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Truelearn Advanced Exam > TL block 8 > Flashcards

TL block 8 Flashcards

1
Q

4 S’s of distaster

A

-staff: make sure to have enough, can pull stuff into ICU areas w/ proper mentoring and guidance
-stuff: be okay w/ no help for 72 hours w/ equipment
-space: might have to expand ICU coverage into ED and PACU
-strategy: coordination of surrounding population, location of hospital system w/ asking for help at a state, federal level

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2
Q

CRPS I v II

A

I: no prior nerve injury
II: after nerve injury (extra I for injury)

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3
Q

pacemaker set up?
-electrocautery used and pt 3rd degree block when cautery active

A

DDD

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4
Q

difference b/w magnet with PM and AICD

A

-PM: puts it into asynchronous mode
-AICD: turns off defib, but PM still functional

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5
Q

How to avoid R on T phenomenon w/ PM

A

-ensure that the pacemaker rate is faster that the intrinsic heart rate

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6
Q

Contraindications to therapeutic hypothermia

A

-GCS > 8
-uncontrolled bleeding
-hemodynamically unstable rhythms
-hemorrhagic stroke

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7
Q

dehydration and jet ventilation

A

-long periods of jet ventilation dry out the respiratory mucosa -> impairs ciliary action -> inc mucous aggregation
-rarely can cause necrotizing tracheobronchitis

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8
Q

first step when discovering a bronchoplural fistula

A

lung isolation! to prevent infxn going to healthy lung
-double lumen tube or bronchial blocker

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9
Q

goal of hyperbaric oxygen

A

to increase the amount of O2 dissolved in the blood

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10
Q

cyanotic congenital heart disease and hyperbaric O2

A

not indicated

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11
Q

Indications for hyperbaric O2

A

-ischemia (skin flaps, retinal artery occlusions)
-treatment of C perfringens
-anemia that can’t be transfused
-pulmonary lavage due to alveolar protein buildup
-air embolism
-decompression sickness
-carbon monoxoide poisoning/cyanide
-intracranial abscesses
-burn injuries
-chronic osteomyelitis
-burns

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12
Q

Order of activation of heart w/ transcutaneous pacing

A

RV -> LV
-loss of atrial kick ( ~20% dec in cardiac output)
-similar to VOO

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13
Q

spread of local anesthetic intrathecal v epidural

A

intrathecal: baricity
epidural: volume

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14
Q

pKa and anesthetics

A

time of onset
-why sodium bicarb added to make it faster

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15
Q

protein binding and drugs

A

duration of action

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16
Q

Cryoanalgesia

A

-extreme cold burning of intercostal nerves for thoracotomy
-quick procedure ~30sec
-lasts 1-3 months -> assoc w/ neuropathic pain
-not enough for pain control -> need supplemental w/ thoracic epidurall/paraverteberal/opioids
-has been shown to decrease opioid use and improve pulm fxn

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17
Q

post exposure ppx for Hep B

A

Hep B hyperimmune globulin

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18
Q

When to decide to place a magnet for a surgery

A

-How PM dpt pt is -> if not using, not needed and asynchronous mode could be catastrophic
-location of surgery: if above umilicus need to consider, if below no need

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19
Q

pacemaker capture and elctrolytes

A

-PM capture is harder if pt is hypokalemic

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20
Q

Most sensitive test for MH?

A

Contracture test
(halothane or caffeine)

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21
Q

Multiple sclerosis anesthesia concerns

A

inc risk of respiratory complications due to resp muscles weakness -> impaired cough, diff vent weaning, inc risk of aspiration PNA

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22
Q

What % improvement in FEV1with bronchodilators would someone w/ obstructive dx need to have to be recommended chronic bronchodilator therapy?

A

> 10%

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23
Q

Equation for pressure gradient across aortic valve

A

P gradient = 4 * (peak velocity)^2

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24
Q

Triad of tamponade

A

far away heart sounds
JVD
hypoTN

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25
Q

Anesthesia considerations w/ cardiac tamponade

A

-Cardiac output dpt on preload, HR
-maintain HR and BP
-if fluid depleted, give fluids prior to induction
-best agents: ketamine (symp activation), and etomidate
-sympathetic surge after pericardiocentesis -> have NG available for then
-keep breathing spontaneously if possible -> minimize TV and PEEP (dec venous return w/ PPV)

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26
Q

Pulsus paradoxus

A

w/ tamponade
-dec in systolic BP by 10 w/ inspiration
-inc venous return due to neg intrathroacic Pressure w/ inspiration -> bulging of RV into LV -> limited forward flow out of LV -> dec BP

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27
Q

dx of pulm HTN

A

pulm artery systolic pressure > 35
-mean pulm artery pressure > 25 at rest
-mean pulm artery pressure > 30 w/ exercise

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28
Q

Goals for anesthesia w/ pulm HTN

A

AVOID: hypoxia, hypercapnia, acidosis, inc sympathetic tone
-minimal TV and minimal PEEP
-euvolemia

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29
Q

Considerations for transplanted heart

A

-dennervated -> no parasympathetic input
-resting HR Is 90-110 w/ little variability
-HR dependent on DONOR atrium -> not connected w/ recipient atrium
-no response to anticholinergics, only respond to direct acting receptors
-Frank-starling curve remains intact

**preload dependent!!

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30
Q

Dichrotic notch on aline

A

aortic valve closure

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31
Q

aortic a line v peripheral a line MAP?

A

lower in peripheral

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32
Q

area under the waveform tracing: aorta a line v peripheral a line

A

higher area under the waveform in aorta

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33
Q

What is myelomeninogcele commonly assoc w/?

A

Hydrocephalus (Chiari II malformation: brain herniates through foramen magnum blocking 4th ventrile)

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34
Q

Indications for cardiac resynchronization therapy

A
  1. EF < 35%
  2. Intraventricular conduction delay > 120 msec
  3. HF symptoms
  4. sinus rhythm

ALL must be met

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35
Q

tricuspid annular plane systolic excursion

A

measure of R ventricular function
1.1 cm: moderately depressed

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36
Q

Carbamazepine toxicity

A

-cardiac: widening of QRS, prolonged QT, tachycardia, hypoTN
-neuro: AMS, delirium, paradoxical dec in sz threshold, nystagmus
-anticholinergic: mydriasis, hyperthermia, urinary retention, dry mouth

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37
Q

Best way to augment cardiac output in pt w/ aortic stenosis, preserved EF, and new onset a fib

A

conversion to NSR!
-loses 20-30% of CO w/ a fib

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38
Q

how to tell apart central sleep apnea from OSA

A

CSA: no respiratory effort during apneic episodes, OSA: always has respiratory effort w/ apneic episodes
-CSA more assoc w/ stroke, opioid use d/o
-snoring more assoc w/ OSA

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39
Q

Treatment for central sleep apnea

A

CPAP
-resp stimulants: theophylline and acetazolamide

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40
Q

what is a hypoglossal n stimulator used for?

A

treatment for OSA

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41
Q

compared to aortic a line, a peripheral a line will have:

A
  1. higher systolic pressure
  2. lower diastolic pressure
  3. inc pulse pressure
  4. delayed and slurred dichrotic notch
  5. more pronounced diastolic wave
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42
Q

Anesthesia concerns for rheumatoid arthritis

A

airway: TMJ hypomobility, atlantoaxial subluxation
pulm: fibrosis, restrictive dx due to arthritis in costochondral
cardiac: pericarditis, tamponade
renal: chronic NSAIDs -> insuff

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43
Q

physiologic changes w/ ECT

A

-inc inn CMR -> inc in CBF -> inc in ICP
-bradycardia -> tachycardia and HTN
-short term memory loss

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44
Q

best lab for detection of intraop MI

A

troponin

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45
Q

Factors predicting high success w/ epidural steroid injxns

A

-shorter symptom duration
-no psychopathology
-assoc w/ disc herniation plus n root irritation or compression

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46
Q

Factors predicting decreased success w/ epidural steroid injxns

A

-chronic symptoms
-assoc w/ spinal surgery
-psychopathology

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47
Q

ischemic optic neuropathy symptoms

A

-sluggish pupils
-dec visual field
-painless vision loss

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48
Q

anterior vs posterior ischemic optic neuropathy types of surgery assoc

A

anterior, anterior part of body: assoc w/ cardiac surgery
-posterior, posterior part of body: assoc w/ spine surgery

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49
Q

Spinal stenosis: worse and better

A

better: squatting, walking uphill
worse: walking downhill, back extension

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50
Q

dx of abd compartment syndrome

A

intra-abd pressures > 20

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51
Q

Sites correlating w/ core temp

A

-distal 1/3 esophagus
-tympanic
-nasopharyngeal
-pulm artery

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52
Q

how far is skin temp off from core temp?

A

2C

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53
Q

most likely cause of adverse outcome related to anesthesia equipment?

A

misuse of equipment

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54
Q

Dosing for etomidate should be

A

lean body weight

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55
Q

dosing for thiopental should be

A

lean body weight

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56
Q

What medications for morbidly obese pts should be dosed on actual body weight?

A

dexmedetomidine
succinylcholine
synthetic opioids

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57
Q

What medication to avoid if concern for increased intracranial pressure and trying to dec BP?

A

NG
nitroprusside
->causes vasodilation in cerebral vessels -> inc ICP

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58
Q

Nitrous oxide CMF CMRO2

A

increases both

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59
Q

how to blunt inc in CBF with nitrous oxide

A

simultaneous admin of IV anesthetics

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60
Q

nitrous oxide plus volatile anesthetics CBF

A

higher CBF

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61
Q

Why does autonomic dysreflexia occur?

A

Pt’s w/ spinal cord injuries T5-T7 or higher have unopposed sympathetic activation below the level of the injury
-pain from below T7 (full bladder, surgical stimulation) -> activation of sympathetic reflexes -> no parasympathetics to even out -> extreme HTN
-so severe vasoconstriction/sympathetic activation below the injury level
-severe HTN is sensed by carotid baroreceptor (carotid sinus) -> vagal response -> vasodilation above level of injury, bradycardia, heart block

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62
Q

Symptoms in autonomic hyperreflexia

A

BP >20-40 from baseline
-unopposed symp below injury -> cold, vasoconstricted lower extremities
-reflex vagal activation to inc in BP -> bradycardia, heart block
-vasodilation in upper extremities, flushing, sweating (diaphoresis), nasal congestion
-HA, risk of hemorrhagic stroke, sz, cerebral edema

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63
Q

How long after spinal cord injury can you get autonomic hyperreflexia?

A

2 weeks to 6 months

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64
Q

normal intraabd pressure

A

< 5-7

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65
Q

intrabd HTN def

A

intra-abd pressures > 12

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66
Q

RF for intraabdominal HTN

A

-dec ability of abd to expand: burns, surgery, trauma
-inc vascular leakage: sepsis, large fluid resuscitation, acidosis, hypothermia
-inc intraluminal contents: gastroparesis
-inc intraabd contents: laparoscopic surgery, acute pancreatitis
-age, coagulopathy, high PEEP, shock

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67
Q

chronic renal insuff and intraabd HTN

A

-is NOT an independent RF, but decreases threshold for intraabd HTN (because easier to put into organ failure if already compromised) -> same w/ cardiomyopathy and pulm dx

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68
Q

How do spinal cord stimulators work?

A

activate the larger Aalpha and Abeta fibers to a larger degree to that this impedes the conduction of the smaller nociceptive Adelta and C fibers past the substania gelatinosa of the dorsal horn of the spinal cord

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69
Q

Treatment for cerebral vasospasm after subarachnoid hemorrhage?

A

Nimodipine

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70
Q

After subarachnoid hemorrhage, when is vasospasm likely

A

-can occur after 72 hours, but peaks at 7-8 days

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71
Q

If trauma, but no nerve injury, what type of CRPS?

A

Type I (nociceptive pain)

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72
Q

What type of pain is CRPS type II associated with?

A

Neuropathic

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73
Q

most common events precipitating CRPS

A

bone fracture
-upper extremities more commonly affected

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74
Q

Elderly response to dobutamine stress test

A

elderly pts have dec elasticity in vessels -> inc in SVR -> inc in afterload -> LVH -> dec ability to relax during diastole -> inability to compensate as well w/ exercise and inc HR
-so inc in HR w/ dobutamine stress test -> less cardiac output -> hypoTN

**elderly very dpt on atrial kick

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75
Q

resting stroke volume 80 v 30

A

same resting stroke volume, but the elderly can’t compensate to increase their stroke volume w/ exercise (diastolic dysfxn and dec beta receptor activity)

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76
Q

Cardiac changes w/ elderly

A

-dec beta receptor sensitivity
-LVH
-diastolic dysfxn
-less elastic vasculature
–> more dpt on atrial kick, impaired ability to augment cardiac output w/ stress or exercise, poor tolerance of inc in heart rate

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77
Q

Large diff b/w peak and plateau pressure

A

-bronchospasm
-mucus plug
-ETT kinking
(inc airway resistance)

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78
Q

Small diff b/w plateau pressure and peak pressure

A

-issue w/ lung compliance
-pulm fibrosis
-inc abd pressure
-poor positioning
-PTX
-obesity
-chest wall deformity
-pulm edema

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79
Q

Why do pts w/ myotonic dystrophy have inc risk of aspiration

A

-weakness in pharyngeal muscles
-delayed gastric emptying, intestinal hypomobility, gastric atony
-thyroid dysfxn, DM, adrenal insuff

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80
Q

Def of functional residual capacity

A

amount of air left in lungs at end of passive TV breath

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81
Q

Inc in PEEP on FRC

A

inc in PEEP opens more alveoli -> volume of air in lungs will be inc -> inc in FRC

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82
Q

I:E ratio w/ COPD

A

dec I:E ratio is a method to prevent auto-PEEP from occuring
-require a longer expiratory time to empty air from their lungs

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83
Q

Causes of low FRC

A

PANGOS
Pregnancy
Ascites
Neonate
General anesthesia
Obesity
Supine

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84
Q

pts w/ duchenne muscular dystrophy preop

A

everyone gets an EKG and echo
-EKG is likely to have Q waves -> progression of cardiac dx, does not need a cath
-if arrhythmias, may need a holter
-severity of muscular dx is NOT assoc w/ severity of cardiac
-biggest correlation w/ morality is LV fxn

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85
Q

EKG in newly transplanted heart

A

May have 2 P waves -> recipient and donor atriums, but they do not communicate

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86
Q

cardiopulm bypass priming solution

A

-primarily crystalloid w/ some additive
-heparin: prevent clotting on circuit
-mannitol -> osmotic diuresis, preventing tissue edema
-colloid: also help limit tissue edema, but is an additive, not primary solution
-calcium: risk of hypoca w/ large amt of blood products

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87
Q

chronic opioids and endocrine

A

-inc in prolactin
-dec in cortisol, testosterone, estrogen, FSH, LH
-immunosuppression

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88
Q

intraaortic balloon pumps

A

-inflate during diastole -> inc Aortic DBP -> inc coronary perfusion
-deflates during systole -> dec afterload, helps inc cardiac output

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89
Q

when doing PFTs, those with ____ COPD will have the biggest change in FEV1 w/ bronchodilator therapy

A

moderate
-minimal change w/ mild or severe COPD and bronchodilators

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90
Q

when does resting PFTs predict exercise performance in lung dx?

A

those with MILD lung dx

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91
Q

PFTs and pneumonectomy

A

-if PFTs initially show that pneumonectomy might not be tolerated -> next step is to do split-function lung testing and see how involved each lung is , to see if pneumonectomy will be tolerated now

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92
Q

Phantom limb pain is what type of pain?

A

Neuropathic

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93
Q

dysesthesias

A

abnormal sensations

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94
Q

acid-base w/ salicylate poisoning

A

combined anion-gap metabolic acidosis w/ respiratory alkalosis (direct stimulator of respiratory drive)

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95
Q

Treatment of salicylate toxicity

A

-supportive (ABCs)
-activated charcoal
-fluids
-dextrose (avoid CSF hypoglycemia)
-bicarb admin -> raises systemic pH dec tissue distribution, raises urine pH inc clearance
-HD if severe

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96
Q

tinnitus, AMS, tachypnea, what intox?

A

Salicylates

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97
Q

Stridor post extubation and concern for airway edema

A

-racemic epi
-heliox
-tx cause -> if unsure nasopharyngeal fiberoptic gold standard to determine

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98
Q

causes of supraglottic airway edema

A

-too much fluid admin
-surgical hematoma
-prone positioning (impaired venous drainage)

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Perfectly
99
Q

causes of subglottic airway edema

A

-traumatic intubation
-damage from ETT (prolonged, excessive cuff pressure, tight-fitting tube)

100
Q

cuff-leak test: results indicating airway edema

A

-< 130cc diff from inh and exp
-< 24% diff from inh and exp volume

101
Q

SSEPS: assess where? and detected where?

A

assess lateral and posterior SC perfusion
-detected in the brain

102
Q

MEPs used to assess? and where detected?

A

assess anterior spinal cord perfusion
detected: peripheral musculature

103
Q

sepsis TEE

A

RV and LV dilation w/ global hypokinesesis with no regional wall abnormalities
-dec EF but normal cardiac output

104
Q

pituitary adenoma symptoms

A

-dec peripheral vision
-galactorrhea, amenorrhea
-hypothyroidism
-dec cortisol, FSH, LH, hypogonadal
-dec cardiac output -> due to dec thyroid (dec SV) and adrenal (hypoTN)

***doesn’t affect posterior pituitary, ADH and oxytocin normal

105
Q

PaCO2 and temp

A

Each degree below 37C, PaCO2 dec by 2

106
Q

stress response proteins

A

proteins initially anabolism -> catabolism (incl breakdown of skeletal m) to mobilize amino acids for gluconeogenesis in liver

107
Q

first step in airway fire w/ no advanced airway (Nasal cannula in place)

A

turn off airway gas flow!

108
Q

first steps in ETT in place airway fire

A

simultaneously extubate pt and turn off flows

-next steps: remove flammable materials -> poor saline down fire (unclamp IV bag and just pour) -> if no lung fire extinguisher

109
Q

GCS

A

eyes, vocal, motors
4, 5, 6 points
eyes
1: none, 2: open to pain 3: open to voice 4: open spontaneous

vocal
1: none, 2: incomprehensible, 3: inappropriate, 4: confused, 5: appropraite

motores:
1: none, 2: extends to pain, 3: flexes to apin, 4: withdraw from pain, 5: localized pain, 6: follows commands

110
Q

PEEP application in a pt w/ systolic heart failure

A

PEEP causes a dec in preload -> is beneficial in pt overloaded from HF
-inc in CVP and PVR -> better V/Q matching -> less preload and forward flow -> improve cardiac index, and dec PCWP (LA)
-b/c of inc intrathoracic pressure, afterload is decreased

111
Q

what fluids to avoid in neurosurgery?

A

anything w/ glucose in it -> inc cerebral edema

112
Q

cannot be allowed in MRI

A

-cochlear implants
-spinal cord stimulators
-aneurysm clips
-intrathecal pumps
-metal fragments
-bullets

113
Q

OK for MRI:

A

-vascular clips
-ortho implants
-staples
-heart valves
-other prostheses

114
Q

Obesity and respiratory things

A

-inc in minute ventilation (bec inc O2 need, inc CO2 prod due to inc metabolism from inc adipose tissue)
-Restrictive lung dx
-Dec FRC (same RV, so dec in ERV)
-high closing volume to FRC -> atelectasis, and hypoxemia
-no change: RV and closing capacity

115
Q

HOCM hemodynamic goals

A

-maintain preload
-low HR -> inc diastolic filling time, less LVOT obstruction
-red contractility
-adequate SVR

116
Q

if pharm not working for HOCM next steps

A

septal reduction by myectomy or ethanol ablation

117
Q

MOA pertussis toxin

A

ribosylation of Gi protein -> inhibits the inhibitor of cAMP -> inc in cAMP
**whooping cough

118
Q

heroin and what toxin?

A

tetanus spores have been found in heroin

119
Q

Neuromotor pathway for MEPs

A

cortex -> internal capsule -> brainstem -> corticospinal tract -> peripheral n -> muscle

120
Q

SSEPs pathway

A

peripheral n -> dorsal root ganglia -> posterior spinal cord -> brainstem -> thalamus -> cortex

121
Q

cardiac dysfxn w/ acromagly

A

LVH!

122
Q

Anesthesia concerns for acromegaly

A

***difficult DL and mask laryngoscopy
-HTN
-DM
-LVH
-OSA

123
Q

congential diaphragmatic hernia, sudden severe hypoxemia w/ doubling of peak inspi pressure

A

PTX -> chest tube or needle thoracotomy

124
Q
A

D: milrinone
A: furosemide
C: hydralazine
E: Norepi/epi

125
Q

Normal cardiac output

A

4-8 L/min

126
Q

Normal Cardiac index

A

2.5-4 L/min/m^2

127
Q

Normal Stroke volume

A

60-100 cc/beat

128
Q

Normal stroke volume index

A

33-47 cc/m^2/beat

129
Q

Complications w/ subarachnoid hemorrhage

A

first 24 hrs: rebleeding
first few days: hypoNa (SIADH or cerebral salt wasting)
after 3 days, peak 5-10 days: vasospasm

130
Q

Which of the neurologic monitors LEAST affected by volatiles?

A

Auditory evoked potentials

131
Q

Neurological monitor most sensitive to volatile anesethetics

A

visual evoked potentials > MEPs > SSEPs > auditory

132
Q

Normal lung change s w/ age

A

-dec elastic recoil in lungs -> inc compliance but dec in chest wall compliance -> dec alveolar surface area
-INCREASE: RV, FRC, CC, dead space
-DECREASE: FEV1, FVC, VC
-dec muscle mass -> flattening of diaphragm -> forced exhalation harder
-PVR inc (hardening of vasculature)
-PaO2 dec, PaCO2 no change
-blunted hypoxic pulm vasoconstriction

***TLC unchanged

133
Q

ppx to treat and reduce hypoxic pulm vasoconstriction

A

Nifedipine
B2 agonists

134
Q

Adjustment body makes w/ inc altitude

A

-hypoxia: inc ventilation -> resp alkalosis -> eliminate bicarb out of CSF and out through kidneys
-Inc in Hct
-severe complications: hypoxic pulm edema (inc risk of pulm HTN) or hypoxic cerebral edema

135
Q

tx for altitude sickness

A

descent
O2
dexamethasone

136
Q

MOA Xenon gas

A

NMDA receptor antagonist

137
Q

Which inhalation anesthetic causes the LEAST inc in ICP?

A

sevo

138
Q

In setting of severe hypoxemia w/ one lung ventilation and dual lung vent cannot occur?

A

Surgery needs to clamp nondependent pulmonary artery

139
Q

Critical closing pressure of the upper airway

A

-if pt obstructing and has no air flow, but has air flow w/ a CPAP of 5 -> Pcrit is 5
-negative in awake individuals, becomes positive during anesthesia

140
Q

Carotid sinus

A

baroreceptor

141
Q

carotid body

A

chemoreceptor

142
Q

How do carotid body chemoreceptors work?

A

If chemoreceptor senses PaO2 < 55 -> afferent glossopharyngeal n -> CNS ventilation centers

143
Q

Why would there be an impairment of chemoreceptor inc in ventilation?

A

-impaired glossopharyneal n
-b/l carotid endarterectomy
-opioids, benzos, volatile anesthesics (down to 0.1 MAC)

144
Q

If you have a pt w/ a AICD and they get into a life threatening arrythmia, steps?

A
  1. take off magnet -> let AICD doing its shock
    -tell surgeon to stop w/ electrocautery
  2. if it doesn’t work, put pads on and shock
145
Q

A alpha fibers

A

convey proprioception

146
Q

A beta fibers

A

convey touch sensation

147
Q

A delta

A

sharp, lancating, easily localizable pain
-because faster, usually what you feel first

148
Q

C fibers

A

mechanical, thermal, and chemical pain
-usually burning sensation you feel 2nd because slower than A delta

149
Q

Symptoms of discogenic pain

A

-worse w/ sitting, better w/ standing
-worse w/ flexion, coughing, sneezing
-better w/ sitting tall (takes pressure off discs)

150
Q

Morning stiffness, pain dx?

A

Ankylosing spondylitis

151
Q

Inc postop morbidity and mortality in post-pneumonectomy if they failed phase 1 testing:

A
  1. Combined FEV1 < 35% with DLCO < 35%
  2. Inability to climb 2 flights of stairs
  3. FEV1 < 30% by itself
  4. mean pulm artery pressure > 35
  5. PaCO2 >45
  6. PaO2 < 60

Values during exercise
1. PVR > 190
2. Max VO2 < 15
3. Dec in arterial O2 sat > 2-4%

152
Q

elderly people and lusitropy

A

-ability for LV to relax -> old people have LVH and diastolic dysfxn -> neg lusiotropy

153
Q

Sign of cerebral protection w/ barbiturate coma, EEG pattern?

A

burst suppression

154
Q

What brain waves are present in deep coma and deep anesthesia?

A

Delta

155
Q

What brain waves are present in encephalopathy?

A

Theta

156
Q

What brain waves are present w/ relaxation and eyes closed?

A

Alpha

157
Q

What brain waves are present during awake arousal?

A

Beta

158
Q

Why burst suppression over isoelectric EEG for barb coma?

A

burst suppression means the brain is still firing, more predictable wake up once meds turned off, with still max reduction in CMRO2

159
Q

Best way to intraop monitor LVADs?

A

Put an aline in if anything other than minor surgery (BP cuffs and pulse ox not reliable) -> w/ intermittent ABG to assess oxygenation

160
Q

Pulsatility index LVAD

A

-normal 3-6, if lower indicationg hypovolemia or impaired cardiac fxn
-pulsatility of LV in real time, higher number means LV is pushing more blood

161
Q

pump speed LVAD

A

revolutions per minute, set by cardiologys, we dont touch

162
Q

If you double your distance from radiation, your exposure dec by factor of what?

A

4

163
Q

Catecholamines and the elderly

A

-higher levels of baseline catecholamines in elderly -> why less significant resp during stress

164
Q

Acute lumbosacral radiculopathy, now what?

A

-NSAIDs, acetaminophen, maybe muscle relaxants first -> conservative measures first (b/c most resolve in 3 months!)
-then if imaging :CT or MRI
-consider steroids PO

165
Q

To reduce intaop AICD firing

A

-place dispertion pad near surgical site
-bipolar cautery
-short bits of monopolar if needed

**in emergency have device interrogated after surgery

166
Q

Myofascial pain syndrome

A

-taut muscle bands
-radiation of pain, but NON-dermatomal when trigger points palpated
-autonomic symp: piloerection, vasoconstriction
-spontaneous EMG activity

167
Q

lung volumes and acromegaly

A

INCREASE
-get an inc in size of lung volumes due to inc in organ size

168
Q

acromegaly and mandibular length

A

increased!
-can get skeletal overgrowth

169
Q

acromegaly and insulin

A

glucose intolerance, insulin resistance, and DM
-dx of acromegaly: inc insulin like growth factor 1 -> test confirmed w/ oral glucose load and no suppression of growth hormone

170
Q

acromegaly and sweating

A

hyperhidrosis!

171
Q

Lung/airway closure in normal people

A

-small airways close first, then larger airways
-dependent lung areas have airway closer first (higher positive intrathoracic pressure causing airways to close) compared to non-dpt regions

172
Q

airway closure emphysema

A

-def of emphysema is damage to alveoli and distal airways
-so alveoli and distal airways close earlier than normal airways when inc in intrathoracic pressure -> air trapping
-airway closure occurs closest to alveoli b/c that’s where the damage is, and where the airways are the thinnest

173
Q

Resistance to airway and radius

A

-resistance inversely proportional to radius to the 4th power!
1/2 side of radius -> resistance inc 16 fold

174
Q

Why atelectasis w/ 100% FiO2

A

-alveoli quickly absorb the O2 and then collapse -> atelectasis
-w/ lower FiO2, still some nitrogen in alveoli keeping them open

175
Q

Cerebral palsy and inhalational anesthetics

A

-have decreased MAC requirements, inc sensitivity to inh anesthetics

176
Q

cerebral palsy and NDNMB

A

inc resistance

177
Q

Anesthesia concerns for CP

A

-dec MAC for inh gases
-opioid sensitivity
-GERD
-OSA
-diff IV
-altered thermoregulation
-impaired airway reflexes
-malnutrition

178
Q

Def of long QT

A

QTc:
men: > 440
women > 460
** > 500 inc risk of torsades

179
Q

treatment of congenital long QT

A

-fix lytes, remove offending dx
-1st: beta blockers
2nd: implantable defib if CI to beta blockers, or life threatening cardiac arrest, or high risk

180
Q

what meds improve SSEP amplitude?

A

ketamine
etomidate

181
Q

what neurologic monitoring is best for posterior fossa surgery to look for brain stem ischemia?

A

auditory evoked potentials
-closest to surgical site
-often GA w/ inh anes is used and auditory is the most resistant

182
Q

SSEP signs of ischemia

A

Latency inc by 10%
amplitude dec by 50%

183
Q

MEP sign of ischemia

A

Amplitude dec by 50%

184
Q

What pressor inc cerebral perfusion pressure and inc cerebral oxygenation?

A

Vasopressin
-inc MAP
-inc nitric oxide causes cerebral vasodilation -> inc oxygenation

185
Q

Phenylephrine cerebral perfusion pressure and cerebral oxygenation

A

inc CPP by inc MAP
-dec cerebral oxygenation b/c cerebral vasoconstriction and dec cardiac output

186
Q

PaCO2 and SSEPs

A

if < 50 and above 25, no changes

187
Q

in pts intubated, how does GCS change?

A

verbal becomes 1 T or I

188
Q

in pt w/ extreme eye/facial swelling how is GCS altered?

A

eye 1 C -> indicates eye is closed

189
Q

def of dead space

A

ventilation w/o perfusion

190
Q

shunt def

A

perfusion w/o ventilation

191
Q

sudden dec in SpO2 and EtCO2 after tourniquet release

A

pulm embolism

192
Q

Best anesthetic plan to limit exacerbation of MS

A

epidural
-spinal, GA have all been assoc w/ exacerbations due to inc stress -> may require extended postop care
-**maintain normothermia, hyperthermia assoc w/ exacerbations

193
Q

postop pneumonectomy, white lung field, air-fluid level inferiorly, febrile, copious sputum production

A

bronchopleural fistula

194
Q

if patient has a bronchopleural fistula and chest tube, what needs to be done before induction?

A

put chest tube on water seal

195
Q

How above systolic BP should an upper extremity tourniquet be?

A

50 above

196
Q

How high above systolic BP should a lower extremity tourniquet be?

A

100 above

197
Q

What causes ANP to be released?

A

hypervolemia -> released by cardiac myocytes in RA in resp to increased stretching

198
Q

What does ANP do?

A

-natriuresis
-peripheral vasodilation
-inhibit renin and aldo secretion
-prevent ATII from activating
-inc GSF

199
Q

how is BNP released?

A

Brain Natriuretic peptide
-released in response to inc stretching in ventricular myocytes
-similar fxn to ANP

200
Q

How does MOCA work?

A

-over 10 years
-250 CME credits, must be category one, no more than 60 credits per year
-30 ? per quarter
-unrestricted license to practice
-participate in 2 activities of evaluation and improvement of practice

201
Q

Contraindications to aortic balloon pump

A

-aortic dissection
-aortic insufficiency (AR)
-severe PVD

202
Q

Indications for aortic balloon pump

A

-cardiogenic shock
-failure to wean from CPB
-R heart failure
-bridge to transplant or VAD
-augment during PCI

203
Q

Indications for aortic balloon pump

A

-cardiogenic shock
-failure to wean from CPB
-R heart failure
-bridge to transplant or VAD
-augment during PCI
-severe MR

204
Q

Gas used to inflate intraaortic balloon pump

A

helium

205
Q

obesity and DLCO

A

increased! -> due to inc pulm blood flow

206
Q

Mechanical ventilation O2 consumption in obesity

A

mechanical ventilation decreases O2 consumption compared to

207
Q

RV obesity

A

unchanged

208
Q

Resp changes w/ obesity

A

DECREASED: FRC, RV, TV
INCREASED: total and pulm blood volume, cardiac output, LVEDP, DLCO, work of breathing, O2 consumption

209
Q

Increases sz duration during ECT

A

etomidate

210
Q

no effect/minimal effect on sz duration

A

methohexital
ketamine

211
Q

Tumescent liposuction: max dose of lidocaine

A

35-55 mg/kg

212
Q

Tumescent liposuction: max dose of epi

A

0.07 mg/kg

213
Q

Tumescent liposuction: when does blood lidocaine levels peak?

A

12-16 hours

214
Q

TCA MOA

A

-inhibition of serotonin reuptake
-NMDA blockade
-opioidergic effects

215
Q

celiac plexus block tx cancer pain where?

A

pancreas

216
Q

superior hypogastric plexus blocked for pain where?

A

bladder, pelvic pain

217
Q

common SE from celiac plexus block

A

-orthostatic hypoTN (MC)
-diarrhea (2nd MC)

218
Q

Cervical epidural steroid injxns and surgery

A

reduces rate of surgery!

219
Q

Inflammatory pain

A

following tissue injury -> dull, aching, poorly localized

220
Q

Paresthesia of S3-S5 also known as

A

saddle anesthesia -> concern for cauda equina syndrome

221
Q

MCC of acute liver failure

A

acetaminophen toxicity

222
Q

Max recommended doses of acetaminophen

A

< 3 g: healthy adults
< 2.6 g: peds, elderly
< 2: alcoholic, liver dx

223
Q

What is ganglion impar blocks used for?

A

perineal pain

224
Q

elderly cancer pt, chronic opioid therapy, confusion and myoclonus after inc morphine dose

A

opioid induced neurotoxicity

225
Q

If pt presenting w/ opioid induced neurotoxicity what to do?

A

-d/c and switch to opioid w/ no active metabolite (ie fentanyl)

-if symptoms severe and sz is a concern: start a trial of benzos to increase sz threshold

226
Q

safest opioids in elderly and ESRD

A

fentanyl
methadone
**no active metabolites!

227
Q

Neuropathic pain pathophys

A

-inflammation in afferent pathway -> central and peripheral sensitization

228
Q

Tramadol MOA

A

weak opioid agonist
-serotonin reuptake inhibitor
-NE reuptake inh
-NDMA antagonist
-directly increases basal release of serotonin

229
Q

pt post thoracotomy pain, morphine making no difference, on heparin infusion, options?

A

TENS

230
Q

At what dose of chronic ER morphine can you switch over to fentanyl patches

A

> 45mg

231
Q

SNARE proteins cleaved by botox

A

synaptobrevin
SNAP-25 (MC)
syntaxin

232
Q

TENS contraindications

A

-demand type pacemakers
-cardiac dysrythmias
-mentally incompetent pts
-pregnancy

233
Q

What is required for a diagnostic block to be successful

A

30-80% reduction in pain for hours-days

234
Q

How long is the suspected relief for a nerve radiofreq ablation?

A

6 months

235
Q

MOA gabapentin

A

inhibits VG Ca channels -> prevents release of glutamate (excitatory NT)

236
Q

Gabepentin SE

A

-peripheral edema
-ataxia
-nausea
-nystagmus
-weight gain
-dizziness
-sedation

**cardiac and resp SE uncommon

237
Q

what is the NT mediative afferent nociceptive transmission from dorsal root ganglia to SC?

A

Glutamate

238
Q

What muscle is closest to the needle tip during a lumbar symp block?

A

psoas major

239
Q

Alternative to celiac plexus block for cancer in upper abd and retroperitoneum

A

splanchnic nerve block

240
Q

Goal cerebral perfusion pressure for TBI

A

50-70

241
Q

At what ICP level should tx be initiated?

A

> 20

242
Q

Mytonic dystrophy anesthesia concerns

A

-preop: TTE, EKG
-if any type of AV conduction issue -> get cardiology involved incl 1st degree (rapid and unpredictable progression)
-pacing equipment should be available
-avoid succ, minimize NDNMB
-prop, methohexital, etomidate, neostigmine, can precipitate myotonia

243
Q

ppx for myotonic crisis in myotonic dystrophy?

A

Phenytoin
Quinidiine
Procainamide

244
Q

Pregnancy w/ idiopathic intracranial HTN -> vision symp, what is the plan for vaginal delivery analgesia?

A

Intrathecal catheter w/ intermittent boluses

245
Q

Carbon monoxide poisoning and arterioles

A

Carbon monoxide poisoning assoc w/ inc in nitric oxide -> vasodilation

246
Q

high dose steroids and TBI

A

increases morbidity and mortality

Truelearn Advanced Exam (15 decks)

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