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AP 1 > Test 2: Orthopedics (pt 4/4) > Flashcards

Test 2: Orthopedics (pt 4/4) Flashcards

1
Q

How do you intubate a patient that is going to be in the prone position?

A

Patient is anesthetized on the gurney and then log-rolled onto the bed, frame, or rolls with good body alignment maintained.

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2
Q

What are indications for prone position in surgery?

A

Posterior fossa, spine, buttocks/rectum, and orthopedic surgeries

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3
Q

How should you place monitors for prone patient?

A

Thoughtful planning of monitor placement allows turning without removal of monitors during this critical period and avoids delays.

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4
Q

What do you do to avoid accidental extubation when proning?

A

Typically, the patient is disconnected from the breathing circuit to avoid accidental extubation. The anesthetist should control the airway, head, and neck, as well as coordinate the turn.

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5
Q

CO and BP are ______ in the sitting, prone, and flexed lateral positions.

A

Decreased; the lower extremities are dependent

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6
Q

Hemodynamics can be maintained with prone if ?

A

The legs are in plane with the torso. If legs are moved up/down, or table is tilted, then venous return is altered?

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7
Q

What is your concern with the abdomen in prone positioning?

A

Abdomen must be free hanging and able to move with ventilation.
-External pressure on abd can elevate both intraabdominal and intrathoracic pressure
-Inc abdominal pressure increases venous pressure in abdominal and spinal vessels, causing IVC compression and dec CO

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8
Q

What are pulmonary implications with prone?

A

-Decreased FRC and TLC
-Accidental extubation or ETT migration
-Can improve pulmonary function with proper positioning of bolsters, Wilson Frame, or Jackson table to minimize abdominal compression
-Increased PIP, Decreased FRC & compliance
-Consider PC with low Vt and higher RR to maintain normal EtCO2 and PIP.

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9
Q

What does increased abdominal pressure do to the pulmonary system?

A

Cephalad displacement of diaphragm = increased PIP, decreased FRC & lung compliance

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10
Q

How do you ventilate a prone patient with increased PIP?

A

May consider PC ventilation with low Vt and higher RR to maintain normal EtCO2 and PIPs.

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11
Q

What are the advantages to the Wilson Frame?

A

-Can be used in place of bolsters to allow for hanging abdomen, breasts, and genitalia
-Allows for the natural curvature of the spine for spine fixation, disc removal, and replacement

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12
Q

Describe the Rotisserie Table

A

-Pt is supine
-Vent circuit, IV tubing, and monitors (except Pulse Ox) are removed to allow for a 180 deg turn
-Allows for A/P spine surgery using same OR table
-MUST ENSURE TOP OF SANDWICH IS VERY SECURE!!!!
-Entire frame turns 180 degrees

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13
Q

A rare but devastating complication of nonophthalmic surgery. It may occur in one or both eyes and refers to a variety of visual defects ranging from decreased visual acuity to total blindness.

A

Postop Vision Loss (POVL)

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14
Q

Accounts for 89% of POVL after prone spinal procedures.

A

Ischemic Optic Neuropathy (ION)
-Optic nerve is susceptible to hypoperfusion

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15
Q

What causes Central Retinal Artery Occlusion?

A

Decreased blood supply to the entire retina as a result of improper head positioning.

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16
Q

Which patients are at high risk of developing POVL?

A

-Lengthy procedures in the prone or steep T burg
-Hypotension & blood loss during surgery

Risk factors:
-HTN, DM, Vascular, Obesity, and smoking

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17
Q

How often should you ensure that eyes, nose, and mouth are free from pressure?`

A

q 15-30 min

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18
Q

What is the anesthetic technique for orthopedic extremity surgery?

A

General, regional, or combo
-Pneumatic tourniquet is used.

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19
Q

What are the most commonly performed procedures on the foot/ankle?

A

-Surgical repair of ankle fx and fusion of the ankle joint.
-Achilles tendon
-Bunionectomy, hammertoe deformities, plantar fasciotomy

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20
Q

What are the most commonly performed procedures on the hand/forearm?

A

Usually precipitated by trauma resulting in fractures, or alleviating numbness associated with compression of nerves (CTS)

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21
Q

10,000 SCI/year in US
80% male with median age 25 years
MVAs, falls, assaults, diving, sports

A

SCI statistics

22
Q

Acute SCI outcomes are dependent on 3 factors:

A

1) The severity of the acute injury
2) The prevention of exacerbation of the injury during rescue, transport, and hospitalization
3) The avoidance of hypoxia and systemic hypotension, which can further compromise neural function.

23
Q

50% of all traumatic SCIs occur in what region?

A

Cervical region.
-Craniocervical junction is 33% = consists of the occiput and the first two cervical vertebrae.

24
Q

What is complete SCI?

A

Complete injuries represent an absence of motor, sensory, bowel, and bladder function below the level of injury. There is some preservation of neurologic function with incomplete injuries.

25
Q

What is an incomplete SCI?

A

Preservation of some neurological function

26
Q

Results in the partial or total loss of use of all four limbs and torso.

A

Tetraplegia (Quad)

27
Q

Cervical SCI is assumed in what situations?

A

any patient who has sustained trauma to the head or face, in any unconscious trauma patient, and in any patient who complains of pain before or after careful palpation of the cervical spine.

28
Q

What are the 6 Ps associated with SCI?

A

Paralysis
Pain
Position
Parasthesias
Ptosis
Priapism

29
Q

Spinal Immobilization should be completed before the patient is _____.

A

Moved

30
Q

How should the head be stabilized in SCI?

A

The head should be stabilized in neutral alignment with no extension, flexion, or rotation. Stabilization can be accomplished by placing a cervical collar on the patient, splinting, and/or sandbagging the head in neutral alignment. The patient should be placed on a long spinal back board before he or she is moved.

31
Q

What is the most common SCI site?

A

C7

32
Q

Radiologic eval of C-Spine must include?

A

All 7 vertebrae

33
Q

SCI above C3 usually leads to?

A

Apnea, rendered ventilator dependent (Diaphragm is C3-C5)

34
Q

Should you use Succ in SCI patients?

A

No, risk of exacerbation due to muscle fasciculations

35
Q

Intubation technique with SCI is dependent on?

A

Level of injury, level of cooperation, hemodynamic stability, and ability to protect airway

36
Q

Is Manual In line Stablization (MILS) recommended when intubating SCI?

A

Yes, despite the fact that it may lead to a less than optimal view, it is still recommended under ATLS Guidelines and the Eastern Association for Surgery in Trauma to minimize the risk of secondary cervical SCI.

37
Q

Early stabilization of a SCI is associated with?

A

Improved outcomes

38
Q

Maintain MAP of ____ for up to 7 days postinjury to optimize spinal cord perfusion

A

85-90 mmHg

39
Q

Which drugs are best for induction of SCI patients?

A

-Propofol: decreases CMRO2, CBF, and ICP (but have to be hemodynamically stable cause of hypotension)
-Ketamine: increases ICP, but helps avoid hypotension in hypovolemic pt

40
Q

Do you use N2O in SCI?

A

No - chance of head injury, lung insult, or bowel obstruction with trauma

41
Q

Can you give TXA to a SCI patient?

A

Yes

42
Q

What is the triad of spinal shock symptoms?

A

Hypotension, bradycardia, and hypothermia

Progressively intensified the more cephalad the SCI.

43
Q

Patients with SCIs at the ____ level or higher have severely impaired CNS function.

A

T6

44
Q

Why do SCI develop spinal shock?

A

Sympathetically mediated cardioaccelerator responses no longer oppose vagal innervation allowing the heart rate to slow dramatically. Loss of sympathetic tone allows vasodilation, pooling of the peripheral circulation, and decreased venous return to the heart. This situation results in a decreased cardiac output and hypotension. The SCI also interrupts sympathetic pathways from the hypothalamus (temperature control center) to peripheral blood vessels. The patient in spinal shock is unable to constrict vessels or shiver in order to produce heat or to dilate vessels to dissipate heat. The patient’s body temperature has a tendency to migrate toward the environmental level.

45
Q

How do you contrast spinal shock from hemorrhagic?

A

Patients in spinal shock are hypotensive and bradycardic with warm, pink extremities. In contrast, patients in hemorrhagic shock tend to be hypotensive and tachycardic with cold, clammy skin.

46
Q

What is tx of spinal shock?

A

-ABP monitoring
-IV access, consider CVP (avoid under and over hydration)
-Vasopressors
-ABG and labs

47
Q

The sudden activation of SNS response secondary to noxious stimuli (colorectal and bladder distention)

A

Autonomic Dysreflexia

48
Q

When can AD occur?

A

Several weeks to six months post SCI

49
Q

AD is found in patients who suffered an SCI above?

A

T6

50
Q

What are symptoms of AD?

A

It often presents with severe hypertension and other life threatening consequences including seizures, pulmonary edema, myocardial infarction, acute renal injury, and intracranial hemorrhage.

51
Q

Up to ____% of high para/quadreiplegics will experience AD following painful injury below level of spinal cord lesion

A

98%

52
Q

How do you manage AD?

A

-Find and correct noxious stimuli
-Bladder Cath, exclude UTI
-Rectal disimpaction
-Rapid reduction of BP (Nitrates, captopril, hydralazine, and labetalol)

AP 1 (32 decks)

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