TL block 9 Flashcards
How to blunt inc in ICP w/ laryngoscopy?
Lidocaine 1.5 mg/kg
Myasthenic syndrome and myasthenia gravis: gender influences
Myasthenic syndrome more likely in males
myasthenia gravis more likely in females
Myasthenic syndrome v myasthenia gravis: more likely to have proximal limb weakness
myasthenic syndrome
Myasthenic syndrome and myasthenia gravis: reflexes
myasthenic syndrome: absent/ dec reflexes
MG: normal reflexes
Treatment for myasthenic crisis
-IVIG
-plasmapheresis
-steroids
-AChE inhibitors
-immunosuppressant agents
With AVM resections and neuromonitoring, best way of assessing tolerance to vessel clamping in parietal lobe
SSEPs or MEPs
What is Demeclocycline used for?
Treatment for SIADH
What is cabergoline used for?
Dopamine agonist -> prolactinoma
What is Calcitriol used for?
to treat hypoCa in hypoparathyroidism
subarachnoid hemorrhage and Hg
Admission Hg -> predictor of cerebral infarction and outcomes
Where does deep brain stimulation target for tx of Parkinson’s Dx?
Subthalamic Nucleus
Internal Globus Pallidus
why aneurysm rupture w/ dec in CSF?
Cerebral perfusion pressure = MAP - ICP -> loss of CSF dec ICP extensively -> inc transmural pressure across wall of aneurysm -> rupture
Why ST changes w/ subarachnoid hemorrhage?
inc circulating catecholamines -> demand ischemia
Hydrocephalus and EKG
QTc prolongation
if pt has spinal cord injury and will likely fail extubation, next steps?
Trach w/i 7-10 days of injury to reduce sedation needs, red mechanical vent days, improve pulm toilet, and participate in therpay
Predictors of complications w/ ICD lead extraction
-leads in place for longer period of time
-inexperienced physician
-laser extraction
-pt is female
-larger # of leads requiring extraction
Treatment for SVT w/ Wolf-Parkinson White
Procainamide
-slows down conduction in the accessory pathway w/o affecting the AV Node
What happens if you give someone w/ Wolff-Parkinson White Adenosine?
Slows conduction at the AV node -> instead heart conducts through the accessory pathway -> v fib -> cardiac arrest
RF for sudden death from congenital long QTc
-QTc > 500
-female
-male w/ QT3
-deafness
-widened T waves
Acute management of congenital prolonged QT
-IV Mag
-replace Ca, K
-AVOID amiodarone
Long term management of long QT syndrome
-beta blocker
-PM/AICD
-L stellate sympathectomy if refractory
A: furosemide
B: ACE inh, NG
C: milrinone
D: NE, epi
centrifugal v roller pumps in CPB: which varies w/ changes in pump preload and afterload
centrifugal
which coronary artery is most likely to get an air embolism w/ open heart surgery?
RCA
Why hypoTN w/ protamine?
Histamine release
Treatment for vasoplegia w/ CPB?
Vasopressin and methylene blue
what TEE view is used to assess accurate placement of the femoral catheter for CPB
mid-esophageal bicaval view
What would you want to look at if you used a transgastric short axis view?
cross section of LV and RV -> assess thickness, contractility, volume status
what is seen in the mid-esophageal long axis view?
LA, MV, LV, LVOT, AV, ascending aorta
What is an esophageal detector device and hows it work?
It’s a ballon, you squeeze it, if in the lungs reinflates, if in esophagus remains collapsed
-can be beneficial to confirm ETT placement during cardiac arrest
Hemodynamic goals w/ cardiac tamponade
-augment preload
-avoid hypoTN, HTN
-inotropy
-maintain HR higher (b/c limited by SV, cardiac output more dpt on HR)
O2 extraction following aortic cross clamping
decreased b/c blood not flowing to half the body -> so less O2 is utilized
Hemodynamic effects of aortic cross clamping
- inc arterial BP above clamp
- inc coronary artery BF
- inc LV wall stress
- inc CVP
- Inc PCWP
- Dec arterial BP below clamp
- Dec cardiac output
- Dec renal BF
Brugada Syndrome
Brugada syndrome
ST elevations in V1-V3
pseudo RBBB
tx of Brugada syndrome
ppx AICD
what lytes cause exacerbation of long QT syndrome?
hypoK
hypoMg
hypoCa
What can trigger fatal arrythmias in Brugada syndrome?
propofol
local anesthetics
Fenoldopam
-MOA
-effects
-what pt population beneficial in?
DA agonist
-dec in peripheral vascular resistance
-natriuresis, diuresis
-beneficial in pts undergoing TAA repairs w/ resistant HTN
CI to Fenoldopam
inc in IOP -> don’t use in pts w/ glaucoma or intraocular HTN
low pitched mid diastolic rumble at PMI
MS
troponin and size of MI
levels correlate w/ size of MI!
troponin and long term outcome
-predictive and prognostic of short and long term outcomes
troponin peak levels
24 hours
Myoglobin peak levels
4 hours
Inamrinone MOA
PDE III inhibitor -> inc cAMP levels -> inc cardiac Ca levels -> improves contractility (inotropy)
-in peripheral vasculature inc in cAMP -> vasodilation -> dec in SVR -> inc cardiac output
SE of inamrinone if used for longer than 24 hrs
thrombocytopenia
Digoxin and WPW
Digoxin is contraindicated
-the slowing of AV conduction w/ inc atrial conduction = inc conduction in accessory pathway
energy for sync cardioversion
100J
When are you most likely to get R on T phenomena?
when PM is asynchronous and pt’s HR is higher than set paced HR
What happens if you get R on T phenomena?
V tach or V fib
What medication predisposes pts to anaphylaxis from protamine?
NPH insulin
what causes the pulm HTN possible RV failure rxn to protamine?
Thromboxane
-released from plts and macrophages after stimulation by protamine-heparin complexes
thermodilution assessment of cardiac output: if smaller amount of injectate is used, CO will be?
overestimated
-b/c return to temp faster
thermodilution assessment of cardiac output: if injectate is warmer than programmed?
overestimation
-b/c won’t get as cold -> so it thinks b/c the hard moving so much
thermodilution assessment of cardiac output: if give a room temp bolus before assessment of cardiac output?
underestimate b/c all fluid colder than anticipated
if doing a TAVR and sudden hypoTN w/ contrast extravasation retroperitoneally what happened?
perforation at ilio-femoral axis
hypo or hyperthermia inc pulm vascular resistance?
hypothermia
Recommended size of defibrillation pads
8-12 cm
Factors that improve successful defibrillation
-adequate pad size
-gel b/w pads and pt
-biphasic debrillatoin
-quick defibrillation (faster the more likely to be successful)
monophasic or biphasic defibrillation for V tach?
Biphasic: more success and can be done w/ less energy
reverse piezoelectric effect
creates u/s waves during transmission
direct piezoelectric effect
converts sount waves to electric current during reception
How to assess % of PONV pt is likely to have?
Each RF is 20%
-female
-nonsmoker
-hx of motion sickness/hx of PONV
-gyn surgery
-young, age < 50
-opioid use
Lidocaine and ET
dec duration of sz
Obese pts and succ
require inc doses
-inc extracellular fluidi and inc in pseudocholinesterase
how should NDNMB be dosed?
ideal body weight
Below what age can a double lumen tube not be used?
12
DL tube what view?
R upper lobe
DL what view?
carina
DL tube, looking at what?
L secondary carina w/ L upper and L lower bronchi
Treatment of Methanol poisoning
- supportive
- prevent conversion of methanol to toxic metabolites (ethanol or fomepizole)
- severe sympm HD
What is fomepizole used for?
Methanol poisoning
What pressure is indicative of compartment syndrome?
> 30
What compartment perfusion pressure is indicative of compartment syndrome?
< 21
MAC care claims in ASA Closed Claims Project most common cause of litigation?
Death (2/2 Respiratory events)
Lipid emulsion bolus for LAST dose
1.5 cc/kg for 2-3 minutes (if over 70 kg bolus 100cc)
-infuse .25 cc/kg/min
Bone cement implantation syndrome
similar to fat embolism syndrome but occurs during cement implantation in OR
-hypoTN, tachycardia, resp distress
What NT is not metabolized in lungs?
Dopamine, Epinephrine, Histamine
Norepi metabolism in lungs
30% on first pass
Serotonin metabolism in lungs
> 95% first pass
Tourniquet pain and spinal anesthesia
Can still get! Especially if tourniquet is on for over an hour
After how long w/ tourniquet do you see n and m compression injuries?
2 hours
Major Diagnostic criteria for fat embolism syndrome
-require at least 1,
-pulm edema or resp insuff
-hypoxia
-petechial rash
-central nerve system depression
How to diagnose fat embolism syndrome
-1 of major criteria (hypoxemia, resp insuff, AMS,petechial rash)
-4 minor critera (tachycardia, fever, dec hct or plts, inc ESR, retinal fat emboli, fat in urine, fat in sputum)
-fat in blood
Hormones after brain death
Brain stem herniation -> ischemia, edema, and pituitary compression -> Diabetes Insipidus -> hypoTN and hyperNa
-give vasopressin to donors
-large inflammatory and catecholamine surge -> give steroids
Goal temp for induced hypothermia for out of hospital cardiac arrest?
32 to 36C
fastest way to cool someone for induced hypothermia?
Endovascular cooling
when do most people die w/ induced hypothermia?
with too rapid rewarming
When should cervical spine injuries be suspecteD?
-Other people died at scene of the accident
-fall from > 10 ft
-pelvic/long bone fx
-accident at > 35 mph
-significant closed head injury or intracranial hemorrhage
-neurological signs consistent w/ cervical spine inur
pt gets CT w/ contrast, 4 days later gets a rash what sup?
delayed hypersensitivity due to T cell rxn
Privileged conversation
conversation b/w 2 individuals in private and can’t be used in a court of law
-husband and wife, priest and church goer, person and their lawyer
Why do elderly have higher initial peaks of medication conc?
-decreased albumin conc
-decreased volume of distribution
-dec circulation time
Factors in Child-Pugh score
-bilirubin
-ascites
-encephalopathy
-INR
-albumin
MELD score factors
I Crush Beer Daily
INR
Creatinie
Bilirubin
Dialysis
spinal/epidural in ALS
has been shown to exacerbate dx
best way to assess progression of ALS
PFTs -> more reliable of progression than musculature to understand severity of the dx
What types of surgery should ASA be held
neurosurg
posterior eye
middle ear surgery
intramedullary spinal surgery (SC)
prostate surgery
Main risks to anesthesia personnel constantly exposed to radiation
Cataracts
Cancer
elderly dead space
increased
elderly TV
no change
elderly residual volume
increased
elderly FRC
increased
elderly TLC
unchanged
lyte changes w/ hypothermia
hypoK, Mg, Phos
U waves on EKG
hypoK
hypothermia and Ca
hyperCa b/c lack of Na/K ATPase -> inc in Ca
What n likely to be damaged if doing a brachial arterial line?
median n
epidurals and n blocks in MS
no association w/ exacerbation!!
what schedule narcotic is cocaine
Schedule II
What schedule controlled substance is oxycodone?
Schedule II
What schedule controlled substance is Ketamine?
III
What schedule controlled substance is midazolam?
Schedule IV
What schedule controlled substance is cough meds?
V
BEST sensitivity to least detection of venous air embolism?
TEE > precordial doppler > Pulm artery catheter > EtCO2 > EKG
Dose of Dantrolene for treatment of MH?
2.5 mg/kg
-can be repeated every 5-10 minutes until signs have abated
spinal: arterial or venous vasodilation?
BOTH
If extensive burns, what drugs can you give less of?
Midazolam (highly albumin bound)
Which drugs do you need to give more of in burn victims?
hypoalbumin -> beta blockers, local anesthetics
-insulin resistance -> insulin!
Qualifying circumstance that affects billing and payment for GA?
emergency
extremes of age
deliberate hypothermia
controlled hypoTN
Dec BP but keep ICP low
Clevidipine
Nicardipine
Beta blockers
Meds contraindicated when giving dantrolene
CCB! Verapamil, Diltazem
what local anesthetic least likely to cross the placenta?
Chloroprocaine -> gets metabolized by plasma cholinesterases rapidly
What nerve runs lateral to the biceps tendon in the antecubital fossa?
radial n
Treatment of hyperMg for preeclampsia
- stop Mg
- give Ca
- give furosemide and fluids (eliminate Mg w/ loop diuretic!)
postintubation croup cuffed v uncuffed ETTs?
less w/ cuffed
why hypoTN after spinal
arterial and venous vasodilation
-arterial will only cause a minor dec in SVR, so doesn’t make a huge diff
-venous vasodilation -> significant diff and sign decreases preload -> hypoTN
**most of the total body volume blood lies in venous system
How does lactulose lower ammonia in acetaminophen OD
prevents the ammonia from getting absorbed in the first place -> dec intestinal pH -> makes it ionized -> cant be absorbed
If pt oliguric but taking diuretics best test to assess cause?
fractional excretion of urea
Anion gap
Na - (Cl + lactate)
TPN and acid base status
-has a large amount of Cl -> can get an anion gap metabolic acidosis
Carbamazepine toxicity
-anticholinergic symp (mydriasis, no sweating)
-QT prolongation, tachycardia, hypoTN
-neuro: nystamus, AMS, delirium
PAO2 equation
PAO2 = FiO2 (Patm -PH2O) - (PaCO2/0.8)
Changes w/ heparin in pregnancy
-inc heparin-binding proteins
-inc renal excretion
-inc enzymes to break down heparin
-inc plasma volume
**dec bioavailability -> dosing needs to be increased
Scleroderma and TEE
contraindication!
Fent v Morphine epidural SE
Fent less N/V and pruritis
qSOFA
RR > 22
BP systolic < 100
AMS, GCS < 15
Anatomic landmarks for infragluteal sciatic n blocks
ischial tuberosity
greater trochanter of femur
sciatic groove
SIADH labs
-Na < 135 (dilutional hypoNa)
-Urine osm > 100
-FeNa > 1%
-Urine Na > 20
-low serum urine acid and BUN
which factor is assoc w/ vWD?
factor VIII!!!
What’s in cryo?
factor VIII
vWF
factor XIII
fibrinogen
Arytenoid dislocation symptoms
neck pain and strained voice, NO difficulty breathing
early post-extubation stridor
laryngeal edema
