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NCE Review Material > Valley Review Book > Flashcards

Valley Review Book Flashcards

1
Q

How much body water is in the ECF? ICF?

A

TBW = 42L
ECF (1/3)= 14L
ICF (2/3)= 28L

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2
Q

Components of phospholipids in the phospholipid bilayer

A 
Hydrophobic head (+ charge)
Hydrophilic tail
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3
Q

Major Intercellular Ions

A

K, Mg, PO4

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4
Q

Major extracellular ions

A

Na, Cl, Ca, HCO3

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5
Q

Examples of ligand gated ION channels

A

5-HT3, GABA(A), Glutamate

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6
Q

Examples of GPCR

A

Muscarinic ACh receptors & most adrenergic receptors

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7
Q

Function of Na-K ATPase (pump)

A

3 Na OUT and 2 K IN

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8
Q

Example of something that stimulates the Na-K Pump

A

Insulin and Beta-2 agonists (aka ritodrine, terbutaline)

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9
Q

The 4 major categories of receptors

A
  • Ligand gated ion Channels
  • GPCR
  • Calalytic
  • nuclear receptors
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10
Q

Effect of increased cAMP in cardiac muscle

A

Increases contractility (d/t inc Ca) (Beta-1)

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11
Q

Effect of increased cAMP in bronchial muscle

A

relaxes bronchial smooth muscle(d/t dec Ca) (Bronchodilation) (Beta 2)

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12
Q

What kind of receptors are beta adrenergic receptors

A

Gs: stimulate increased cAMP

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13
Q

Subunits of the GPCR

A

heterotrimeric:
Gamma
Beta
Alpha

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14
Q

List the common second messengers

A 
cAMP
cGMP
Ca
Calmodulin
Inositol Phosphate (IP3)
Diacylglycerol (DAG)
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15
Q

Metabolizes cAMP into AMP

A

PDE

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16
Q

cAMP simulates

A

Protein Kinase A

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17
Q

Activates cGMP

A

NO, NTG, Nitroprusside, Nitric Oxide Donors

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18
Q

Function of phospholipase C

A

create IP3

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19
Q

Normal serum osmolality

A

300 mOsm/kg (270-310)

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20
Q

Most electrolytes are reabsorbed in what part of the nephron?

A

Proximal Tubule

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21
Q

Site of action of carbonic anhydrase inhibitors

A

Proximal Tubule

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22
Q

Function of the descending loop of henle

A

Reabsorbs H2O (Impervious to Na)

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23
Q

Site of action of loop diuretics

A

Ascending Thick LOH

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24
Q

Function of Ascending Thick LOH

A

NA/K-Cl Pump

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25
Q

Site of action of ADH

A

Collecting Ducts

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26
Q

MOA of ADH

A

Inserts Aquaporins (V2) into the collecting duct to facilitate reabsorption of H2O

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27
Q

The site of action of aldosterone

A

collecting duct (primarily) and Late Distal Tubule

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28
Q

MOA of aldosterone

A

Facilitates Na (therefore H2O) reabsorption and K+ excretion

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29
Q

Site of action of hydrochlorothiazide (HCTZ)

A

Early Distal Tubule

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30
Q

Site of action of Spironolactone (K sparing)

A

Late Distal Tubule

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31
Q

The peritubular capillaries of the LOH

A

Vasa Recta

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32
Q

Components of the nephron found in the cortex

A

Glomeruli, proximal tubules, distal tubules

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33
Q

Components of the nephron found in the medulla

A

LOH and Collecting Ducts

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34
Q

CO delivered to kidneys

A

1.25L/min (25%)

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35
Q

What establishes the osmotic gradient in the medulla of the nephron?

A

Loop of Henle

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36
Q

Where is glucose reabsorbed in the nephron

A

Proximal Tubule

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37
Q

Where is vasopressin synthesizes? Released?

A

Synthesized in the paraventricular and supraoptic nuclei of the hypothalamus
Released from the posterior pituitary (Neurohypophysis)

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38
Q

What stimulates ADH release?

A

Increase plasma osmolarity (also Stress, hypotension Pain, CPAP, PEEP, VA)

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39
Q

Normal urine osmolarity

A

1200-1500 mOsm (AVP level low 0.5mg/kg/hr)

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40
Q

Urine osmolarity seen with high levels of AVP/ADH/Vasopressin

A

50-100 mOsm (AVP level 2-25 mg/kg/hr)

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41
Q

Causes of SIADH

A

Intracranial Tumor, Hypothyroidism, Porphyria, small Oats cell carcinoma of the lung

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42
Q

the major determinant fo extracellular fluid volume

A

Sodium content

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43
Q

Most important HORMONE for regulation of extracellular fluid volume

A

Aldosterone

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44
Q

Things that increase Na excretion

A

increased GFR, increased ANP, decreased aldosterone

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45
Q

Things that decrease Na excretion

A

decreased GFR, increased aldosterone, decreased ANP

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46
Q

Where is aldosterone produced

A

Zona Glomerulosa of the adrenal cortex

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47
Q

Where in the nephron is most of the sodium reabsorbed

A

proximal tubule (active process requiring energy)

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48
Q

Where in the nephron is most of the potassium reabsorbed?

A

Proximal Tubule 60%; Ascending LOH 25%

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49
Q

What factors increase K+ excretion?

A
  • Aldosterone secretion
  • Increased Distal Tubular flow rate: Increased flow rate seen with Lasix
  • BiCarbonate Concentration in Tubular Fluid: increase urine alkalinity increases K+ excretion
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50
Q

List some loop diuretics

A 
(ide)
furosemide
bumetanide
Torsemide
Ethacrynic acid
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51
Q

What is the target for loop diuretics?

A

Inhibition of the Na-K-2Cl symporter: inhibit the reabsorption of these ions (located in the Thick Ascending LOH)

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52
Q

Side effects of loop diuretics

A

Hypokalemia, Fluid volume deficit, Otho Hypo, reversible deafness

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53
Q

MOA of thiazide diuretics

A

Inhibit Na reabsorption in the early distal tubule

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54
Q

Examples of Thiazide diuretics

A

Chlorothiazide, Hydrochlorothiazide, Chlorthalidone, Metolazone

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55
Q

MOA of potassium-Sparing Diuretics

A

Decrease Na reabsorption form the late distal tubule and collecting duct

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56
Q

MOA of Spironolactone

A

Competitively inhibits aldosterone:

- therefore inhibits sodium reabsorption in the late distal tubule and collecting duct

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57
Q

Side effects of thiazide diuretics

A

Hypokalemia due to increased K+ secretion

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58
Q

Side effects of potassium-sparing diuretics

A

Hyperkalemia

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59
Q

MOA of carbonic anhydrase inhibitor

A

Inhibits the enzyme carbonic anhydrase in the proximal tubule which inhibits bicarb reabsorption

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60
Q

Example of carbonic anhydrase inhibitor

A

Acetazolamide

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61
Q

Actions of carbonic anhydrase inhibitors

A

Dec Bicarb reabsorption
Dec sodium reabsorption
-> these cause diuresis
-> hyperchloremic metabolic acidosis

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62
Q

One of the principal therapeutic uses of acetazolamide

A

Decrease IOP by decreasing formation of aqueous humor

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63
Q

Side effects from osmotic diuretics

A

Hypokalemia (K+ secretion is increased secondary to flow through the distal tubule and collecting duct)

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64
Q

Prerenal causes of perioperative oliguria

A

Decreased RBF
Hypovolemia
Decreased CO

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65
Q

Renal causes of perioperative oliguria

A

Renal Tubular Damage (acute tubular necrosis)
Renal Ischemia
Nephrotoxic Drugs
Release of HgB or Myoglobin

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66
Q

Postrenal causes of perioperative oliguria

A

Obstruction
Bilateral ureteral obstruction
Extravasation due to bladder rupture

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67
Q

Tests to differentiate prerenal from renal failure

A 
Renal failure (Aka acute tubular necrosis, ATN)) has high fractional excretion of sodium (FENa) > 0.03 (3%)
Prerenal failure FENa < 0.01 (1%)
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68
Q

Normal GFR

A

125 ml/min

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69
Q

GFR for renal insufficiency

A

12-50 mL/min

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70
Q

Pathophysiology of CKD

A 
Chronic anemia
Pruritus
Coagulopathies 
Hyperkalemia
Hypocalcemia
Hypermagnesemia
HTN
Pericardial Dz
Metabolic acidosis
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71
Q

Treatment options for hyperkalemia

A 
give Ca
Give HCO3
Hyperventilate
Loop Diuretics
Give insulin-glucose
Administer B2 agonist (terbutaline)
Kayexelate
Dialysis
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72
Q

Where is most of the HCO3 absorbed?

A

In the proximal Tubule (90%)

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73
Q

Formula for anion Gap

A

([Na]+[K])-([Cl]+[HCO3])

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74
Q

Normal anion gap

A

12mM

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75
Q

What is the definition of anion gap?

A

total of unmeasured anions (-) such as Proteins, HPO4, & SO4

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76
Q

Ion responsible for RMP in nerve? Depolarization? REpolarization?

A 
RMP = K
Depolarization= Na INTO cell
Reploarization = K OUT of cell
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77
Q

Motor neurons are what kind of nerve fiber?

A

A-alpha fibers (Large, myelinated, fast conduction velocity)

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78
Q

Receptors found in the motor end plate

A

Nm (nicotinic ACh receptors)

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79
Q

What affect does ACh binding to PREsynaptic Nicotinic receptors in the NMJ have?

A

Positive feedback: increases release of ACh

This accounts for fade seen with NDMB and phase II blocks with succ

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80
Q

Ions that diffuse across NMJ as a result of ACh binding to nicotinic receptors

A 
Ca and Na IN
K OUT (Hyperkalemia with succ)
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81
Q

What subunit does ACh (and succ) bind to on the Nicotinic receptor in the NMJ

A

2 Alpha subunits (one ACh to each)

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82
Q

MOA of NDMB

A

Competitive inhibition of ACh- binding sites (Alpha subunits) in the NMJ

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83
Q

How long after succ does myalgia occur?

A

24-48 hours

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84
Q

Characteristics of NDMBs

A 
aka Phase II Block:
Competitive inhibition
Fade after high frequency stimulation
Exhibits post-tetatinc facilitation 
Antagonized by anticholinesterases
NO fasciculations
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85
Q

Metabolism of succinylcholine

A

Plasma cholinesterase ( false, pseudo, non-specific, or type-II)

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86
Q

Characteristics of depolarizing muscle blockers

A

AKA Phase I Block:

  • decreased single twitch hight
  • response to high frequency stimulation is maintained
  • minimal or No fade after TOF
  • Antagonized by non depolarizers
  • potentiated by anticholinesterase
  • Fasciculations precede block
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87
Q

Intermediate action NMBs

A 
(30-45min)  (CAR-V)
Cisatracurium
Atracurium
Rocuronium
Vecuronium
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88
Q

Define DOA of NMBs

A

The time from injection to return of 25% twitch height

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89
Q

The amino steroid NMB

A

“curonium”
Rocuronium
Vecuronium
Pancuronium

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90
Q

The benzylisoquinoline NMB

A

“curium”
Atracurium
Cisatracurium
Mivacurium

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91
Q

What are some properties of NMBs?

A

100% ionized at physiologic pH
VERY highly protein bound
Do NOT cross BBB/Placenta (d/t ionization)
excreted in urine (d/t ionization)

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92
Q

NMB with primarily biliary excretion

A

Vec and Roc

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93
Q

Metabolism is the primary route of elimination for which NMBs

A

Succ, atracurium, Cis, mivacurium

the “curiums” + Succ

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94
Q

NMB which is metabolized by hofmann elimination

A

Cisatricurium

Atracurium ( and ester hydrolysis by non-specific esterase’s)

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95
Q

NMB’s that elicit the release of histamine

A

Succ, Miv, atra …

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96
Q

Why does succinylcholine elicit bradycardia

A

Mimics the action of ACh at muscarinic receptors in the SA node

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97
Q

NMB that is a direct vagolytic

A

Pancuronium ( aka antimuscarinic actions)

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98
Q

Potassium changes seen with succinylcholine

A

Increases plasma K by 0.5 mEq/L in healthy

5-10 mEq/L in Burn, trauma or head injury

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99
Q

Why is the twitch response greater on the paralyzed size of a hemiplegic patient?

A

Due to up-regulation of ACh receptors

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100
Q

Signs of malignant hyperthermia

A

Increased EtCO2, Pyrexia, Tachycardia, Cyanosis, Rigidity, or master spasm (trismus)

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101
Q

Serum abnormalities seen in MH

A

increased H, K, Ca, and CO2

Decreased O2

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102
Q

What defect is present that causes MH

A

Mutation in ryanodine receptor (RyR1)

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103
Q

One of the earliest, most sensitive and specific signs of MH

A

Elevation in EtCO2

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104
Q

Antibiotics that increase the degree of blockade with NDNMBs

A

Neomycin, streptomycin

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105
Q

LAs that increase the degree of blockade with NDNMBs

A

Amides (dec dose by 1/3 to 1/2)

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106
Q

Effect of VAA on degree of blockade from NDNMBs

A

increased blockade

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107
Q

Lithiums effect on NMBlockade

A

increases degree of block

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108
Q

Effect of myasthenia graves on succinylcholine

A

block DECREASED

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109
Q

Clinical response to 75-80% blockade

A

TV > 5mg/kg; single twitch as strong as baseline

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110
Q

Clinical response for 90% blockade

A

ABD relaxation adequate for most and surgeries (1 twitch on TOF)

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111
Q

Clinical response for 70-75% Blockade

A

No palpable fade, sustained tetany for 5 seconds, VC at least 20 mL/kg ( reliable indicator for recovery)

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112
Q

Clinical response for 50% blockade

A

Neg insp test -40cm H2O, Head Lift for 5 seconds, sustained strong hand grip, SUSTAINED BITE, (reliable indicator of recovery

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113
Q

When does a phase II block occur with succinylcholine

A

Treatment with higher doses, and/or prolonged exposure (this is diagnosed by the presence of FADE)

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114
Q

The predominant neurotransmitter in the periphery

A

ACh

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115
Q

Where is NE released in the periphery

A

From all sympathetic POST-ganglionic nerves (the exception is sweat glands)

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116
Q

The adrenal medulla is innervated by

A

Sympathetic Preganglionic Neurons that release ACh

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117
Q

Where are muscarinic receptors found

A

peripherally in tissues innervated by parasympathetic postganglionic neurons

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118
Q

List the nerve fiber types and their transmitted sensation

A 
A-alpha: Muscle contraction &amp; proprioception
A-beta: Proprioception, touch, pressure
A-gamma: Skeletal muscle tone
A-delta: Pain, Temperature, Touch
B-Fibers: Autonomic
sC-Fibers: Autonomic
dC-Fibers: Pain, Temperature, Touch
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119
Q

Origin of the sympathetic nervous system

A

Thoracolumbar: T1-L2 or T1-L3

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120
Q

Origin of cardiac accelerators

A

T1-T4

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121
Q

Origin of the stellate ganglion

A

Inferior cervical and first thoracic ganglia

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122
Q

Signs and symptoms of Horner Syndrome

A 
(Stellate ganglion block)
Ipsilateral Miosis
Ptosis
Enophthalamos
Flushing
Increased Skin Temp
Anhydrosis
Nasal Congestion
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123
Q

All sympathetic preganglionic fibers pass through the _______

A

White Ramus located from T1-L2

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124
Q

Function of grey rami

A

Allow for coordinated mass discharge of the SNS

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125
Q

What is the function of presynaptic Alpha 2 receptors

A

Negative feedback for the release of NE

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126
Q

Pathway for the synthesis of NE

A

Tyrosine-> L-Dopa-> Dopamine (DA) -> NE -> Epi

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127
Q

What is the % of NE and Epinephrine in the adrenal medulla?

A

20% NE; 80% Epi

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128
Q

What metabolizes NE

A

MAO in the nerve terminal; COMT in the plasma

80% of NE is not metabolized but undergoes reuptake from the synaptic cleft

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129
Q

Drugs to avoid in patients taking MAOI’s

A

Indirect acting sympathomimetics (ephedrine) and Meperidine: They may lead to hypertensive crisis Meperidine > ephedrine

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130
Q

Effect of Beta 1 stimulation on the heart

A

Increased HR(SA node) , Contractility (muscle fibers), and conduction speed (AV node)

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131
Q

Effect of Beta 2 stimulation on the lungs

A

increased secretions and bronchodilation

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132
Q

Beta receptor of the kidney

A

Beta 1: increases renin release -> Increase BP

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133
Q

Beta receptor of the liver

A

Beta 2: Gluconeogenesis and glycogenolysis

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134
Q

Effect of Beta stimulation on the uterus

A

Beta 2: relaxation (Ritodrine)

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135
Q

Resting BP is controlled mainly by _______

A

Renin (85%)

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136
Q

Where is renin released

A

Juxtaglomerular cells of the AFFERENT arteriole

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137
Q

Function of Renin

A

Converts angiotensinogen to Angiotensin I

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138
Q

Where is ACE found

A

On the endothelial surface of capillaries especially in the PULMONARY Capillaries (this is why it causes cough)

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139
Q

The two most important stimuli for aldosterone release

A

Angiotensin II and High serum potassium

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140
Q

Function of aldosterone

A

Increase potassium excretion and sodium reabsorption (Promotes volume expansion)

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141
Q

What causes Renin release

A

Dec RBF

Inc SNS stimulation or [Cl-]

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142
Q

Why do we see a decrease in MAP and Diastolic BP with low dose EPI

A

Beta 2 mediated vasodilation (decreased SVR)

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143
Q

Anatomical landmark for T4

A

Nipple

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144
Q

What are some side effects of ritodrine?

A

Hyperglycemia, Hypokalemia, tachycardia

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145
Q

Origin of the parasympathetic nervous system

A

Craniosacral
Cranial Nerves: oculomotor CN III, facial CN VII, glossopharyngeal CN IX, and Vagus CN X
Sacral nerves S2-S4

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146
Q

Drug that can cause cholinergic crisis

A

Physostigmine (i.e. excess acetylcholine)

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147
Q

Symptoms of cholinergic crisis

A 
DUMBBELL STPD (accessive AcH)
Diarrhea, Urination, Miosis, Bradycardia, Bronchoconstriction, Emesis, Lacrimation, Lethargy, Salivation, & Seizures. 
Treatment Atropine, Pralidoxamine, and Diazepam
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148
Q

Which antimuscarinic least crosses the BBB

A

Glycopyrolate (d/t charged ammonium group)

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149
Q

Signs of anticholinergic syndrome

A

delirium, dry mouth, flushed skin, blurred vision, tachycardia, rash, hypotension

(mad as a hatter, Dry as a bone, Red as a beet, Blind as a bat….)

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150
Q

Treatment for anticholinergic syndrome

A

Physostigmine

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151
Q

Bronchodilation is promoted by stimulation of which receptor

A

Beta 2 Adrenergic

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152
Q

MOA of leukotriene antagonists?

A

competitive antagonists of leukotriene

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153
Q

What is the function of the reticular activating system (RAS)

A

functions to maintain alert/awake state

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154
Q

What is the purpose of SSEP monitoring

A

Monitor for posterior chord ischemia or brain ischemia

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155
Q

Site of SSEP stimulation at the ankle

A

Tibial Nerve

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156
Q

Indicators of damage in nerve being monitored surging SSEP

A

DECREASE in amplitude

INCREASE in latency

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157
Q

Motor evoked potentials are used to monitor for

A

Ischemia to the anterior (ventral) cord

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158
Q

BAEP monitor the integrity of

A

CN VIII

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159
Q

VEPs monitor the integrity of

A

The optic nerve CN II

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160
Q

Order the evoked potentials according to their sensitivity to anesthetic agents

A

VEP (Very)
SSEP (Somewhat)
BAEP (Barely)

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161
Q

Where is the substantial gelatinous located

A

In Lamina II & III of the dorsal horn

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162
Q

Major neurotransmitter of A-delta fibers

A

Glutamate which binds to AMPA and NMDA

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163
Q

Major neurotransmitter for C Fibers

A

Substance P which binds to NK-1 receptors

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164
Q

What is the function of the dorsolateral tract

A

(descending tract) modulates pain

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165
Q

What is the function of the lateral spinothalamic tract?

A

Carry pain and temperature

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166
Q

What is the function of the ventral spinothalamic tract

A

crude touch and pressure

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167
Q

Root associated with clavicle dermatome

A

C4

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168
Q

Root associated with nipple dermatome

A

T4

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169
Q

Root associated with xiphoid dermatome

A

T6

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170
Q

Root associated with umbilicus dermatome

A

T10

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171
Q

Root associated with tibia dermatome

A

L4-L5

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172
Q

Root associated with perineum dermatome

A

S2-S5

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173
Q

What decreases the release of substance P from C-Fibers

A

Enkephalin (Modulates Pain)

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174
Q

Spinal opioid analgesia is mediated through what receptor

A

Mu-2 primarily (S in Spinal looks like 2)

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175
Q

Name the hydrophilic opioids

A

Morphine

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176
Q

Name the lipophilic opioids

A

fentanyl, alfentanil, sufentanil

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177
Q

Site of action of IV opioids? Intrathecal/Epidural?

A
  • IV: Periventricular/periaqueductal grey

- Spinal/Epidural: Substantia Gelatinosa

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178
Q

Supraspinal analgesia is mediated by

A

Mu-1 (primarily), Delta, and Kappa receptors

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179
Q

Side effects from Mu-1 receptors

A

Bradycardia and Euphoria

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180
Q

Opioid receptor responsible for physical dependence and respiratory dependence

A

Mu-2

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181
Q

Kappa receptors are responsible for

A

sedation and dysphoria

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182
Q

Competitive opioid antagonist

A

Naloxone (narcan)
Naltrexone (trexate)
Nalmefene

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183
Q

White rami carry _______

A

myelinated sympathetic preganglionci neurons

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184
Q

List the Cranial Nerves

A 
Oh Oh Oh To Touch And Feel A Girls Vagina Ahh Heaven
Olfactory
Optic
Oculomotor
Tochlear
Trigeminal
Abducens
Facial
Acoustic (Vestibulococclear)
Glossopharyngeal
Vagus
Accessory
Hypoglossal
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185
Q

Site of formation of CSF

A

Choroid Plexus of the Lateral, Third, and Fourth ventricles

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186
Q

Site of reabsorption of CSF

A

Arachnoid Villi and arachnoid granulations (both are part of the arachnoid membrane

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187
Q

List the flow of CSF in the brain

A

Choroid plexus -> Lateral Vent -> Foramina of Munro -> Third Ventricle -> Aqueduct of Sylvius -> Fourth vent -> Foramina of Lusaka & Magendie -> Subarachnoid Space -> Brain -> Arachnoid Villi

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188
Q

Major vessels that supply the circle of willis

A

Internal Carotid arteries and the basilar artery

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189
Q

What is stump pressure

A

measures the pressure transmitted through the circle of willie back to the carotid artery

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190
Q

Desired stump pressure

A

> 40 mmHg

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191
Q

Effects of VAA on CBF? CMRO2

A

Dec CMRO2

Increased CBF

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192
Q

Effects of IV anesthetics in CBF & CMRO2?

A

Decrease both (Except ketamine which increases both)

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193
Q

Arterial blood supply to the spinal cord

A

(1) one anterior spinal artery
(2) two posterior spinal arteries
(3) small segmental spinal arteries

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194
Q

Major source of blood to the spinal cord

A

75% via the anterior spinal arteries

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195
Q

Origin of the artery of adamkiewicz

A

From the left side in the lower thoracic (T8-T12 75%) or upper lumbar region (L1-L2 10%)

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196
Q

Decorticate rigidity is cause by

A

Damage to the brain above the cerebellum and brainstem aka supratentorial (upper ext flexion lower ext extension with feet turned medial)

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197
Q

Decerebrate rigidity is caused by

A

Extensive damage to the brainstem or cerebral lesions that compress the thalamus and brainstem

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198
Q

Mechanical ventilation is required for which form of rigidity

A

Decerebrate d/t damaged brainstem which contains vital responses centers

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199
Q

What is the normal ICP?

A

< 15 mmHg

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200
Q

Components of Cushing’s triad

A

Increased BP (MAP)
Decrease in HR
Irregular respiration

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201
Q

Cushing’s triad is the result of

A

increased intracranial pressure

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202
Q

What is the correct placement of the single orifice catheter

A
  1. 0 cm ABOVE the junction of the SVC and atrium

2. 0cm Below for MULTI orifice catheters

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203
Q

At what age does the anterior fontanelle close

A

18 months

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204
Q

Which fontanelle closes last

A

Posterolateral

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205
Q

The P wave correlates with what cardiac event

A

Atrial depolarization

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206
Q

The PR Interval correlates with what cardiac event

A

Atrial systole & AV nodal delay

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207
Q

The QRS Complex correlates with what cardiac event

A

Ventricular Depolarization (and atrial repolarization)

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208
Q

The QT interval correlates with what cardiac event

A

Ventricular systole

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209
Q

The T wave correlates with what cardiac event

A

Ventricular depolarization

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210
Q

Phases in the SA node action potential

A

Phase 4: Diastole (K+ OUT & some Na IN) (Ca is in the last 1/3)
Phase 0: Slow depolarization (Ca & Na INTO cell)
Phase 3: Depolarization (K+ OUT of the cell)
Phase 4: Diastole (Na/K Pump restores Na and K lvls)

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211
Q

On what phase for the nodal action potential do CCB work?

A

They slow the rate of Phase 4 depolarization

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212
Q

On what phase of the cardiac action potential do CCB work?

A

The work on Phase 2 (Plateau)

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213
Q

RMP of cardiac ventricular cells

A

-90 mV

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214
Q

What happens when gates Na channels are inactivated?

A

Cell enters the absolute refractory period

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215
Q

Diagnosis of RBBB on the ECG

A

Look at leads V1 & V6
V1 = rSR’ (broad R’ wave)
V6= qRS

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216
Q

Diagnosis of LBBB on the ECG

A

Look at leads V1 & V6
V1= Loss of R wave
V6= Wide R wave with a notch

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217
Q

Diagnosis of 1st degree heart block

A

PR interval > 0.20 seconds

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218
Q

Diagnosis of 2nd degree AV block Type I

A

Progressive increase in PR interval until a beat is skipped

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219
Q

Diagnosis of 2nd degree AV block Type II

A

Appearance of a NON-CONDUCTED P-wave (No progressive prolongation of PR)

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220
Q

Diagnosis of 3rd Degree AV block

A

Independent P-wave (atrial) and QRS wave (Ventricular) activity

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221
Q

What is the cause of Heart rate increase from Right atrial stretching

A

Bainbridge Reflex

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222
Q

Indication of myocardial ischemia on ECG

A

Subendocardial ischemia = ST depression > 1mm

Transmural Injury = ST elevation > 1mm

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223
Q

What part of the ventricular action potential correlates with the QRS complex?

A

Phase 0

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224
Q

What part of the ventricular action potential correlates with the T wave?

A

Phase 3

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225
Q

What part of the ventricular action potential correlates with the QT Interval?

A

Phase 2

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226
Q

EKG changes for hyperkalemia

A

Peaked or tented T waves

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227
Q

EKG changes for hypokalemia

228
Q

HR for paroxysmal atrial tachycardia (PAT)

A

HR 150-250 bpm

229
Q

Diagnostic criteria for WPW

A

Presence of Delta wave

can induce V-Fib

230
Q

Leads indicating obstruction to posterior descending artery

A

V1-V2 (posterior)

231
Q

Leads indicating obstruction to RCA

A

II, III, aVF (Inferior walls)

232
Q

Leads indicating obstruction to LAD

A

I, aVL, V1-V4

233
Q

Leads indicating obstruction to circumflex artery

A

I, aVL, V5-V6

234
Q

Best leads for monitoring for ST depression or elevation

A

V3-V5, III, aVF (In that order)

235
Q

Best lead to monitor narrow QRS complex rhythms

A

Lead II (arrhythmia)

236
Q

Mnemonic for where in the adrenal cortex hormones are produced?

A

Glomerulosa / Aldosterone (mineralcorti)
Fasciculata / Cortisone (Glucocorticoid)
Reticularis / Testosterone
(GFR) / (ACT)

237
Q

Things that determine Stroke Volume

A

preload, afterload, and contractility

238
Q

Preload is determined by what 3 factors

A

intravascular volume, venous tone, and ventricular compliance

239
Q

The major determinant of intravascular volume

A

Sodium (Na) in the body

240
Q

What represents preload and afterload in the frank starling law

A 
Preload = force
Afterload= Tension
241
Q

What causes concentric hypertrophy

A

Chronic untreated HTN
Chronic AS
Coarctation of the aorta

242
Q

What causes eccentric hypertrophy

A

Chronic AR
Chronic MR
Morbid obesity

243
Q

Where does systole begin/end on the PV loop?

A

Begins at Point B (Bottom RT) and ends Point D (top LT)

244
Q

When does Diastole begin/end on the PV Loop?

A

Begins at point D (top LT) and ends Point B (bottom RT)

245
Q

What provides evidence if increased EDV?

A

Increased PCWP

246
Q

How does AS affect the PV Loop?

A

PV loop shifts upwards (higher pressures)

247
Q

How does MS affect PV loop?

A

Shorter and narrower and shifted to the left (lower EDV)

248
Q

What does the area under the arterial pressure curve represent?

A

Area/time = MAP

249
Q

How does pressure change as you move into the periphery?

A

Increases as you move distally (greatest at the dorsalis pedis)

250
Q

Most accurate reading of arterial pressure

A

Use the area under the AORTIC pressure curve

251
Q

Examples of direct acting vasodilators

A

Hydralazine, Diazoxide, NTG, Nitroprusside (arterial and venous)

252
Q

Effect of PDEi’s

A

Block breakdown of cAMP leading to increased myocardial contractility, and decreased SVR

253
Q

What is adenosine used for?

A

To treat paroxysmal supra-ventricular Tachycardia (example: WPW)

254
Q

What is SAM seen on ECHO

A

Systolic Anterior Motion (SAM) of the mitral valve leading to LVOT obstruction (normally seen with hypertrophic Cardiomyopathy)

255
Q

What are the signs and symptoms of AS?

A

Angina , syncope, and dyspnea

256
Q

Indicator of hypertrophic cardiomyopathy

A

Bisferiens pulse (an aortic waveform with two peaks per cardiac cycle, a small one followed by a strong and broad one)

257
Q

What is the drug of choice for treatment of hypotension in patients with hypertrophic cardiomyopathy?

A

Phenylephrine (does not increase contractility)

258
Q

The most common genetic CV disease of all ages

A

Hypertrophic cardiomyopathy

259
Q

Management of Aortic Regurgitation

A

Fast: Increase HR
Full: volume (increase preload)
Forward: decrease afterload

260
Q

Things that cause AR

A

Aortic annulus dilation: Syphilis, ankylosing spondylosis, RA, & psoriatic arthritis
Also infective endocarditis, trauma, or aortic dissection

261
Q

When is AR considered severe?

A

Severe regurgitant volume is >60% of SV
Moderate 30-60%
Mild <30%

262
Q

Manifestation of Chronic AR

A 
Diastolic murmur at Lt sternal border
WIDENED pulse pressure
Decrease diastolic pressure
Bounding peripheral pulses
MR
263
Q

When is MR considered Mild, Moderate, or Severe?

A

MR RULE OF 1/3
Severe regurgitant volume is >60% of SV
Moderate 30-60%
Mild <30%

264
Q

Murmur heard with MR

A

Blowing HOLOSYSTOLIC murmur best heard at the APEX

265
Q

Most common valvular lesion in the US

A

Aortic Stenosis

266
Q

Most common cause of LVOT

267
Q

Normal Aortic valvular area

A

2.3-3.5 cm2

268
Q

Valve area for severe and critical AS?

A

Severe 0.8-1.0 cm2

Critical 0.5-0.8 cm2 and a transvalvular gradient of 50 mmHg

269
Q

Murmur for aortic stenosis

A

Systolic murmur at the right second intercostal space with transmission into the neck

270
Q

Drugs to AVOID in patients with AS

271
Q

Valve area for symptomatic MS

A

s/s begin at area of 1.5cm2 or less (normal is 4-6cm2)

272
Q

Adhesion of platelets to damaged vascular wall requires

A

Von Willenbrand Factor (VIII:vWF); functions as an anchor

273
Q

Activation of platelets requires

A

Thrombin (Factor IIa)

274
Q

Aggregation of platelets requires

A

ADP & Thromboxane a2 (TxA2) which uncover fibrinogen (Factor I) receptors

275
Q

What is required for the production of fibrin

A

Extrinsic, intrinsic, and final common pathway

276
Q

Steps involved in primary hemostasis

A

Platelet adhesion
Activation of platelets
Aggregation of platelets
Production of fibrin

277
Q

Average lifespan of platelets

278
Q

Where is vWF produced and released?

A

in the endothelial cells

279
Q

The most common inherited coagulation defect

A

Von Willebrands disease

280
Q

First line treatment for Von Willebrands disease

A

Desmopressin (DDAVP) 0.3 mcg/kg IV over 10-20 min

(second line treatment is cryoprecipitate or purified factor VIII

281
Q

Problem with treatment of Type 2B Von Willebrands disease with DDAVP

A

Causes thrombocytopenia

282
Q

What does cryoprecipitate contain

A

Factor VIII, Factor I (fibrinogen) & Facto XIII (fibrin Stabalizing factor)

1,8,13

283
Q

ADP receptor antagonist

A

Clopidrogel
Prasurgel
Ticagrelor

284
Q

GPIIb/IIIa receptor antagonist

A

Block fibrinogen receptor:
Eptifibatide (d/c 24 hours b4 sx)
Abciximab (d/c 72 hours b4 sx)
Tirofiban (d/c 24hours b4 sx)

285
Q

Vitamin K dependent clotting factors

A 
Prothrombin (II)
Proconvertin (VII)
Christmas factor (IX)
Factor (X) 
(also protein C &amp; S)
286
Q

Cross-linking fibrin strands requires

A

factor XIIIa (fibrin stabilizing factor)

287
Q

Clotting Factors of the Extrinsic pathway

A

Factor III (TF) activates factor VII which activates factor X (along with cofactor IV i.e calcium)

3 , 7, 10

288
Q

Clotting Factors of the Intrinsic pathway

A

(XII, XI, IX, VIII) (Remember 12 + 11.98)

XII -> XI -> IX also VIII;Ca

289
Q

Clotting Factors of the Final Common pathway

A

(XIII, I, II, V, X) (5 and Dime for I or II dollars on the XIII)
X activated + V activated -> activate factor II -> activates factor XIII -> stabilized fibrin

290
Q

What measures the intrinsic pathway?

A

aPTT (LONG pathway)

ACT

291
Q

What measures the extrinsic pathway?

A

PT (SHORT pathway)

INR

292
Q

Factor 10 inhibitors

A 
Drugs with  AN "X":
FundaparinuX
RivoraXaban
ApiXaban
AndeXXa
LMWH
293
Q

Factor II inhibitors

A

Dabigatron
Argatroban
Bivalirudin

294
Q

What is hemophilia A and how is it treated?

A
  • Factor VIII:C deficiency
  • Second most common inherited disorder
  • Treated with FFP & Cryo but preferred is Factor VIII Concentrate
295
Q

What is hemophilia B and how is it treated?

A

Factor IX Deficiency (Christmas Factor)

Treated with Factor IX

296
Q

Most important clue to bleeding disorder?

A

patient history

297
Q

What procoagulants are missing in FFP?

298
Q

How does one unit of pRBC affect Hgb?

A

Increases HgB 1g/dL

Increases Hct 3-4%

299
Q

How does one unit of platelets affect platelet count?

A

increases by 5,000-10,000/mm3

300
Q

How does heparin work?

A

By increasing effectiveness of antithrombin by 1,000x

301
Q

How does antithrombin work?

A

Binds mostly factor II and X therefore neutralizing the final common pathway

302
Q

Patients with antithrombin deficiency

A

Liver Dz

Nephrotic syndrome

303
Q

Normal bleeding time

A

3-10 seconds

304
Q

Normal PT

A

12-14 seconds

305
Q

Normal PTT

A

25-35 seconds

306
Q

Normal ACT

A

80-150 seconds

307
Q

Indicates adequate heparinization

A

> 400-450 Seconds

308
Q

Function of plasmin

A

Breakdown fibrin

309
Q

Where is tPA produced

A

by endothelial cells (Stimulated by thrombin and venous stasis)

310
Q

Fibrinolytic produced by B-Hemolytic streptococci

A

Streptokinase

311
Q

MOA of Amicar

A

Plasmin inhibitors (also Aprotinin)

312
Q

Lab findings in DIC

A 
Low PLT (<50,000)
Low Fibrinogen (<150)
Low Prothrombin
Decrease levels of factor V, VIII, and XIII
Increased fibrin split products
313
Q

Most common cause of an isolated high PT

A

Liver disease

314
Q

Observation when there is B/L RLN damage

A

Both cords are floppy and in an intermediate position. Can cause respiratory distress and intubation is needed
(Aphonia, and airway Obstruction)
(Hoarsness Unilateral & Stridor Bilateral)

315
Q

What is the normal P50 on the oxyhemoglobin dissociation curve?

A

26-28 mmHg

316
Q

An SpO2 of 70, 80, & 90% correlate with what PaO2?

A 
70% = 40 mmHg
80% = 50 mmHg
90% = 60 mmHg
317
Q

What does the Steep portion of the oxyhemoglobin dissociation curve represent?

A

The unloading of oxygen at tissues

318
Q

Things that cause a leftward shift in the oxyhemoglobin dissociation curve?

A 
(Left =Love)
Dec P50
Decrease temp,
Dec PCO2
Dec 2,3 DPG
Dec [H+] (Inc pH/Alkalosis)
HbF
Carboxyhemoglobin
Methemoglobin
319
Q

Things that cause a Rightward shift in the oxyhemoglobin dissociation curve?

A 
(Right = Release)
Inc P50
Inc temp
Inc PCO2
Inc 2,3 DPG
Inc [H+] (Dec pH/Acidosis)
Maternal Hb
Sickle cell (HbS)
320
Q

How to calculate dissolved O2 in the blood?

A

0.003 x PaO2

321
Q

What is the Haldane effect?

A

Describes how changes in there PP of O2 in the blood influences the CO2 dissociation curve

322
Q

How does PO2 affect the CO2 dissociation curve?

A

Inc in PO2 shifts it down and to the right

Dec in PO2 shifts it up and to the left

323
Q

How is CO2 carried in the blood?

A

HCO3 (~90%)

also dissolved or chemically bound to proteins

324
Q

What converts CO2 into HCO3?

A

Carbonic anhydrase

325
Q

What is a Chloride shift?

A

The exchange of HCO3 for Cl (aka the Hamburger Shift)

326
Q

What is the biggest driver for ventilation?

A

[CO2] but [O2] is the Strongest driver aka hypoxic drive

327
Q

The heiring-breur reflex is most active in what population?

328
Q

The central chemoreceptors are stimulated by

A

Increase H+

329
Q

Carries sensory input from the carotid bodies

A

Glossopharyngeal nerve

330
Q

The respiratory pacemaker of the medulla

331
Q

The function of the VRG

A

both inspiration and expiration

332
Q

What is the function of the pneumotaxic center (PnC)?

A

Shuts OFF inspiration

333
Q

What is the function of the Apneustic center (ApC)

A

Promotes a pattern of maximal lung inflation with brief expiratory gasps

334
Q

Convert 1 atm into mmHg and cm H2O

A

1 atm = 760 mmHg = 1,033 cmH2O

335
Q

What is the Normal V/Q?

A

V/Q= MV/CO = 4/5 = 0.8 L/min

336
Q

What happens in the patient in the lateral position when they are awake vs anesthetized?

A

Awake= Non-dependent lung DEC vent/DEC perfusion
Dependent lung INC vent/INC perfusion
Anesthetized= Nondependent Lung INC vent/DEC perfusion; Dependent Lung DEC volume/INC perfusion

337
Q

V/Q that indicates a shunt? deadspace?

A 
Shunt = V/Q < 0.8
Deadspace = V/Q > 0.8
338
Q

How to determine if there is a V/Q mismatch?

A

there will be an increases A-a O2 gradient

339
Q

Normal A-a O2 Gradient

340
Q

Normal a-A CO2 gradient

341
Q

Ventilation strategies for one lung ventilation

A

CPAP the Non-Dependent Lung (Most affective)

PEEP the Dependent Lung

342
Q

What happens in each of the West Lung Zones?

A

Zone 1 = PA>Pa>Pv = Collapse (Deadspace)
Zone 2 = Pa>PA>Pv= Waterfall (matched vent and perf)
Zone 3= Pa>Pv>PA= Distention (Shunt)
Zone 4= Pa>Pisp>Pv>PA=Inc Interstitial pressure

343
Q

Where is the PA catheter placed?

344
Q

Why do we preoxygenated?

A

To fill FRC with O2 and increase apnea time

345
Q

PFT results that indicate Obstructive disease

A

Decreased FEV1/FVC (i.e < 0.7)

346
Q

Lung volumes not directly measured by spirometric readings

A

FRC, RV, TLC

347
Q

Ratio that is useful in differentiating between restrictive vs obstructive disease

348
Q

The best test for small airway disease

349
Q

Examples of obstructive pulmonary disease

A

Asthma, COPD, chronic bronchitis, emphysema

350
Q

Examples of restrictive pulmonary disease

A

Pulmonary fibrosis, Pneumothorax, Chest wall Dz(scoliosis), Neuromuscular disease (ALS, Myasthenia Gravis)

351
Q

Normal FEV1/FVC ratio

352
Q

PFT that indicated restrictive disease

A

Low FEV1 (<80%) and FVC (<80%) with FEV1/FVC > 0.7

353
Q

When does FRC equal CC?

A

Upright 66 y/o

Supine 44 y/o

354
Q

What is Zero Order Kinetics?

A

A constant AMOUNT of drug is eliminated per unit time

aka drug EXCEEDS enzyme metabolizing capacity

355
Q

What is First Order Kinetics?

A

A constant FRACTION of drug is eliminated per unit time

356
Q

Most drugs undergo what type of kinetics?

A

First Order

357
Q

The alpha phase of first order kinetics represents? Beta phase?

A

Alpha Phase: Distribution

Beta Phase: Elimination

358
Q

List the Types of Phase I metabolic reactions

A

Oxidation
Reduction
Methylation
Hydrolysis

359
Q

What is responsible for phase I reactions?

A

CYP 450 system

360
Q

List the Types of Phase II metabolic reactions

A 
(Conjugation reactions)
Glucuronidation
Glutathione Conjugation
Sulfation
Acetylation
361
Q

What are phase II metabolic reactions?

A

Conjugation reactions

362
Q

What are Phase III metabolic reactions?

A

Elimination

363
Q

What indicates a drugs time-to-onset of action?

364
Q

What indicates a drugs potency?

A

Lipid solubility

365
Q

What indicates a drugs DOA?

A

Protein binding is the most important (But also lipid solubility)

366
Q

What is the level of a sympathetic blockade relative to a sensory block with spinal anesthesia?

A

2-6 dermatomes HIGHER

4-8 Dermatomes higher than MOTOR

367
Q

What is the level of motor blockade relative to a sensory block with spinal anesthesia?

A

2 dermatomes LOWER

368
Q

How many nodes must be blocked by LA to stope nerve conduction?

A

2-3 Nodes of Ranvier

369
Q

What is the key target of LA?

A

Voltage-Gates Sodium Channels

370
Q

The degree of nerve blockade with LA depends on what?

A

Drug Concentration and Volume

371
Q

What drug to avoid for seizures with LAST if CV instability is present?

A

Propofol (use benzos instead)

372
Q

What is a normal Dibucaine number?

373
Q

What is the diagnostic criteria Atypical homozygous pseudocholinesterase?

A

dibucaine number of 20%

374
Q

What is the diagnostic criteria Atypical heterozygous pseudocholinesterase?

A

Dibucaine number of 30-70%

375
Q

What happens in patients with atypical pseudocholinesterase?

A

Do not metabolize amide LA and also succ

376
Q

What is Methemoglobin?

A

Iron in the FERRIC state (Fe3+)

377
Q

Iron in normal HgB is in what state?

A

FERROUS (Fe2+)

378
Q

What is the pKa of Procaine, tetracaine, Bupi, Ropi, Chloroprocaine, Lidocaine, Etidocaine, mepivacaine

A 
Procaine 8.9
Tetracaine 8.6
Bupi/Ropi 8.1
Chloroprocaine 8.7
Lidocaine 7.7-7.9
Etidocaine 7.7
Mepivacaine 7.6
379
Q

How is MAC related to potency?

A

Inverse relationship

380
Q

List the Oil:Gas partition coefficient for the VAA

A

N2O 1.4
Des 18.7
Sevo 55
Iso 98

381
Q

List the MAC for the VAA

A

N2O: 104%
Des 6.6%
Sevo 1.8%
Iso 1.17%

382
Q

How do changes in temperature influence the solubility of a gas in a liquid?

A

More soluble in cold temperatures (This is known as LeChatelier Principle)

383
Q

List the Blood:Gas Solubility coefficient of the VAA

A 
HE IS Doing Nothing (Greatest to Least mnemonic)
Halothane: 2.54
Iso: 1.46
Sevo: 0.69
Des: 0.42
N2O: 0.46
384
Q

Law that explains diffusion hypoxia

385
Q

MOA of barbiturates

A

GABA-A Agonists

386
Q

Sulfur containing barbs

A

Thiopental

387
Q

In what population should you avoid thiopental

A

Severe asthmatics (Histamine release)
Sulfa allergy
Porphyria

388
Q

In what patients should ketamine be avoided?

A

Cardiac Patients
Glaucoma
Pt with elevated ICP

389
Q

Why does diazepam have such long DOA?

A

it is 98-99% protein bound

390
Q

The termination of CNS effects of IV anesthetics is primarily due to what process?

A

Redistribution

391
Q

Order the synthetic opioids by potency

A

Alfentanil < Fentanyl/Remifentanil < Sufentanil

392
Q

List the Vapor Pressures of the VAA

A

Sevo 157 mmHg (157 -170)
Iso 240 mmHg
Des 669 mmHg

393
Q

What is the Partial Pressure of saturated water vapor?

394
Q

When Bourdon Gauge reads “0” what is the pressure inside the cylinder?

395
Q

Flow is directly proportional to

A
  • radius to the 4th power

- hydrostatic pressure

396
Q

Flow is inversely proportional to

A

fluid viscosity, length of the tube

397
Q

Law that explains flow through vessels

A

Poiseuille’s law

398
Q

What does henry’s law state?

A

That the amount of gas that dissolves in a liquid is proportional to the PP of the gas in the gas phase

399
Q

What remains constant in Boyles Law?

A 
Constant Temp (inverse relationship of P &amp; V)
P1xV1=P2xV2
400
Q

What remains constant in Charles Ideal gas Law?

A 
Constant Pressure (Directly relationship of V &amp; T)
V1/T1=V2/T2
401
Q

What remains constant in Gay-Lussac’s Ideal gas law?

A 
Constant Volume ( Direct relationship of P &amp; T)
P1/T1=P2/T2
402
Q

Triangle for gas laws

A

B
P V
G T C

Big Gas Cars/ PhoToVoltaic

403
Q

What does Daltons law state?

A

The total pressure in a mixture of gases is equal to the sum of the pressures of the individual gases

404
Q

The temperature above which a substance can not be liquified

A

Critical temperature

405
Q

Explains why a cylinder cools when it is opened

A

Joule-Thompson Effect (“Joule Is Cool”)

406
Q

Diffusion rate is directly proportional to what?

A

PP gradient
Membrane surface area
Solubility of gas in membrane

407
Q

Diffusion rate is inversely proportional to what?

A

Membrane thickness

Molecular weight

408
Q

What are some applications of Fick’s Law

A

Concentration Effect
Second Gas effect
Diffusion Hypoxia

409
Q

What law explains why smaller substances diffuse in greater quantities?

A

Grahams Law (as well as Ficks)

410
Q

Which law is the basis of Pulse Oximetry?

A

Beer-Lambert Law

411
Q

What are the Routes of heat loss?

A

Radiation (60%): most significant source of heat loss
Convection (15-30%)
Evaporation (20%)
Conduction (<5%)

412
Q

Who establishes requirements for the design, construction, testing, etc… of compressed gas cylinders?

413
Q

Who sets basic performance and safety requirements for components of the anesthesia machine and ET tubes?

A

The American National Standards Institute (ANSI)

414
Q

Who promulgates standards for medical devices and gases?

415
Q

Who develops purity specifications for medical gases?

A

Pharmacopeia of the US

416
Q

What is the most fragile part of the cylinder?

A

The Cylinder Valve

417
Q

PISS index system for gases

A

Air 1-5
O2 2-5
N2O 3-5

418
Q

What prevents a full cylinder from emptying into and empty cylinder?

A

The Hanger Yoke Valve

419
Q

At what flow rate does the O2 Flush Valve deliver oxygen? What PSI?

A 
Flow rate 35-75 L/min
PSI 50 (intermediate pressure)
420
Q

What triggers the closure of the Oxygen failure cutoff Valve (aka Fail safe system)?

A

O2 pressure drops below 25 PSI

421
Q

What is the pressure of the flowmeters?

A

16 PSI (low pressure system)

422
Q

What are the 5 roles of oxygen?

A 
Delivery of O2 to patient
Power O2 flush valve
Activate fail-safe system (If < 25 PSI)
Activate O2 Low Pressure alarm
Driving gas for the ventilator
423
Q

What prevents reversal of flow through the vaporizer?

A

The Check Valve

424
Q

Properties of Injection vaporizers

A

Tec 6 (Des)
Dual Circuit (Not Split)
Heated to 39 C
Pressurized

425
Q

Properties of variable bypass vaporizers

A

Gas Split
Flow over
automatic temp compensation

426
Q

What are the components of the Low pressure system?

A 
(16 PSI)
Flow Meter tubes
Vaporizers
Check Valves
Common Gas Outlet (CGO)
427
Q

What are the components of the Intermediate pressure system?

A 
(40-50 PSI)
Ventilator power inlet
Pipeline inlets, Check Valves, Pressure gauges
Flow Meter VALVES
O2 pressure-failure device
O2 Second stage regulator
Flush Valve
428
Q

What are the components of the High pressure system?

A

Hanger Yolk
Yoke Block
Cylinder pressure gauge
Cylinder pressure regulator

429
Q

Properties of Open Breathing Systems

A

NO RESERVOIR
no rebreathing
no absorbent
no dead space

430
Q

What are some examples of Open Breathing Systems?

A

Open drop either
NC
Simple FM
Insufflation

431
Q

Properties of Semi-Open Breathing Systems

A

NO REBREATHING
Reservoir
Causes room pollution
Req high Gas flow

432
Q

Properties of Semi-Closed Breathing Systems

A

PARTIAL REBREATHING
Reservoir
Most common in US

433
Q

Properties of Closed Breathing Systems

A

Reservoir
COMPLETE REBREATHING
FGF=O2 consumption

434
Q

What is the best Mapleson system for spontaneously breathing

A

Mapleson A

435
Q

Order of Mapelson stystem for controlled ventilation

436
Q

Max cuff pressure for LMA

437
Q

Most common adverse effect of using an LMA

A

Sore Throat ( incidence 10%)

438
Q

ETT that can be accommodated by the FasTrach LMA

439
Q

What is evidence of an incompetent expiratory valve?

A

No return to baseline (‘0”)

Prolong inspiratory Limb (Beta Angle)

440
Q

List the BIS values for each level of anesthesia

A 
Light/Mod Anesthesia: 90-70
Deep Sedation: 60-70
GA: 60-40
Deep Hypnotic State: 40-10
Flat Line EEG: 10-0 ****
441
Q

Red light absorbs what wavelength? IR light?

A 
Red = 660nm deoxyhgb
IR= 940nm OxyHgb
442
Q

Identify the components of the CVP waveform?

A
  • A wave: atrial contraction (end Diastole)
  • C wave: Tricuspid elevation during early vent systole (early systole)
  • V Wave: Venous return against a closed tricuspid valve (Late systolic filling of the atrium)
  • X descent: Atrial relaxation (Mid Systole)
  • Y Descent: Early Vent. Filling (Early Diastole)
443
Q

What is the depth to the Right Atrium based on insertion site of the catheter?

A 
Subclavian       15cm
Right IJ             20cm
Left IJ                25cm
Right AC           40cm
Left AC             45cm
Femoral            50cm
444
Q

Depth from RA to RV? How about to the PA?

A

RA to RV is 10 cm
RV to PA is 15 cm
(RA to PA is 25 cm)

445
Q

What is the normal PCWP?

446
Q

What is the maximum wedge time?

A

15 seconds

447
Q

What are some complications from PA catheters?

A

Pneumothorax

Air Embolism

448
Q

What is the normal RVEDP?

449
Q

What is the normal PA systolic? PA Diastolic?

A

PA systolic 15-25 mmHg

PA Diastolic 8-15 mmHg

450
Q

What portion of the ECG correlates with the Dicrotic Notch on the arterial waveform?

A

Occurs at the end of the T wave

451
Q

How much higher is invasive BP versus noninvasive BP?

452
Q

Karotkoff sounds identify __________

A

The onset of systole

453
Q

How many vertebrae are there?

A

33 Vertebrae

  • 7 cervical
  • 12 Thoracic
  • 5 Lumbar
  • 5 Fused Sacral
  • 4 Fused Coccygeal
454
Q

The high points of the vertebral column

455
Q

The Low points of the vertebral column

456
Q

Where is the epidural space widest?

A

L2 (5-6 mm)

457
Q

Where is the epidural space is narrowest ?

A

C5 (1.0-1.5 mm)

458
Q

The spinal cord extends from the __________ to the _________

A

Foramen Magnum

extends to L1 (L3 in newborn)

459
Q

The spinal cord terminates at the ____________

A

Conus Medullaris

460
Q

How many spinal nerves are there

A

31 paired spinal nerves

461
Q

Where does the Arachnoid matter end?

A

Ends at S2

462
Q

What are the factors that play a role in the spread of spinal blockade?

A 
Density of the drug solution
Site of Injection
Dose
Position
Baricity
463
Q

Treatment options for bradycardia that result from spinal anesthesia

A

Prophylactic ondansetron (5-HT3 antagonists)
Atropine 0.4-0.6 mg
ephedrine 5-25 mg
Epinephrine (if severe bradycardia)

464
Q

What is the best means for treating hypotension during spinal anesthesia?

A

Physiologic, give IV fluids if hypovolemic

465
Q

When can you restart heparin after epidural removal?

A

1 hour after removal (or 1 hour after placement)

466
Q

When is it safe to remove catheter after stopping a heparin?

A

4-6 hours after the last dose

467
Q

Guidelines for unfractionated heparin and neuraxial blockade

A

Daily dose < 20,000 Units: 12 hours after sub-Q heparin
Daily Dose > 20,000 Units: 24 hours after Sub Q heparin
(ALWAYS CHECK LABS)

468
Q

At what INR is it safe to provide neuraxial anesthesia in a patient on warfarin?

469
Q

Guidelines for fibrinolytic or thrombolytic drug therapy and neruaxial anesthesia

A

D/c for 10 days before

470
Q

Guidelines for LMWH with neuraxial anesthesia

A

Delay 12-24 hours

remove all catheters 2 hours before first LMWH dose

471
Q

The inferior border of the scapula correlates with what spinal level

472
Q

What Dermatome is covered by nerve roots L2-L3?

A

The Knee and below

473
Q

The perineal dermatome correlates with which spinal levels

474
Q

Absolute contraindications for spinal anesthesia

A

Infection at Injection Site
Coagulopathy
Hemodynamic Stability
Patient Refusal

475
Q

What 2 structures are avoided with a lateral approach to spinal anesthesia?

A

Supraspinous Ligament

Interspinous Ligament

476
Q

Most common causative agent of epidural abscess

A

Staph Aureus

477
Q

Most common complication of neuraxial anesthesia

478
Q

What is the angle of the bevel on the Tuohy needle?

A

30 degrees

479
Q

The order of nerve fiber blockade after epidural?

A

B > C/A-delta > A-gamma > A-beta >A-alpha

480
Q

What is the distance from the skin to the epidural space?

A

Adult 4-6 cm
Obese up to 8 cm
Thin 3cm

481
Q

The most sensitive indicator of initial onset of sensory block

A

Alcohol swab to assess for loss of temperature

482
Q

The most accurate assessment of overall sensory block with epidural

483
Q

Why are caudal blocks not used in adults?

A

after age 12 sacral anatomy changes and makes it more difficult

484
Q

Site of needle insertion for caudal epidural block

A

Sacrococcygeal Membrane

485
Q

Dosage for caudal epidural in children

A

0.5-1.0 mL/kg (0.125%-0.5% Bupivacaine)

486
Q

Dosage for caudal epidural in adults

A

S5-L2: 15-25 mL

S5-T10: 35 mL

487
Q

Nerve roots of the cervical plexus

488
Q

Nerve roots of the phrenic nerve

A

C3-C5 (70% for C4)

489
Q

Nerve roots for the brachial plexus

490
Q

Extension of the elbow test what nerve

A

Radial Nerve

491
Q

Flexion of the elbow test what nerve

A

Musculocutaneous Nerve

492
Q

Flexion of the wrist test what nerve

A

Ulnar nerve

493
Q

Opposition of the middle, forefinger, and thumb test what nerve

A

Median Nerve

494
Q

Volume for cervical plexus block

A

4mL per level

495
Q

What are the approaches to the brachial plexus block?

A

Interscalene
Supraclavicular
Infraclavicular
Axillary

496
Q

What volume of LA is used for an inter scalene block?

497
Q

Where does the musculocutaneous nerve lie

A

Within the coracobrachialis

498
Q

What are the landmarks for an Ulnar nerve block at the elbow?

A

The medial condyle of the humerus

Olecranon process of the Ulna

499
Q

The femoral nerve block (aka 3 in 1 block) is used to provide anesthesia to what areas?

A

Anterior thigh, knee, and a small part of the medial foot

500
Q

What nerves are blocked in the 3-in-1 approach?

A

Femoral, Genitofemoral, & lateral femoral cutaneous nerve

501
Q

What nerve roots contribute to the Sciatic Nerve?

A

L4-L5 & S1-S3 (lumbosacral trunk)

502
Q

Sensory innervation of the sciatic nerve

A

Posterior Hip Capsule and the Knee, Sensory to everything distal to the knee except the anteromedial aspect
(Motor to hamstring and all muscles distal to the knee)

503
Q

List the 5 nerves that are blocked in the ankle block

A 
Posterior Tibial: L4-L5/S1-S3
Sural: branch of Tibial
Saphenous: Branch of femoral (L3-L4)
Deep Peroneal:  L4-L5/S1-S2
Superficial Peroneal:  L4-L5/S1-S2
504
Q

What is the largest division of the sciatic trunk?

A

Posterior Tibial Nerve

505
Q

What nerves provide Sensory innervation to the foot?

A
  • Post. Tibial: Skin of the heel and medial aspect of the sole of the foot
  • Sup. Peroneal: Dorsum of the foot & 1st-5th toes
  • Saphenous: medial side of the leg, ankle, and foot
  • Sural (is Lateral): post lateral aspect of lower calf and lateral side of the foot and fifth toe
  • Deep Peroneal: Medial half of the dorsal foot between the 1st and 2nd digits
506
Q

What is the most common postoperative peripheral neuropathy?

A

Ulnar nerve damage

507
Q

How does ulnar nerve damage present?

A

Claw Hand: decreased sensation the ring and pinky

508
Q

What is the second most common postoperative neurologic injury?

A

Brachial Plexus

509
Q

How is the brachial plexus injured intraoperatively?

A

Stretch injury: Head extended and turned away and arm is abducted > 90 degrees
Compression injury: B/w clavicle and 1st Rib with improper placement of shoulder braces or spreading of the sternum

510
Q

Presentation of radial nerve injury

A

Wrist drop

511
Q

presentation of Median nerve injury

A

APE Hand (unable to oppose thumb)

512
Q

Inability to abduct the arm indicates injury to which nerves?

A

Axillary n.

513
Q

Inability to flex the forearm indicates injury to which nerves?

A

Musculocutaneous n.

514
Q

What is the most common mechanism by which the sciatic nerve is injured?

A

Improperly placed in lithotomy

515
Q

What is the most commonly damaged nerve of the lower extremity?

A

Common Peroneal Nerve

516
Q

What is one of the common ways in which damage to the common peroneal nerve occurs?

A

Compression of nerve between fibula (lateral aspect of knee) and metal brace while in lithotomy

517
Q

Damage to this nerve causes foot drop

A

Anterior Tibial Nerve
Sciatic nerve
Common peroneal

518
Q

How does damage to the femoral nerve occur?

A

Compression agains pelvic brim by self retaining retractors and by excessive angulation of the thigh when placed in lithotomy

519
Q

How is the Obturator nerve damaged?

A

Excessive flexion of thigh to the groin

Difficult forceps delivery

520
Q

How is MAC affected by pregnancy?

A

It is decreased (Also faster induction d/t higher alveolar ventilation)

521
Q

What are the Cardiac Output changes during the phases of labor?

A 
Increases
Latent Phase 15%
Active phase 30%
Second Stage 45%
Postpartum 80%
522
Q

What is the normal uterine blood flow during pregnancy?

A

10% of CO =700-800mL/min

523
Q

What is the uterine blood flow in a non pregnant state?

524
Q

List the stages of labor and when they begin and end

A

1st stage: From Onset of contractions to complete dilation
2nd stage: Dull cervical dilation (10cm) to delivery of the infant
3rd stage: Ends with delivery of the placenta

525
Q

Pain from the stages of labor originates in which nerve roots?

A

1st stage: T10-T12 progression to L1

2nd stage: T10-S4

526
Q

Innervation to the perineum is via what nerve?

A

The pudendal Nerve (S2-S4)

527
Q

What are some signs of fetal distress?

A

Nonreassuring FHT
Fetal Scalp pH < 7.20
Meconium Stained Amniotic Fluid
Oligohydraminos

528
Q

Symptoms of placenta previa

A

PAINLESS vaginal bleeding

529
Q

Symptoms of Placental abruption

A

PAINfull vaginal bleeding

Uterine tenderness

530
Q

Lab values for DIC

A 
Fibrinogen <150mg/dL
PLT count <50,000
Thrombin time > 100 sec
PT > 100 sec
PTT >100 sec
531
Q

normal fibrinogen levels

A

200-350 mg/dL

532
Q

Normal thrombin time (TT)

A

8-12 seconds

533
Q

What is HELLP

A

Hemolysis
Elevated Liver enzymes
Low Platelets

534
Q

Dosing of magnesium for preeclampsia

A

Bolus 4-6mg over 30 min

Infusion 1-2 g/hr

535
Q

Normal magnesium level

A

1.8-2.5 mg/dL

536
Q

Pediatric airway characteristics

A

Laryngeal location at C2-C4 (vs C3-C6 in adults)
Narrowest (fixed) portion Cricoid
Omega shaped epiglottis (U shaped)
Less vertical takeoff of RT mainstem bronchus
Funnel shaped larynx

537
Q

How to determine pediatric tube size?

A

(age/4)+4 (-0.5 for cuffed tubes)

538
Q

How to determine pediatric tube depth at mouth?

A

ETT size x 3

[ or (age/2)+12 or (kg/5)+12]

539
Q

How to calculate EBV for pediatrics?

540
Q

How to calculate Max allowable blood loss?

A

EBVx(Hct - Min Hct)/ actual Hct

541
Q

How to calculate fluid maintenance?

A

For infants < 6months
4mL/kg (1st 10kg)
2mL/kg (2nd 10kg)
1ml/kg (over 20kg)

For infants > 6months
10-40mL/kg over 1-4 hours

542
Q

What is the % TBW in Preterm, Term and 6-12 month old?

A

Preterm= 80-90%
Term= 75%
6-12 Months= 60%

543
Q

Where is the most common site of congenital diaphragmatic hernia?

A

70-90% of defects are on the left side (Left foramen of bochdalek)

544
Q

Hallmark signs of congenital diaphragmatic hernia?

A 
Arterial hypoxia (d/t Lt to Rt  shunt)
Barrel shaped chest
SCAPHOID abdomen,
545
Q

What is the goal of anesthetic management of the patient with a congenital diaphragmatic hernia?

A
  • Maintain Preductal saturation > 85% with PIP < 25cmH2O (allow PCO2 to rise to 45-55mmHg)
  • Decompress the stomach
  • Avoid hypothermia, hypoxia, acidosis
546
Q

What is VACTERL syndrome?

A 
Vertebral Defect
Anal Atresia
Cardiac anomalies
Tracheoesophageal fistula
Esophageal atresia
Renal dysplasia
Limb anomalies
547
Q

What is the most common type of TEF?

A

Ends in a blind pouch and a lower esophagus that connects to the trachea (Type C)

548
Q

How do we ventilate patients with TEF?

A

Small TV faster rate (avoid PPV)

549
Q

What is the most common metabolic presentation of Pyloric stenosis?

A

Hypokalemic, hypochloremic primary metabolic alkalosis, with secondary respiratory acidosis

550
Q

What are some signs and symptoms of pyloric stenosis?

A

non-bilious projectile vomiting at 2-5 weeks of age
Jaundice (d/t starvation)
OLIVE-LIKE MASS palpated in the epigastrium

551
Q

Common postoperative complication for patients who undergo surgery for pyloric stenosis?

A

PostOp ventilatory depression

552
Q

What are the S/S of Acute Epiglottitis?

A
  • Age 3-6years
  • High Fever
  • Rapidly progresses from sore throat to dysphagia
  • Sitting forward & upright; Chin up, mouth open, drooling
553
Q

What is the etiology of acute epiglottis?

A

Bacterial (Hemophilus influenza Type B, Staph aureus)

554
Q

What are the S/S of laryngotracheal bronchitis?

A

AKA CROUP

  • Age 6 months - 3 years
  • Low grade fever
  • Croupy “barking” Cough
  • Slow Onset
  • Hoarsness
  • Steeple sign
555
Q

What is the treatment for Croup?

A

Cool humidified O2 & racemic Epi

556
Q

What is the etiology of Croup?

557
Q

Consideration for gastroschisis

A

Prevent hypothermia, infection, and dehydration

558
Q

Which pediatric congenital abdominal herniation abnormality is associated with other anomalies?

A

Omphalocele (has a SAC or Amnion covering)

559
Q

Shivering increases O2 consumption by how much?

560
Q

Time of onset of post operative cognitive dysfunction

A

delayed onset , may present weeks or months AFTER surgery

561
Q

What is the most sensitive indicator of renal function in the elderly?

A

Creatinine Clearance

562
Q

How is MAC affected by age?

A

Reduced by 4-6% per decade over the age of 40

563
Q

How to calculate IBW?

A 
Female = Ht(cm) - 105
Male = Ht(cm) - 100
564
Q

Type of obesity that is associated with increased risk of CV events?

A

Android (Cushingoid, Centra, Truncal, Apple)

565
Q

A major predictor of problematic intubation in the Obese patient?

A

Neck Circumference (large)

566
Q

The only ventilatory parameter that has been shown to improve respiratory function in the obese patient

567
Q

What are the most sensitive indicators of anastomotic leak after bariatric surgery?

A

Tachycardia (MOST SENSITIVE)
Fever
(also ABD pain)

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