Test 1: General Flashcards
of days beforehand to stop ASA preop
7
coumadins antidose
vit k (takes 1-2 days to reverse)
a faster antidote to coumadin than vitamin k
FFP
herbal medicines have what more common adverse affect….
make you bleed
which of of these is not a risk factor for surgical/anesthesia complication? copd, obesity, tobacco history, neuromuscular disease, coma, history of cancer, age
history of cancer
preop for pulmonary disease should include…
baseline arterial blood gas, oxygen saturation, and a pulmonary function tests
which of these is not a treatment for pulm patients preop? 1. nebulized SABAs 2. steroids 3. chest PT 4. incentive spirometry
incentive spirometry
in a pulmonary preop workup using PFTs, if the FCV/FEV1 ratio is less than 50% you should think what about their intra-op period?
this patient has a higher risk of surgical complications
T or F, diabetics in the OR are at increased risk for infection?
true
Gatroparesis can cause…
aspiration
who gets neurogenic bladder more commonly
diabetics
does hypothyroidism or hyperthyroidism put you at risk for a-fib intra op?
hyperthyroidism
in a trauma, a lab test that can tell what specific clotting factors are working is called…
Thromboelastography
Routine pre-op labs for bleeding include…
PT, PTT (not INR)
a paitient with a history of kidney problems present to you for pre-op evaluation, you notice a fistula in the patients arm, what should you do?
Renal specific: obtain baseline labs (electrolytes, BUN, Cr) and order nephro consult. Additional items: patient weight, CBC, coag profile, and U/A
at what age is an EKG and Xray mandatory preop?
50+
Low potassium and a low magnesium can cause what?
arrythmias
patients must be NPO _____ hours preop
8
Abx should be given _____ hours pre-incision
1
Call MD if Systolic blood pressure drops below…
90
Call MD if pulse is between ___&____
60, 110
Call if respiration’s exceed
30
Call if temp exceeds
101.5
Call if urine output is less than
250 ml per shift (or less than .5/kg/hr)
ADCVANDISAL stands for…
Admit, Diagnosis, Condition, Vitals, Allergies, Nursing, Diet, IV/I&O, Special orders (consults), Activity, Labs
acute abdomen accounts for what % of all ER visits
5%
Appys reveal themselves within ____ hours after onset of pain
24 hours
which of these is not a potential cause of extra-abdominal pain. 1) Diabetic Ketoacidosis 2) Systemic Lupus Erythmatosus 3) Sickle Cell Crisis 4) Divertiulitis 5) Herpes Zoster 6) Pneumonia 7) Myocardial Infarcation
Diverticulitis
flank echymosis d/t pancreatitis is called
Gray Turners sign
periumbilical echymosis d/t pancreatitis is called
Cullens Sign
Perforation of esophagus from vomiting is called
Boehave’s Syndrome (oh behave) LIFE THREATENING
preop imaging study to r/o abdominal perforation
plain film (abdominal xray)
dilated loops of small bowel d/t nearby inflammation such as pancreatitis or appendicitis are called
sentinel loops
best imaging study for intusucception
barium or air enema (diagnostic and therapeutic) (also good for to eval a volvulus or diverticulum)
currant jelly stools mean
intussuception
definitive test for acute choly
HIDA (MRI in pregnancy)
pain out of proportion to the exam
ischemic bowel. patient will likely have a vascular history.
tx for ischemic bowel
emergency laparotomy (correct the metabolic acidosis, check lactate hopefully < 2.)
how you best dx an ischemic bowel
angiogram
Whats it called when pain in the shoulder is referred from splenic rupture
Kehr’s sign
appendicitis, gradual or acute onset?
gradual
MCC of appy?
appendicolith
what kind of appy presents with dysuria and hematuria?
retrocecal appendix
gold standard modality for ruptured ectopic
TVUS
tx for diverticulitis
bowel rest, antibiotics flagyl, zosyn, and cipro.
most common site of divertic?
sigmoid colon
tx for diverticulitis abcess
Drain it in VIR
dilated loops of small bowel, and air fluid levels in a stepladder like fashion on xray?
SBO. MCC: adhesions.
what is the transitional point in an SBO
where we think the obstruction is
what scoring tool evaluates the extent of liver disease
Child Pugh Criteria
scoring tool that evaluates the mortality from pancreatitis
Ranson’s Criteria
Tx for acute pancreatitis
NPO, fluid resuscitation, TPN, and admit for obs
Charcot’s triad
Fever, Jaundice, Abdominal Pain (Hallmark of acute cholangitis)
What labs do you expect to see elevated in acute choly?
Bili, alk/phos, and white count.
You would admit for any 1 of what 4 symptoms of a choly?
Fever, intractible vomiting, jaundice, intractible pain (FIJI)
white blood cell casts in the urine
pyelonephritis
cervical motion and adnexal tenderness
salpingitis
abrupt colicky, intermittent sharp pain, unilateral, could be a growing pain, pallor, diaphoretic
Renal colic (calcium oxalate stone)
stones < 4mm will pass _______% of the time
90%
alpha blockers increase chance of passing stone ______% of the time
60%
most common ulcer
duodenal ulcer (relieved by food)
tx for perf’d ulcer
ELAP (exploratory laparotomy)
Describe each… ASA 1 ASA 2 ASA 3 ASA 4 ASA 5 ASA 6 E
ASA 1: normal healthy adult ASA 2: adult with mild diabetes ASA 3: adult with severe diabetes ASA 4: adult with severe diabetes constant in life ASA 5: dying patient who will not survive w/o surgery ASA 6: brain dead patient to be harvested E: emergent
what 2 drugs in combo have a higher chance of causing Malignant Hyperthermia (MH)?
Succinylcholine (paralytic) and Halothane (inhaled anesthetic). Tx with IV Datrolene
If a normal albumin is 4. And that patients shows an albumin of 3. You need to raise the patients Calcium by how much for each drop of 1 point value in albumin?
.8 (point 8) So if the patient had a Calcium of 8, they should now try to be at 8.8
we do the ____ minute scrub, with ___ strokes to each side
3 minute scrub, 8 strokes each side
how does the 4-2-1 rule work of maintenance fluid
for the first 10 kg, you give them 40ml/hr for the 2nd 10 kg, you give them another 20ml/hr everything above 20 kg, they get 1:1. so a 60 kg person, is 100ml/hr (or 1200 for the day)
how many ml’s of urine output should you expect post op minimum
.5 ml//kg/hr (minimum 30)
LV failure and pulmonary edema occur to what % of surgical patients under 40?
40%
peristalsis returns after how many hours after surgery?
24
abcess’ take ____ days to form
7
most common wound complication
hematoma
the five w’s of post op fever
wind (atelectasis) water (uti) walking (dvt/pe) wound (abcess) wonder drug (anesthesia)
What will cause the post-op fever on day…. 1-3 4-5 5-7
1-3: PNA, atelectasis 4-5: infection/dehiscence 5-7: leak, abcess, PNA (also check for thrombophlebitis)
most likely cause of fever 6 hours post op
atelectasis
fever of 104 post op think…
Malignant Hyperthermia, TRALI (transfusion rxn acute lung injury), xfusion rxn, nec fasciitis
_______ is the single most important indicator of critical illness
tachypnea (metabolic acidosis is also an important indicator but no the single most)
the most common vardiovascular disturbance in the seriously ill is______________?
hypotension d/t hypovolemia or sepsis
what is the most accurate measurement of organ perfusion?
Mean Arterial Pressure
what are the 4 determinants of cardiac output according to one of the earlier slides?
preload afterload contractilty heart rate
where should the tip of a central venous catheter rest?
In SVC just proximal to the Right atria (prevent ectopy)
shock is NOT associated with which sign… a. hypoperfusion b. altered mental status c. oliguria d. apnea d. acidosis
apnea
Right atrial pressure normally
2-8 mmHg
Right ventricular systolic pressure normally
20-30 mmHg
TRUE or FALSE, right ventricular pressure at diastole should be less than right atrial pressure?
true
Pulmonary arterial systolic and diastolic pressure should be between
20-30 systolic 5-15 diastolic
Normal cardiac output range (L/min)
4-6 liters per minute
SVo2 should be what range? (percentage of oxygen saturation in the pulmonary arterial blood)
65-75%
what regulates stroke volume? what regulates cardiac output?
stroke volume: preload, afterload, contractility (well its HR x SV = CO) Cardiac output: heart rate and rhythm
Decreased CO, INCREASED filling pressures, decreased contractility, decreased LV stroke work, and the body adjusts by increasing SVR. What kind of shock am I?
Cardiogenic shock
Decreased CO, DECREASED filling pressures, and the body compensates by increasing SVR, what kind of shock am I?
Hypovolemic shock
Normal CO, LOW SVR, and LOW/NORMAL filling pressures is what type of shock?
Distributive shock
The 4 types of distributive shock
Neurogenic, Adrenal, Sepsis, Anaphylaxis (NASA)
Which type of distributive shock shows increased CO, decreased SVR, hypotension, and a consumptions of clotting components d/t to hyperinflammation and hypercoagulation
septic shock (fill the tank before you give pressors)
Decreased CO, increased SVR, VARIABLE filling pressures depending on etiology. What shock am I?
Obstructive shock (cardiac tamponade, tension pneumothorax, massive PE)
When administering saline, with such a high chloride content you could cause….
hyperchloremic acidosis
MAP target
> 60
What dosage of dopamine has a mild inotrope and renal effect
2-3 mcg/kg/min
What dosage of dopamine has a inotropic effect only?
4-10 mcg/kg/min
What dosage of dopamine has a strong vasoconstrictive and chronotropic effect?
10+ mcg/kg/min
What drug would be best to DROP systemic vascular resistance to improve cardiac output and strengthen cardiac contractility at the same time? a. dopamine b. dobutamine c. epinephrine d. norepinephrine
b. Dobutamine (DO NOT give this if they are already hypotensive)
What is the best inotrope/vasopressor for someone in septic or hypovolemic shock without tachycardia? a. dopamine b. dobutamine c. epinephrine d. norepinephrine
d. Norepinephrine (,05mcg, and titrate to effect. its a potent pressor at higher doses)
What pressor has both alpha and beta actions for inotropic and vasopressor effecs, but might increase myocardial 02 consumption. a. dopamine b. dobutamine c. epinephrine d. norepinephrine
C. Epinephrine
Oliguria, a marker of hypoperfusion is defined as…
< .5 ml/kg/hr for more than 2 hours.
If you suspect oliguria, and want to know if its pre-renal, renal, or post-renal, what will a high BUN/Cr tell you?
Its pre-renal (same as with hypovolemia)
Nl pCo2: 40 Nl pH: 7.4 If pCo2 drops lets say 10 points (to 30), what do you expect the change in pH to be?
7.48 (an inverse relationship of .08 change in pH for every change of 10 in pCo2)
You evaluate a patients urine and find a BUN/Cr ration of 20:1, specific gravity of 1.020 (heavy), urine osmo of 500, and low urine sodium. What is the likely culprit of this person’s oliguria? a. Pre-renal b. Renal c. Post-renal
Pre-renal
T or F: in pediatrics, blood pressure is a sufficient way to measure organ perfusion.
False
First line treatment for peds renal insufficiency
Fluid bolus at 20 ml/kg to goal BP or a total of 60 ml/kg.
2nd treatment includes using a vasopressor. What is the best one for peds?
Epinephrine
What is a likely cause of obstructive shock in neonates?
Congenital obstructive left heart syndrome (hypoplastic, underdeveloped left ventricle)
T or F: serum levels of K+ accurately reflect actual levels?
false
3 treatments of hyperkalemia?
Insulin/glucose combo, SABA, Sodium bicarb
What electrolyte is administered in hyperkalemia to prevent cardiac toxicity?
Calcium gluconate
Which option is least appropriate for reducing serum K+ levels in the body. a. Diuretics b. Sodium Polystyrene Sulfonate c. Dialysis d. Inhaled Corticosteroids
d. Inhaled Corticosteroids (A SABA might do it, but not this one)
What do you do for hypOvolemic hypOnatremia
normal saline (and make sure to r/o adrenal insufficiency)
What do you do for hypERvolemic hypOnatremia
increase water loss (diuretic)
Which action is NOT appropriate to correct for EUvolemic hypOnatremia? a. Restrict water intake b. Increase water loss c. Give normal saline d. Give hypertonic saline e. Administer sodium gluconate
e. Administer sodium gluconate
What 2 things can happens if you correct sodium too fast?
Demyelinating syndromes, and cerebral edema
Seizures can occur in peds as a result of hypo or hypernatremia?
Hyponatremia
Hypocalcemia causes muscle… Hypercalcemia causes muscle…
tetany weakness
What drug is given to correct hypocalcemia?
Calcium gluconate
What two actions are best in correcting hypercalcemia?
Dilute with NS, and diurese with thiazides
A patient comes in to your office c/o non-specific abdominal pain, nausea, and vomiting for last 3 days. He states he feels lightheaded when he gets up too quickly, and has ongoing feelings of palpitations. You obtain labwork and notice a sodium of 82, potassium of 6.5, blood sugar of 73. What is the most likely diagnosis?
Acute Adrenal Insufficiency. (Correct any fluid loss, give glucose, give dexamethason or hydrocortisone, and refer for ACTH testing)
For hyperglycemic syndromes like DKA and HHNS, once your insulin drip gets them to 250 or so, coadminister ________ to avoid cerebral edema?
Glucose (Correct K+ and PO4 too)
An exaggerated manifestation of thyroidism is called thyroid storm. List 5 Specific drugs to help them…
Propylthiouracil or methimazone Propanolol K+ Dexamethason Sodium Ipodate
What is a manifestation of severe hypothyroidism which shows swelling of the face, and what do you do for them?
Myxedema coma Tx: Airway, fluids, glucose, warming (they are cold), hydrocortisone, and Levothyroxine
What 3 reasons do we give LR instead of NS intraop?
- LR is slighly more neutral than NS 2. LR includes K+ and Bicarb 3. LR has slighly less Na and Cl (preventing hyperchloremia)
What type of drain is a closed drain connected to a suction device? a. Blake and/or JP b. Davol c. Penrose
Blake and/or JP
What type of drain uses a sump with an airflow system to keep the lumen of the drain open when fluid isn’t passing through it? a. Blake/JP b. Davol c. Penrose
b. Davol
What type of drain is open passively? a. Blake/JP b. Davol c. Penrose
c. Penrose
What is the preferred local anesthetic for surgical incisions?
Marcaine (long-acting) (same as whats in the q-balls…intercostal nerve block)
A patient weighs 50 kilograms, what are their hourly maintenance fluid needs?
90 ml/hr (40 for 1st 10, 20 for 2nd 10, 30 for last 30) (40 + 20 + 30 = 90)
What is a collection of fluid under the skin that can cause a hematoma?
Seroma
“A hematoma is almost always cause by ___________”
“imperfect hemostasis”
Best method to reduce risk of atelectasis post-op
Incentive spirometry (ambulate also)
What is the most common bug implicated in Necrotizing Fasciitis?
GABHS (and strep pyogens)
Overall, the risk of anesthesia related deaths in health patients are estimated at 1:100k-200k. This is an example of. a. incidence b. prevalence
b. Prevalence (is this right?)
A helpful way of remembering the Glasgow coma score?
EVM 4-5-6 Eye (4 points) Voice (5 points) Movement (6 points) (the first and last are always normal and none, I focused on the buzzwords in the middle)
Eye (simplified) 4 of them
1 Normal 2 Loud voice 3 Pain 4 None
Voice (simplified) 5 of them
1 Normal 2 Confused, Disoriented 3 Inappropriate 4 Incomprehensible 5 None
Movement (simplified) 6 of them
1 Normal 2 Localizes 3 Withdrawls 4 Decorticate 5 Decerebrate 6 None
Which thyroid state (hypo/hyper) is associated with decreased metabolic clearance of drugs
Hypothyroid
In a pre-op patient whom you suspect has a coagulopathy? Which of these is LEAST important to know? a. Easy bruising b. Excessive bleeding after minor surgeries c. History of bleeding from a major laceration d. Family hx or bleeding e. History of liver disease f. Medications
c. History of bleeding from a major laceration
What % of patients are d/c’d from the ED with a dx of “nonspecific abdominal pain”?
34-56%
Diverticulitis….gradual or acute onset?
gradual (like an appy)
What 6 labs are appropriate for abdominal complaints?
CDC w/ diff Amylase HCG LFTs hCG U/A
Best imaging modality for renal calculi?
Non-con CT
What is the treatment for an acute bowel obstruction that isn’t a complete obstruction?
NG Decompression
What is the treatment for an acute and COMPLETE SBO?
Surgery
MCC of acute pancreatitis?
ETOH
Which of the following is NOT part of Ranson’s criteria? a. Age b. WBC c. Glucose d. Bun/Cr e. LDH f. ALT
d. Bun/Cr (WAAGL: wbc, age, alt, glucose, ldh)
malampati score
IV
(severe difficulty with intubation)
mallampati score
II
mallampati score
III
mallampati score
I
What is the highest risk this patient is at risk for with this kind of anesthesia?
Cardiac risk
(spinals, epidural, and peripheral nerve blocks)
(lasts 2 - 5 hours)
while closed suction is usually preferred (like witha JP or Blake), when would you need something like a Davol (sump drain)?
when the amount of drainage is large or when drainage is likely to plug other kinds of drains
(Davols can be flushed easily)
Which is not part of the child-pugh criteria for liver disease?
- Encephalopathy
- Albumin
- Asciites
- Lactate Dehydrogenase
- PTT
- Bilirubin
Lactate Dehydrogenase (LDH)
