Toronto Notes Gems Flashcards
6 As of General Anesthesia
Anesthesia Anxiolysis Amnesia Areflexia (muscle relaxation not always required) Autonomic Stability Analgesia
Discuss β-blockers (b1 vs. b2) & its cautions
• b1 receptors are located primarily in the heart and kidneys
• b2 receptors are located in the lungs
• Non-selective b-blockers block b1 and b2 receptors. Caution is required with non-selective b-blockers, particularly in patients with respiratory conditions
where b2 blockade can result in
airway reactivity
Pre-Anesthetic Checklist
SAMMM
- Suction: connected and working
- Airways: laryngoscope and blades, ETT, syringe, stylet, oral and nasal airways, tape, bag and mask
- Machine: connected, pressures okay, all meters functioning, vaporizers full
- Monitors: available, connected and working
- Medications: IV fluids and kit ready, emergency medicines in correct location and accessible
Suspect Difficult Bag-Mask Ventilation with:
BONES
Beard Obesity/Obstetrics No teeth Elderly Sleep apnea
Differential Diagnosis of Poor Bilateral Breath Sounds after Intubation
DOPE
Displaced ETT
Obstruction
Pneumothorax
Esophageal intubation
Causes of Intraoperative Shock
SHOCKED
Sepsis or Spinal shock Hypovolemic/Hemorrhagic Obstructive Cardiogenic anaphylactiK Extra/other Drugs
Discuss Opioid Equivalency for morphine, codeine, oxycodone & hydromorphone
- 10 mg morphine
- 100 mg codeine
- 5 mg oxycodone
- 2 mg hydromorphone
Use NSAIDs with Caution in Patients with:
- Asthma
- Coagulopathy
- GI ulcers
- Renal insufficiency
- Pregnancy, 3rd trimester
Common Side Effects of Opioids
- Nausea and vomiting
- Constipation
- Sedation
- Pruritus
- Abdominal pain
- Urinary retention
- Respiratory depression
When prescribing opioids, consider:
• Breakthrough dose
• Anti-emetics
• Laxative
Classic Presentation of Dural Puncture Headache
- Onset 6 h-3 d after dural puncture
- Postural component (worse sitting)
- Occipital or frontal localization
- ± tinnitus, diplopia
Differential of ST Segment Changes
ST Elevation “I HELP A PAL”
- Ischemia with reciprocal changes
- Hypothermia (Osborne waves)
- Early repolarization (normal variant; need old ECGs)
- LBBB
- Post-MI
- Acute STEMI
- Prinzmetal’s (Vasospastic) angina
- Acute pericarditis (diffuse changes)
- Left/right ventricular aneurysm
ST Depression “WAR SHIP”
- WPW syndrome
- Acute NSTEMI
- RBBB/LBBB
- STEMI with reciprocal changes
- Hypertrophy (LVH or RVH) with strain
- Ischemia
- Post-MI
Important Contraindications to
Exercise Testing
• Acute MI, aortic dissection,
pericarditis, myocarditis, PE
• Severe AS, arterial HTN
• Inability to exercise adequately
Treatment of NSTEMI/Immediate Treatment of Acute MI
BEMOAN
β-blocker Enoxaparin Morphine O2 ASA Nitrates
Complications of MI
CRASH PAD
Cardiac Rupture Arrhythmia Shock Hypertension/Heart failure Pericarditis/Pulmonary emboli Aneurysm DVT
Use Ejection Fraction to Grade LV
Dysfunction
- Grade I (EF >60%) (Normal)
- Grade II (EF = 40-59%)
- Grade III (EF = 21-39%)
- Grade IV (EF ≤20%)
Five Most Common Causes of CHF
• CAD (60-70%) • HTN • Idiopathic (often dilated cardiomyopathy) • Valvular (e.g. AS, AR and MR) • Alcohol (dilated cardiomyopathy)
Precipitants (c.f. exacerbations) of Heart Failure
HEART FAILED
- Hypertension (common)
- Endocarditis/environment (e.g. heat wave)
- Anemia
- Rheumatic heart disease and other valvular disease
- Thyrotoxicosis
- Failure to take meds (very common)
- Arrhythmia (common)
- Infection/Ischemia/Infarction (common)
- Lung problems (PE, pneumonia, COPD)
- Endocrine (pheochromocytoma,
hyperaldosteronism) - Dietary indiscretions (common)
Features of Heart Failure on CXR
HERB-B
Heart enlargement (cardiothoracic ratio >0.50) Pleural Effusion Re-distribution (alveolar edema) Kerley B lines Bronchiolar-alveolar cuffing
Discuss the regime with beta blocker use in acute on chronic HF patients
Patients on β-blocker therapy who have acute decompensated heart
failure should continue β-blockers
where possible (provided they are
not in cardiogenic shock or in severe pulmonary edema)
Chronic Treatment of CHF
- ACE inhibitors*
- β-blockers*
- ± Aldosterone antagonists* (if severe CHF) e.g. spironolactone
- Diuretic
- ± Inotrope
- ± Antiarrythmic
- ± Anticoagulant
*Mortality benefit
(4) types of Cardiomyopathy
HARD
- Hypertrophic cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy
- Restrictive cardiomyopathy
- Dilated cardiomyopathy
(3) Major Risks Factors for DCM
Alcohol, cocaine, family history
Acute Pericarditis Triad
- Chest Pain
- Friction Rub
- ECG Changes
Ewart’s Sign
Bronchial breathing and dullness to percussion at the lower angle of the left scapula in pericardial effusion due to effusion compressing left lower lobe of lung.
Classic Quartet of Tamponade
- Hypotension
- Increased JVP
- Tachycardia
- Pulsus paradoxus
Beck’s Triad in cardiac tamponade
- Hypotension
- Increased JVP
- Muffled heart sounds
DDx Pulsus Paradoxus
- Constrictive pericarditis (rarely)
- Severe obstructive pulmonary disease (e.g. asthma)
- Tension pneumothorax
- PE
- Cardiogenic shock
- Cardiac tamponade
Symptoms of Acute Limb Ischemia
6 Ps – all may not be present
- Pain: absent in 20% of cases
- Pallor: within a few hours becomes mottled cyanosis
- Paresthesia: light touch lost first then sensory modalities
- Paralysis/Power loss: most important, heralds impending gangrene
- Polar/Poikilothermia (cold)
- Pulselessness: not reliable
Classic Triad of Ruptured AAA
- Pain
- Hypotension
- Pulsatile abdominal mass
Trousseau’s disease/sign
Migratory superficial thrombophlebitis is often a sign of underlying malignancy
Antiarrythmic Drug Classification
Some Block Potassium Channels
I – Sodium channel blocker
II – β-Blocker
III – Potassium channel blocker
IV – CCB
The Cockcroft-Gault Equation (estimate creatinine clearance (CrCl) in adults 20 yr of age and older)
• For males CrCl (mL/min) =
[(140 – age in yr) x Weight (kg)] x 1.2 / serum Cr (μmol/L)
- For females, multiply above equation x 0.85
- Only applies when renal function is at steady state
How many half lives does it need to reach steady state with repeated dosing or to eliminate a drug once dosing is stopped?
For most drugs it takes 5 half-lives
Keloids vs. Hypertrophic Scars
• Keloids: extend beyond margins of original injury with claw-like extensions • Hypertrophic scars: confined to original margins of injury
DDx of Hyperpigmented Macules
• Purpura (e.g. solar, ASA, anticoagulants, steroids, hemosiderin stain) • Post-inflammatory • Melasma • Melanoma • Fixed drug eruption
ABCDE of Melanoma
Asymmetry Borders (irregular) Colour (variegated) Diameter (>6 mm) Evolution (over time)
Triggers for Atopic Dermatitis
• Irritants (detergents, solvents, clothing, water hardness) • Contact allergens • Environmental aeroallergens (dust mites) • Inappropriate bathing habits (long hot showers) • Sweating • Microbes (S. aureus) • Stress
PSORIASIS: Presentation and
Pathophysiology
- Pink papules/Plaques/Pinpoint bleeding (Auspitz sign)/Physical injury (Koebner phenomenon)
- Silver scale/Sharp margins
- Onycholysis/Oil spots
- Rete Ridges with Regular elongation
- Itching
- Arthritis/Abscess (Munro)/Autoimmune
- Stratum corneum with nuclei
- Immunologic
- Stratum granulosum absent
PSORIASIS: Triggers
• Physical trauma (Koebner phenomenon)
• Infections (acute streptococcal
infection precipitates guttate psoriasis)
• Stress (can be a major factor in flares)
• Drugs (systemic glucocorticoids, oral lithium, antimalarial drugs, interferon)
• Alcohol ingestion
Drug Hypersensitivity Syndrome Triad
- Fever
- Exanthematous Eruption
- Internal Organ Involvement
Risk Factors for Melanoma
no SPF is a SIN
- Sun exposure
- Pigment traits (blue eyes, fair/red hair, pale complexion)
- Freckling
- Skin reaction to sunlight (increased incidence of sunburn)
- Immunosuppressive states (e.g. renal transplantation)
- Nevi (dysplastic nevi; increased number of benign melanocytic nevi)
Initial Management of Any Patient in Shock
- ABCs
- IV fluids
- Oxygen
- Monitor (HR, BP, urine, mentation, O2 saturation)
- Control hemorrhage
NG Tube Contraindications
- Significant mid-face trauma
* Basal skull fracture
Unilateral, Dilated, Non-reactive
Pupil, think:
- Focal mass lesion
- Epidural hematoma
- Subdural hematoma
Signs of Increased Intracranial
Pressure (ICP)
- Deteriorating LOC (hallmark)
- Deteriorating respiratory pattern
- Cushing reflex (high BP, low heart rate, irregular respirations)
- Lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis)
- Seizures
- Papilledema (occurs late)
- Nausea/vomiting and headache
Signs of Basal Skull Fracture
- Battle’s sign (bruised mastoid process)
- Hemotympanum
- Raccoon eyes (periorbital bruising)
- CSF Rhinorrhea/Otorrhea
Treatment of Increased ICP
- Elevate head of bed
- Mannitol
- Hyperventilate
- Paralyzing/sedating agents
Seatbelt Injuries may Cause:
- Retroperitoneal duodenal trauma
- Intraperitoneal bowel transection
- Mesenteric injury
- L-spine injury
Reasons for Emergent Orthopedic Consultation
- Compartment syndrome
- Irreducible dislocation
- Circulatory compromise
- Open fracture
- Injury requiring surgical repair
Vascular injury/compartment syndrome is suggested by “The 6 Ps”:
- Pulse discrepancies
- Pallor
- Paresthesia/hypoesthesia
- Paralysis
- Pain (especially when refractory to usual analgesics)
- Polar (cold)
Acute Treatment of Contusions
RICE
Rest
Ice
Compression
Elevation
Where NOT to use local anesthetic with epinephrine:
Ears, Nose, Fingers, Toes and Penis
Gynecological Causes of Pelvic Pain:
- Ovarian cyst
- Dysmenorrhea
- Mittelshmerz
- Endometriosis
- Ovarian torsion
- Uterine fibroids/neoplasm
- Adnexal neoplasm
- PID + cervicitis
Signs of PE on CXR
Westermark’s sign: abrupt tapering of a vessel on chest film.
Hampton’s hump: a wedge-shaped infiltrate that abuts the pleura.
Causes of Syncope by System
HEAD, HEART, VeSSELS
Hypoxia/Hypoglycemia
Epilepsy
Anxiety
Dysfunctional brainstem
Heart attack Embolism (PE) Aortic obstruction Rhythm disturbance Tachycardia
Vasovagal Situational Subclavian steal!! ENT (glossopharyngeal neuralgia) Low systemic vascular resistance Sensitive carotid sinus
Treatment of Asthma
ASTHMA
Adrenergics (β-agonists) STeroids Hydration Mask (O2) Antibiotics (if concurrent bacterial pneumonia)
If patient has Wolff-Parkinson-White and is in AFib use […]. Avoid […] agents as this can increase conduction through bypass tract leading to cardiac arrest
use amiodarone or procainamide.
Avoid AV nodal blocking agents (adenosine, digoxin, diltiazem, verapamil, betablockers)
Causes of CHF Exacerbation (c.f. precipitants)
FAILURE
Forgot medication Arrhythmia (Dysrhythmia)/Anemia Ischemia/Infarction/Infection Lifestyle (e.g. too much salt) Upregulation of cardiac output (pregnancy, hyperthyroidism) Renal failure Embolism (pulmonary)
Acute Treatment of CHF
LMNOP
Lasix (furosemide) Morphine Nitroglycerine Oxygen Position (sit upright), Pressure (BiPAP)
Risk Factors for VTE
THROMBOSIS
Trauma, travel Hypercoagulable, HRT Recreational drugs (IVDU) Old (age >60) Malignancy Birth control pill Obesity, obstetrics Surgery, smoking Immobilization Sickness (CHF, MI, nephrotic syndrome, vasculitis)
Precipitating Factors in DKA
The 5 Is
Infection Ischemia Infarction Intoxication Insulin missed
4 Criteria for DKA Dx
- Hyperglycemia
- Metabolic acidosis
- Hyperketonemia
- Ketonuria
HELLP Syndrome (seen only in preeclampsia/eclampsia)
Hemolytic anemia
Elevated Liver enzymes
Low Platelet count
Causes of Acute Ataxia
UNABLE TO STAND
- Underlying weakness (mimic ataxia)
- Nutritional neuropathy (vitamin B12 deficiency)
- Arteritis/vasculitis
- Basilar migraine
- Labyrinthitis/vestibular neuronitis
- Encephalitis/infection
- Trauma (post-concussive)
- Other (rare genetic or metabolic disease)
- Stroke (ischemia or hemorrhage)
- Toxins (drugs, toluene, mercury)
- Alcohol
- Neoplasm/paraneoplastic syndrome
- Demyelination (Miller Fisher, Guillain Barré, MS)
(3) main types of Kidney Stones
- 80% Calcium
- 10% Struvite
- 10% Uric acid
High Risk Criteria for Infection of wounds
Wound Factors • Puncture wounds • Crush injuries • Wounds >12 h old • Hand or foot wounds • Wounds near joints
Patient Factors
• Immunocompromised
• Age >50 yr
• Prosthetic joints or valves
