Test 1 Flashcards
What percentage of a diagnosis can be correctly determined from a patient history alone?
56%
What constitutes a medical history exam?
- Underlying condition requiring surgery
- Medical history/problems
- Previous surgeries/anesthetic history
- Anesthetic complications
- ROS
- Current meds
- Allergies
- Tobacco/ETOH/illicit drug use
- Functional capacity
What 4 things are BMI used to calculate (per powerpoint slide)?
1 - estimate/calculate drug dosages
2 - determine fluid volume requirement
3 - calculate acceptable blood loss
4 - adequacy of urine output
What is important to establish from a focused physical exam?
The patients baseline (neuro, CV, respiratory etc) in all systems
What acronym is used for an emergent physical exam? In an emergency if you can only pick 2, which do you pick?
A - allergies
M - medication
P - PMH
L - last meal
E - events leading up to surgery
Emergency pick 2 = allergies and PMH
What accounts for almost half of perioperative mortalities?
Problems with the CV system
^Mitigate risk by optimizing heart failure patients, etc
What is a G6PD deficiency?
The body lacks that enzyme, which the lack of causes hemolytic anemia. RBCs break down faster than they are made in response to stress
What court case established informed consent? Outcome of the surgery?
Salgo v Leland Stanford Jr. University Board of Trustees. An aortogram left the pt paralyzed
What surgeries carry a high mortality risk (>5%)? Intermediate (1 - 5 %) or low (<1%)?
High = aortic and major vascular surgery
Intermediate = Intra-abdominal or intrathoracic surgery, carotid endarterectomy, head/neck surgery
Low = ambulatory, breast, endoscopic, cataract, skin, urologic, orthopedic
What is the goal of METs?
greater than 4
Define emergency, urgent and time-sensitive surgeries
Emergent = life or limb would be threatened if surgery did not proceed within 6 hours
Urgent = life or limb would be threatened if surgery did not proceed within 6 - 24 hours
Time-sensitive = delays exceeding 1 - 6 weeks would adversely affect patient outcomes
What are Saklad’s 5 degrees of ASA PS grading of operative risk?
1 - Pt’s physical state
2 - the surgical procedure
3 - the ability/skill of the surgeon
4 - attention to post-op care
5 - past experience of the anesthetist in similar circumstances
What is the goal of pre-operative evaluations?
- Ensure patients can safely tolerate anesthesia for surgery
- Mitigate perioperative risks
- Clinical examination = H&P examination
What is the benefit to the patient of a pre-op evaluation?
- Reduce anxiety
- Educate (medications + procedure)
- Reduce post-op morbidity
- Answer questions
What benefit does a pre-op evaluation offer anesthesia providers?
- Learn medical Hx
- Make anesthetic plan
- Call consultants PRN
- Discuss DNR
What benefit does a pre-op evaluation offer the surgeon/hospital?
- Decrease cost of perioperative care
- Improve efficiency
- Decrease cancellations/delays
What BMI is underweight?
<18.5
What BMI is normal?
18.5-24.9
What BMI is overweight?
25.0-29.9
What BMI is obese?
30.0 & above
What is the BMI formula [metric]?
BMI = weight (kg) / [height (m)]2
^Note, 2 is supposed to be an exponent
What are the components of an airway examination?
- Mallampati classification
- Inter-incisors gap
- Thyromental distance
- Forward movement of mandible
- Range of cervical spine motion: Flexion & Extension
- Document loose or chipped teeth/tracheal deviation
What cardiovascular disorder would be grounds for cancelling a case in class?
Audible aortic stenosis, especially in the neck.
In a patient who is anesthetized, we can’t really “see” hypoxia outside of assessment + the monitor. Assessment wise, what three severe complications would result from hypoxia?
Seizure, coma, death
^Note; most things will lead to seizure, coma, death if you’re not sure..
Also, would not see seizure because of paralysis, would not see coma because the patient is asleep, would just see death. Important to assess. Also important with hypoglycemia to do finger sticks
Define: GA, IV/monitored sedation, Regional and Local anesthesia
GA = total LOC, ET or LMA, major surgeries (total joints, open heart surgery, bowel surgery)
IV/Monitored = LOC ranges, drowsy to deep sleep. NC or face mask, requires vigilant observation
Regional = numbs a large part of the body using a local anesthetic (epidural or spinal), good for child birth or a hip replacement
Local = one-time injection that numbs a small area i.e. biopsy. Can be used in conjunction with GA or conscious sedation
What does the pituitary/adrenal disorder pheochromocytoma manifest as when under general anesthetics?
High BP as soon as they go to sleep
What is the #1 cause of malignancy?
Alcohol
What common drug artificially raises Hemoglobin?
Smoking tobaco
Do heart transplant patients respond to vagal stimulation?
No - no vagal response with the heart. Reversal with atropine/glycopyrrolate will note work
Aside from the obvious, why is it important to talk to patients about DNR status pre-op?
Much of what CRNAs do fall into the criteria of what a DNR prohibits (intubation, vasoactive medications, etc).
DNR often suspended for the perioperative period; need to make sure patient is aware
What is the revised cardiac risk index?
- Prediction tool recommended by ACC/AHA
- Estimates risk of cardiac complications after surgery
Pre-op assessment ppt, slide 28; need to know it
What are the components of the revised cardiac risk index?
- High risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures)
- Ischemic heart disease
- Hx. of CHF
- Hx. of CVA
-DM requiring insulin
- Creatinine 2mg/dL<
What is functional capacity?
Assessment of cardiopulmonary fitness
What are the steps within the preoperative cardiac risk assessment algorithm?
- Step 1: Emergency surgery
- Step 2: Active cardiac conditions (ACS, decompensated HF, significant arrhythmia, severe valvular disease)
- Step 3: Estimate risk of perioperative death or MI (cardiac risk index)
- Step 4: Assess functional capacity
- Step 5: Assess whether further testing will impact care
- Step 6: Proceed t surgery or consider alternative strategies (less invasive/palliative if needed)
What is ASA I?
A normal healthy patient.
i.e. Healthy, nonsmoking, no or minimal alcohol use.
What is ASA II
A patient with mild systemic disease.
Mild diseases only, without substantive functional limitations.
i.e. Current smoker, social drinker, pregnancy, obesity, controlled DM/HTN, mild lung disease
What is ASA III?
A patient with severe systemic disease.
Substantive functional limitations: One or more moderate to severe diseases.
i.e. Poorly controlled DM/HTN, COPD, morbid obesity, hepatitis, alcohol dependence or abuse, pacemaker, reduced EF, ESRD on HD, premature infant post conceptual age <60 weeks, MI within <3months, CVA, TIA, or CAD/stents
What is ASA IV
A patient with severe systemic disease that is a constant threat to life.
i.e. Recent (<3months) MI/CVA/TIA or CAD with stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of EF, sepsis, DIC, ARDS, or ESRD not on HD
What agents most commonly have side effects in anesthesia?
- Neuromuscular blockers
- Latex
- Antibiotics
- Chlorhexidine
- Opioids
What is ASA V?
A moribund patient who is not expected to survive without the operation.
i.e. ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or MODS
What is ASA VI?
A declared brain-dead patient whose organs are being removed for donor purposes.
When is pre-op testing indicated?
If it can identify abnormalities, change the diagnosis and management plan, or the patients outcome.. not routinely ordered for all patients.
In regard to pre-op testing, what criteria must be met for tests to be considered useful?
- Diagnostic efficacy (Correctly identify abnormalities?)
- Diagnostic effectiveness (change diagnosis?)
- Therapeutic efficacy (change the management of the patient?)
- Therapeutic effectiveness (change the patients outcome?)
What are examples of pre-op tests that might be ordered as discussed in class?
- CBC/Hg/Hct
- Renal function testing
- Electrolytes
- Liver function testing
- Coagulation testing
- Serum glucose & Glycated Hemoglobin (HbA1c)
- UA
- Pregnancy test (recommended for all women of childbearing potential; elderly women to r/o urosepsis)
- ECG
-CXR
What medications do you continue prior to surgery?
- HTN meds (excepts ACEs and ARBs)
- BBs/digoxin
- Anti-depressants
- Anxiolytics
- TCAs (get an EKG d/t prolonged QT)
- Thyroid meds
- Oral contraceptives (unless they are at high risk of thrombosis, then dc 4 weeks prior)
- Eye drops
- Gerd meds
- Opioids
- Anti-convulsants
- Asthma
- Corticosteroids
- Statins
- ASA (unless concern regarding bone healing)
- COX and MAOIs (avoid meperidine and ephedrine)
What medications do you DC prior to surgery?
- ASA
- P2Y12 (plavix, prasugrel, ticlopidine) 5-10 days
- Topical meds (day of)
- Diuretics (except HCTZ) day of surgery
- Sildenafil 24hrs
- NSAIDs 48hrs
- Warfarin 5 days
- Post-menopausal HRT 4 weeks
- Non-insulin anti-diabetics (day of)
- Short acting insulin (if insulin pump, take pump off but keep basal rate going)
- Long acting insulin (type 1 = take 1/3 usual dose
- Long acting Type 2 = take none or up to half usual dose)
Echinacea effects?
Activates of cell-mediated immunity
- May decrease effectiveness of immunosuppressants
- Cause allergic reactions intraop
- Potential for immunosuppression in the long term
No data about need to DC prior to surgery
Ephedra effects?
- Increase HR/BP.
- Risk of MI/CVA from tachycardia/HTN
- Ventricular arrhythmias w/ halothane
- Long term use can cause hemodynamic instability d/t decreased catecholamines.
- Life threatening Rx with MAOI’s
- Stop 24 hours before
Garlic/Ginseng/Ginger/Ginkgo/Green tea effects? (all of the G’s really)
- All have change coagulation in some way.
. - G for bleeding.
- No data for ginger.
- Stop garlic /ginseng / green tea 7 days before.
- Stop ginkgo 36 hours
Note ginseng can cause hypoglycemia.
Kava effects?
- Sedative/Anxiolytic
- Stop 24 hours before
Saw Palmetto
May increase bleeding risk, no data on when to stop
St Johns wort
- Helps with depression by inhibiting neurotransmitter reuptake.
- Induction of CYP450
- Decreased digoxin level
- Linked with delayed emergence
- Stop 5 days before
Valeria
- Sedation
- May increase anesthetic requirements/effects, with benzo-like acute withdrawals.
- No data on when to stop
Goals of premedication aspiration prevention?
Less than 25 ml in the stomach and a pH greater than 2.5
What are the risk factors for PONV via the Apfel score? Koivuranta score?
Apfel:
- Female
- Hx of PONV/motion sickness
- Non-smoking status
- Post-op opioids,
Koivuranta:
- Female
- Hx of PONV/motion sickness
- Non-smoking status
- Age less than 50
- Duration of surgery
Meds that can help prevent PONV?
- Scopolamine (Can cause sedation)
- Lyrica (reduces opioid requirement)
- Ondansetron (prevention, not treatment)
- Phenergan
- Dexamethasone (after induction)
Anesthetic wise, propofol can help
Most common antibiotics and dosages?
Ancef (2g, 3 g if weight is over 120kg, 30 mg/kg in peds, give q4h over 30 min)
Clindamycin (900 mg, 10 mg/kg in peds, give q6h over 30 - 60 min)
Vancomycin (15 mg/kg in adults/peds, infuse 15 mg/min
What should be conducted prior to administration of any mind-altering substance?
An anesthesia timeout.
Use:
- Patient name
- Age
- Sex
- Hospital name
- MRN
- Source of history
- Date/Time of admission
What must be kept in mind regarding temperature in critically ill patients?
Core temperature will likely be different than a temporal/axillary temperature and can affect the temperature which can affect the QI measure.
(Axillary 1 degree lower than actual temp.)
What is anthropometry?
The scientific study of the measurements and proportions of the human body
Height, weight, abdominal girth, mid arm circumference
What areas can be used for a BP measurement?
- Radial
- PT/DP
- Brachial
- Popliteal.
Any of these spots can be used for an arterial line too, especially if you’re trying to ensure continuity of IV/pulse ox usage. Make sure to use a proper cuff.
What risks are involved with a rectal temperature?
Perforation.
Avoid in uncooperative or immunosuppressed patients
Define a pack year for a smoker
20 cig/pack
1 PPD x 365 days = 1 pack year.
1/2 - 1PPD = bad
> 55y/o w/ >30 pack year history is high risk for lung cancer, need CT
What is the leading cause of beta blocker OD?
Accidental excess intake, particularly with the elderly
What is mediate or indirect percussion used to evaluate?
The abdomen and thorax
What is percussion used to evaluate for?
The presence of air or fluid in body tissues
What is immediate percussion used to evaluate?
The sinus or an infant thorax
Strike surface directly with fingers
What is fist percussion used to evaluate?
The back and kidney
Don’t knock them out - place one hand flat against the body surface, strike back of hand with a clenched fist of the other hand.
What is circumferential cyanosis?
Blue-ish discoloration around the mouth and NOT on the lips. It is not harmful and should go away with gentle external warming
What are some common causes of jaundice?
- Acute inflammation of the liver
- Inflammation or obstruction of the bile duct
- Hemolytic anemia
- Cholestasis
- Pseudo-jaundice (harmless, results from excess of beta-carotene - eating large amounts of carrot, pumpkin or melon)
What are some genetic causes of jaundice?
Crigler-Najjar syndrome - inherited condition that impairs an enzyme responsible for processing bilirubin
Gilberts syndrome - inherited condition that impairs the ability to excrete bile
Dubin-Johnson syndrome - inherited form of chronic jaundice that prevents conjugated bilirubin from being secreted from the cells of the liver
Describe the physiology of Vitiligo
An auto-immune issue where the melanocytes (control coloring of skin, hair, mucous) are attacked.
Generally shows up after a triggering event like a cut, scrape or bruise.
What are “raccoon eyes”?
Battles sign - symptom of a basilar skull fracture. Assume the worst.
Causes of petechiae?
- Prolonged straining
- Medications
- Infectious disease
- Leukemia
- Thrombocytopenia
What is the incidence of true anaphylaxis involving anesthesia? What is the most common cause?
1:20,000
Rocuronium
Which patients often will have latex allergies?
Those with spina bifida
Do most patients with a vancomycin allergy truly have an allergy?
No - often times red man syndrome, which is a product of giving vancomycin too fast + histamine induced side effect.
Which two antibiotics are the most common cause of anaphylaxis?
PCN & cephalosporins
What food allergies cross react with latex?
- Mango
- Kiwi
- Avocado
- Passion fruit
- Banana
- Chestnut
Which local anesthetic has a higher incidence of allergic response? How do we avoid this?
Esters
Look for a preservative free ester (preservative = para-aminobenzoic acid [PABA])
Do we d/c P2Y12 inhibitors within 6 months of dual anti platelet therapy?
No
Your patient takes hydrocortisone at home. What happens physiologically, and what might you have to do during surgery for this patient?
- Hydrocortisone suppresses the adrenal gland, so it will not respond to stress in a normal manner.
- We might have to give some form of synthetic steroid to make up for the lack of production during surgery if adrenal insufficiency is present
Note: especially true if patient on long term steroids. Not so much for short term steroids.
What is Mendelson syndrome?
Increased risk of aspiration.
> 25mL gastric residual with pH less than 2.5.
Bonus: Mendelson coined the term “NPO” when working with pregnant people in 1946
Regarding NPO status, how many hours should someone be NPO before surgery?
Full meal - 8 hours
Light meal - 6 hours
Breast milk - 4 hours
Clear liquids - 2 hours
What can be used pre-op to raise pH of gastric contents?
Sodium citrate, H2 antagonists, PPI
In regard to pre-procedure antibiotics, what time frame does the patient need to receive prophylactic antibiotics to maintain core measures?
1 hour before incision or less
When might you give ancef, clindamycin, or vancomycin?
Ancef - Broad spectrum B-lactam abx, kills most aerobic gram+ bacteria that cause surgical site infections
Clindamycin - Alternative for b-lactam allergy or a MRSA infection. Kills most gram+/- anaerobic bacteria. Also effective against gram+ aerobic bacteria. Recommended for hysterectomies, c-sections, appendectomies, Gastroduodenal tract, billiard tract, small intestine, colon, and rectum incisions. Also treats infections in head, neck, respiratory tract, bone, soft tissue, abdomen, and pelvis.
Vancomycin - Gram+ bacteria. Alternative for B-lactam allergy/MRSA infection. Recommended for distal ilium, colon, appendix surgical sites.
What five results come from collaboration in the preoperative evaluation?
- Decreased cost
- Efficient services
- Clinical productivity
- Timely access to clinic
- Patient and surgeon satisfaction.
Suspect cause of unilateral edema? Bilateral?
Uni = think clot, parasite bite, lymph issue, or injury
Bilat = suspect a central issue such as CHF or systemic infection
What is Koilonychia?
Spoon nails - sign of hypochromic anemia or iron-deficiency anemia. The nails are flat or even concave in shape.
What causes nail clubbing?
Generally a cardiovascular or pulmonary problem, such as lung cancer, ILD or cystic fibrosis.
What is Paronychia?
inflammation around the nail, usually due to a staph aureus infection or candida albicans… Risk factors: Nail biting or hangnails.
What do beau’s lines indicate?
Can indicate a wide variety of issues, such as external injury, infection if its only on one nail.
Multiple nails = systemic illness Such as: (ARF, mumps, thyroid, syphilis, chemotherapy, endocarditis, melanoma, DM, pneumonia, scarlet fever, zinc deficiency)
What are some causes of hirsutism?
Polycystic ovary syndrome,
- Cushing syndrome (high levels of cortisol, either an adrenal issue or too much prednisone over time)
- Congenital adrenal hyperplasia
- Tumors
- Medications (hair growth medications such as Minoxidil Rogaine Androgel, or testime)
What is the purpose of physical assessment?
- Establish relationship
- Gather health data
- Identify patient strengths
- Identify actual/potential health problems
- Evaluate physiological outcome of care
What age group is more prone to infection?
Elderly/children
Why is it important to assess prior to treatment?
If there is a change from baseline, you wouldn’t know unless you assessed. If it isn’t charted, you didn’t do it = lawsuit down the line if it looks like you had malpractice
Does unpleasant odor of a patient mean they are homeless?
Not always, it may be a cultural thing.
What is part of a general examination?
- Gender/race
- Age
- Sign of distress
- Body type
- Posture
- Gait
- Body movement
- Hygiene and grooming
- Dress
- Body order
- Speech
- Affect and mood
- Signs of abuse
- Substance abuse
What is health history?
Collection of subjective and objective data that provide a detailed profile of the client’s health status
How do language, marital status, education, occupation, or monthly income help the anesthesia provider?
- Language: ask what they prefer to be consented with language wise
- Marital status: matters for consent
- Occupation: changes risk factors
- Income: helps you know if they can take their medications/if you need to help to provide resources
Why are the details of admission important?
Helps you understand the patients picture.. i.e. if they came from the ER, you might need to place a new IV because you will likely have AC access. If they came from home, maybe they drove? Maybe they fell and have been on the floor for 6 hours?
What baseline data do we want when caring for a patient?
- Height/weight
- RR
- HR
- BP
- Abdominal Girth
- Temp
Note: careful not to use baseline vitals taken during i.e. prodding a femur Fx, use actual baseline measurements.
Patients with redundant neck tissue usually means what? What about snoring?
Prone to airway obstruction w/ sedation.
Pro tip: just ask who they sleep with if they snore or not
When assessing allergies, what should you ask the patient?
What reaction do they have when they take said drug - if they take Epi and have a faster HR, it’s probably not a true allergy
When asking about drug use, should you dig for information?
No. Just aim for a yes or no, and focus on meth/coke. Drug abusers often are dishonest, so it’s better to aim for a yes/no rather than a lecture.
Why should you observe patient activities for yourself?
Reported habits and actual habits may differ. Patient also may or may not have taken home meds/other substances.
Why is reviewing family information of the patient important?
Indicates potential level of support from family.
Particularly important in pediatric patients.
Why is it important to review environmental factors of the patient?
More important now than ever post-covid, helps to know housing/sanitary environment patient lives in to pre/post-op plan.
How can we reduce risk of corneal abrasion or aspiration pre-op?
Remove dentures and contacts
Crazy patients are still crazy during anesthetics. Mandible Fx patients are notorious for waking up rough. Why?
Use assessment skills - mandible Fx are most common from fist fights. They are probably rowdy/got in a fight and someones fist met their jaw
What is the sequence of physical assessment?
- Inspection (looking at things; body language is more telling)
- Palpation (touch; texture, masses, fluid, skin temp… let patient know when, where, and how you’re touching them)
- Percussion (whack it with fingers/fist [gently])
- Auscultation (listening)
- Olfaction (be familiar with nature and source of body odors)
Why is it especially important to keep safety in mind when assessing patients?
Could have drugs, a gun, bugs, etc in the bed. Take appropriate precautions; use a light, don’t rush.
What types of palpation are there?
Performed in this order
- Light: Hardly touching
- Deep: little deeper, maybe femoral artery palpation
- Bimanual: Using two hands to shape something out.. if you need to do this, probably should be doing imaging as well.
What is mediate/indirect percussion used for?
Evaluating abdomen/thorax.
Touch area with one hand, whack that hand with your other hand
When percussing, what would a tympany sound indicate?
Air containing space, enclosed area, gastric air bubble, puffed out cheek
When percussing, what would a Resonant sound indicate?
Normal lungs
When percussing, what would a Hyper resonant sound indicate?
Emphysematous lungs
When percussing, what would a dull sound indicate?
Liver
When percussing, what would a Flat sound indicate?
Muscle
Why might your patient be pale?
Maybe they never go outside, but could also be something like anemia, hypo perfusion, MI
When auscultating, what four things should we note?
- Intensity
- Pitch
- Duration
- Quality
What questions should you ask yourself about skin lesions?
Natural? Abuse? Infection/disease process?
What could poor skin turgor indicate?
Could be dehydration or maybe a chronic condition
Chemo patients often lose hair. What happens to their skin?
It becomes very sensitive, often tears/bleeds.
Why do we have a face?
To protect the brain.
What is ptosis?
Drooping of the eye lid
Ectropion vs entropion?
Ectropion = eversion, eye lid margin turned out
Entropion = inversion, lid margin turns inwards
What is horners syndrome?
When we paralyze a nerve supplying the eye causing miosis (pupil constriction) and a droopy eyelid (ptosis)
Snellen test? Random E test?
Snellen = this is the letter chart you use to assess vision
E = vision test, you use a capital E and rotate it and you have to visually identify it’s position
Webers vs Rinnes test?
Webers = Tuning fork on the head and feel for vibrations
Rinnes = Tuning fork outside the ear or placed on the post-auricular bone
What does cherry lips, bright red skin and bright red blood indicate? Treatment?
Treatment?
Carbon monoxide poisoning. Tx = cyanokit/oxygen
How to check biceps reflex?
Flex the elbow against resistance, bend arm at 90 degrees, strike the antecubital tendon and the arm should flex
How to check triceps reflex?
Flex the arm at the elbow, bring arm across the chest and strike the tendon behind the elbow, arm should extend
How to check patellar reflex?
tap patellar tendon just below patella, make sure patient is sitting with leg hanging freely
How to check plantar relfex?
lie supine, feet relaxed and stroke from the heel to soft ball of foot, curving across ball of foot toward big toe, the toes should flex
How to check gluteal reflex?
Side lying, spread the cheeks and stimulate the perineal area, sphincter should contract
Describe the romberg test
Checks proprioception, pt stands up, eyes closed, and see if they can maintain balance with arms out in front of them.
+ test = a proprioception issue
What CV issue might cause cyanosis or pallor?
MI
What CV issue might cause fatigue/syncope?
Decreased CO
If someone has a hernia that is gastric related, how do we treat their NPO status?
As if they have a full stomach
What kind of things do we assess in the GI system?
- Size
- Shape
- Distention
- Scars
- Stool frequency/character
- Last BM
- Ostomy?
- Sounds
What kinds of things do we assess in the GU system?
- Urinary complains
- Discharge
- Anuria
- Hematuria
- Dysuria
- Incontinence
- Retention
- Last voided?
- Catheter present?
What specific male GU assessments are done?
- Opening of penis location?
- Discharge? If so, describe
What might we need to be careful in patients with prostate cancer?
Possible metastatic cancer. Many times these patients are older with comorbidities, possibly coagulopathic.
What specific female GU assessments are done?
- Last known period
- Discharge? If so, describe
What consideration must be made in regard to urology cases?
Urine output may not be able to be adequately measured.
What things can be assessed musculoskeletal wise?
- Range of motion
- Weakness
- Paralysis
- Contractures
- Joint swelling
- Pain
- Strength
Why does wrist extension/flexion matter?
Can indicate C spine injury with ascending paralysis if not normal. Get a baseline.
Have feeling here post spinal? Maybe not adequate coverage.
What medication is often given that impacts deep tendon reflexes?
Magnesium sulfate.
Is shoulder movement independent from elbow movement nerve wise?
Yes
Can nerve block one or the other without impact to each other
What might shoulder abduction/adduction issues indicate?
Brachial plexus injuries
Assess baseline function
What might impact dorsiflexion/plantar flexion?
CVA, spinal injuries
What is lordosis?
Increased lumbar curvature
What is scoliosis?
Lateral spinal curvature
What is kyphosis?
Exaggeration of posterior curvature of thoracic spine
Worry about airway here
In people with spinal curvature abnormalities, what consideration should we have in regard to the OR?
May need extra padding in certain areas to make sure there are no pressure injuries.
What might we assess in a neurological examination?
- Orientation to place, person, or time
- LOC: are they confused, alert, restless, lethargic, or comatose?
- Coordination to walk
- Equilibrium test
- Sensation test
When might the pronator drift test be used? What is it?
Stroke evaluation: if positive, indicates large occlusion, could be candidate for thrombectomy
Hold bold arms up for 10 seconds, palm up. If one drifts, test is positive.
How might a vision test be done?
Finger to each corner of vision, side to side, up and down. Is there any double vision or issues seeing?
How might someone test for aphasia?
- Ask what two random objects are.
- Ask the patient to say a phrase, such as “today is a sunny day.”
- Ask the patient to open their fist and close it.
Positive result if the patient is unable to do one of the tasks
How does one test for neglect?
Have the patient close their eyes. Touch them on the left, right, or both arms and ask where they are being touched. If they are not correct, they have a positive test.
Also, have the patient look at you. If they actually look at you, it is negative. If they look at you with peripheral vision, it is positive.
What might be a differential diagnosis to CVA in a postoperative patient (or really any patient)?
Hypoglycemia
How is the Achilles reflex performed? What consideration must be made?
- Have patient sit with their legs hanging freely off the bed, similar to patellar reflex position.
- Slightly dorsiflex patients ankle by grasping toes in palm of your hand.
- Strike achilles tendon just above the heel at ankle malleolus.
- This should result in planter flexion of the foot.
Consideration: Commonly missed injury. Palpate first to ensure it is intact, then strike it. If struck and not intact, it can be very painful.
What assessment might be made with the eyes?
- External eye structure
- Position and alignment
- Exophthalmoses
- Strabismus
- Eye brows
- Eye lid
- Eye lashes
- Eye balls
- Conjunctiva and sclera
- Cornea/iris
- Arcus senilis
- PERRLA
Funny looking kids are often hard to intubate. Before judging, what should you do?
Make sure their parents aren’t funny looking too - maybe that’s just how they are
What pupillary reactions might be seen in Stage 2 of anesthesia?
- Presence of roving eye ball (maximum movement of eye).
- Pupil is partially dilated.
- Loss of eyelash reflex -> 1st reflex to be lost.
- No loss of eyelid reflex.
What is Arcus seniles?
Depositing of phospholipid/ cholesterol in the peripheral cornea in patients over the age of 60.
Appears hazy white, grey, or blue opaque ring (peripheral corneal opacity).
Arcusis common and benign when it is in elderly patients.
How do anesthesia providers cause constricted pupils? How do we fix it?
Opioids
Narcan
Instead of the Suellen test or random E test, what can you do?
Have the patient focus on and count your fingers - this can tell you a lot
Why do extraoccular movements matter?
- Can be a nerve impacted by regional anesthesia or injury.
- An orbital fracture with nerve or muscle entrapment is an emergency vs a delayed procedure.
Assess prior to procedure to avoid being sued.. sometimes the ophthalmologist have not seen these patients yet
What is the most common cause of peripheral vision loss?
Glaucoma (damages optic nerve)
What are basic causes of peripheral vision loss?
- Glaucoma
- Retinitis pigments
- Eye strokes
- Detached retina
- CVA
- Optic neuritis
- Compressed optic nerve (papilledema)
- Concussions
What drug class impact glaucoma (increases IOP)
Sux/Anticholinergics
What might we assess in the ears?
- Structure
- Symmetry
- Obstruction
- Position and alignment
- Size
- Shape
- Discharge
- Inflammation
- Hearing aids
- Internal ear structure with use of otoscope
- Hearing acuity
- Auricles
What might we assess in the mouth, pharynx, and neck?
- Lips
- Buccal Mucosa
- Gums/teeth
- Tongue
- Floor of mouth
- Pharynx
What are the concerns with sinus issues?
- Barotrauma
- Air trapping
- Bleeding (especially with ETT placement in nose); pretreat with Afrin if able
In a patient with elevated ICP or sinus pressure, what gas shouldn’t be used? Why?
Nitrous oxide - can diffuse into cavities and increase pressure further potentially.
Why is assessment of mouth/pharynx/neck important?
Often times we may be the discoverer of some medical issue.
Important because it can result in high risk of airway issues.
In the mouth, where is a good place to visualize jaundice or pallor?
Buccal mucosa
If the lips have pallor, what medical condition might they have?
Anemia
If the lips are cyanotic, what medical issue(s) might they have?
Respiratory or CV problems
If the lips are cherry colored, what issue might they have?
Cyanide poisoning (and likely death shortly after)
What might cause a white tongue?
- Thrush
- Dehydration
- Poor hygiene
What might cause a red tongue?
- Vitamin (B12/iron) deficiency
What might cause a black tongue?
- ABX
- Vascular occlusion –> necrosis
- Untreated cancer
What might we assess with the nose?
- Shape
- Size
- Lesions
- Inflammation
- Deformity
- Edema
- Mucous color
- Patency of air
- Epistaxis
- Discharge
- Polyp’s
What is a common topical anesthetic/hemostatic used in ENT surgeries?
What is the consideration here physiologically?
4% cocaine; can have systemic effect
Is mucous color important?
Maybe if it’s bloody, but most of the time not really.. can be impacted by external factors.
How can you assess sinuses with a light?
Stick a flash light in the patients mouth, aim up, close their mouth, and the sinus should illuminate. Blockages/occlusions should be visible if someone is congested (abnormal).
What might we assess on the patients lips?
- Color (remove lipstick)
- Dryness
- Smoothness
What is an easy concern to fix with patients lips in surgery?
Dryness; add a little lacrilube to prevent dryness
What might we assess with patients teeth?
- Arrangement
- Dental hygiene
- Loose teeth (pull them?
- Color of teeth
- Halitosis
- Dentures (don’t choke)
Have a frank discussion with patient regarding possibility of needing to pull teeth out for safety.
Where should the upper molars rest in regard to the lower molar? How about the upper/lower incisors?
Upper molar should rest directly on the lower molar with upper incisors slightly overriding the lower incisors
What might we assess in a patients gums?
- Color
- Edema
- Gingivitis
- Ulcer
What are the characteristics of healthy gums?
Pink, smooth, moist
What is the cause of spongy gums? What is the physiologic characteristic?
Vitamin C deficiency
Bleeds easily
What is leukoplakia?
Thick white patches on gums because of smoking/alcohol.
How is the pharynx assessed, and what are the components?
- Extend his neck slightly, open the mouth widely and say “ah‟.
- Place tongue depressor on the middle third of tongue.
- Use penlight for inspection.
Inspect for edema, ulcer, inflammation, lesions. - Assess gag reflex
- Assess dysphagia
How is the neck assessed?
- Anatomical position?
- Function of sternocleidomastoid muscle: ask the patient to flex the neck with the chin to the chest.
- Function of the trapezius muscles: movement of the head sideway so that the ear moves toward the shoulder.
- Neck should move freely without any pain.
How is the thyroid gland assessed, and where is it?
The thyroid is in the anterior lower neck, in front of the neck and both sides of trachea.
-Inspect for visible mass of thyroid gland, symmetry and fullness at the base of neck.
-Give water then see for bulging of the gland.
- Flex the neck forward and laterally toward the side being examined.
-Have the patient hold a cup of water and take a sip to swallow.
- Anterior assessment: using the pads of the index and middle finger, palpate the left lobe with the right hand and right lobe with left hand.
- Posterior assessment: Both hands are kept around the neck with two finger of each hand on the side of trachea.
What do we assess in the breast (female)?
- Symmetry
- Pain
- Lump
- Discharge
- Swelling
- Trauma
- Hx breast disease?
- Surgical Hx?
What do we assess in the breast (male)?
- Lump
- Swelling
- Gynecomastia
What do we assess in the thorax/lung?
- Thorax size
- Thorax shape
- Chest movement
- Respiratory rate
- Rhythm
- Breathing pattern
- Breath sounds
- Chest pain with breathing
- Cough
- Productive or nonproductive cough
- Hemoptysis
What is pectus escavatum?
AKA pigeon chest, the chest pushes on the heart.. can result in CV compromise, sometimes surgery is needed.
You are assessing someone’s thorax/lung, and they say it is painful all of the time no matter what they do. What might you consider?
MI/chest pain
You are assessing someone’s thorax/lung, and they say that it is painful only when they move. What might it be?
Musculoskeletal pain
