Things to Know Flashcards
Which EKG Lead is best for monitoring ischemia
V5
Lead V5 alone will detect 75% of ischemic episodes in men 40 – 60 years of age, adding lead V4 increases this to 90%, and the combination of leads II, V4, and V5 add up to a 96% detection rate
Which EKG Lead is best for monitoring for arrhythmia
II
What is HELLP Syndrome
Hemolysis, Elevated Liver enzymes, Low Platelets
Signs & Symptoms
1) RUQ pain or epigastric pain
2) HTN
3) Headache
4) N/V
5) Proteinuria
Pre-Eclampsia Definition
Pre-Eclampsia Definition
Mild
1. Two readings of SBP > 140 or DBP > 90, ideally 2 measurements at least 4 hrs apart
2. Proteinuria – 24 hr urine level > 300 mg or urine protein/cr ratio of 0.3
3. > 20 weeks gestation
Severe Pre-Eclampsia (severe features)
- Sustained SBP > 160 or DBP > 110 (ideally 2 measurements 4 hrs apart)
- New renal insufficiency (Cr > 1.1 or doubling of Cr)
- New CNS disturbances i.e headache or vision changes
- Pulmonary edema
- Liver dysfunction (LFTs doubling)
- Epigastric or RUQ pain (distention of Glisson’s capsule)
- Thrombocytopenia < 100,000
Age of gestation to need Mg for neuroprotection
24-32 weeks
Steroids for fetal lung maturity
One course of antenatal corticosteroids should be administered to all patients who are between 24 and 34 weeks of gestation and at risk of delivery within 7 days
Affects of maternal magnesium
Seizure prophylaxis, decreased SVR, increased uteroplacental perfusion
Complications: muscle weakness, respiratory & CV depression
Neonatal resuscitation
MOM IS PRIMARY PATIENT MAKE SURE MOM IS BEING TAKEN CARE OF
1) Assess neonate for term, tone, breathing
2) Clear the airway
3) Warm, dry, stimulate
4) Supplemental oxygen as needed to maintain target SpO2
If following above HR was below 100 or remained apneic and gasping
5) Provide PPV starting with room air then titrating upwards
6) Place SpO2 on RUE, consider placing EKG
After 30 seconds if HR less than 60
7) Intubate
8) Begin chest compressions at 3:1 rate with breaths
9) Establish IV access - Umbilical vs. IO
10) Place EKG if not already placed
If after 60 seconds HR remains < 60 bpm
11) Administer 0.01-0.03 mg/kg epi
12) Give fluid or blood if hypovolemic
13) Eval for possible pneumothorax, hypoglycemia, magnesium toxicity
Neonatal target O2 Sat
1 min - 60-65%
2 min - 65-70%
etc up to 10 min 85-95%
Heparin dose for CBP
300 U/KG (about 21,000 units in a 70kg man)
SVR calculation
SVR = [(MAP - CVP)/CO]*80
MAP: Mean Arterial Pressure
CVP: Central Venous Pressure
CO: Cardiac Output
Normal 750-1200
PVR calculation
PVR = [PAP-PCWP/CO]*80
Normal 100-200
Treatment for uterine atony
Reduce inhalational agent first if GA
1) Oxytocin
2) Methergine (methylgonovine) 0.2 mg IM
3) Hemabate/Carboprost - 15-methyl-prostaglandin F2-alpha 250 mcg IM
3) Misoprostol (cytotec, prostaglandin E1 analogue), 400 mcg sublingual or 800 mcg-1000mcg per rectum
4) Dinoprostone (prostaglandin E2) - 20 mg vaginal or rectal
If none of the above working consider: Intra-uterine balloon B-lynch sutures Ligation of internal iliac, uterine and ovarian arteries Hysterectomy
Oxytocin, Methergine, Hemabate - how do they work and any contra-indications
All work by contracting myometrial smooth muscle by increasing intracellular calcium levels
Hemabate - associated with bronchospasm
Methergine - associated with HTN
Oxytocin - associated with hypotension
Rule of thumb for what PaO2 should be for a certain FiO2
FiO2 x4-5
Sevoflurane vs. Desflurane vaporizer type
Sevoflurane is a variable bypass vaporizer - variable amount of gas is directed into a vaporizing chamber
Des vaporizer electrically heats to create a vapor pressure of 2 atmospheres then pure des vapor is mixed with fresh gas
PSI of full O2 tank
~2000 psi in full tank, about 660 liters O2
Time remaining (hrs) = Pressure (PSIG) / [200 x flow rate (L/min)]
Sickle cell disease
Substitution of valine for glutamic acid in beta chains of hemoglobin leads to hemoglobin S (sub on chromosome 11)
Preoperative hematocrit of 30% for patients undergoing moderate and high risk surgeries
Treatment of sickle cell crisis: pain control, IV hydration, supplemental oxygen, maintaining hematocrit, treating infection, exchange transfusion to reduce fraction of Hfb S to less than 40%
Risk factors for aspiration
obesity delayed gastric emptying (pain, acute abdomen, cirrhosis, chronic alcohol use, autonomic neuropathy) pregnancy neurologic dysphagia bowel obstruction disruption of the GE junction extremes of age history of GERD
Effects of local anesthetics on the heart
Inhibition of voltage gated sodium channels
slowed cardiac conduction (increased PR interval, widened QRS), decreased rate of depolarization, reduction in cardiac-contractility, depressed spontaneous pacemaker activity in the sinus node
Signs of LAST
Initial signs and symptoms include agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, and dysarthria. Without adequate recognition and treatment, these signs as symptoms can progress to seizures, respiratory arrest, and/or coma as well as cardiac toxicity
Intra-lipid dose for LAST
20% lipid emulsion
1.5 ml/kg initial bolus (repeat in 5 mins if no effect)
Followed by 0.25 ml/kg/min for 30-60 mins
Dantrolene MOA and dose
binds to the ryanodine receptor, inhibiting calcium release from the sarcoplasmic reticulum (SR)
Loading dose 2.5 mg/kg, may repeat in 5-10 mins
(Limit 10 mg/kg)
maintain with 1 mg/kg q 4-6 hours at least for 24 hours after MH episode
ABG in malignant hyperthermia
ABG analysis will reveal a combined mixed resp and metabolic acidosis, along with associated hyperkalemia
Aortic stenosis categories by Valve area and gradient
Normal valve area 2.5-4.0
Mild valve area 1.5-2.0, valve gradient <25 mmHg
Moderate valve area 1.0-1.5, valve gradient 25-40 mm Hg
Severe valve area 0.7-1.0, valve gradient 40-50 mm Hg
Critical valve area <0.7, valve gradient > 50 mm Hg
6 indications for IE prophylaxis
1) Prior episode of IE
2) Cyanotic heart lesion unrepaired
3) Prosthetic cardiac valve or prosthetic material used for valve repair
4) Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or device
5) Cardiac transplant patients who develop cardiac valvulopathy
6) 6 month post-op period following repaired congenital heart defect using prosthetic material or device
SQH & Neuraxial
small dose for DVT prophylaxis - 4-6 hr delay before block placement or catheter removal if 5000U BID or TID, check platelets of > 4 days due to possibility of HIT, monitor aPTT
IV Heparin & Neuraxial
Delay 2-4 hrs after administration, do not give heparin until 1 hour after neuraxial
Complete heparinization (i.e. for cardiac surg) and neuraxial
Delay heparinization 60 mins following neuraxial
Removal delayed 2-4 hrs and until normal coags restored
Surgery delayed 12-24 hrs following traumatic needle placement
Monitor aPTT & ACT
LMWH & neuraxial
10-12 hrs after low dose and 24 hrs after high dose
Low dose is 30-40 U BID or Qday
High dose is 1 mg/kg BID or 1.5 mg/kg per day
Post-op:
For prophylaxis/low dose: catheter removed 10-12 hrs following last dose, subsequent dosing delayed 2 hrs after catheter removal
For therapeutic: lovenox delayed 24 hrs after surgery and catheter removed 2 hrs prior to administration
Warfarin & neuraxial
Delay neuraxial until INR normal, Coumadin should be d/cd 4-5 days and INR < 1.5
Monitor PT/INR
Clopidogrel & neuraxial
7 days
Ticlopidine & neuraxial
14 days
Prasugrel & neuraxial
7-10 days prior to placement, hold for 6 hrs after catheter removal or neuraxial instrumentation
Pradaxa (direct thrombin inhibitor) & neuraxial
5 days, contra-indicated with indwelling catheter
Fondaparinux & neuraxial
if 5-10 mg qday: delay 72 hrs
if < 2.5 mg qday: delay 48 hrs
Both contra-indicated with indwelling catheter
Apixaban/rivaroxaban & neuraxial
Delay 72 hrs, delay further dosing for 6 hrs following instrumentation or catheter removal
Direct factor Xa inhibitors
Cardioversion energy for afib
Monophasic: 200 J
Biphasic: 100-120 J
Addisonian crisis
Life threatening condition due to insufficient cortisol production
Fever, abdominal pain, dehydration, nausea/vomiting, hypoglycemia, acidosis, hyperkalemia, hyponatremia, AMS
Nitroglycerine vs. Nitroprusside vs. Nicardipine
Nitroglycerine: significant venodilation and some arterial vasodilation
Nicardipine: less venodilation, more likely to reduce afterload without affecting ventricular preload
Sodium Nitroprusside: direct acting vasodilator with more selectivity for veins than arteries but works on both (can cause cyanide toxicity)
Conditions not to give sux
MS Paralysis Burn victims Bedbound MH MD Stroke GBS
Risks of perioperative hyperglycemia
Infection/Impaired immune response, impaired wound healing, dehydration, electrolyte disturbances
What FVC predicts post-operative ventilatory support?
< 30-35%
Extubation Criteria
all muscle relaxants fully reversed
vital capacity > 10-15 ml /kg
tidal volume > 5-6 ml/kg
SpO2 > 90%/PaO2 > 60 on 40-50% FiO2 with < 5 cm PEEP
Protecting airway/responsive to simple commands
Arterial pH > 7.3
Other possible criteria
RSI < 100
NIF > -20-30
Cobb angle re: pulmonary dysfunction
< 10 normal surgery recommended if > 40-50 Often pulmonary dysfunction at > 60 > 70 pHTN w/ exercise > 110 pHTN at rest
Muscular Dystrophy & anesthesia
Caused by recessive X linked mutation
Duchenne muscular dystrophy (DMD) - complete loss of dystrophin
Becker Muscular Dystrophy (BMD) - partially functional dystrophin protein
May have increased susceptibility to MH but in any case are at risk for an MH like syndrome & hyperkalemia with sux –> non triggering anesthetic
Delayed gastric emptying, diminished laryngeal reflexes, macroglossia
Cardiac issues –> MVP, pHTN
Common paraneoplastic syndromes
Humoral Hypercalcemia - tumor release of PTHrp
SIADH - hyponatremia, decreased serum osm, euvolemia
Cushing’s syndrome - increased ACTH or CRH, hypokalemia, alkalosis, HTN, psychosis
Lambert Eaton Myasthenic Syndrome - most commonly associated w/ small cell
LEMS vs. MG
LEMS - antibodies to prejunctional voltage gated calcium channels, released ach release at the motor end plate, proximal weakness of the lower extremities, autonomic dysfunction, strength improves with repeated muscle activity
MG - antibodies to post-synaptic nicotinic acetylcholine receptors at the NMJ, strength improvs with rest, starts with bulbar involvement
Contra-indications to mediastinoscopy
- STRONG contraindication = previous mediastinoscopy
Relative contraindications include: severe tracheal deviation, cerebrovascular disease, severe cervical spine disease with limited neck extension, previous chest radiotherapy, thoracic aortic aneurysm
Signs and symptoms of SVC Syndrome
headache, facial neck and upper limb edema, chest pain, dysphagia, lightheadedness, orthopnea, hoarseness, nasal stuffiness, nausea, pleural effusions, papilledema, visual disturbances, mental confusion, facial cyanosis, cough, JVD
Monitoring during mediastinoscopy
Mandatory to have some monitoring of the right radial/RUE - can be aline, pulse ox or continuous palpation
Alternative labor pain control to epidural
lamaze, NSAIDs, IV narcotics, TENS, regional blocks: paracervical for stage 1 and pudendal for stage 2
Paracervical: high risk of fetal bradycardia & decreased uteroplacental perfusion
Dermatomes for pain of different stages of labor
First Stage
Sympathetic nerve fibers (going through the inferior hypogastric plexus on the way to the sympathetic chain) that originate from the T10-L1 segments of the spinal cord (referred to the back as well as abdominal wall).
Second Stage
Pain for the second stage is transmitted via the pudendal nerve (S2-4)
For csection need to cover up to T4
Stages of Labor
Stage I: A) Latent phase
Variable duration
Starts at onset of labor
Complete when the rate of cervical dilation increases (~ 3 cm)
B) Active phase (contractions every 2-3 mins, last 1 min, up to 70 mm Hg)
Normal active labor should progress 1 cm/hr
Most common measure of uterine activity is the Montevideo unit (avg intensity frequency per 10 minutes)
Stage II: interval between maximal dilation and delivery (20-120 mins)
Stage III: placental delivery (5-20 mins)
What is DIC
Pathological activation of the coagulation cascade causing wide spread small clots in blood vessle,s consuming coagulation factors and platelets
Leads to thrombocytopenia, hemolytic anemia, diffuse bleeding, thromboembolic phenomena
Lab findings of DIC
Increased PT & PTT Decreased fibrinogen < 100 mg/dL Thrombocytopenia Decreased AT3 Presence of fibrin degradation products and d-dimer
Treatment of DIC
Treat hypovolemia, low BP, hypoxemia and acidosis
Administer cryo (if fibrinogen < 50), FFP, platelets, PRBCs
Needle thoracostomy location vs. chest tube location
14g in the 2nd intercostal space mid clavicular line
CT: 4th or 5th intercostal space anterior to the mid axillary line
Accounting for difference between measured BP and circle of willis
subtract 0.77 mm Hg for every cm gradient
recommended CPP
at MAP 70-80
How to diagnose pheo
plasma free metanephrines plasma catecholamines plasma chromagranin A total urinary catecholamines urinary metanephrines urinary VMA (vanillylmandelic acid) Clonidine suppression test MRI, CT or scintigraphy
alpha blockade for pheo
Should be initiated 10-14 days prior to surgery
phenoxybenzamine
some say to to d/c 24-48 hrs before surgery to reduce risk of hypotension
why alpha blockade before beta blockade for pheo
blockade of vasodilitory B2-receptors results in unopposed vasoconstriction, hypertensive crisis and CHF
drugs to avoid in pheo
succinylcholine (abdominal fasciculations), histamine releasing drugs (morphine, atracurium), increased sympathetic activity such as atropine, pancuronium ketamine, ephedrine, halothane, droperidol, reglan, ephedrine
Treatment of HTN during pheo
nicardipine
sodium nitroprusside
short acting agents such as phentolamine, esmolol, dilt, mag
Hunt & Hess classification
used to grade the severity of non-traumatic SAH
0 = unruptured aneurysm
1 = asymptomatic with minimal headache
2 = moderate to severe headache, cranial palsy or no neuro deficit
3 = drowsy, confused or mild focal deficit
4 = stupor, hemiparesis, vegetative disturbances
5 = deep coma, moribund, decerebrate posture
How to provide neuroprotection during neuro cases (like aneurysm clipping)
Thiopental, propofol, barbiturates Higher MAP than normal Minimize occlusion time of clip Neuromonitoring (EEG & SSEP) Brain relaxation (CSF drainage, mannitol, hypocapnia) Mild hypothermia (32-34 degrees)
Hypothermia induced oxygen consumption reduction?
5-7% for every 1 degree C
Post-op complications from cerebral aneurysm
#1 = cerebral vasospasm hematoma, seizure, increased ICP, pneumocephalus, metabolic derangements
Normal PaO2 formula for age
102-(age/3)
Acid/Base Compensations
Acute respiratory acidosis = Hco3 up by 1/10 mm Hg
Chronic resp acidosis = hco3 up to 4/10 mm Hg
Acute rep alkalosis = Hco3 down by 2/10 mm Hg
Chronic resp alkalosis = Hco3 down by 4/10 mm Hg
Acute metabolic acidosis = PaCo2 down by 1.2x the decrease in hco3
Acute metabolic alkalosis = Paco2 up by 0.7x the increase in hco3
Which side DLT and what is standard sizing
LEFT is easier to place due to early right RUL take off
35 and 37 L for women
39 and 41 L for men
standard
Risks of TURP
hypothermia bladder perforation hemorrhage hemolysis fluid overload DIC septicemia hyponatremia hyperglycinemia (glycine solutions) hyperammonemia (glycine) hyperglycemia (sorbitol)
AHA/ACC guidelines for recent MI
If BMS –> wait 1 month
If DES –> wait 12 months ideally, 180 days at minimum, absolutely do not proceed with d/cing antiplatelet agents before 3 months
Elective surgery as long as MI occurred more than 4-6 weeks ago and no further myocardium at risk
14 days after balloon angioplasty
Drugs to avoid in pseudocholinesterase deficiency
succinylcholine, and mivacurium, as well as ester local anesthetics, including cocaine and procaine
Dibucaine number
The amount pseudocholinesterase is inhibited by dibucaine
80% is normal
40-60% is heterozygous
20-40% is homozygous (1/2500-3000)
Causes of postop visual disturbances
Corneal abrasion
Acute glaucoma - severe and diffuse periorbital pain, dry pale eye, dilated pupil
Glycine toxicity - serum glycine > 17 mg/L, dilated/nonreactive pupils, normal IOP, fundus exam & eye movement
Cortical blindness - normal pupillary response
Hemorrhagic Retinopathy - vision spots/floaters, unilateral or bilateral, blurry vision, retinal edema
Retinal Ischemia - branch and central retinal artery occlusion, initially normal optic disc then becomes pale and edematous, painless
CRAO: cherry red macula, absent light reflex
Branch RAO: normal light reflex
Ischemic optic neuropathy - painless visual loss, absent light reflex, visual field deficits or complete vision loss
AION: optic disc edema and/or hemorrhage
PION: optic disc appears normal initially
How to perform awake fiberoptic intubation
Topicalized or nebulized 1-2% lidocaine (glossopharyngeal)
Superior Laryngeal nerve block: 2 ml of 2% lidocaine anterior to the cornu of the hyoid on each side
Transtracheal recurrent laryngeal nerve block
Airway Innervation
SENSORY:
-Maxillary branch of the trigeminal nerve –> supplies sensory innervations to the nasopharynx
-Glossopharyngeal nerve –> sensory of the posterior 1/3rd of the tongue, pharynx and areas above the epiglottis
Larynx from epiglottis to the cords –> Superior laryngeal nerve
Mucosa below the cords –> Recurrent Laryngeal Nerve
MOTOR
- The recurrent laryngeal nerves supply all of the intrinsic muscles of the larynx except for the cricothyroid muscle
- Cricothyroid muscle is innervated by the external branch of the superior laryngeal nerve.
Myasthenia Gravis
Autoimmune disorder, antibodies to the postsynaptic nicotinic acetylcholine receptor
With repeated stimulation, muscles fatigue
Associated with thymus hyperplasia, thymomas, other autoimmune disorders
Effectively fewer receptors, so resistant to sux, sensitive to nondepolarizers
Predictors of post-op ventilation in myasthenia gravis
1) Disease Duration > 6 years
2) Daily pyridostigmine dose > 750 mg
3) Concurrent respiratory disease such as COPD
4) Vital capacity < 40 mL/kg
Lambert-eaton syndrome
Autoantibodies to pre-synaptic calcium channels that prevents acetylcholine release
Strength improves with repeated stimulation
Usually proximal limb weakness
Sensitive to both depolarizing & nondepolarizing muscle relaxants
Often seen as a paraneoplastic syndrome
Cholinergic symptoms
DUMBBELLS
diarrhea, urination, miosis, bronchorrhea, bronchospasms, emesis, lacrimation, laxation, sweating
Cor pulmonale EKG signs
Right atrial hypertrophy: peaked P waves in II, III and avF
RVH: right axis deviation, partial or complete RBBB
Types of crisis in SCD Patient
Vaso-occlusive Aplastic Splenic sequestration Hemolytic Acute chest
Pre op hemoglobin goal for SCD patient
> 10, especially if hemodynamically unstable in any way
Prefer HbAA at least 50%
Contributing factors to myocardial ischemia
Inadequate oxygen supply to meet metabolic demands
Causes of decreased supply: tachycardia anemia hypoxia decreased coronary perfusion pressure (hypotension, vasospasm, coronary obstruction, severe AS, severe AR, elevated LVEDP)
Causes of increased demand: tachycardia increased wall tension contractility increased afterload (systemic hypertension)
Coronary perfusion pressure
Aortic diastolic pressure minus left ventricular end diastolic pressure
CPP = AoDBP-LVEDP
ACC/AHA BB Recommendations (2014)
Beta blockers should be continued in patients undergoing non-cardiac surgery who have been on the drugs chronically.
It may be reasonable to begin perioperative beta blockers for patients with intermediate or high risk myocardial ischemia, or for patients with three or more Revised Cardiac Risk Index risk factors such as heart failure, coronary artery disease, renal insufficiency, diabetes mellitus, or even cerebrovascular accident.
Initiation of therapy should be long enough in advance to assess the safety and tolerability of any beta blocker before surgery - at least one day but preferably 2-7 days
Do not initiate beta blocker on the day of surgery (class 3, harm)
Revised Cardiac Risk Index
1) Elevated-risk surgery - Intraperitoneal; intrathoracic; suprainguinal vascular
2) History of ischemic heart disease
3) History of congestive heart failure
4) History of cerebrovascular disease - prior TIA or stroke
5) Pre-operative treatment with insulin
6) Pre-operative creatinine >2 mg/dL / 176.8 µmol/L
Risk of major cardiac event* per score:
0 - 3.9% (2.8-5.4%)
1 - 6.0% (4.9-7.4%)
2 - 10.1% (8.1-12.6%)
≥3 - 15% (11.1-20.0%)
*Defined as death, myocardial infarction, or cardiac arrest at 30 days after noncardiac surgery (from Duceppe 2017).
Jet ventilation initial pressures for peds vs. adults
5-10 psi for kids
15-20 psi for adults
Jet ventilation complications
Not recommended for: decreased chest wall compliance 2/2 obesity, restrictive lung disease, gastric distention etc OR reduced exhalation (COPD, laryngospasm, glottic lesions, etc)
1) misalignment of the gas jet causing poor ventilation and gastric distention
2) transmission of blood, smoke, debris into the distal airways
3) excessive vocal cord vibration
4) barotrauma - pneumomediastrinum, subQ emphysema, pneumothorax
Steps for airway fire
1) Alert the OR
2) disconnect airway from oxygen supply/circuit
3) remove the ETT
4) Flood airway with saline
5) Once fire over ventilate with 100% O2
6) Perform DL/rigid bronch to asses for airway edema and remove debris
7) Re-intubate and delay extubation for 24 hrs
8) consider chest Xray, steroids, pulm consult, monitor closely
Toxic dose of lidocaine
With epi 7mg/kg
Without epi 5 mg/kg
Liposuction 55 mg/kg (w/ normal hepatic function and no inhibition of P-450)
Liposuction complications
Related to obesity but also, perioperative fluid overload, pulmonary edema, LAST, systemic epinephrine uptake, cardiac arrythmias, pulmonary embolism
Toxic doses of bupivacaine
2.5 mg/kg without epi
3 mg/kg with epi
Toxic dose of ropi
3 mg/kg
How to perform celiac plexus block
Patient in the supine position, place two needles about 5-7 lateral to the midline at the L1 level, advance needles under fluoroscopy until they are just anterior to L1 and after aspiration and confirming not intra-vascular inject local anesthetic for test block, if pain resolves then inject either alcohol or phenol
Complications of celiac plexus block
Most common: orthostatic hypotension
Most serious: paralysis due to spinal or epidural damage or damage to the artery of adamkiewicz
Others: diarrhea, RP hemorrhage, sexual dysfunction, pneumothorax, damage to the kidneys or pancreas
CRPS types
Type 1: RSD - minor injuries, burns, crush, surgery, etc
Type 2: Causalgia - known nerve injury
CRPS Diagnostic Crtieria
Budapest criteria
Must report at least one symptom in all four of the following categories:
1) sensory – reports of hyperaesthesia and/or allodynia
2) vasomotor – reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry
3) sudomotor/oedema – reports of oedema and/or sweating changes and/or sweating asymmetry
4) motor/trophic – reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin).
Must display at least one sign at time of evaluation in two or more of the following categories:
1) sensory – evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement)
2) vasomotor – evidence of temperature asymmetry (> 1 °C) and/or skin colour changes and/or asymmetry
3) sudomotor/oedema – evidence of oedema and/or sweating changes and/or sweating asymmetry
4) motor/trophic – evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
There is no other diagnosis that better explains the signs and symptoms.
Acute epiglottitis
Most common age 2-7
Caused by HiB most frequently
Sudden onset
Fever, drooling, stridor, respiratory distress
Inspiratory stridor indicating supraglottic obstruction
Thumbprint sign on xray
Signs of acromegaly
Skeletal and soft tissue overgrowth Large mandible, tongue, soft palate, epoglottis HTN Accelerated atherosclerosis Cardiomyopathy OSA, arthritis, insulin resistance Glottic stenosis RLN Palsy
Terbutaline
beta agonist
relaxes uterus and airways (can be used for asthma and premature labor)
can cause pulmonary edema
Locations and their local anesthetic systemic absoprtion
IV > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > sciatic/femoral > subQ
In time i can please everyone but sister sally
Factors that affect local anesthetic uptake
Location
Lipid solubility –> Higher lipid solubility decreases rate of systemic absorption
Protein binding –> higher protein binding decreases rate of systemic absorption
Use of Epi –> decreases systemic absorption
Congenital heart defects associated with cyanosis
Anything that causes right to left shunt
1 - Truncus arteriosis 2 - Transposition of the great vessels 3 - Tricuspid atreisa 4 - Tetrology of Fallot 5 - TAPVR
What is tetrology of fallot
Most common cyanotic congenital heart legion
4 defects
1) VSD
2) RVOT Obstruction
3) Overriding aorta
4) Right ventricular hypertrophy
Causes of tet spells
Crying, feeding, defecating, tachycardia, hypovolemia, increased myocardial contractility
sudden increase in PVR
dynamic outflow obstruction of the RV
decrease in SVR
Autonomic hyperreflexia
Intra-op HTN & bradycardia with painful stimulus below the level of the lesion, at risk with injuries T7 and above
Because of sympathetically mediate vasoconstriction below the lesion causing reflex vasodilation above the lesion
Above lesion: nasal stuffiness, headache, visual changes, dysrhythmias, nausea, confusion and difficulty breathing
Pre renal vs. renal lab differences
FeNA:
Pre-renal - 1% or less
Renal - > 2%
BUN:Cr
> 20 - prerenal
< 10-15 - renal
Urine osmolarity (mOsm/L)
> 500 in prerenal
< 400 in renal
Urine Na
< 20 mEq/L in prerenal
> 40 mEq/L in renal
Drugs for treatment of thyrotoxicosis
Methimazole - decrease thyroid hormone synthesis
PTU - decrease thyroid hormone synthesis
Iopanoic acid - reduce T3
Potassium iodide - blocks Thyroid hormone synthesis via Wolff-Chaikoff effect
Glucocorticoids - block peripheral conversion of T4 to T3
How to assess bilateral RLN injury
Have patient say “EE” they will be aphonic
Stridor after thyroidectomy?
Laryngeal nerve injury, laryngospasm, bronchospasm, tracheomalacia, hematoma formation, inadequate muscle relaxant reversal, residual anesthetic, hypocalcemia (though usually takes 24 hrs to develop after inadvertent Parathyroid removal)
Signs of functional carcinoid tumor
Flushing, diarrhea, bronchospasm, dramatic swings in BP, increased HR or palpitations, heart murmurs (tricuspid or pulmonary lesions), right heart failure
How to diagnose carcinoid tumor
urinary 5-HIAA
serum chromogranin A
Metabolic disturbance caused by octreotide
glucose intolerance
