Special Populations Exam 2 Flashcards
1
Q
In Trauma this is a continuous, priority driven process of patient assessment, resuscitation, and reassessment.
Rapid overview
A
Initial evaluation
2
Q
In trauma, ____ ____ is designed to assess and treat life threatening injuries rapidly?
A
Primary survey
3
Q
What are the 4 leading causes of death in trauma patients?
A
airway obstruction
respiratory failure
hemorrhagic shock
brain injury
4
Q
All trauma patients are considered what?
A
Full stomach
RSI
5
Q
Intubation for patient with cervical spine injury in C-collar?
A
Video laryngoscopy vs fiberoptic intubation
Manual in line stabilization
avoid nasal intubation
6
Q
This condition is a life-threatening emergency where a large air collection in the pleural space compromises respiration and cardiac function.
Clinical diagnosis
- cyanosis, tachypnea, hypotension, neck vein distention, tracheal deviation.
- requires needle decompression
A
Tension Pneumothorax
7
Q
This condition is when an injury creates a hole in the chest wall that allows air from the environment to enter the pleural cavity.
- 3 sided dressing and chest tube
A
Open pneumothorax
8
Q
This condition may occur when 3 or more ribs are broken in at least 2 places. Causes a segment of the chest wall to move independently of the rest of the chest wall.
Paradoxical movement.
Increased dead space, decreased intrathoracic pressure.
A
Flail chest
9
Q
What is the most common cause of shock in trauma patients?
A
Blood loss
hypovolemic shock
10
Q
What is the #1 cause of death in trauma patients?
A
TBI
11
Q
What can initially be used to assess the adequacy of tissue perfusion in a trauma patient?
A
Capillary refill of > 2 secs may indicate poor perfusion.
12
Q
What must be considered if a patient presents with pale, cold extremities and in shock?
A
Pericardial tamponade must be ruled out
13
Q
In primary survey if GCS < what need to intubate?
A
< 8
14
Q
GCS score of 15
A
Alert
normal
15
Q
GCS score of 12-13
A
Verbally responsive
16
Q
GCS score of 5-6
A
Physically responsive
17
Q
GCS score of 3
A
Unresponsive
18
Q
What 2 things are terrible for an injured brain?
A
Hypoxia
Hypotension
19
Q
Injured brain, maintain MAP to what?
Maintain SpO2 to what?
A
MAP > 80
SpO2 > 92%
20
Q
Treatment of high ICP?
A
Head elevation
Temporary hyperventilation
Mannitol/Furosemide
Increase Sedation
21
Q
Spinal shock can result in what?
A
Hypotension from vasodilation and bradycardia
Catecholamine surge - Pulmonary edema
22
Q
At what cervical level does an injury impair respiration?
A
C4 or above
23
Q
The purpose of this is to obtain a detailed history, perform a head to toe exam, reassess vital signs, and obtain pertinent lab and imaging studies to identify injuries and metabolic abnormalities?
A
Secondary survey
24
Q
What factor has the greatest effect on IV catheter flow rate?
A
Radius
Short and fat = better
25
What are the 2 induction agents of choice for trauma patients?
Etomidate 0.2-0.3 mg/kg
or ketamine 1-2mg/kg
26
What MAC should you keep patient at if TBI is suspected?
0.5 MAC
avoid nitrous
27
What ratio of RBCs, plasma and platelets mirror the content of whole blood?
1:1:1
28
If patient has low fibrinogen what should be administered for treatment?
Cryoprecipitate.
29
Acidosis, Coagulopathy, and Hypothermia is known as what?
The lethal triad
30
How much calcium should be given for every 2-3 units of blood product?
0.5-1g
31
What drugs are used in attempt to offset the body peripheral vasoconstriction response in order to increase microcirculatory perfusion?
Titrated opioids or volatile agents
need SBP > 90
32
What is a temporizing measure of support for vital organ perfusion, decrease the amount of bleeding distal to the occluded site?
REBOA
Resuscitative endovascular balloon occlusion of aorta
33
What should be avoided for resuscitation for polytrauma in neurosurgical procedures?
Avoidance of colloids
34
This condition is associated with Hypotension, bradycardia, and hypothermia.
Injury above T6 level
Most common in complete C-spine transection.
MAP goal 85
Spinal shock
35
Rule of nines for burn measurement is not accurate in which patients?
Children and Obese
36
Mortality from burns is caused by which 3 primary factors?
Inhalational injury
>40% burned
Age > 60 yrs
37
Full thickness burns are what %?
>10% TBSA
38
Partial thickness burns are what %?
> 25% TBSA
39
Major burns exceeding 25% cause a cytokine mediated inflammatory response 2- phase? What happens in the first 24-48 hrs
Burn shock (ebb) phase
decreased cardiac output and blood flow in the first 48 hours.
40
What happens in 48-72 hours following a major burn of >25%?
Hypermetabolic (flow) phase
Increased O2 consumption, CO2 production and cardiac output and enhanced blood flow to all organs
41
T/F
Carbon monoxide has 200x greater affinity for Hgb than O2?
True
42
Carbon monoxide shifts oxygen dissociation curve which way?
To the LEFT
holds onto oxygen
43
Any inhalation injury with anion gap metabolic acidosis despite adequate oxygen delivery can cause what?
Cyanide toxicity
44
What is the gold standard of inhalation injury ventilatory support?
Tidal volumes < 6 mL/kg ideal body weight
Plateau airway pressures < 30 cm H2O adults.
45
What is the parkland formula for fluid resuscitation?
Volume of crystalloid= 4mL x % TBSA x kg
Half given in first 8 hours
Half given in next 16 hours
46
Goal for urine output in patients?
0.5-1 mL/kg/hr
47
Which receptors are down regulated in burn patients?
Beta receptors
48
Blood loss estimate is ____% loss for ___% burn excised?
2.6% loss for 1% excised
49
Burn patients have a
____ of nicotinic receptors
____ binding of alpha-1 glycoproteins
_____ to non-depolarizer NMBA
Upregulation
Increased
Resistance
50
Which drug should be avoided after 48hrs post burn injury and for at least 1 year?
Succinycholine
51
All of the following statements regarding manual in-line stabilization (MILS) during laryngoscopy and tracheal intubation are true, EXCEPT:
A. MILS must be performed whenever the rigid cervical collar is removed from any trauma patient with potential cervical spine or spinal cord injury.
B. MILS facilitates direct laryngoscopy and tracheal intubation by improving the laryngoscopist’s view of the vocal cords.
C. During rapid sequence induction, MILS should be the sole responsibility of one properly trained provider.
D. Patients with cervical spinal cord injury rarely have worsening of their neurologic function when laryngoscopy and tracheal intubation are performed with MILS.
B
Because properly applied MILS limits both flexion and extension of the cervical spine and atlantooccipital joint, laryngoscopic view of the vocal cords may be restricted and increase the difficulty of tracheal intubation.
52
A 32-year-old unhelmeted female bicyclist is struck by a car at an urban intersection, evaluated at the scene by prehospital emer- gency medical providers, and transported to the hospital on a backboard with a rigid cervical collar. In the emergency department, her airway, breathing, and vital signs are within normal range, and she has a grossly deformed right ankle that appears to be dislocated. On neurologic examination, she speaks no words or sentences, and can only grunt and moan. She withdraws each extremity to pinprick; her eyes are closed and only open when her right leg is moved. Her Glasgow coma scale (GCS) score is:
A. 6
B. 8
C. 10
D. 12
B
The neurologic examination translates into a Glasgow coma scale motor score of 4, a verbal score of 2, and an eye score of 2, for a total Glasgow coma scale score of 8
53
You are asleep in the on-call room at 3:00 a.m. when you receive a call from the operating room notifying you that a 37-year-old woman with a single, high- caliber gunshot wound to the epigastrium just arrived in the emergency room. Because of her unstable vital signs (blood pressure 72/38, heart rate 132, respiration rate 36), the patient will be transported to the operat- ing room within the next 10 minutes for an exploratory laparotomy. The “Emergency and Trauma Anesthesia Checklist” can guide your rapid preparation for this procedure in which of the following areas?
A. Drugs for general anesthesia induction and tracheal intubation
B. Drugs and equipment for intraoperative resuscitation
C. Preparation of operating room equipment and anesthesia workstation
D. All of the above
D
The “Emergency and Trauma Anesthesia Checklist” can be of particular value in preparing to anesthetize a critically ill patient on short notice or in the middle of the night by providing a specific list of trauma-specific equipment and procedures that should be available
54
Which of the following statements regarding “hypotensive resuscitation” of the hemodynamically unstable trauma victim is TRUE?
A. The hemodynamic goal of the resuscitation is a lower-than-normal blood pressure that still provides sufficient perfusion to vital organs until hemostasis is achieved, after which the blood pressure is normalized.
B. Hypotensive resuscitation is of potential value in patients with traumatic brain injury (TBI).
C. The hemodynamic goal of the resuscitation is normal, age-appropriate blood pressure until hemostasis is achieved, after which the blood pressure is pharmacologically reduced to lower-than- normal levels that still provide vital organ perfusion.
D. Hypotensive resuscitation is of greater value in patients with blunt abdominal trauma than those with penetrating trauma.
A
Hypotensive resuscitation temporarily targets a lower-than-normal blood pressure until major hemorrhage is controlled and is more likely to burn injuries >48 hours old because of quantitative and qualitative changes in neuromuscular acetylcholine receptors that accompany burn injuries.
55
The concept of “1:1:1 volume resuscitation” in hypovolemic, hypotensive trauma victims refers to administering equivalent numbers of units of packed red blood cells, fresh frozen plasma, and platelet. TRUE or FALSE?
A. True
B. False
A
The goal of 1:1:1 volume resuscitation is to maintain proper oxygen carrying capacity (i.e., red cell mass) and normal coagulation function and to avoid the anemia and dilutional coagulopathy that can occur with high-volume isotonic crystalloid resuscitation. Studies in both military and civilian populations suggest that this resuscitation strategy improves survival compared with high-volume crystalloid resuscitation.
56
When caring for trauma and burn patients, unintended hyperkalemia can result in all of the following clinical settings EXCEPT:
A. Administration of six units of 23-day-old packed red blood cells to a 3-year- old girl with a traumatic leg amputation from a lawn mower accident
B. Rapid administration of 12 units of 2-day-old packed red blood cells containing citrate preservative to a 53-year-old woman undergoing emergent splenectomy for blunt abdominal trauma
C. Hemolytic transfusion reaction in a 23-year-old woman who received improperly cross-matched packed fresh frozen plasma following traumatic brain injury
D. Succinylcholine administration to a 44-year-old man with 43% total body surface area flame burn on day 5 of hospitalization
B
Hyperkalemia can occur when potassium is released from lysed red blood cells, such as following transfusion in small children of old units of packed red blood cells (that may have undergone lysis during prolonged storage) or acute, immune-mediated hemolysis. Succinylcholine can precipitate hyperkalemia in patients with large burn injuries >48 hours old because of quantitative and qualitative changes in neuromuscular acetylcholine receptors that accompany burn injuries.
57
A 35-year-old male competitive bicycle racer sustains an isolated closed pelvic fracture (iliac wing and pubic ramus) in a bicycle crash. Assuming that his preinjury hematocrit was 45% and that during the first 24 hours of his hospitalization he maintained normal vital signs while being resuscitated to euvolemia with isotonic crystalloid only, what is his predicted hematocrit on day 2 of hospitalization?
A. 45%
B. 35%
C. 25%
D. 15%
C
Pelvic fractures are accompanied by significant internal hemorrhage—2 to 3 L due to bleeding from the large bone fragments, as well as injury to nearby retroperitoneal veins. Because approximately half the patient’s blood volume could be lost into the pelvis, crystalloid resuscitation to euvolemia would be expected to dilute his remaining red cell mass to a hematocrit approximately 50% below his baseline.
58
A 3-year-old, 21-kg girl sustains a 29% total body surface area burn after pulling a pot of boiling water off the stove. Using the Parkland formula for postburn fluid resuscitation, what volume of isotonic crystalloid should she receive in the first 8 hours of hospitalization?
A. ∼400 mL
B. ∼800 mL
C. ∼1,200 mL
D. ∼2,400 mL
C
The Parkland formula (Table 32-6) calculates isotonic fluid resuscitation for the first 24 hours after injury as 4.0 mL × body weight (kg) × %TBSA burn. Thus, the total 24-hour resuscita- tion volume would be (4 × 21 × 29) = 2,436 mL. Since half of this volume is to be administered in the first 8 hours, her 8-hour fluid volume would be (2,436/2) = 1,218 mL.
59
A 75-year-old otherwise healthy woman is rescued from a house fire and arrives shortly thereafter at the hospital receiving supplemental face-mask oxygen at 10 L/min. She has no apparent burn injuries, but is lethargic and coughing up carbonaceous sputum. Which of the following laboratory assessments would you NOT EXPECT to observe?
A. Pulse oximetry reading of 95%
B. Carboxyhemoglobin level of 26%
C. Arterial blood gas with partial pressure of oxygen (PO2) of 57 mm Hg
D. Co-oximeter measured arterial oxyhemoglobin saturation of 72%
C
With a history of smoke inhalation in an enclosed space and carbonaceous sputum, significant inhalation injury is likely, including carbon monoxide poisoning. Carbon monoxide poisoning would be reflected in an elevated carboxyhemoglobin and a low oxyhemoglobin saturation, both measured by arterial blood co-oximetry in the laboratory. Peripheral pulse oximetry is typically normal because this device only measures the relative values of oxyhemoglobin and deoxyhemoglobin, and does not measure carboxyhemoglobin. Arterial PO2 would be normal because carboxyhemoglobin does not affect the partial pressure of oxygen dissolved in the plasma.
60
In a mass casualty incident, patients are triaged based on the severity of their injuries. In general, those with the most severe, multiple injuries and near death receive the highest priority for care. TRUE or FALSE?
A. True
B. False
B
Because emergency medical care resources are limited and insufficient to treat all victims of mass casualty incidents, those with the most severe injuries and near death (e.g., cardiac arrest) are managed expectantly. Instead, the highest priority for care is given to those who are in need of emergent surgery to save life, limb, or eyesight.
61
As a result of trauma a 60-year-old patient is undergoing an emergent leg amputation in the hospital. An indication for transfusion of whole blood is:
A. A hemoglobin level of <5 g/dL
B. A blood pressure of <70/50 mm Hg for
10 minutes
C. Ongoing blood loss exceeding 8,000 mL
D. None of the above
D
Whole blood is only indicated in rare circumstances (such as a war zone) where there is no ability to separate whole blood into components or to store those components. Hemorrhage from trauma can be effectively treated with PRBC and crystalloid fluids, with plasma given if there is evidence of a coagulopathy or factor deficiency.
62
A otherwise healthy 25-year-old woman is admitted to the hospital with clinical and radiographic signs of appendicitis. Workup yields the following data: blood pressure 115/85 mm Hg, heart rate 110, tempera- ture 39°C, white blood cell count 12,000, hemoglobin 7.5 g/dL, urinalysis normal. The most appropriate next step is:
A. Proceed urgently to perform an appendectomy
B. Administer erythropoietin and then pro- ceed to surgery
C. Transfuse 2 units of PRBCs and then proceed to surgery
D. Delay surgery for 24 hours to determine the cause of the anemia
A
In an otherwise healthy patient who is hemodynamically stable, there is no need to treat moderate anemia with a hemoglobin >7 g/dL. It is important to determine the cause of the anemia, but surgery need not be delayed to perform the evaluation.
63
All of the following are indications for transfusion of fresh frozen plasma EXCEPT:
A. Dilutional coagulopathy
B. A deficiency of coagulation factors
C. Hypovolemia with a normal hemoglobin
D. Bleeding due to a warfarin overdose
C
Indications for FFP are treatment of dilutional coagulopathy, factor deficiency, and as a second- line agent for warfarin reversal. FFP should not be administered solely for volume replacement.
64
The recommended indications for platelet transfusion include all of the following EXCEPT:
A. Patient having intraocular surgery; platelet count 75,000 per microliter
B. Asymptomatic patient; platelet count 25,000 per microliter
C. Patient scheduled for resection of abdominal aortic aneurysm; platelet count 40,000 per microliter
D. Patient scheduled for resection of intracranial meningioma; platelet count 80,000 per microliter
B
Bleeding during craniotomy or intraocular procedures is a serious complication. The threshold for platelet transfusion is more liberal at <100,000 per microliter. For patients having other major surgical procedures the threshold for platelet transfusion is <50,000 per microliter. Patients who are not bleeding will usually not incur spontaneous hemorrhage until the platelet count is <10,000 per microliter.
65
A 25-year-old man is seriously hemorrhaging secondary to trauma. Until his blood type can be identified, which of the following would be the BEST choice of blood for transfusion until type-specific blood is available?
A. Type O Rh-positive
B. Type A Rh-negative
C. Type B Rh-negative
D. Type AB Rh-negative
A
In an emergency, uncross-matched type O blood is best as a “universal donor” for patients of unknown blood type. While Rh-negative blood is preferred, particularly for women of child- bearing age, administration of Rh-positive to men
66
Which of the following is a sign of an acute hemolytic transfusion reaction during general anesthesia?
A. Tachycardia
B. Hypotension
C. Bleeding
D. All of the above
D
Unfortunately, there is no precise sign for diagnosis of AHTR in the anesthetized patient. Tachycardia and hypotension could be secondary to AHTR or hypovolemia from surgical hemorrhage. Bleeding could be due to surgery or due to AHTR-induced DIC.
67
Which of the following is the most common infection transmitted by blood transfusion?
A. Escherichia coli
B. Hepatitis B
C. Hepatitis C
D. Human immunodeficiency virus
B
Although transmission of hepatitis C and HIV are commonly discussed in the media, the incidence of transmitted hepatitis B is most prevalent due to a higher prevalence of the disease in the population and a longer window of time between infection and the ability to test blood for the virus. Bacterial contamination of banked blood is rare.
68
For most patients undergoing major surgical procedures associated with significant blood loss, the overall most efficacious alternative to RBC transfusion is:
A. Blood salvage with “cell saver” technology
B. Autologous blood donation
C. Acute normovolemic hemodilution
D.Perfluorocarbon blood substitutes
A
Although there are several alternatives to RBC transfusion, and each method has peculiar risks and benefits, overall blood salvage techniques have the lowest risk, lowest cost, and are most effective for general use.
69
What coagulation factor is responsible for conversion of fibrinogen to fibrin?
A. Tissue factor (TF)
B. Factor VIII
C. Thrombin
D. Factor XIII
C
TF and factor VIII are involved early in the coagulation pathway. Thrombin converts fibrinogen to fibrin. Factor XIII crosslinks and stabilizes the fibrin clot.
70
All of the following statements about aspirin are true EXCEPT:
A. It inhibits cyclooxygenase
B. It prevents synthesis of thromboxane
C. It interferes with platelet activation
D. Its effect is readily reversible
D
Aspirin is an irreversible inhibitor of cyclooxygenase, thereby preventing the synthesis of thromboxane, a major stimulant for platelet activation.
71
Which of the following factors increase the risk of otitis media in children?
A. During infancy, the eustachian tube has a large cross-sectional area.
B. During infancy, the eustachian tube is relatively short.
C. Children have a poorly developed immune system.
D. During infancy, the eustachian tube has
more rigid walls.
B
Otitis media has a peak incidence at 1 year of age. This is due to a variety of factors in this age group, including that the eustachian tube drains poorly due to its small cross-sectional area and its floppy cartilaginous walls. Additionally, its short length increases exposure of the middle ear to the mucous and bacteria of the nasopharynx.
72
Myringotomy and ear tube placement is most frequently performed with which of the following anesthetic techniques?
A. Intravenous induction of general anesthesia
B. Local anesthesia with moderate sedation
C. General anesthesia with endotracheal
intubation
D. Inhalation induction with a face mask
D
The short length of performing myringotomy and ear tube placement and its noninvasive nature allow use of inhaled anesthetics alone. Inhalation induction and maintenance using a face mask is frequently sufficient. Myringotomy and ear tube placement requires general anesthesia to provide the surgeon with the absolute immobility required for working under a micro- scope. These procedures are most frequently performed without intravenous access or endotracheal intubation.
73
A child presents to the emergency room with stridor, drooling, odynophagia, outright dysphagia, and high fever. The most likely diagnosis is:
A. Allergic reaction
B. Foreign body aspiration
C. Croup
D. Epiglottitis
D
Epiglottitis is a life-threatening condition typically caused by a bacterial infection. It often affects the epiglottis, aryepiglottic folds, arytenoids, and uvula. Clinical signs include stridor, drooling, odynophagia, outright avoidance of food and drink, and high fever.
74
A patient is undergoing surgery to correct strabismus. Suddenly, the heart rate decreases to 20 beats per minute. The next step should be:
A. Administration of intravenous epinephrine
B. Removing any stimulation
C. Administration of intravenous atropine
D. Decreasing the anesthetic depth
B
A sudden decrease in heart rate during ophthalmologic procedures is usually caused by the oculocardiac reflex. Treatment begins with cessation of any stimuli. Atropine may be required and, in rare situations, epinephrine, if the bradycardia progresses to cardiac arrest.
75
Which of the following drugs should be avoided in patients who have received intraocular sulfur hexafluoride?
A. Desflurane
B. Nitrous oxide
C. Timolol
D. Phenylephrine
B
Sulfur hexafluoride is used in retinal detachment repair to replace the volume of vitreous humor lost during surgery. Because nitrous oxide is much more soluble than nitrogen, it can enter the bubble quicker than nitrogen can exit, causing expansion of the gas bubble, increasing the IOP, and potentially causing retinal ischemia.
76
Secondary injury to the spinal cord following traumatic spinal cord injury can result from which of the following?
A. Local post injury inflammatory response
B. Tissue edema in the spinal cord and surrounding structures
C. Spinal cord ischemia
D. All of the above
D
Primary injury to neuronal structures occurs immediately at the time of traumatic injury, whereas secondary injury can occur in the immediate minutes to days following the injury. Secondary neuronal injury is largely caused by spinal cord ischemia and neuronal hypoxia that can result from systemic hypotension, inadequate local tissue perfusion, arterial hypoxemia, or local post-injury inflammatory responses including neuronal and interstitial edema.
77
Neurogenic shock following traumatic spinal cord injury occurs in which of the following clinical settings?
A.T4 vertebral burst fracture with no motor or sensory deficit
B. L1 vertebral burst fracture with complete motor or sensory deficit distal to the injury
C. T4 vertebral burst fracture with complete motor or sensory deficit distal to the injury
D. C7 spinous process fracture with no motor or sensory deficit
C
Neurogenic shock results from the loss of sympathetic vascular tone (i.e., reduced systemic vascular resistance) to large portions of the arterial vascular system. Generally, spinal cord injuries at the level of T6 and higher that result in complete motor and sensory deficits below the level of injury will functionally denervate enough of the arterial vasculature to result in hypotension and neurogenic shock, whereas injuries below this level will not. Bradycardia may or may not be present depending on whether sympathetic innervation of the sinoatrial node of the heart is also affected.
78
An otherwise healthy 24-year-old female is undergoing posterior spinal instrumentation (rodding) and fusion in the prone position for an acute, American Spinal Injury Association class D traumatic fracture of T8 and T9 sustained in a 10-foot fall from a ladder, with no associated traumatic injuries. She is receiving general anesthesia with sevoflurane 0.7 minimum alveolar concentration (MAC) and continuous remifentanil infusion. Intraoperative somatosensory-evoked potential monitoring reveals new, acute increases in signal latency and decreases in signal amplitude associated with surgeon placement of the stabilizing rods. Appropriate next steps include all of the following EXCEPT:
A. Communicate the observed changes with the surgeon
B. Increase the sevoflurane concentration to 1.5 MAC
C. Ensure that the mean arterial pressure is >85 mm Hg
D. Consider converting the general anesthetic technique to total intravenous anesthesia
B
Acute intraoperative changes in neurophysiologic monitoring of the spinal cord must be immediately communicated to the surgeon in the event that reversible surgical manipulations of the cord have occurred. Other steps should include repositioning the patient to maintain neutral spinal column alignment, correcting hypotension, metabolic abnormalities, anemia, and hypo- or hyperthermia, and minimizing volatile anesthetic agents (due to their dose- dependent negative impact on evoked potential signals).
79
An 83-year-old woman with symptomatic spinal stenosis from T6-12 is scheduled for posterior decompression with multilevel instrumentation (rodding) and fusion. Due to previous spine surgery as a young adult, the procedure is anticipated to take 8 hours and involve significant blood loss and large volume shifts associated with crystalloid and blood product administration. Which of the following steps would you take with respect to the potential complication of perioperative visual loss (POVL)?
A. Perform a careful visual acuity assessment and discuss the potential complication of POVL with the patient during the preanesthetic visit
B. Discuss preoperatively with the surgeon the potential steps to prevent POVL, including possible staging of the surgical procedure and the use of Mayfield pins to immobilize the head and neck intraoperatively (to prevent pressure on the prone patient’s face)
C. Place an arterial line for careful and continuous intraoperative blood pressure monitoring
D. All of the above
D
The etiologies and risk factors for POVL are described in Table 26-6. Due to the significant morbidity of this complication and its incidence of up to 2% following spine surgery, explicit discussion of POVL should occur with the patient during the preanesthetic visit as well as with the surgeon prior to the procedure. Careful blood pressure monitoring and judicious use of crystalloid fluids should take place during the intraoperative period.
80
Which of the following statements is true regarding venous air embolism (VAE) occurring intraoperatively during spine surgery in a prone patient receiving general anesthesia with an endotracheal tube?
A. VAE is accompanied by a sudden decrease in expired carbon dioxide
B. VAE can be immediately treated by raising the surgical site to a level above the right heart
C.VAE can be immediately treated by turning the patient to the right lateral decubitus position
D. The hemodynamic effects of VAE result from air accumulation in the left heart
A
The presentation and management of VAE are described in Table 26-7. Due to accumulation of air in the right heart, VAE impedes venous return and pulmonary blood flow, leading to an abrupt decrease in expired carbon dioxide. VAE can be immediately treated by flooding the surgical field with irrigation fluid and lowering the surgical site to a level below the right heart (to prevent further entry of air into the venous circulation). Air can potentially be removed from the right heart by placing the patient in the left lateral decubitus position and by aspirating a central venous catheter placed at the junction of the superior vena cava and the right atrium.
81
Potential beneficial effects of regional anesthesia or analgesia in patients undergoing orthopedic extremity surgery include all of the following EXCEPT:
A. Reduced perioperative opioid analgesic consumption
B. Postoperative analgesia that facilitates immediate joint rehabilitation and physical therapy
C. Reduced intraoperative surgical bleeding due to increased sympathetic tone
D. Possible reduced risk of postoperative thromboembolism
C
In addition to the general benefits of regional anesthesia or analgesia, orthopedic surgery patients have a high incidence of perioperative deep venous thrombosis and are frequently required to begin extremity movement and rehabilitation therapy as soon as possible. Regional anesthesia may be advantageous in both instances. Sympathectomy due to regional blockade causes peripheral vasodilation.
82
Regional anesthesia for arthroscopic rotator cuff repair is best accomplished with which of the following nerve plexus blocks?
A. Infraclavicular block
B. Interscalene block
C. Intravenous regional (Bier) block
D. Axillary block
B
Proximal upper extremity (shoulder and upper arm) surgery requires proximal brachial plexus blockade, most commonly achieved by the interscalene approach.
83
All of the following statements regarding tourniquet management for extremity surgery are correct EXCEPT:
A. For the upper extremity, tourniquet pressure should generally not exceed systolic pressure by more than 100 mm Hg
B. Tourniquet inflation time should never exceed 2hrs
C. For the lower extremity, tourniquet pressure should generally not exceed systolic pressure by more than 150 mm Hg
D. Morbidly obese patients may require a higher tourniquet pressure than non-obese patients
B
Tourniquet inflation pressures must exceed systolic pressure to prevent blood flow to the surgical field. This is generally accomplished in the upper extremity with inflation pressure 100 mm Hg over systolic pressure and in the lower extremity with inflation pressure 150 mm Hg over systolic pressure. Because of additional soft tissue in the extremities of the morbidly obese, higher inflation pressures may be needed to effectively prevent arterial inflow. The maximal tourniquet inflation duration is not well defined. It should generally be limited to 2 hours, but may be used longer depending on the tourniquet location and surgical procedure.
84
A 75-year-old otherwise healthy woman is undergoing hip arthroplasty for a recent femoral neck fracture under spinal sub- arachnoid anesthesia with light sedation, with nasal prong oxygen at 2 L/min. During placement of the femoral prosthesis, she becomes acutely confused, agitated, and her pulse oximetry reading falls from 99% to 72%. This clinical picture is highly suggestive of fat embolus syndrome.
A. True
B. False
A
Major criteria for fat embolism syndrome diagnosis include acute changes coincident with increases in intramedullary pressure at the surgical site, such as respiratory distress (hypoxia, pulmonary edema), neurologic impairment ranging from confusion or lethargy to seizures and coma, and petechia on the conjunctiva and upper trunk. Minor diagnostic criteria include fever, tachycardia, fat globules in sputum and urine, and decreased platelets and hematocrit. Initial treatment focuses on aggressive cardio- vascular and pulmonary supportive therapy.
85
An otherwise healthy 65-year-old male is scheduled to undergo surgical repair of a severe hallux valgus deformity (bunion) on his right foot. Appropriate anesthetic options include all of the following EXCEPT:
A. Ankle block
B. General anesthesia
C. Combined sciatic-popliteal nerve block
and saphenous nerve block
D. Femoral nerve block
D
Femoral nerve block
86
What is this drug?
analog of lysine
- acts by competitively blocking the lysine binding site of plasminogen
- antifibrinolytic
-1000mg over 10 mins
contraindicated with history of DVT or PE. Coagulopathy or CKD
- coronary stents < 6 months
Tranexamic acid (TXA)
87
SSEPs assess the dorsal column pathways of proprioception and vibration which has what blood supply?
2 Posterior spinal arteries
88
Partial diaphragmatic paralysis should be expected if the muscles controlled by ____ nerve roots are flaccid?
C5
89
How is blood pressure affected in beachchair position?
Every 20cm of height difference there is a 15mmHg difference in MAP.
If MAP at arms is 65 then MAP at brain is 50.
90
Which medication can help treat Cor Pulmonale?
Digoxin
91
What is responsible for blood supply to the Tonsils?
External Carotid
92
Sensory innervation to the tonsils is supplied from which 2 nerves?
Glossopharyngeal
Lesser Palatine nerves
93
Ludwig's Angina airway should be secured via what?
Nasal fiberoptic or Tracheostomy due to trismus
94
What is the most common cause of Stridor?
Laryngomalacia
(soft larynx)
95
Younger children most common item aspirated?
Peanut
96
Older children most common item aspirated?
Coin
97
The classic triad of aspirated foreign body include what 3 things?
Wheezing
Cough
Diminished breath sounds
98
Which LeFort fracture can be nasally intubated?
LeFort 1
99
Which LeFort fracture is pyramidal involving the nasal bones?
NO nasal intubation
No NG tubes
LeFort 2
100
Which LeFort fracture runs parallel to the base of the skull.
- Rhinorrhea
- Loss of supporting facial structure?
Difficult intubation
LeFort 3
101
With this block the needle punctures the bulbar fascia and enters the orbital muscle cone?
onset is 2 mins
Retrobulbar (intraconal)
2-4 mL
onset 2 mins
102
With this block the needle is directed parallel and lateral to the bulbar fascia rather than passing through it?
onset is 10-20 mins
Peribulbar
4-10mL
onset 10-20 mins
103
Which layer of the blood vessel contains Von Willebrand factor and is the most internal?
Tunica Intima
104
Which layer of the blood vessel is the smooth muscle layer and is typically thicker in arteries?
Tunica Media
105
Which layer of the blood vessel is primarily connective tissue and serves as vessel protection outer layer?
Tunica Externa
106
Adhesion, Activation, and Aggregation are associated with which hemostasis?
Primary Hemostasis
Unstable Platelet plug
107
The coagulation Cascade is associated with which hemostasis?
Secondary Hemostasis
108
Tertiary hemostasis is also known as what?
Fibrinolytic system
109
What are the 3 stages of primary hemostasis in order?
1. Adhesion
2. Activation
3. Aggregation
110
Formed in Bone marrow and do not reproduce
- Life span 7-12 days
- normal count 150-300k
- Pushed aside near the vessel wall surface to react
- Contains Thrombin, vWF, fibrinogen
Platelets
111
What part of hemostasis is this?
- vWF is mobilized from within the endothelial cells and emerges from endothelial lining.
- vWF makes the platelets sticky to adhere to injury site
- Gplb (on platlet) adheres to vWF.
Adhesion phase (#1) of
Primary hemostasis
112
What part of hemostasis is this?
- The binding of Gplb to vWF causes platelet activation and degranulation.
- ADP, Thromboxane A2 and Thrombin recruit other platelets to site of injury
Activation phase (#2) of Primary hemostasis
113
What part of hemostasis is this?
- Gpllb-lla complex links to other activated platelets and a primary unstable clot/plug is formed.
Aggregation phase (#3) of Primary hemostasis
114
Which factors are Vitamin K dependent?
II, VII, IX, X
115
Factors II, VII, IX, X are all what?
Vitamin K dependent
116
What is the inactivated and activated form of Factor I?
Fibrinogen = inactivated
Fibrin a = Activated
117
What is the inactivated and activated form of Factor II?
Prothrombin = inactivated
Thrombin a = activated
118
Which factors start the Intrinsic pathway of coagulation?
- In order
XII 12
XI 11
IX 9
VIII 8
119
Which factors start the Extrinsic pathway of coagulation?
- In order
III 3
VII 7
120
Which factors start the Common pathway of coagulation?
- In order
X 10
V 5
II 2
I 1
121
Clot formation is accomplished at the end of the common pathway by which factor?
XIII 13
antihemophiliac
122
Which lab test would you check for the Intrinsic pathway?
- Tests for Heparin
Normal value 25-32 secs
APTT
123
Which lab test would you check for the Extrinsic pathway?
- Tests for Coumadin/Warfarin
Normal value 12-14 secs
PT/INR
124
Accronym for the common pathway?
Small bills
10 + 5 dollars
2 dollars
1 dollar
125
Enough ____ must be present to convert ____ to ____ to the stable secondary hemostatic plug?
enough Thrombin
to convert Fibrinogen to Fibrin
126
What is responsible for breaking down fibrin into fibrin degradation products?
Plasmin
127
Protein C and Protein S inhibit which 2 factors ?
V and VIII
5 and 8
128
Heparin binds to what?
Antithrombin III
129
Which test measures the conversion of Fibrinogen to Fibrin?
Thrombin Time
normal is 15 secs
130
When looking at a TEG, which value is considered the Clot initiation?
R value or
Reaction time : clotting factors
131
When looking at a TEG, which value is is considered the Clot formation time?
K value : Fibrinogen
132
When looking at a TEG, which value is the rate at which fibrin cross linking occurs?
Alpha angle : Fibrinogen
133
When looking at a TEG, which value is is the maximum clot firmness?
Maximum Amplitude (MA)
: Platlets
134
When looking at a TEG, which value is Clot stabilization?
LY-30= clot lysis
: antifibrinolytic agents
135
What is the treatment for abnormal K value and Alpha angle on a TEG?
Fibrinogen
Cryoprecipitate
136
What is the treatment for abnormal Maximum amplitude on a TEG?
Platelets
Desmopressin
137
What is the treatment for abnormal LY-30 on a TEG?
TXA
Amicar
138
What is the treatment for abnormal R time on a TEG?
FFP
139
Antiplatelet drugs work by inhibiting what?
- Clopidogrel, Aspirin
Primary hemostasis
(platelet plug)
140
Anticoagulants work to inhibit what?
- Coumadin, Heparin, Warfarin, Xarelto
Secondary Hemostasis
(Coagulation pathway)
141
Which type of drugs are known as "clot busters"?
Fibrinolytic/Thrombolytic
Activates tertiary hemostasis or fibrolytic system
- TPA, streptokinase, urokinase
142
Which type of drugs prevent the breakdown of clots?
Antibrinolytic
Inhibits tertiary hemostasis
- Tranexamic acid (TXA)
143
What is the lethal triad of Trauma?
Acidosis
Coagulopathy
Hypothermia
144
1 unit of PRBC will increase Hgb by approximately __?
1g/dL
145
Anemia caused ____ shift of oxyhemoglobin disassociation curve?
Right shift
Increased 2,3, DPG, acidosis, and increased CO2
146
When giving a RBC transfusion, Citrate binds to calcium which causes ___?
Hypocalcemia
147
One unit of platelets will raise the count by ____ in average adults?
6,000 increase
148
Transfusion of what product is associated with highest risk of bacterial infection?
Platelets
they are stored at higher temp
149
Which transfusion product contains all coagulation factors?
10-20ml/kg
Plasma
FFP
150
What is the universal donor when it comes to plasma?
AB
151
What are the recombinant factors?
Factor VII, VIII, IX
152
This product contains fibrinogen, Factor VIII, XIII, vWF, and fibronectin ?
Cryoprecipitate
1 unit per 10kg body weight will raise level by 50 mg/dL
153
PCC 3 factor contains which factors?
2, 9, 10
154
PCC 4 factor contains which factors?
2, 7, 9, 10
155
What is the most common transfusion reaction?
Febrile Nonhemolytic Transfusion Reaction
156
What is the 4 diagnosis criteria for TRALI?
1. Acute onset < 6hrs
2. Hypoxemia
3. Bilateral lung infiltrates
4. No evidence of left atrial HTN
157
What condition is associated with Acute respiratory distress within 6hrs of transfusion?
- Increased CVP
- Volume overload
- Bilateral pulmonary edema
- Elevated BNP
TACO
Transfusion associated circulatory overload
158
RhoGam is given IM to moms at 28 weeks who are Rh _?
Negative
159
What is the most common inherited bleeding disorder?
- facilitates platelet adhesion
- Plasma carrier for Factor VIII
- Elevated aPTT
Von Willebrand's disease Type 1
160
Desmopressin treatment is helpful for which type of Von Willebrand's disease?
Type 1 = yes
Type 2A= sometimes
Type 2M= sometimes
161
Hemophilia A is the most common type of hemophilia (X linked recessive/men) and is associated with which Factor deficiency?
- Desmopressin (DDAVP) is helpful
Factor VIII
8
162
Vitamin K replacement can take how long for full effect?
Oral- ?
IV- ?
Oral- 24 hours
IV- 6 hours
163
Protein C and S deficiencies are associated with which 2 factors?
5 and 8
164
This condition is a gene mutation that makes Factor V resistant to the inactivation by protein C ?
- High risk for DVT
Factor V Leiden Thrombophilia
165
T/F
Heparin Induced Thrombocytopenia type II is most commonly due to UFH and leads to a HYPERcoagulable state for the patient?
True
Risk for DVT, Arterial VT and skin necrosis
166
DIC acute or chronic?
- Rapid consumption of coagulation factors and platelets that outpace their production?
- Consumption coagulopathy
Acute/decompensated
167
T/F
HgBSS is the most severe form of sickle cell and has 2 genes?
True
also known as sickle cell anemia
HgBS lifespan is 17 days
