would most likely result in CONCENTRIC LV hypertrophy?
Aortic stenosis
Ankylosis spondylitis has the following neurologic complications
Cauda Equina syndrome
Atlantlo-occipital subluxation
Spinal cord compression
Uvula cannot be visualized MAllampati is
3
Calculate preop fluid deficit for child 8kg , NPO x 6 hours
192 ml
5-HT3 Receptor antagonist is what type of receptor
Inotropic
3 endocrine functions of the kidney
Erythropoietin
RAAS
Vit D
Largest: What Amount of Glomerular filtrate reabsorbed where?
67% of filtrate reabsorbed in PROXIMAL TUBULE
Poorly reabsorbed by the renal tubules
Urea, uric acid, creatinine , phosphate, sulfate
Exquisite control of water excretion
ADH
UO and DM
UO increases glucose load exceeds transport max leading to OSMOTIC diuresis.
Where is ADH synthesized
Paraventricular and SUPRAOPTIC nuclei of the HYPOTHALAMUS.
Stimulate release of Vasopression from posterior pituitary
Nerve action potentials
Explain how ADH gets released?
In response to an increase in ECF osmolarity (SODIUM CONCENTRATION ) paraventricular and supraoptic nuclei shrink and nerve axons fire action potential which cause ADH release rom posterior pituitary.
What is the MOST POWERFUL stimulus triggering the release of ADH?
Increase in ECF osmolality (kg)
OSMOLARITY vs OSMOLALITY
Think OSMO- LARRY DRINKS A LITER
LALI KILLS HIM (LALI - KILO)
In the absence of ______ the ____and_____are impermeable to water
ADH; Distal tubule and collecting duct, impermeable to water.
When circulating ADH is HIGH
Small volume of CONCENTRATED URINE (1200-1500)
When circulating ADH is LOW
LARGE volume of Dilute URINE (50-100 mOsm)
Increases the permeability of the distal and collecting tubules to water
ADH
Most common cause of Diabetes insipidus is
Failure of ADH synthesis or release (Central )
Insensitivity of the distal and collecting tubules to ADH
With increase ADH , urine OSMOLARITY is _____ volume is ______
HIGH ; Low
With decrease ADH , urine OSMOLARITY is _____ volume is ______
LOW: HIGH
SIADH can be caused by
Hypothyroidism
Small (oat’s cell carcinoma)
Diagnostic of SIADH
Increase urine Na+ and osmolality wit HYPONATREMIA
and decrease plasma osmolality
Determines ECF volume
Sodium content
Most important for regulating ECF volume
Aldosterone
Creatinine clearance measures what
GFR
Resp alkalosis and free ionized calcium
Free ionized calcium decreases
Hyperventilating patients 2 electrolyte abnormalities are
HYPOKALEMIA and HYPOCALCEMIA(decrease free calcium)
ph is determined by
HCO3 and PaCO2 (ratio of HCO3 to PaCO2)
Normal HCO3
22-27
If an acid base disturbance is completely compensated, it is a
Resp disturbance
Complete compensation cannot be achieved if there is
Metabolic acidosis or metabolic alkalosis
Most susceptible to ischemia , what region of the kidney?
Inner stripe of outer medulla.
Glucose transport out of the nephron only occurs in the _______and is subject to the
PROXIMAL TUBULE ; nephron’s maximal capacity to absorb glucose which is known as transport maximum.
The loop of HENLE act as a
COUNTERCURRENT MULTIPLIER and CREATES OSMOTIC GRADIENT.
What hormone control Extracellular fluid volume?
What hormone control EXTRACELLULAR SODIUM concentration?
ALDOSTERONE
ADH (sodium)
ECF Water follows
Sodium
ECF volume follows
Aldosterone
Combinaion of ANP and Aldosterone that lead to highest sodium excretion
Low aldosterone, HIGH ANP
K+ excretion will be low with what extracellular Na+ levels
HIGH
Not seen with CRF (electrolyte imbalance)
HYPERCALCEMIA
Which diuretic prevent bicarbonate in the proximal tubule.
ACETAZOLAMIDE
Which combination of acute electroly abnormalities would make nerve, skeletal muscle and cardiac ventricular muscle cells more excitable?
HYPERkalemia
HYPOCALCEMIA
Why is hypokalemia a side effect of mannitol administration?
Promotes a HIGHER FLOW RATES through the distal tubules.
Common side effect of erythropoietin treatment in Chronic renal patients?
Shortened bleeding times
HTN
Decrease intensity of pruritus
Most important as far as I’m concerned side effect of erythropoietin
HTN
Cell’s RMP will be hypopolarized (less negative) due to which ion imbalance
HYPERKALEMIA
Which treatmet of HYPERKALEMIA does not correct the underlying ion imbalance
Calcium administration
Normal RMP is
-70 mV
With HYPERKALEMIA, (think Potassium leaving cell), cells becomes DEPOLARIZED meaning
NEGATIVE (-60mv, -50) so hyperpolarize
Normal EXTRACELLULAR K+
4 mEq
Normal INTRACELLULAR K+
140 mEq
Normal EXTRACELLULAR Na+
145 mEq
Normal INTRACELLULAR Na+
10 mEq
Major INTRACELLULAR ANION
Phosphate
With acute hyperkalemia cells
Depolarize (-60, -50- -40)
In the neurones, Voltage gated sodium channels are found principlally in the
AXON and are concentrated in the nodes of RANVIER.
How does high potassium concentration of cardioplegia arrest the heart? Succinylcholine on skeletal muscles? LAs with nerve conduction
Causes membrane depolarizion , which LOCKS the SODIUM CHANNELS in the INACTIVE STATE
Same with succinylcholine , depolarize skeletal muscle motor end plate inactivate sodium channels.
LA inactive by locking sodium channel in the INACTIVE STATE.
Responsible for depolarizing the AXON
Diffusion of sodium into the cells
Repolarization of the axone
Diffusion of POTASSIUM ions out fht ecells.
When the sodium channel is in the ______state , another action potential ____be fired. the neuron is in ______r ____period
INACTIVE; ANOTHER ACTION POTENTIAL CANNOT BE FIRED. ABSOLUTE REFRATORY PERIOD.
Ach at the nicotinic receptor is _____feedback loop? which is responsible for the _____seen with NDNMB
POSITIVE; fade
Events at NMJ, ions go in and what comes out
Sodium and Calcium goes in
K diffuses out
The release of neurotransmitter from all nerve terminals including the motor nerve terminals , depends on
Entry into the terminal of calcium ions
______comes in , neurotransmitter comes out
Calcium
Hypocalcemia and neurotransmitter release?
Decrease the amount of neurotransmitter released vice versa
Hypomagnesemia and neurotransmitter release?
INCREASE amount of neurotransmitter release.
Hypermagnesemia and neurotransmitter release?
Decrease the AMOUNT OF NEUROTRANSMITTER RELEASE
2 ions with ANGONISTIC EFFECTs at nerve terminals?
Calcium and magnesium.
How many molecules of Ach does it take to open Acetylcholine-gated channel ?
2
Plasma cholinesterase aka
Butyrylcholinesterase.
What are the MONOQUATERNARY Aminosteroids?
Vec and roc
What are the BISQUATERNARY Aminosteroids?
Pancuronium
What are the BisQUATERNARY Benzylisoquinoliniums?
Atracurium, Cis-atracurium
Potency of MR is
relationship between twitch depression and dose
ED95% of Muscle relaxants represents
95% of block of a single twitch compared to a control single twitch
MR with BILIARY as primary route of elimination
VEC and ROC
MR with METABOLISM as primary route of elimination
Succ, atra, cisatra, miva
Atracurium is eliminated by
Ester hydrolysis by NONSPECIFIC ESTARASES, and HOFFMAN ELIMINATION ph and temperature dependent.
HOFFMAN elimination ONLY
Cis-atracurium (NON specfic estarases NOT INVOLVED)
Succinylcholine produces bradycardia why?
Because it directly stimulates muscarinic receptors of the SA node.
MR that causes significant HTN
Pancuronium , GALLAMINE
MR that elicits histamine S
Succinylcholine
Mivacurium
Atracurium, d-tubocurarine, metocurarine.
MR with reflex tachycardia
d-tubocurarine, metocurarine.
Succinylcholine and K+ increase in normal patients
0.5 mEq/L
Succinylcholine and K+ increase in burn, trauma or head injury patients
5-10 mEq/L
Defect in MH is
Mutation in RyR1 of the SR of skeletal muscle.
Earliest and most sensitive and specific signs of MH
Elevation of ETCO2
Why isnt cardiac muscle directly involved in MH
Because cardiac myocytes express the RYR2 isoform o the ryanodine recptor.
Hypokalemia and NMB (BLock increased/decreased)
block increased
ABT that increased NDNMBLock
Neomycin
Streptomycin
GENTAMYCIN
Tetracycline
PCN affect NDNMB block
NO
Cephalosporins , tetracyclines on block
no effects
LA on NDNMB block
increased
VA on NDNMB
Increased
LA on Succ block
Increased
Anticholinestease agents on succinylcholine block
INCREASED
DEFAULT ANSWERS for block
INCREASED
TOF , how many stimuli, how long, strength
4 stimuli, 0.5 sec 2 Hz
What % of receptor occupied when TV returns to normal
75-80 %
What % of receptor occupied when single twitch as strong as baseline
75-80%
What % of receptor occupied when Diaphragm moves ? how many twitches?
95% NO TRAIN OF FOUR TWITCHES
What % of receptor occupied when Abdominal relaxation adequate for most intra-abdominal procedures ? how many twitches?
90% ; 1
What % of receptor occupied when no palpable fade in TOF
70-75%
What % of receptor occupied when patient passes insp pressure test of at least -40 cm H2o, head life
50%
The release of Ach from the NMJ will be increased in the follwoing conditions?
HYPOMAGNESEMIA
The presynaptic action of succinylcholine
ENHANCES IT POST SYNAPTIC ACTION>
MR with ANTIMUSCARINIC ACTIONS
PANCURONIUM
Patient paralyzed on the right side and you put the nerve stimulator on the right side what will you see with the TOF
Greater amplitude of twitches on the right compared to the left.
What happens to the depolarizing NMB and nondepolarizing NMB if NEOMYCIN is administered
BOTH increased.
Characteristic of a NDNMB
T4/T1 < 70%
Post tetanic facilitation present
What happens to the number of nicotinic receptors in skeletal muscle in a patient with spinal cord injury?
NUMBER INCREASES in DENERVATED SKELETAL MUSCLE
Patient with biliary disease is given VECURONIUM, how will the vecuronium be eliminated?
By metabolism and renal excretion
With a nondepolarizing block, DBS produces
2 unequal fading twitches
A good vital capacity of at least 20ml/kg when what % of neuromuscular receptors are blocked?
75%
Predominant neutransmitter in the periphery?
Ach.
with one exception , NE is released from all SYMPATHETIC POSTGANGLIONIC nerves except
SWEAT GLANDS>
Nicotinic ACh receptors are
Ionotropic
Muscarinic ACh receptors are
METABOTROPIC
Throbbing apin and temperature
dC fibers
Conduct with greater velocities Myelinated vs unmyelinated
Myelinated nerve
Conduct with greater velocities ; small or large diameter
Larger diameter at greater velocities
Sympathetic and parasympathetic preganglionic neurons are
B fibers
Stellate ganglion is formed by
Inferior cervical
First thoracic ganglia
Sympathetic outflow is
Thoracolumbar
Horners syndrome
Ptosis, Miosis, anhydrosis
Increased skin temperature
Ipsilateral MIOSIS
**All sympathetic PREGanglionic fibers pass through
WHITE RAMI
Some but not all sympathetic POSTganglionic fibers pass through
GRAY RAMI
GRAY RAMI are distributed to
ALL SPINAL NERVES FROM THE GANGLIA
GRAY RAMI allows
COORDINATED, mass discharge of the SNS
When presynaptic alpha-2 receptors are stimulated by NE or any other drug with alpha 2 agonist activity what happens?
The synthesis and release of NE is decreased . THIS IS NEGATIVE FEEDBACk.
In adrenal medulla, NE comprises ____% and epinephrine comprises _____%
20%; 80%
Release of NE
Action potential travels along axon of sympathetic post ganglionic neurons
Depolarization opens voltage-gated Ca++ channels
What is required to release neurotransmitter?
Calcium.
Termination of action of Norepinephrine: WHAT IS THE FIRST STEP in the termination of action?
Diffusion of NE away from receptors is the first step in the termination of action (efficacy)
What is the fist step in termination of action of a LIGAND?
Diffusion of the ligand away from the receptor.
What amount of NE is returned to the nerve terminal? By what mechanism?
REUPTAKE; 80%
What happens after Norepinephrine diffuses away from the receptor it attached to?
It is removed from the synaptic cleft by
- REUPTAKE (80%)
- Metabolism by MAO in the synaptic cleft
- Diffusion into the plasma where metabolism by COMT occurs.
SA nodes receptors; Increase chronotropy through
Beta-1
AV node receptors: Dromotropy
Beta-1
Muscle fibers : INotropy
Beta 1
Arterial Blood vessels Vasoconstriction
ALPHA-1
Skeletal muscle relaxation
Beta -2
Veins : Vasoconstriction through what receptor
Alpha1
Kidney : RENIN release increase through what receptor
Beta 1
Kidney : RENIN release decrease through what receptor
Alpha 1
Liver Glycogenolysis and Gluconeogenesis: Through what recepto
Beta-2
Uterus relaxation through what receptor
Beta 2
Na-K PUMP stimulates pump through what receptor
Beta-2
2 most important stimuli for aldosterone release are
Angiotensin II
High Serum Potassium
Renin release occurs in response to
Decrease renal BP (renal artery stenosis)
Increase SNS activity and Chloride
Clonidine is an
Alpha -2 AGONIST
Phenylephrine is an
ALPHA -1 agonist
Dobutamine receptor stimulated
BETA 1
Isoproterenol receptor stimulated
Beta 1 , and Beta 2
Norepinephrine receptors stimulated
Alpha 1, Alpha 2, beta 1
Does NE have any beta 2 activity?
NO
Dopamine receptor stimulated
Alpha 1, Alpha2, Beta 1
Ephedrine (JUSt LIKE METARMINOL) receptors stimulated
Alpha 1, alpha 2, Beta 1, Beta 2
Primary mode of action of these 3 drugs is indirect stimulation of presynaptic nerve terminals, which results in the displacement of NE into the synaptic cleft
Metaraminol
Ephedrine
Mephentermine
Diastolic arterial Blood pressure changes in the same direction as
Systemic vascular resistance
Decrease in diastolic Blood pressure and possibly also MAP with low dose of epineprhine are attributable to
Beta-2 mediated vasodilation (beta-2 mediated decrease in SVR)
Guanethidine (Ismelin) is
No longer in the UNITED STATES
Phenoxybenzamine is
Alpha 1 and Alpha 2 antagonists
Prazosin is a
Alpha 1 antagonists ONLY alpha 1
Labetalol block what receptors
Alpha 1
Beta 1 and Beta 2
Labetalol alpha receptor
Alpha 2
PROPRANOLOL BETA SELECTIVE
NO
BETA-2 BLOCKED STRONGER THAN BETA 1
YOHIMBINE type of mediction
Selective Alpha 2 adrenergic antagonists u
What is YOHIMBINE used to treat?
Impotence.
Side effects of Beta Antagonists on bronchioles
Bronchoconstriction
Myocardial depression in the PRESENCE OF BETA BLOCKADE –> WORST to better
Ketamine Enflurane Halothane Opioids KEHO-
I=S=D
2 drugs to avoid with MAOIs
Meperidine
Ephedrine
Ridodrine is a
tocolytic
Ritodrine is a
Beta-2 adrenergic receptor agonist
Beta 2 adrenergic agonist, 3 side effects
Hyperglycemia
Hypokalemia
Tachycardia
System that is ESSENTIAL for the MAINTENANCE OF LIFE
Parasympathetic nervous system.
What is a disadvantage feature of anti-muscarinic agents on the GI tract?
LOWER esophagel sphincter tone
2 Antimuscarinic (Anticholinergics) with the most sedation?
Scopolamine, Atropine,
Antimuscarinic (Anticholinergics) with the NO sedation
Glycopyrrolate
Antimuscarinic (Anticholinergics) with the MOST Antisialalogue
Scopolamine
Antimuscarinic (Anticholinergics) with the LEAST Antisialalogue
Atropine
Antimuscarinic (Anticholinergics) with the MOST MYDRIASIS CYCLOPEGIA
Scopolamine
Antimuscarinic (Anticholinergics) with the PREVENTION of MOTION SICKNESS
SCOPOLAMINE
What can cause anticholinergic syndrome occurs?
High doses of atropine or scopolamine
Anticholinergic syndrome treatment?
Physostigmine (antilirium) 15-60 mcg/kg IV
cAMP on bronchioles
Vasodilation
The effects of ephedrine are due mostly to its
Stimulation of the nerve terminal to release norephinephrine
Could an opioid agonists/antagonists reverse opioid-induced respiratory depression?
yes because opioid agonists/antagonists such as nalbuphine , butorphanol, and buprenorphine can be used. They competitive inhibit MU RECEPTORS< effectively displacing opioid from MU-2 and reversing respiratory depression
What is the advantage of using an opioid agonists/antagonists to reverse opioid-induced respiratory depression?
Its good because some degree of spinal analgesia and SUPRASPINAL analgesia would be maintained because the opioid agonist/ antagonists stimulate KAPPA and DELTA RECEPTORS.
How is the spinal nerve root connected to the paravertebral sympathetic ganglia?
By communicating channels called white and gray rami communicans.
Preganglionic fibers arises from the
Intermediolateral horn of the spinal cord.
What are the 2 division of the PNS
Somatic division (motor nerves to skeletal muscles and sensory nerves for pain, touch, pressure, temperature), and AUTONOMIC DIVISION (ANS, PNS)
The basilar artery is supplied by the
Right and left vertebral arteries
All circle of willis arteries are paired except
Basilar
Anterior communicating
The MAJOR vessels of the circle of willis
Right and left INTERNAL CAROTID arteries
BASILAR artery
VA;CBF _____CMRO2
Increase, Decreases
IV anesthetics of CMRO2, and CBF? Exception is
decreases; ketamine
The only IV anesthetic increases both CMRO2 and CBF
Ketamine
The only GAS anesthetic increases both CMRO2 and CBF
Nitrous Oxide
Major souRce of BLOOD of the spinal cord is the
ANTERIOR SPINAL ARTERY
THE ANTERIOR SPINAL ARTERY IS THE MAJOR SOURCE OF BLOOD OF THE spinal cord providing
75% of the blood
3 blood supplies of the spinal coard
1 Anterior
2 POSTERIOR
small segmental spinal arteris.
Artery of adamkiewics enter from the
LEFT SIDE in the majority of patients in the lower thoracic region or UPPER lumbar region.
Provide the lower 2/3 of anterior spinal cord
Artery of Adamkiewicz.
What is inverse steal called also
Robin Hood, reverse steal)
What is inverse, (robin hood , reverse) steal?
When the patient with an ischemic region of brain is hyperventilated, such that PACO2 falls, BLood vessels in NONISCHEMIC brain constrict and blood is diverted to ISCHEMIC BRAIN. GIVE TO THE POOR>
Improves blood flow to ISCHEMIC BRIAN
HYPERVENTILATION
CEREBRAL steal aka
Luxury perfusion
What is CEREBRAL STEAL?
In ischemic brain regions, blood vessels are maximally dilated, in nonischemic brain regions, blood vessels have tone
When vasodilator such as nitroprusside is given, or when the patient is HYPOVENTILATED, CO2 accumulates, vessels in nonischemic areas of the brain dilates, flow to non-ischemiec brain increases, and flow to ischemic brain decreases. VASODILATORS and HYPOVENTILATION promote cerebral steal
What bone houses the sella turcica
sphenoid
Frontal lobes rest on this fossa
Anterior cranial fossa
Temporal lobes rest on this fossa
Middle cranial fossa
Brain stem and cerebellum rest on
Posterior cranial fossa
What is the correct positioning of a single orifice catheter is
3cm above the JUNCITON OF THE SVC -atrialjunciton
What is the correct positioning of a MULTI ORIFICE
2 cm below the SVC-ATRIAL JUNCTION
Wave that represents ventricular repolarization
T wave
Precise activity of this wave unknown
U wave
Atrial repolarization wave
QRS complex
Ventricular depolarization wave
QRS compex.
Action potentilas that are biphasic
in the SA node and in the AV nodes
Action potentials with plateau phases are found is
Atrial muscle cells and ventricular muscle cells.
What causes change in the HR?
Slope of phase 4 depolarization.
On what phase of the NODAL action potential does DIGOXIN work to slow the heart rate?
Phase 4
On what phase of the NODAL action potential does CCBs work to slow the heart rate?
Phase 4
On what phase of the VENTRICULAR action potential does CCBS work to slow the heart rate?
Phase 2
What is the first negative deflection of the ECG
Q wave
Congenital heart diseases associate with right-to-left shunting include : 5 Ts PH single double
Pulmonary Atresia
Hypoplastic left heart syndrome
Single ventricle
Double-outlet ventricle,
Tricuspid atresia Tetralogy of Fallot Transposition of the great vessels Truncus arteriosus Total anomalous pulmonary venous return
First positive deflection of ECG
R wave
A negative deflection following the R wave is the
S wave
On ECG each mm is
0.04 seconds
QRS complex results from ventricular depolarization which is phase
0
T wave results from ventricular repolarization
Phase 3
QT interval reflects duration of
Plateau phase, Phase 2
Hypocalcemia on QT
PROLONGED
Hypercalcemia on QT
SHORTENEDED>
U waves reflect
HYPOKALEMIA
MAP is determined by 2 factors
CO and SVR
SV is determined by 3 factors
Preload, afterload , contractility
Preload is determined by 3 factors: IVV
Intravascular volume, Venous tone, Ventricular compliance
The major determinant of Intravascular volume is
AMOUNT OF SODIUM IN THE BODY
With an increase in preload, filling
Increases bu the ventricles empties to the same level, SV increases
With a decrease in preload, filling
Decrease but the ventricles empties to the samel level (SV decreaseS)
What provides evidence of the increased in EDV?
INCREASE PULMONARY CAPILLARY WEDGE PRESSURE
Cardiac tamponade on preload
Decrease
When afterload increases, what happens to SV?
Decreases
When afterload increases, what happens to EDV, and ESV?
Increases, (because the ventricular chamber dilates when afterload increases)
When afterload decreases, what happens to EDV, and ESV?
Decrease (because the ventricular chamber sHRINKS when afterload decreases)
When afterload decreases, what happens to SV?
Increases
Pressure loop with an increase afterload,
shifts toward greater pressure and greater volume (UP to the RIGHT)
Pressure loop with an decrease afterload,
Shifts toward smaller pressure and smaller volume (down and to the left)
Ken Cooper, a 63 year old long distance runner undergoes a cardiac catherization to assess his LV function after he has noticed difficulty in completing a recent marathon. What is the best parameter to use as the index of his cardiac preload?
LVEDV
After a medication given , patient with an increase SV and no other changes in pressure most likely was
Beta-1 agonist
In response to an acute increase in afterload, the pressure volume shifts
UP (greater pressure) and to the right (greater volume)
In response to an acute decrease in afterload, the pressure volume shifts
DOWN (lower pressures) and to the left (less volume)
EARLY RELAXATION phase :of the Isovolumetric relaxation phase is NOT ISOVOLUMETRIC (meaning the volume changes)
AORTIC INSUFFICIENCY
THINK A R We know that the AORTIC INSUFFICIENCY when Isovolumetric relaxation phase is NOT ISOVOLUMETRIC , what differentiate acute vs chronic
Acute small loop
CHRONIC BIG ass LOOP and almost covers whole
Chronic aortic insufficiency is associated with
Eccentric (VOLUME)
Think M S EARLY SYSTOLIC PHASE of the pressure loops is ____________ in MITRAL INSUFFICIENCY
NOT ISOVOLUMETRIC
HOw to remember mitral vs aortic changes
ARMS
Aortic insuffi. not isovolum. RELAXATION
Mitral insuffic not isovolum Systolic phase
Afferent action potentials from the baroreceptors of the AORTIC ARCh are carried to the brainstem centers via the
VAGUS nerve (think AV)
Control of BP -> Baroreceptor reflex
Increase arterial BP –.> increased stretch of baroreceptors in AORTIC SINUS and AORTIC ARCH–> Increase action potentials in afferents VAGUS NERVE and HERING”S nerve from carotid sinus
Afferent action potentials from the baroreceptors of the CAROTID SINUS are carried to the brainstem centers via the
HERING’S NERVE branch of the GLOSSOPHARYNGEAL
Hering’s nerve is a branch of the
GLOSSOPHARYNGEAL
Which one is more important physiologically carotid baroreceptors, vs aortic arch baroreceptors
CAROTID and are primarily responsible for minimizing acute BP alterations
Efferent of baroreceptors are the
VAGUS NERVE (to the SA node in hearts,) and SYMPATHETIC nerve, to the ventricles of the heart and the systemic vasculature.
Fluid flow when there is
Pressure gradient
Flow is________to the pressure gradient
directly proportional to the pressure gradient
CO and the area under the curve
INVERSELY PROPORTIONAL under the thermodilution curve (smaller AUC, bigger CO)
3 mechanisms of edema formation
Increase plasma hydrostatic pressure
Decreased plasma colloid osmotic pressure
Lymphatic obstruction.
Myocardial Oxygen SUPPLY
HR
O2 content,
Coronary vascular resistance
Diastolic BP
Myocardial Oxygen Demand
HR and SV (preload, contractily , afterload)
A venodilator only
Nitroglycerin
Arterial and venous dilator
Nitroprusside
Arterial Dilator
Hydralazine.
Action of inamrinone (Inocor); milrinone (primacor)
Block breakdown of cAMP, Increase myocardial contractility, decrease SVR,
Adenosine an endogenous
Nucleotide occurring in all cells in the body.
Adenosine works by
slowing the conduction through the AV nodes. Interrupt reentry pathways through the AV node
Elimination half time of Adenosine____why?
Less than 10 seconds; owing to rapid metabolism
ECG tracing has an unusually wide QRS complex, what type of cardiac electrical abnormality is most likely
Bundle Branch block.
Increase in BV, venoconstriction , and ventricular compliance lead to an
increase in stroke volume, and increase in diastolic volume.
DIlated LV with unusually LV volume
Chronic Aortic stenosis.
Isosorbide dinitrate stimulates
Nitric oxide mediated vasodilation
Isosorbide dinitrate work by
donates nitrix oxide molecules to vessel wall.
Oppose systemic edema formation
Dehydration
MI patient who is also HYPOTENSIVE which treatment
PHENYLEPHRINE.
Pulse pressure highest in which vessels
Dorsalis pedis artery
Selectively induces venous, but not arterial dilation
Nitroglycerin
Hypertrophic cardiomyopathy accompanied by
LVOT
Pathophysiology of hypertrophic cardiomyopathy
Diastolic dysfunction reflected by HIGH LVEDP.
In HCM,what is narrowed
Subaortic area is narrowed.
Obstruction of the LV ouflow is worst with what type of contractility ?
Increased contractility
Obstruction of the LV ouflow is BEST with what type of contractility ?
Decreased contractility
Obstruction of the LV ouflow is worst with what type of preload? such as
Decreased preload (hypovolemia, TACHYCARDIA)
Obstruction of the LV ouflow is BEST with what type of preload?
increase preload
How does PPV affect HCM LVOT
Worsened because it decreases preload
Where do you want afterload, preload and contractility with patient with HCM LVOT
Afterload INCREASE
PRELOAD INCREASE
Increase contractility
Arterial waveform associated with LVOT
bisferiens pulse
Can cause regurgitation
Aortic annulus dilation
Regurgitant volume of acute aortic regurgitation depends on
HR and diastolic pressure gradient.
Regurgitant volume of acute aortic regurgitation depends on
HR
Diastolic pressure gradient across the valve
Initial symptoms of aortic regurgitation
Exertional dyspnea
Orthopnea
PND (Paroxysmal nocturnal dyspnea)
Acute Aortic regurgitation presents as a sudden onset of
Pulmonary edema and hypotension
Signs of CV collapse with acute aortic regurgitation
Severe dyspnea, hypotension, weakness.
Chronic aortic regurgitation pulse pressure
widened
AR best vasopressor
Ephedrine.
Symptomatic progression of MR : mild symptoms
regurgitant factors < 30%
Symptomatic progression of MR : moderate symptoms
regurgitant factors 30-60%
Symptomatic progression of MR: SEVERE SYMPTOMS
regurgitant factors >60%
Blowing holosystolic murmur
MR
Best heart at apex
MR
Radiation the axilla
MR
MR and neuraxial
well tolerated but avoid bradycardia
Normal aortic valve area
2.5 - 3.5 cm2
Severe AS valve area
0.8 - 1 cm2
Critical severe AS
0.5-0.8 cm2 WITH a transvalvular gradient of 50 mmHg
Critical Severe AS transvalvular gradient i
50 mmhg
Classic symptoms of Aortic stenosis
SAD NECK
Syncope
Angina
Dyspnea (DOE)
Murmur radiates to neck
Severe AS what is contraindicated
Spinals and epidurals.
Avoid this IV anesthetic in AS
Avoid ketamine
Normal mitral valve area
4-6 cm2
For mitral stenosis, which neuraxial is preferred and why?
Epidural, due to gradual onset of sympathetic block with epidural.
Mitral stenosis vasopressor preferred
Phenylephrine because lack beta adrenergic activity.
Murmur MASTER
ARDS
MRSA
MSDA
ASS Arch
With Mitral stenosis, enlarged LA effects
May apply pressure to the LEFT recurrrent laryngeal nerve and cause hoarseness.
When does symptoms of mitral stenosis will begin to manifest as far as valve area goes?
Less than 2 cm2
In a patient with mitral regurgitation , the LV ventricle will compensate by
Increasing EDV
In a patient with mitral regurgitation , the LV ventricle will compensate by Increasing EDV while initially maintaining normal ESV, these compensations are explained by which law or principles?
FRANK STARLING
MR has a regurgitant volume that is based on
Mitral valve size , HR, pressure gradient between atria and ventricle.
Mitral Regur management : Preload
Maintain or slighly increase preload.
Aortic stenosis is associated with _____SV how come?
Maintained SV because of Ventricular concentric hypertrophy
Your patient has severe AS. Where would you expect to see the effects of concentric hypertrophy on the 12-lead ECG?
R wave
Diastolic murmur best heart at the left sternal border
AR
AR is termed minimal when the regurgitant volume is _____and is severe if regurgitant volume is
< 40% of SV; > 60%
What will a magnet do to a pacemaker/ICD in a patient with Hypertrophic obstructive cardiomyopathy?
Asynchronus pacing , turn ICD off
Where would you expect to see hypertrophy in patient with HCM?
Ventricular septum
When does the obstruction peak in a patient with hypertrophic cardiomyopathy?
Mid-to-late systole.
What does von willebrand’s do or promote
Platelet adhesion
Von willebrands factor is manufactured by
Endothelial cells
Von willebrands factor is released by
Endothelial cells
What is the first line of treatment for Von willebrand’s disease?
DDAVP
Among numerous mediators released from the activated platelets are 2
THROMBOXANE A2 and ADP
Role of thromboxane A2 and ADP
promotes platelet aggregation
What activate the platelet
Thrombin (aka factor II)
The platelet after being activated by thrombin releases
Thromboxane A2 and ADP which promotes platelet aggregation
Thromboxane A2 and ADP promotes platelet aggregation by
binding to receptors and activating signal transduction
What actually aggregates the platelets
FIBRINOGEN (FACTOR I)
NSAIDS vs ASA
NSAIDS only prevents platelet aggregation but the depression of Thromboxane A2 only last 24-48 hours
The acetyl group of ASA causes
Acetylation of cyclooxygenase.
The rate limiting enzyme in the conversion of ARACHIDONIC ACID to Thromboxane A2
Cyclooxygenase
Tirofiban (aggrastat) discontinue how long before surgery
24 hours
Abciximab (reopro) discontinue how long before surgery
3 days (72 hours)
Eptifibatide (Integrillin) and surgery? when do you discontinue?
D/C 24 hours before surgery.
The most common acquired blood clotting defect is due to
Inhibition of cyclooxygenase production by ASA or NSAIDS.
Source of the PRO-coagulant fibrinogen (I)
LIVER
What is the source of the PRO-coagulant Prothrombin (II)
LIVER
Source of the PRO-coagulant TISSUE factor of (III)/Thromboplastin
Vascular wall and extravascular cell membranes
Source of the PRO-coagulant CALCIUM (IV)
DIET
Source of the PRO-coagulant von willebrand (VIII)
ENDOTHELIAL CELLS
Vit K dependent factors
2, 7, 9, 10 (Procoagulants) Anticoagulants factors (C+S)
Fibrin Stabilizing factor is factor
XIII
What are the 3 factors NOT MADE in the livet
VIII(vwf); III, IV (348)
How do you remember extrinsic pathway
For 37 cents you can have the extrinsic pathway.
How do you remember intrinsic pathway
If you cannot buy the intrinsic pathway for 12, you can get it for 11.98 (12, 11, 9,8)
How do you remember COMMON PATHWAY
The final pathway can be purchase at the FIVE and DIME for 1 or 2 dollars on the 13th of the month.
2 Labs that assess extrinsic pathway
PT/ INR
Med that interfere with extrinsic pathway
Ex means war
WARFARIN
2 Labs that assess intrinsic pathway
PTT
ACT
Med that interfere with intrinsic pathway
HEPARIN
Most important clue to clinically significant bleeding disorder in an otherwise healthy patient remains
The history
The most common reason for coagulopathy in patients receiving massive blood transfusion is
lack of functioning platelets.
All procoagulants except ______ are present in _____
All procoagulants except PLATELETS are present in FFPs.
RBC and increase in Hct
1cc/kg of RBC increase HCT by 1%
One unit of RBCs increase HCT by
3-4%
Appropriate heparinization indicated by ACT of
400seconds - 450 seconds
What is normal bleeding time
3-10 minutes
PT normal
12-14 secon
aPTT normal
25-35
PTT assess what pathways
Intrinsic + common
ACT normal
80-150
Plasminogen to it active form which is
PLASMIN
What converts plasminogen to plasmin?
Tissue type plasminogen activator (tPA)
Urokinase type plasminogen activator. (upa)
Plasminogen is converted to plasmin by tpa and upa which in turn down what
Breaks down fibrin to Fibrin degradation products.
Two medication that works by inhibiting plasmin
Amicar
Aprotinin
When plasmin is inhibited , fibrin that is formed is
breaks down slowly, so bleeding is decreased.
Most common cause of an isolated high PT
LIVER DISEASE>
What clotting factor activates the platelet at the site of vascular injury>
II (thrombin)
Cryopreciptate contains what factors
I,8, 13
What is the most common cause of coagulopathy after a massive blood tranfusion?
Lack of functioning platelets (THROMBOCYTOPENIA)
How does protamine work to reverse heparin?
PROTAMINE combines ELECTROSTATICALLY with heparin, a neutralization reaction
3 substances that convert plasminogen to plasmin
uPa
tPa
streptokinase
How does coumadin work?
competitively inhibits the vitamin K dependent factors, 2, 7, 9,10
How does heparin work?
Increase the activity of (turns it on) of antithrombin III
What is the best test for PRIMARY HEMOSTASIS, platelet function?
standardized skin bleeding time
Enzyme that break down fibrin
Plasmin
Average life span of platelets in NORMAL BLOOD
8-12 days
Average life span of platelets in TRANSFUSED BLOOD
1-2 days
Von willebrand’s factor normally binds to platelets at which receptor
GP 1B
1st line tx of von willebrand’s disease is
DDAVP
How does Eptifibatide inhibit platelet aggregation?
RECAPS fibrinogen receptor on platelets
Oral corticosteroids may inhibit platelet aggregation because steroids
Prevent PHOSPHOLIPASE A2 from acting on membrane phospholipids
Thrombin induces a _____Feedback cycle in secondary hemostasis
POSTIVE
How does thrombin induce a positive feedback cycle in secondary hemostasis?
by increasing activation of which upstream factors 5, 8, 11
What role does factor IV (CALCIUM) play in the coagulation cascade?
Postions clotting factors on platelet surface
Which blood product selectively contains high concentration of factor I, 8, 13
Cryoprecipitate
Molecule that inhibits plasmin activity
APROTININ
Common precipitating factor for DIC
Ischemia
The most common cause of an ISOLATED PT value is
Liver disease.
External branch of the SLN innervates the
Cricothyroids muscle
What is the MAJOR MOTOR nerve of the larynx
RECURRENT LARYNGEAL nerve
What is the MAJOR SENSORY nerve of the larynx
Internal branch of the superior laryngeal nerve.
aBDucts Vocal cords (take out back door)
Posterior cricoarytenoids.
aDDUCT vocal cords
Lateral cricoarythenoids
Which closes the rima glottidis?
Transverse
Tense Vocal cords
cricoThyroid (TENSE)
Relax vocal cords
thyroiaRytenoids (they relax)
Widens the inlet *ThyroW
THYROEPIGLOTTICS
Narrows inlet (ARINA)
Aryepiglottics
Damage to the external branch of the SLN
weakness and huskiness of the voice
Damage to the Ext. branch of the SLN nerve paralyzed
Cricothyroid
Unilateral RIGHT RLN damage characterized by
hoarseness, and a PARALYZED cord that assumes an intermediate position , midway between abduction and adduction
What is the most common injury after a SUBTOTAL THYROIDECTOMY?
Unilateral RIGHT RLN damage
If one cord is flaccid and in an intermediate position what kind of damage
Unilateral RLN paralysis
Unilateral RLN paralysis signs
Hoarseness
If both cords are flaccid and in an intermediate position what kind of damage
Bilateral RLN paralysis
Bilateral RLN paralysis signs
APHONIA (LOST OF SPEECH)
AIRWAY OBSTRUCTION
Normal P 50
26-28 mmHg
PaO2 to SaO2
40mmhg - 70 %
50mmHg - 80%
60 mmHg - 90%
What does the flat portion of the oxygen dissociation curve represents? (you put something flat to load up)
it facilitates the loading of O2 by the blood because in the flat portion of this curve, LARGE CHANGES IN THE PARTIAL PRESSURE OF ARTERIAL BLOOD (paO2,) only produces small changes in SaO2.
What does the STEEP portion of the oxygen dissociation curve represents? (steep , hard to unload)
Facilitates the UNLOADING of Oxygen at tissues because large amounts of oxygen are unloaded from hemoglobin. (large decrease in Oxygen saturation) in response to a small change in the partial pressure of O2.
Fetal hgb on the Oxyhemoglobin dissociation curve
Left
Maternal hgb on the Oxyhemoglobin dissociation curve
RIGHT
Leftward shift
All weird hemoglobin (Fetal, carboxyhgb, methemoglobi)
P50 increases when there is a (
RIGHT SHIFT
P50 decrease when there is a
LEFT SHIFT
What is the Bohr effect?
Refers to the shift in the oxyhemoglobin dissociation curve in response to an increase or decrease in PCO2
Opioids shift the hgb to where?
Opioids produces resp depression, which increase Co2, so to the RIGHT
Leftward shift
LOVE (loading O2 love )
Rightward shift
RELEASE (unload) O2
Dissolved O2 makes
Only a very small contribution to the O2- carrying capacity of the blood
Calculating the amount of dissolved oxygen in the blood
PaO2 x 0.003 at 37C
Whose law permits calculation of the amount of dissolves oxygen in the blood
Henry’s law.
O2 carried in 2 forms
Dissolved
hgb bound
if you’re given the SaO2, use it to
estimate partial pressure
40-90 rule
If SvO2 is 70% , how much oxygen is dissolved in venous blood?
0.12
What is the HALDANE EFFECT?
How a change in partial pressure of O2 (PaO2) in the blood influences the blood Co2 dissociation curve
The CO2 dissociation curve shifts UP to the left when
PO2 decreases
The CO2 dissociation curve shifts DOWN to the RIGHT when
PO2 increases
Breakdown of how Co2 is carried in the blood?
5% dissolved in plasma water 3% dissolved in RBC water 2 CARBAMINOHGB 20% in RBCs HCO3 in plasma 70%
Approximately 90% of the CO2 is transported by the blood is in the form of
HCO3.
CO2 is carried in the blood in 3
Dissolved
As BICARBONATE
chemically bound to plasma proteins and hgb.
How do you calculate the amount of CO2 dissolved in blood?
Multiply PCo2 x 0.067. and the result is the mL of Co2 dissolved in each 100 ml of blood
Which law allows you to calculate the amount of CO2 dissolved in blood?
Henry’s LAW.
The central chemoreceptors are stimulated by
Increased H+
What in the brain can automatically cause an increased in H+
Increase in cerebral spinal CO2
What drives respiration normally?
CO2
Peripheral chemoreceptors are stimulated by
Increased PCO2, Decreased pH or decreased PaO2 < 60 mmHg
The glossopharyngeal nerves carries_______while the vagus nerve carries ______
Sensory information from the carotid bodies (GC)
Vagus nerve carries sensory impulses from the AORTIC bodies and also STRETCH receptors found in the lung parenchyma (VA)
What is the INSPIRATORY pacemaker?
Dorsal Inspiratory Group
Dorsal Inspiratory Group controls what
Diaphragm and External INTERCOSTAL MUSCLES
