White - Test 2 Flashcards
1
Q
Tension Headache
A
Mild to moderate headache, lasting 30 minutes to 7 days
Often bilateral, non-pulsating, and not aggravated by physical activity
2
Q
Migraine
A
Recurrent moderate to severe headache, lasting 4 to 72 hours
Often unilateral, pulsating, and aggravated by physical activity
Associated with nausea, photophobia, and phonophobia
3
Q
Musculoskeletal
A
Mild to moderate headache accompanied by neck and/or shoulder pain
4
Q
Preeclampsia/Eclampsia HA
A
Hypertension and/or HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome
Headache often bilateral, pulsating, and aggravated by physical activity
5
Q
Posterior reversible (leuko)encephalopathy syndrome “PRES”
A
Severe and diffuse headache with an acute or gradual onset
Possible focal neurologic deficits and seizures
6
Q
Stroke (cerebral infarction/ischemia and subarachnoid hemorrhage) HA
A
Ischemic or hemorrhagic.
Cerebral infarction/ischemia: new headache that is overshadowed by focal signs and/or disorders of consciousness.
Subarachnoid hemorrhage: abrupt onset of an intense and incapacitating headache.
Often unilateral accompanied by nausea, nuchal rigidity, and altered consciousness.
7
Q
Subdural Hematoma HA
A
Headache usually without typical features
Often overshadowed by focal neurologic signs and/or altered consciousness
8
Q
Carotid artery dissection HA
A
Late developing headache that is constant in nature
Bilateral or unilateral location
9
Q
Cerebral venous and sinus thrombosis HA
A
Nonspecific headache that may have a postural component.
Often accompanied by focal neurologic signs and seizures
10
Q
Brain Tumor HA
A
Progressive and often localized headache
Often worse in the morning
Aggravated by coughing/straining
11
Q
Idiopathic intracranial HTN (pseudotumor cerebri/benign intracranial HTN) HA
A
Progressive non pulsating headache
Aggravated by coughing/straining
Associated with increased CSF pressure and normal CSF chemistry
12
Q
Spontaneous Intracranial hypotension HA
A
No history of dural trauma
Diffuse, dull headache worsening within 15 minutes of sitting or standing
Associated with neck stiffness, nausea, tinnitus, and photophobia
CSF opening pressure < 60 mm H2O in the sitting position
13
Q
Pneumocephalus HA
A
Frontal headache
Often an abrupt onset immediately after dural puncture
Symptoms can worsen with upright posture
14
Q
Meningitis HA
A
Headache is most frequent symptom
Often diffuse
Intensity increases with time
Associated with nausea, photophobia, phonophobia, general malaise, and fever
15
Q
Sinusitis HA
A
Frontal headache with accompanying facial pain
Development of headache coincides with nasal obstruction
Purulent nasal discharge, anosmia, and fever
16
Q
Caffeine Withdrawal HA
A
Onset of headache within 24 hours of cessation of regular caffeine consumption
Often bilateral and pulsating
Relieved within 1 hour of ingestion of caffeine 100 mg
17
Q
Lactation Headache
A
Mild to moderate headache associated temporally with onset of breast-feeding or with breast engorgement
18
Q
Ondansetron Headache
A
Mild to moderate headache associated with ondansetron intake
19
Q
PDPH HA symptoms
A
Headache within 5 days of dural puncture
Worsens within 15 minutes of sitting or standing
Associated with neck stiffness, tinnitus, photophobia, and nausea
The hallmark of a PDPH is this postural component.
20
Q
PDPH: contraindications to the administration of an epidural blood patch are related to complications of placing a needle in the central neuraxis or the injection of blood into the epidural space, they include:
A
- known coagulopathy (e.g., concurrent pharmacologic anticoagulation)
- local cutaneous infection or untreated systemic infection
- increased ICP caused by a space-occupying lesion
- patient refusal
21
Q
A patient with postdural puncture headache experiences an ___________of symptoms when she moves from the horizontal to the upright position, possibly owing to __________ intracranial pressure and secondary cerebral vasodilation, which affect pain-sensitive intracranial structures.
A
increase, loss of
22
Q
No therapies reliably prevent the development of postdural puncture headache after unintentional dural puncture with an epidural needle. T or F?
A
True
23
Q
What is the initial therapy for postdural puncture headache?
A
Conservative treatment is indicated in the presence of mild-to-moderate discomfort, and includes: bed rest, hydration, and simple analgesics. Caffeine (500 mg intravenously or 300 mg orally) has also been used in the treatment of PDPH, but the therapeutic effect is transient.
24
Q
The gold standard therapy for postdural puncture headache is?
A
Epidural blood patch.
25
**the classic presentation is sudden onset of a severe headache that is unlike any previous headache (“worst headache of my life”).
Subarachnoid hemorrhage
26
Amniotic Fluid Embolism: signs/symptoms and when it occurs?
Amniotic fluid embolism is rare and may occur during labor, vaginal, or operative delivery and it is occasionally associated with placental abruption.
```
Signs and symptoms of amniotic fluid embolism include:
o Anxiety
o Dyspnea
o Hypoxia
o Hypotension
o Cardiovascular collapse
o Coagulopathy
```
27
The pathogenesis of amniotic fluid embolism is likely related to what?
an anaphylactoid reaction to the amniotic fluid and not purely an embolic event.
28
Clinical management of amniotic fluid embolism?
Clinical management is supportive and includes airway management, hemodynamic resuscitation, and appropriate treatment of coagulopathy.
29
What is an Amniotic fluid embolism?
Amniotic fluid embolism is a rare catastrophic and life-threatening complication of pregnancy that occurs when there is disruption in the barrier between the amniotic fluid and the maternal circulation.
30
Causes of ischemic stroke include?
cerebral venous sinus thrombosis, preeclampsia/eclampsia, thromboembolism related to valvular heart disease, and profound and persistent hypotension (e.g. cervical arterial dissection, amniotic fluid embolism).
31
Preeclampsia: What is the hallmark and why do we treat it?
The hallmark of preeclampsia is an abnormal placentation-implantation.
Can lead to Disseminated Intravascular Coagulation “DIC”
32
Treatment for preeclampsia? (for seizures)
Magnesium sulfate is the anticonvulsant of choice because it is more effective and has a better safety profile than benzodiazepines, phenytoin, or lytic cocktails.
33
Management of Preeclampsia? (what should they do on the daily, what do you monitor, what do you want to control, and what do you want to prevent at all cost)
- Bed rest
- monitor BP, reflexes, weight, and proteinuria
- Control BP (diastolic < 90-100)
- Seizure prophylaxis by mag sulf
34
Management of Eclampsia? (4)
- Supplemental O2
- Mag sulf + benzo
- Monitor fetal status
- Initiate steps to delivery
35
Magnesium sulfate dose?
Magnesium 4–6 g IV followed by 1–2 g/h IV as a continuous infusion (goal is to maintain serum concentrations of 2.0–3.5 mEq/L)
36
Toxicity with mag sulfate?
7–10 mEq/L associated with loss of deep tendon reflexes
10–13 mEq/L associated with respiratory paralysis
≥15 mEq/L associated with altered cardiac conduction
>25 mEq/L associated with cardiac arrest
37
Epidural Anesthesia How much surgical anesthesia time does it allot you?
This combination normally results in approximately 90-120 min of surgical anesthesia.
38
What LA does not need sodium bicarbonate mixed with it?
Sodium bicarbonate cannot be added to bupivacaine as it results in precipitation when the pH is raised.
39
Multimodal analgesia?
The rationale of multimodal analgesia is the optimization of additive or synergistic effects of different modes of analgesia or drug classes, while reducing the dose and minimizing the side effects of individual drugs with different mechanisms of action.
40
What is Placenta accrete?
refers to a placenta that is abnormally adherent to the myometrium but has not invaded the myometrium.
-Placenta accreta is the most common indication for a cesarean hysterectomy.
41
What is Placenta increta?
the placenta has invaded the myometrium.
42
What is Placenta percreta?
is invasion through the serosa.
43
**When may hemorrhage occur with a delivery?
Massive hemorrhage may occur when removal of the placenta is attempted after delivery.
**Peripartum hemorrhage remains a leading cause of maternal mortality worldwide.
44
What is Placenta Previa and what are the clinical signs?
occurs when the placenta covers the cervix.
- The classic clinical sign of placenta previa is painless vaginal bleeding during the second or third trimester (the lack of abdominal pain and/or absence of abnormal uterine tone helps distinguish placenta previa from placental abruption)
45
If the placenta does not seperate easily, what may occur?
- If the placenta does not separate easily, placenta accreta may exist. In such cases, massive blood loss and the need for cesarean hysterectomy should be anticipated.
46
What is placental abruption?
complete or partial separation of the placenta from the decidua basalis before delivery of the fetus.
47
Criteria for the diagnosis of preterm labor include?
gestational age between 20 and 36 weeks’ gestation and regular uterine contractions accompanied by a change in cervical dilation, effacement, or both (or initial presentation with regular contractions and cervical dilation of 2 cm or more)
less than 10% of women with the clinical diagnosis of preterm labor actually give birth within 7 days of presentation
48
Tococolytic treatment?
The ACOG has stated that evidence supports the use of tocolytic treatment with beta-adrenergic receptor agonist therapy, calcium entry blocking agents, or NSAIDs for short-term prolongation of pregnancy (up to 48 hours) to allow for antenatal maternal corticosteroid administration.
49
Factors associated with a lower rate of successful VBAC include?
- socioeconomic
- ethnic
- medical factors
50
***Contraindications to VBAC?
previous classic or T shaped incision or extensive transfundal uterine surgery.
Previous uterine rupture.
Medical or obstretric complication that precludes vaginal delivery.
Inability to perform emergency cesarean delivery because of unavailable surgeon, anethesia (provider), sufficient staff, or facility.
Two prior uterine scars and no vaginal deliveries.
51
Hypertension during pregnancy is considered?
Is BP > 140/90 mmHg after 20th week and resolve within 48 hrs after delivery
52
Symptoms of Preeclampsia?
Hypertension, proteinuria (> 5 g/day) and edema (hand, face, lung)
Oliguria (< 500 ml /day), headache, visual disturbance, hepatic tenderness, hyperreflexia
53
symptoms of eclampsia?
(+) Seizures in preeclampsia
54
symptoms of eclampsia?
(+) Seizures in preeclampsia
55
HELLP syndrome?
high maternal and fetal mortality, call for immediate delivery
- Hemolysis, Elevated Liver enzymes, Low Platelet count
56
Risk factors for Hypertension in pregnancy?
- Nulliparity, AA, extreme of age (< 15 or > 35), multiple gestation
- vascular disease due to Systemic Lupus and DM
- + family history
- chronic HTN
- HELLP syndrome
57
Pathophysiology of HTN during pregnancy?
increased thromboxane A2, increased endothelin-1, increased renin.
Decreased PGI2, decreased NO
58
S/S of pregnancy induced hypertension?
Vasospasm, decreased I/V volume, decreased GFR, edema, CNS dysfunctions
decreased uterine BF
59
Only cure for PIH? 2 medications to give in lue of delivery?
what med can cause CN toxicity?
If seizure occurs what do you give?
- Only cure is delivery of baby. Monitor PT, PTT
- Hydralazine and methyldopa to control HTN
- High dose of nitroprusside can cause cyanide toxicity
- Seizures require mag sulf and benzo
60
Mag sulfate to prevent convulsion, what antagonizes Mag sulfate?
Calcium
61
What does mag. sulfate depress and prevent?
Magnesium depresses CNS by decreasing Ach release
| Prevents Ca++ entry into cell leading to smooth muscle relaxation
62
Mag toxicity? S/S
has very narrow therapeutic index
o Ventilatory failure (requires prompt intubation and ventilation)
o Absent deep tendon reflexes
o Heart block (Prolong PQ and wide QRS), cardiac arrest
o Hypotension
o Drowsiness, atonia, and hypoventilation in fetus
63
Treatment of magnesium toxicity?
o D/C magnesium
o Intubation and ventilation
o IV calcium gluconate (calcium antagonizes effects of magnesium)
64
Complications related to PIH?
- Pulmonary edema/cerebral hemorrhages (leading causes of maternal death)
- Prematurity
- Prematurity/fetal distress
- Intrauterine growth retardation
- Placental abruption
- AR, cerebral edema
- Fetal/maternal death
• Anesthesia consideration: avoid ketamine as it causes HTN
65
A multivariate analysis identified five independent risk factors for difficult face mask ventilation:
1. age older than 55 years
2. body mass index (BMI) greater than 26 kg/m2
3. presence of a beard
4. lack of teeth
5. a history of snoring
66
Difficult tracheal intubation has been variously defined by:
1. time taken to intubate
2. the number of attempts
3. the view at laryngoscopy
4. the requirement for special equipment
67
The majority of obstetric general anesthetics are administered for emergency deliveries, often during off-hours;
these anesthetic procedures may be conducted by inexperienced anesthesia providers with less proficiency in difficult airway management.
68
Increasing WHAT is associated with more rapid oxygen desaturation during apnea during the induction of general anesthesia.
BMI
69
If you are confronted with a difficult airway and you are going to do a C/S, you give Succ, but aren’t able to intubate but can mask ventilate and vitals sign are normal. What to do?
Wake up the patient and ask about fiberoptic (best option since they aren’t in distress)
70
Breast enlargement during pregnancy may impede intubation by interfering with correct placement of the laryngoscope blade and laryngoscopic manipulation to improve visualization of the larynx. What can you do to minimize this problem.
Various strategies can minimize this problem, the most important of which is optimizing the patient’s position.
71
At term gestation the pregnant woman who requires anesthesia should be regarded as having an incompetent lower esophageal sphincter. When do they return to normal?
48 HOURS after delivery
72
The administration of CPAP in patients breathing spontaneously or the administration of PEEP in patients undergoing mechanical ventilation restores WHAT? (3 answers)
functional residual capacity,
reduces pulmonary shunting,
and reverses hypoxemia.
73
Is the administration of corticosteroids for aspiration pneumonitis recommended?
NOT recommended
74
NONparticulate antacids, examples?
sodium citrate, Bicitra, Alka-Seltzer, effervescent
75
how much sodium citrate should you give over what time period?
30mL within 30 min. before surgery.
76
How do H2-receptor antagonists work?
slight reduction in gastric volume in the fasting patient.
When given intravenously, an H2-receptor antagonist begins to take effect in as little as 30 minutes, but 60-90 min are required for maximal effect (so, it can’t be given on the way to the OR).
77
Examples of H2 receptor antagonists?
famotidine 20 mg given 60-120 min before the induction of anesthesia or ranitidine 50 mg
78
DOA of PPI, toxicity, and maternal and fetal blood concentrations at the time of delivery.
are a long duration of action, low toxicity, and the potential for low maternal and fetal blood concentrations at the time of delivery.
79
ex. of PPI?
omeprazole 40 mg
80
What is metoclopramide?
Metoclopramide 10 mg is a procainamide derivative that is a peripheral cholinergic agonist and a central dopamine receptor antagonist.
81
how quickly can Metoclopramide work? what makes it not work as well? what side effects does it cause?
- Metoclopramide can have a significant effect on gastric volume in as little as 15 min
- Unfortunately, prior administration of an opioid or atropine antagonizes the effect of metoclopramide
- Extrapyramidal effects are a major potential side effect of metoclopramide
82
The most effective way to decrease the risk for aspiration? (3 answers)
Comprehensive airway evaluation,
prophylactic administration of nonparticulate antacids,
and use of regional anesthesia decrease the risk of aspiration.
83
The mother undergoing elective cesarean delivery should fast from solid food. Preoperative antacid prophylaxis may include?
“Before surgical procedures (e.g., cesarean delivery and postpartum tubal ligation), consider timely administration of nonparticulate antacids, H2-receptor antagonist, and/or metoclopramide for aspiration prophylaxis.”
84
if airway difficulty is anticipated and GA is unavoidable what kind of intubation can you do?
awake intubation may be indicated in women in whom airway difficulties are anticipated.
85
The hallmark of aspiration pneumonitis is?
Bronchospasm and disruption of surfactant likely account for the slight decrease in PaO2 and increase shunting that are observed. The anesthesia provider witnesses regurgitation of gastric contents into the hypopharynx. Patients who aspirate while breathing spontaneously have a brief period of breath-holding followed by tachypnea, tachycardia, and a slight respiratory acidosis.
86
Is the oral intake of clear fluids allowed during labor?
No, a healthy patient undergoing elective C/S may drink modest amounts of clear liquids 2 hrs before induction of anesthesia. Patients with addition risk factors for aspiration may have further restrictions – determined case by case.
87
Does eating during labor results in larger residual gastric volumes?
Yes. A reduction in gastric content acidity and volume is believed to decrease risk for damage to the respiratory epithelium if aspiration should occur. Fasting periods for solids 6-8 hrs is recommended.
88
1. A patients BP is 80/40, HR is 120, RR 26, and are getting prepped for an emergency C/S. What should you do?
a. Spinal
b. Epidural
c. LMA
d. ETT
ETT
89
2. BP is 80/40 so will you use etomidate or propofol?
Etomidate
90
Tx for gestational diabetes?
o Diet control
o Insulin
o Avoid oral hypoglycemic agent (can cause fetal hypoglycemia)
91
Maternal complications due to gestational diabetes?
```
Preterm labor
Polyhydramnion
C/S for macrosomia
Preeclampsia/eclampsia
DM type II
```
92
Fetal complications due to gestational diabetes?
```
Macrosomia
Shoulder dystocia
Perinatal mortility 2-5%
Congenital defects
Hypoglycemia **
```
93
what are s/s of mild preeclampsia?
> 140/90
Headache, somnolence, blurred vision,
epigastric pain, rapid weight gain, edema, JV distension,
hyperactive reflexes (esp ankle), clonus,
Proteinuria (> 300 mg/24 hrs)
94
s/s of severe preeclampsia?
```
S/S of mild preeclampsia PLUS:
> 160/90
Proteinuria (> 5 g/24 hrs or 3+ on dipstick)
Oliguria
Pulmonary edema, cyanosis
HELLP syndrome,
oligohydramnios,
intrauterine growth retardation
```
95
Three most common symptoms preceding eclamptic attack?
1. Headache, visual changes
2. RUQ/epigastric pain
3. Seizures; severe if not controlled with anticonvulsant therapy
96
Management of preeclampsia?
If term or fetal lung mature then deliver
If severe, expedite delivery by induction or C/S
Bed rest, monitor BP, reflexes, weight, and proteinuria
Control BP, diastolic < 90-100
Seizure prophylaxis by mag sulf
97
Management of Eclampsia?
Supplemental O2
Mag sulf + benzo
Monitor fetal status
Initiate steps to delivery
98
Pathogenesis of HIV?
- T-helper cells coordinates the immune response of T & B lymphocytes, monocytes, and macrophages
- Therefore, impaired immunity of both cell-mediated and humoral immunity occur
- HIV is also neurotropic and neurological dysfunction is common
99
Lab. diagnosis of HIV?
- Look for antibodies against viral proteins
- Presumptive Dx made with ELISA “RULE OUT test”
- Positive results are then confirmed with Western blot assay “ RULE IN test”
- HIV PCR / viral load tests
- AIDS diagnosis < or equal to 200 CD4 (N = 500-1500)
100
four stages of HIV?
1. Flu-like (acute)
2. Feeling fine (latent) – during latent phase virus replicates in lymph node
3. Falling count
4. Final crisis
101
Clinical features of HIV?
- Asymptomatic
- Persistent fevers and chill
- Drenching night sweats
- Fatigue, arthralgias (joint pain), myalgias (muscle pain)
- Unintentional weight loss “HIV wasting syndrome”
- Depression, apathy, as early signs of HIV-related encephalopathy
102
**Your external cephalic version is successful if?
not in the pelvis
the fetal back is not positioned posteriorly
the presentation is either frank breach or transverse
103
What is the most common complaint of HIV?
FEVER
104
Other causes of pulmonary distress if you have HIV?
Tuberculosis (-ve tuberculin test) – because there is no immune system to activate against antigen
105
Therapy for HIV?
- Azidotheymidine (AZT) with CD4 < 500
o Reverse transcriptase inhibitor
- With CD4 < 200 add pneumocystis prophylaxis
o Trimethoprim-sulphamethoxazole
- Vaccination for pneumococci, influenza, and hepatitis
- NO live vaccine (polio, rubella) should be administered (even to the person who lives close to the patient). WHY? The live virus becomes very strong in them
- High risk of TB
106
most serious risk factor associated with surgery during pregnancy
Uterine asphyxia
107
what position do you avoid due to uterine displacement?
avoid supine position, can cause hypotension
108
How to prevent DVT in a pregnant lady?
with pneumatic compression stockings during C-section
109
Hypotension is the most frequent complication of spinal and epidural; treated by?
Left uterine displacement, IV hydration, and ephedrine
110
What can you give to stop premature contraction?
alpha 2 agonist e.g. ritodrine
111
side effects of ritodrine for mom and fetus?
o Mom: hypokalemia, hyperglycemia, tachycardia
| o Fetus: hypokalemia, hyperglycemia, tachycardia (+/-)
112
Avoid atropine with ritodrine why?
can cause tachycardia leading to pulmonary edema
113
Mag sulfate increases sensitivity to??
both depolarizing and non-depolarizing muscle relaxant, therefore, decrease the dose.
114
Lidocaine in high dose causes what to the uterus?
vasoconstriction and increased tone
115
Problems with GA? (problems that occur through the act of intubating) (3)
Rapid desaturation, laryngeal spasm/edema, aspiration
116
most commonly injured nerve during abd hysterectomy?
Femoral nerve
117
nerve that may be injured during vaginal hysterectomy?
common peroneal nerve leading to foot drop
118
Most commonly injured nerve during vaginal delivery?
lumbosacral nerve
119
Most common morbidity for the pregnant patient? (2)
Hemorrhage and preeclampsia
120
administration of droperidol, zofran, and oxytoxin may be associated with?
prolongation of QT interval
121
oxytocin may be associated with?
ST segment depression
