TL block 7 Flashcards
1
Q
CAM-ICU questions
A
- acute change in mental status or fluctuating?
- pt inattentive or easily distracted?
- RASS other than zero?
- disorganized thinking?
2
Q
trigger point myofascial pain
A
-limited ROM
-muscle spasm upon palpation
-radiation of pain to somewhere else w/ palpation
-palpation can cause autonomic symp
3
Q
Concerns for ACLS in pregnant patients
A
if >20 weeks
-L displacement of uterus w/ compressions
-Same energy charge for defib
-delivery of fetus in 4 minutes if no ROSC
-if Mg running, stop and give calcium
-have LMAs available incase ETT is too difficult
4
Q
Common SE w/ interscalene blocks
A
-ipsilateral Hornor syndrome (stellate ganglion blocked) -> ptosis, miosis, anhidrosis
-ipsilateral phrenic n blocked
5
Q
Asthma DLCO
A
Increased
-inc lung volumes
6
Q
exercise DLCO
A
increase! b/c cardiac output is increased -> more flow through pulm vessels -> more Hg in lungs -> Inc DLCO
7
Q
L to R cardiac shunt DLCO
A
increased
-more blood going to lungs
8
Q
What determines DLCO?
A
-blood flow (cardiac output)
-Hg conc
-lung parychema (fibrosis)
9
Q
Zenker’s diverticulum
A
CI to TEE
10
Q
Absolute contraindications to TEE
A
-Zenker diverticulum
-Active GI bleed
-esophageal tumor
-recent esophageal surgery
-Mallory Weiss tear
-Scleroderma
-perforated esophagus
-esophageal rings/strictures/webs
-esophageal trauma
-recent variceal bleeding
-esophagectomy
11
Q
RF for MR following acute MI
A
-adv age
-inferior/posterior MI
-extending infarct
-hx of prior MI
-multiple vessel CAD
-recurrent ischemia
12
Q
Setting of power failure, what works and what doesn’t?
A
Works: O2 delivery, manual PPV, if vaporizers variable-bypass they will work
doesn’t: monitoring, all electrical, or if cassette vaporizers
13
Q
Anion Gap Equation
A
Na - (Cl + bicarb)
14
Q
Causes of non-anion gap metabolic acidosis
A
- Giving Cl -> excessive NS, TPN
- GI/renal losses of bicarb: renal tubular acidosis, acetazolamide, diarrhea, high ostomy output
- Dec acid secretion -> hyperaldo, renal tubular acidosis
15
Q
surgical blood loss replacement in neonates
A
1:1 colloid (blood, albumin)
1:1.5 isotonic crystalloid
16
Q
when to restart subq 5k BID heparin after catheter?
A
immediately
17
Q
how long to hold heparin 5k BID before catheter removal?
A
4-6 hours
18
Q
how long to restart heparin 5k BID after catheter removal?
A
immediately
19
Q
heparin 7.5k-10k BID how long to hold before epidural?
A
12 hours AND normal coag status
20
Q
heparin 7.5k-10k BID when to restart after neuraxial?
A
avoid if catheter in place
21
Q
heparin 7.5k-10k BID when to restart after catheter removal?
A
immediately
22
Q
Therapeutic subq heparin > 20k per day: when to hold before neuraxial?
A
24 hours AND normal coags
23
Q
Therapeutic subq heparin > 20k per day: when to restart once epidural placed?
A
avoid if catheter in place
24
Q
Therapeutic subq heparin > 20k per day: when to restart when catheter removed?
A
immediately
25
IV UFH: when to hold prior to neuraxial?
4-6 hours AND normal coags
26
IV UFH: when to restart once catheter in place?
1 hour
27
IV UFH: how long to hold before catheter removal?
4-6 hours AND normal coags
28
IV UFH: how long after catheter removal can we restart?
1 hour
29
LMWH ppx daily how long to hold before neuraxial?
12 hours
30
LMWH ppx daily how long to wait after catheter placed to restart?
12 hours
31
LMWH ppx daily how long to hold before catheter removal?
12 hours
32
LMWH ppx daily, how long to wait to restart after catheter removal?
4 hours
and NO no earlier than 12 hours after catheter placement
33
LMWH ppx BID dosing:how long to hold before neuraxial?
12 hours
34
LMWH ppx BID dosing: how long to wait to restart after catheter in place?
Avoid while catheter in place
35
LMWH ppx BID dosing: how long after catheter removed to wait until restarting?
4 hours AND no earlier than 12 hours after initial catheter placement
36
Therapeutic LMWH dosing: how long to hold before catheter placement?
24 hours
37
Therapeutic LMWH dosing: how long to wait to restart after catheter placed?
avoid if catheter in place
38
Therapeutic LMWH dosing: how long to wait to restart after catheter removed?
4 hours AND no earlier than 12 hours after intial placement
39
Complications of refeeding syndrome
-weakness (incl resp weakness)
-myocardial depression
-rhabdo
-hemolytic anemia
-arrhythmias
-neuro disturbances
-impaired O2 delivery
-immunosuppression
40
Situations that worsen refeeding syndrome:
-hyperventilation: low CO2 causes intracellular shift of phosphate
-inc renal elimination of phos: hyperPTH, loop diuretics
-dec phos absorption: Vit D def
41
Normotensive pt, most effective way to reduce inc ICP
propofol bolus
42
post-craniotomy 3d ago, now new surgery nitrous during case, post op not following commands or waking up, dx? next steps?
Dx: tension pneumocephalus
next step: CT scan
tx: neurosurg air loculi aspiration
43
if HIPPA breached, next steps?
Pt must be notified up to 60 days after date of discovery
44
if breach of pt information affected more than 500 individuals next steps:
-notify individuals
-US Dept of Health & Human services notified
-prominent media outlet in the sate or jurisdiction where breach happened
45
Allodynia
perception of ordinarily nonnoxious stimulus as painful
(touch of clothes as painful)
46
Anesthesia dolorosa
pain in an area that lacks sensation
(after trigeminal neurolytic block)
47
Difference between mixed venous O2 saturation and central venous O2 saturation
mixed venous: taken from pulm artery catheter
central venous: taken from central line
-central venous is 2-5% less than mixed venous b/c high extraction of head and upper extremities
48
Direct inhibitors of hypoxic pulmonary vasoconstriction
-hypocarbia
-infxn
-vasodilators (NG, nicaridipine, nitroprusside)
-metabolic alkalosis
-volatiles at greater than 1 MAC
49
Microcirculation and cardiogenic shock
-due to pump failure -> venous congestion
-to compensate we get arterial vasoconstriction
-b/w capillaries and organ interstitium -> favor of fluid movement into intersititum and then capillaries become leaky and also favor fluid movement into interstitium -> but reversible
50
LWhat is octreotide used for?
Acromegaly: suppresses GH
51
Where is lumbar sympathetic ganglia located?
L1-L5
52
What symp n block causes diarrhea?
Celiac plexus (T5-12)
-innervation to intraabd organs
53
Tetralogy of Fallot
-VSD
-overriding aorta
-RVOT obstruction
-Right ventricular hypertrophy
54
Tet spells steps!
tet spell: shifted to R->L shunting of blood
1st step: give O2 and bend legs, squat (inc SVR to promote BF to pulm, O2 pulm vasodilation)
2nd step: IVF and narcotic like morphine (inc preload, dec HR, dec PVR, dec RR)
3rd step: beta blocker (dec HR, improve preload, relax RVOT obstruction)
4th step: phenylephrine (inc SVR, promote blood flow)
5th: ECMO, emergency surgical repair
55
treatment if pt w/ tetralogy of fallot starts to experience heart failure
digoxin and loop diuretics
-goal to maintain SVR
56
Def of wide complex QRS
>0.09 seconds
57
energy for synchronized cardioversion in peds
0.5-1 J/kg
58
unstable wide complex tachycardia
synchronized cardioversion
59
sinus tachycardia v SVT in peds
sinus: p waves
-HR < 220 for infants
-<180 for children
-<150 for adults
SVT: no p waves
HR >220 infants, >180 peds
60
posterior fossa surgery, acute HTN and bradycardia w/ retraction why?
Brainstem compression -> cushings triad
61
Once pt gets diabetic neuropathy, what's next?
depression of reflexes -> motor weakness
-autonomic neuropathy -> sluggish pupillary light reflexes, gustatory hidrosis (lots of sweating at head and upper torso after meals)
-resting tachycardia
62
superior laryngeal nerve
innervated cricothyroid muscle (VC adductor)
-so if RLN damage -> VC adduction
63
Meds to avoid w/ myotonic dystrophy
-neostigmine
-succinylcholine
-K containing solutions
**shivering will also cause myotonias!
64
Lab findings primary hyperparathyroidism
-hyperCa
-hypoPhos
-non AG metabolic acidosis (dec bicarb reabsorption)
-normal to high 24hr urinary calcium
65
post parathyroidectomy, weak voice mild neck discomfort in PACU, next morning voice sounds different and weakens after speaking for a long time
superior laryngeal n injury
66
Most common n injured in parathyroid/thyroidectomy
superior laryngeal n
67
SIADH dx criteria
hypoNa w/ urine Na > 20
-inc urine osm while dec serum osm
-euvolemic/hypervolemia
68
How to tell SIADH apart from cerebral salt wasting
volume status!
SIADH: euvolemic
cerebral salt wasting: hypovolemic
69
Diabetes insipidus labs
-either ADH not produced or kidneys not responsive
-hyperNa (>145), hyperosm blood, (>305) urine low sodium, urine low osm (<300)
-usually euvolemic, can easily become hypovolemic
70
normal urine osmolality
500-850
71
normal urine specific gravity
1.005-1.030
72
infant blood transfusion, when to start?
Hct <20 if hemostasis achieved
Hct < 25 if additional bleeding still expected
-initial volume of 10-15 cc/kg
73
maximum allowable blood loss eq
MABL = est blood volume * ([starting Hct - target Hct] / starting Hct)
74
how much does 1u PRBCs raise Hg or Hct in adults?
Hg inc 1
Hct inc 2-3%
75
Peds 10-15 cc/kg pRBC raise hg or hct in adults?
hg inc 1
Hct inc 2-3%
76
How to tell MH apart from thyroid storm
Hypercapnia
inc CK
lactic acidosis
77
Thyroid storm treatment
propthiouracil and supportive
78
lab values in Addison's dx
primary adrenal insuff
-hypoNa, hyperK, metabolic acidosis, hyperCl, hypoglycemia, hyperCa
(hypercalcemia due to dec in GFR 2/2 hypovolemia with an increase in Ca release from the bone)
79
Prazosin MOA
selective alpha 1 blocker
80
why inc HR w/ phenoxybenzamine
non-selective alpha blockade -> loss of alpha 2 presynaptic inhibition of norepinephrine release
81
if pt has a tracheoesophageal fistula, what other anomaly is most likely in this child?
congenital heart defects
82
Which electrolyte is inc w/ TPN?
calcium
83
Pierre Robin
cleft palate
micrognathia
glossoptosis
congenital heart disease
84
Treacher Collins syndrome
micrognathia
aplastic zygomatic arches
microstoma
choanal atresia
congenital heart dx
-treacher like teacher, the movie with the congenital kiddo -> micgronathia, ears, no arches
85
Goldenhar syndrome
-unilateral facial hypoplasia
congenital heart dx
eye,ear, and vertebral anomalies on affected side
86
Hunter or Hurler Syndrome
-mucopolysaccharidoses
-upper airway obstruction
-difficult intubation 2/2 infiltration of lymphoid tissues
-macroglossia
-small mouth opening
-excessive thick secretions
87
congenital craniofascial synostosis, maxillary hypoplasia, beaked nose
Crouzon syndrome
88
hypoCa EKG
prolonged QT
89
ideal spinal level for a TURP
T10
90
Benefits of regional v GA for TURP
-better immediate resp if bladder rupture
-dec bleeding (dec CVP)
-dec DVT
**no change in cognitive fxn**
91
Primary hyperthyroid test results
-inc free T3, T4
-dec/normal TSH
-inc thyroid hormone binding ratio
92
ETT v LMA in setting of peds URI
ETT causes more stimulation to inflamed airways -> carries more pulm risks than LMA
93
Treatment for severe hyperCa or acute moderate hyperCa
IVF!
-calcitonin (ca excretion too) to dec bone reabsorption, osteoclas inh (onset 4-6 hours) -> can lower 1-2 mg/dL -> tachyphylaxis only works first 48 hours
-bisphosphonates to dec bone reabsorption (takes 24-28 hours to work) -> ex: Zoledronic acid
94
Zoledronic acid
bisphosphonate that prevents bone reabsorption
-takes 24-72 hours to start working
95
RF for allergic contrast reaction
-allergic to other medications
-asthma
-hx of previous reaction to contrast
--> recommendation prednisone course beforehand
96
What inhibits nonshivering thermogenesis
BETA BLOCKERS
inhalational anesthestics
97
what triggers nonshivering thermogenesis
Norepinephrine
Thyroxine
Glucocorticoids
98
Present 4-12 hours after pituitary surgery, post op, polyuria, polydipsia
central diabetes insipidus
tx: exogenous ADH
99
peds XR retropharyngeal soft tissue widening
retropharyngeal abscess
100
Croup
101
Epiglottitis
102
retropharyngeal abscess
103
pretreatment for hyperK periodic paralysis
Acetazolamide, thiazides
-if severe: insulin and glucose
104
lid lag: hyper/hypothyroid?
hyperthyroid
105
number of beta adrenergic receptors inc: hyper/hypothyroid?
hyperthyroid -> why you get an overstimulation of sympathetic NS
106
onycholysis: hyper/hypothyroid?
hyperthyroid
nail separates from nail bed
107
delayed relaxation of deep tendon reflexes: hyper/hypothyroid?
hypothyroid
108
prior to robotic surgery, what testing does someone w/ polycystic kidney disease need?
CT angio of the head
-more likely to have berry aneurysms -> and steep positioning of robotic surgery inc ICP
109
hyperK EKG
peaked T waves, but also ST depressions
110
hypoNa severe EKG changes
widening of QRS, ST elevation
111
hypercalcemia EKG
prolonged PR, shortened ST and QT interval
112
hyperparathyroidism causes
113
early post HD period
-hypoK
-dry weight, euvolemic or hypovolemic
-can have inc PTT due to heparin used in HD
114
Lytes in chronic ESRD
HyperK
HyperMg
Hyperphos
HypoCa
Anemia
hyperlipidemia
HTN
2ndary hyperparathyroidism
115
CA 19-9 levels used to dx
pancreatic cancer
116
CEA levels used to dx
colon cancer
117
5-hydroxyindoleacetic acid in urine
Serotonin syndrome
118
Urine metanephrines
pheochromocytoma
119
Carcinoid syndrome triad
flushing
asthma
R sided heart disease
120
Right marginal artery supplies
Lateral RV and cardiac apex
121
Blood supply for anterolateral papillary muscles
LCx and LAD
122
Blood supply for posteromedial papillary muscle
RCA
123
Where do the intercostal nerve, artery, veins run?
inferior surface
124
Complications of intercostal n blocks
-PTX
-high systemic absorption of local anesthetics -> toxicity esp if multiple levels or catheters are used
125
McConell's sign
akinesis of the mid-free RV wall w/ preserved RV apical motion
-specific for PE
126
succ, cricoid pressure, LES tone
succ inc LES tone
cricoid pressure dec LES tone
127
contraindications to cricoid pressure
cervical spine fracture
laryngeal fracture
active vomiting
128
Sphenopalatine ganglion innervation
nasal cavity mucosa, hard palate, lacrimal gland
129
Infraorbital nerve innervates
lateral aspect of skin overlying the nose, cheek, and upper lip
(blocked for cleft lip)
130
zygomaticofacial nerve
innervation of the cheek
131
retrobulbar block -> severe left ocular pain, no increase in intraocular pressure
puncture of the posterior globe
132
closing of upper eyelid, proptosis, and increase in intraocular pressure
retrobulbar hemorhage
133
oculocardiac reflex, afferent, efferent
afferent: trigeminal nerve (V1)
efferent: vagus
134
bicarb + ropi/bupi=
precipitant formation
135
pH for local anesthetic
time of onset
136
what lumbar branches make up iliohypogastric?
T12-L1
137
what lumbar branches make up ilioinguinal?
L1
138
what lumbar branches make up genitofemoral?
L1, L2
139
what lumbar branches make up LFCN
L2, L3
140
what lumbar branches make up obturator n?
L2-L4
141
what lumbar branches make up femoral nerves?
L2-L4
142
what branches make up the sciatic nerve?
L4-S3
-spared w/ lumbar plexus block
143
current to get a stimulus which indicates intraneural?
< 0.3 mA
144
which color lead should be attached to needle?
black (cathode)
145
What type of stimulus is preferred to give for a nerve block?
Square wave stimulus
146
What stimulating current is ideal for nerve block?
0.4-0.5 mA
147
common peroneal n twitch
foot eversion
dorsiflexion
148
tibial n stimulation twich
foot inversion
plantarflexion
149
if trying to block tibial nerve, and semimembranosus twitch
redirect medially
BF: biceps femoris
G:gastrocnemius
SM: semimembranosus
ST: semitendinosus
150
if trying to block tibial nerve and biceps femoris twiches
redirect medially
BF: biceps femoris
G:gastrocnemius
SM: semimembranosus
ST: semitendinosus
151
Which nerves affected by TAP block?
intercostal
subcostal
ilioinguinal
iliohypogastric
152
structures?
153
resurge of motor weakness 8 hours after termination of lumbar epidural, dx?
epidural hematoma -> get MRI
154
development of urinary incontinence and back pain days after epidural placement
epidural abscess -> cauda equina syndrome
**time frame -> DAYS
155
What upper extremity block has the highest rate of PTX?
Supraclavicular
156
Most common complication of supraclavicular n block?
phrenic nerve blockade
157
Meralgia paresthetica
entrapment of LFCN
-assoc w/ burning pain over the distribution
158
structures gone through for a spinal
skin
subcutaneous tissue
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
dura mater
159
When is a cervical plexus block used?
Surgeries in C2-C4 distribution
-LN dissection/ CEA
160
Complications/side effects of deep cervical plexus block
-blockage of phrenic and superior laryngeal nerve
-spread of local anesthesia into epidural and subarachnoid spaces
-intravascular injxn
161
anatomic landmarks for deep cervical plexus block
posterior sternocleidomastoid
-transverse process of C6 (Chassaignac tubercle)
-mastoid process
162
what boarders musculocutaneous n at axillary n block location?
b/w biceps and coracobrachialis
163
when performing an interscalene n block, what n is transversed?
middle scalene
164
b/l RLN injury: partial vs complete
complete: VC both being inn a paramedian position causing aphonia and aspiration risk
partial: COMPLETE obstruction -> unopposed adduction of vocal cords
165
What can you add to peribulbar or retrobulbar blocks to reduce inc in orbital pressure from injected volume, enhanced quality of block, and dec change of injury to muscles?
hyaluronidase
166
ankle block: what nerve is posterior to the tip of the medial malleolus?
posterior tibial nerve
-motor and sensory innervation to the plantar aspect of the foot
167
RF for PDPH
age < 40
prior PDPH
BMI < 30
hx of air travel
muliple dural attempts
cutting needle (Quinke)
168
obturator block
between the adductor longus and brevis muscles
ALABAMa
superifical to deep
Adductor Longus
Adductor Brevis
Adductor Magnus
169
labor spinal/epidural, BP corrected and still nauseous, tx?
Atropine or Glyco! Glyco doesn't cross placenta
-unopposed parasymp -> inc in gut paristalsis -> nausea
170
Ankylosing spondylitis anesthesia concerns
-inc risk of epidural hematoma (multiple attempts, long-standing NSAID use affecting plts)
-difficult DL (dec ROM due to disc ossification) -> atlantoaxial instability
-difficult mask ventilation (TMJ hypomobility)
171
borders of the femoral triangle
medially: adductor longus
laterally: sartorius
superiorly: inguinal ligament
172
if unsure where tip of catheter is and getting fluid return, best test to distinguish b/w saline and CSF?
glucose test
-CSF has glucose, saline does not
-point of care test, quick
173
conc and volume for a bier block
40-50cc 0.5% lido
174
Why dec BP after spinal
sympatectomy -> venous vasodilation and dec preload
175
what cell type produces surface-active lipoprotein?
type II alveolar cells
176
What are type I alveolar cells?
Flattened, thin-walled squamous cells covering 80% of alveolar surface
177
type III alveolar cells
alveolar macrophages
178
Most common risks of TPN
-thrombophlebitis
-infxn (MC)
179
what ulcer ppx providers better protection against ventilator assoc PNA?
sucralfate
-b/c doesnt change pH of gastric fluid
180
MOA of carbon monoxide positioning
inhibition of mitochondrial cytochrome oxidase
181
EKG tricyclic antidepressant OD
prolonged QRS interval
182
Strong Ion Difference
SID = (Na + K + Ca + Mg) - (Cl + lactate)
-dec in SID = acidosis
-inc in SID = alkalosis
-if you dilute plasma -> decreases SID
183
normal strong ion difference
40-42
184
SID and pH
INC SID = INC in pH
185
screening test for C diff
nucleic amplification for glutamade dehydrogenase
186
confirmatory test for C diff
toxin enzyme immunoassay
187
first line treatment for CN toxicity
hydroxocobalamin
188
Parkland formula for burns
4 x kg x % burned (use whole number not decimal)
-1/2 should be the 1st 8 hours, and then remaining over the next 16 hours
189
EKG changes and phosphate
hyperphos: prolonged QT
190
When should TPN be started?
AT LEAST 7 days after ICU admission
191
Why do you get hypoPhos w/ TPN?
w/ glucose loading w/ TPN -> inc in intracellular movement of phosphate
192
Absolute contraindications to percutaneous tracheostomy
-infants
-insertion site infection
-severe/uncontrolled coagulopathy
-unstable cervical spine injury
193
Signs of propfol infusion syndrome
impaired free fatty acid utilization and impaired mitochondrial activity -> inadequate aerobic metabolism
-metabolic lactic acidosis
-cardiac failure
-renal failure
-rhabdo
-hyperK
-hyperTG
-hepatomegaly
-pancreatitis (inc TG)
194
Early onset ventilator assoc PNA (24-72 hrs)
MSSA
H influenza
Strep PNA
-Proteus, Klebsiella, Enterobacter
195
late onset vent assoc PNA
MRSA
Pseudomonas
Acinetobacter
196
Treatment for botulism
> 1: Equine-derived antitoxin
<1: human dervied immune globulin
197
How do neuraxial opioids work?
then work at the mu opioid receptors in the substantia gelatinosa spinal cord dorsal horn
-inhibit release of substance P and glutamate
-hyperpolarized postsynaptic nerve
198
frequency of blood moving towards u/s probe
higher than the frequency of the u/s probe
199
frequency of blood moving away from u/s probe
lower frequency than the u/s probe
200
pts at higher risk of jaundice w/ multiple pRBC transfusions
Gilbert Syndrome
201
When are phrenic nerve stimulators used?
cranial or cervical spinal cord injuries -> used to improve lung function and reduce atelectasis -> higher rates of weaning from ventilator support
202
side effects of phrenic nerve stimulators
-infxn
-dislodgement w/ neck movement
-paradoxical chest movement in peds (inc chest wall compliance)
-phrenic n injury
