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76 Cards in this Set
- Front
- Back
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Intra operative complications or considerations with Down Syndrome |
Atlanto-axial instability Bradycardia with induction Congenital heart defects Subglottic stenosis Macroglossia Micrognathia Hypotonia and redundancy of soft tissue DIFFICULT MASK or ETT |
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Evaluate Atlanto-axial instability |
History of symptoms (cord compression), previous difficult intubation Cervical spine films - anterior atlantodental interval of >4/5mm in lateral film Exam with full flexion and extension to see if sxs exhibited DELAY IS SXS! Get films and neurosurgical consult! |
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Intubation considerations for asthmatic |
Anticholinergic to reduce secretions Pretreatment with albuterol Adequate IV access and drugs such as epinephrine available RSI may induce bronchospasm |
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Induction with an anterior medistinal mass |
Position so that pt is most comfortable and can reduce cardiac or pulmonary compression Awake fiberoptic - easily aborted, identify most patent bronchus Maintain spontaneous respirations to keep airway patent and prevent reduction in preload - induce with KETAMINE have surgeon in room for rigid bronch for stenting/jet vent as well as sternal saw — lift mass up! Consider cannulating femoral arteries prior to induction with local anesthesia in case CPB become necessary Have multiple ETTs of varying size: use armored, also long tubes, micro laryngeal tubes, endobronchial tubes Can flip prone to relieve mass compression! |
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Differential for loss of spontaneous ventilation during induction of anterior mediastinal mass What would you do? |
Airway compression Asthma attack/bronchospasm Laryngospasm 1. Hand ventilate with 100% O2 2. Listen to chest 3. Optimize position 4. Try to intubate 5. Asthma concern? Deepen anesthesia, give albuterol or epi 6. Rigid bronch 7. Prone position 8. Sternal saw and lift mass 9. Start CPB
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What is negative pressure pulmonary edema? |
High intrapleural pressures secondary to inspiration against a closed or obstructed upper airway causes increased trans capillary pressure gradient and pulmonary edema Occurs within minutes to 3hr Sxs include coughing, pink sputum, tachypnea and hypoxia Treat is supportive with O2 and diuretics and possible intubation Resolved quickly |
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Why are steroids not indicated in acute spinal cord injury? |
Hyperglycemia, fluid retention with respiratory compromise, HTN, impaired wound healing, infection with immunosuppression, GI bleeding |
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Timing of alcohol withdrawal |
6-8 hrs - tremors 24-36hrs - hallucinations and seizures 72hrs - delirium tremens (confusion, agitation, autonomic instability with fever, tachycardia and HTN) |
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Wernicke-Korsakoff syndrome |
Thiamine (B1) deficiency seen with chronic alcoholics Sxs include confusion, double vision, ataxia, memory loss, hallucinations, confabulation, difficulty with word finding |
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Blood supply to spinal cord |
Anterior 2/3: anterior spinal artery fed by vertebral arteries and radicules arteries (artery of Adamkiewicz supplies anterior lower 2/3 of spinal cord)
Posterior 1/3: posterior cerebral artery fed by vertébrales and PICA |
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Causes of delayed emergence |
Residual anesthesia/narcotics Residual NMB Hypercapnea Hypoxia Hyper or hypo glycemia Seizure Stroke Alcohol withdrawal (Ensure adequate ventilation, assess medications given, check twitches and reverse, check glucose and lytes. Then consult neurology and get CT and/or EEG) |
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When would you consider giving NaHCO3? |
pH<7.1 or bicarbonate <10 Concern for arrhythmias, hypotension, myocardial depression and resistance to catecholamines Severe hyperkalemia |
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Differential for post operative vision loss Cause of posterior ischemic optic neuropathy RFs |
Anterior or posterior ischemic optic neuropathy, retrobulbar hemorrhage, cortical blindness (r/o with MRI) Ischemia to retrolaminar part of nerve, optic disc will be normal (abnormal in anterior ION) occurring 24-48hrs after surgery RFs: case >5hrs, EBL>45% blood volume, prone, obesity, male |
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Differential for hypertension |
Pain Light anesthesia Hypovolemia Surgical stimulation Hypoxia Hypercapnea Bladder distension |
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Major concern for induction during an esophagectomy |
Aspiration! Pretreat with H2 and bicitra, reverse T, preO2 RSI with cricoid Consider placing single lumen tube first and then exchange for double after nasogastric decompression |
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When would antibiotics be indicated following aspiration? |
Signs of bacterial infection, failure to improve or worsening symptoms after 2-3d, high likelihood of gram-negative or anaerobic organisms (bowel obstruction) |
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Signs of a PDPH Treatment? |
Frontal occipital HA, n/v, neck stiffness, back pain CN 6 stretch - difficulty with accommodation and diplopia CN 8 stretch - tinnitus, hearing loss Hydration, Caffeine, abdominal binder, pain control |
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Extubation criteria |
Adequate oxygenation and normocarbia Stable hemodynamics Sufficient TVs with spontaneous ventilation Reversal of muscle relaxants Awake, alert with intact airway reflexes |
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Indications for endocarditis prophylaxis |
Prosthetic valve, previous EC, congenital hear D or treated in last 6mo, transplant pt with valvular pathology AND Dental or pulmonary procedure or skin infection or known enterococcal infection |
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R on T phenomenon |
PVCs that occur during the refractory period of the cardiac action potential which occurs in the middle of the T wave. Can lead to v tach |
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Dependence vs abuse vs addiction |
Dependence - physiologic state of adaption toward a drug resulting in withdrawal when withheld Abuse - use of a drug in a manner that is detrimental to individual or society Addiction - compulsive use with loss of self control or irrepressible craving |
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How does hypothermia cause coagulopathy? |
Dec platelet aggregation at 33-37 (best rested with Thromboelastography) Defective coags factors <33 |
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Calculate maximum allowable blood loss |
(Starting - acceptable)/starting x TBV TBV W 65 M 70 Child 75 3mo-1yr 80 Full term 90 Premie 100 |
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Neutral temperature definition and values for premie, full term and adult |
Ambient temperature where O2 consumption is minimized but acidosis and body temperature has little variation 34oC premie 32 full term 28 adult |
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Where is a pericardial Doppler placed? |
Right of sternum between the 2nd and 4th ribs Get contrast or bubble TTE before surgery with risk of air embolism! |
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Other issues with osteogenesis imperfecta |
Plt dysfunction VSD/PDA/MR/AR Inc incidence of aortic aneurysms Atlantiaxial instability **sux can cause fxs! |
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Define A-a gradient |
Alveolar O2 - arterial O2 Nml = (age/4) + 4 PAO2 = (FiO2 (760-42)) - (paCO2/0.8) |
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Contraindications to ECMO |
<34wks <2000g H/o ICH Congenital heart defect |
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Risk factors for post op apnea |
<50wks Anemia Opioids GA Sepsis Congenital abnormalities |
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Electrolyte changes with refeeding syndrome? Sxs? |
Dec Mg, Ph, K Heart failure, arrhythmia Respiratory failure Neurologic dysfunction |
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Pickwickian Syndrome |
Severe complication of OSA leading to pulm HTN and RHF |
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Obesity hypoventilation syndrome |
Obesity with nocturnal hypoxia and daytime hypercapnea + polycythemia |
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Obesity hypoventilation syndrome |
Obesity with nocturnal hypoxia and daytime hypercapnea + polycythemia |
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Complications of liposuction |
LAST Fluid overload from tumescent absorption —> pulm edema, HF Fat embolism |
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Systemic effects of acromegaly |
Accelerated atherosclerosis with CAD DM HTN Viseromegaly with CHF |
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Affect of aldosterone on electrolytes |
Inc Na Dec K |
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Prinzmetal angina |
Angina with ST elevations d/t vasospasm Tx: Ca ch blocker, nitrates |
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Treatment of DKA |
IVF!! Don’t treat glucose too fast —> cerebral edema! |
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Myxedema coma |
Severe hypothyroidism causing non pitting edema (deposition of mucopolysaccharides in dermis), AMS, hypothermia. Can see dec HR and hypoTN |
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High frequency oscillating ventilation |
Active inspiration and expiration with oscillating membrane Set oscillating amplitude and frequency, FiO2 and pressure |
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Tx of phrenic nerve injury |
Phrenic nerve stimulation |
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Caudal anesthesia indications and dosing |
Risk of apnea, bladder surgery d/t dec sacral sparing 0.5mg/mL sacral dermatomes 1mg/mL low thoracic 1.25mg/mL mid thoracic |
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RF for gastroschisis |
Young mother, APAP, ASA, pseudoephedrine, smoking |
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Beckwith-Weideman syndrome |
Omphalocele with macroglassia, organomegaly, hypoglycemia and polycythemia |
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Risk factor for polyhydramnios, oligohydramnios |
Swallowing issues: TEF, duodenal atresia, inc urine production (Antenatal Bartter syndrome), twin to twin transfusion ACEI |
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Sheehan syndrome |
Panhypopituitary from necrosis d/t PPH No lactation, fatigue, inc UOP Tx: replace hormones |
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Factors in FFP and cryo Vit K dependent factors? |
FFP: II, V, VII, IX, X, protein c and s, antithrombin Cryo: Fibrinogen, vWF, I, VIII, XIII Vit K: II, VII, IX, X, protein c and s |
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Drug of choice for treating local anesthesia arrhythmia? |
Amiodarone |
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Factor V Leiden |
Resistance to protein c increasing thrombin and fibrinogen |
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Lab changes in hemolysis |
Dec haptoglobin Inc LDH Inc bilirubin |
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How does uremia cause coagulopathy? |
Impaired vWF from the uremia causes impaired platelet aggregation and function |
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Sensory distribution of musculocutaneous |
Lateral forearm |
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Nerve roots and specific ns blocked by TAP |
T7/9-L1 Subcostal Ilioinguinal Iliohypogastric |
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Meralgia paresthetica |
Entrapment of LCFN causing burning lateral thigh pain |
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Tetanus, botulism, polio |
T: inh of SNARE in CNS causing dec GABA release and spastic paralysis. Also see autonomic dysfunction P: CNS motor destruction from enterovirus B: inh of SNARE proteins at peripheral nerve causing flaccid paralysis and urinary retention. Tx is supportive and trivalent equine antitoxin |
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Side effects of suggamadex |
Bradycardia, HypoTN Prolonged PTT and PT Negates OCPs |
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SEs milrinone |
Tachycardia Hypotension Dec plts |
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SEs amiodarone |
Hypotension Bradycardia (refractory to atropine) Thyroid dysfunction (inc or dec) Pulm toxicity Inc LFTs Blue discoloration of skin |
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Dx of OSA |
Number of apneic events lasts 10s per hour of sleep |
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How does uremia affect bleeding? |
Increased bleeding from inh vWF, inc NO causing plts inhibition |
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Causes of pacemaker failure |
Lead failure MI Electrolyte abnormality Acid/base disturbance Anti arrhythmic drugs Tx: transcutaneous pacing, transVENOUS |
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Treatment of Vtach |
Stable: 12 lead to confirm, procainamide or amiodarone (preferred in HF), adenosine to convert Previous RBBB + SVT can look like VTach, compare to previous ECG Vfib: shock, chest compressions, intubate, shock, epi, amiodarone (procainamide mot indicated for vfib, can give lidocaine), Mg if Torsades, NaHCO3 if code>10min or severe acidosis |
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IV infiltration treatment |
Try aspirate back Elevate limb with cold or warm compress Stellate ganglion block Phentolamine if vasoconstriction infiltration |
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Sentinel event |
Must reach patient and cause harm |
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Adverse events of hetastarch |
Dec plt aggregation and acquired fibrinogen deficiency Has glucose and lactate Allergic reaction |
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Risk factors for post op delirium |
Pre op anxiety Post op pain Age (1-5yo) Abd or breast Surgery Prolonged surgery Use of volatiles (Sevo) Tx: treat pain, calm environment, reassure pre-op, anxiolytics pre-op, drain bladder, give prop or precedex |
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Cyanide toxicity and treatment |
Binding of cytochrome c oxidase prevents aerobic respiration resulting in metabolic acidosis, rhabdomyolysis, AMS, m. weakness, Arrhythmias, and inc MvO2 due to O2 not being used Tx: hydroxocobalamin Also Amyl nitrate (inhaled), Na thiosulfate with risk of thiocyanate toxicity with prolonged use: m. spasm, tinnitus, nausea, psychosis |
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Transfusion related immunomodulation |
Thought that organ donation or WBCs in blood products cause inflammation and immunosuppression. This results in higher infection rate and possible cancer occurence. However, also improves the graft survival in kidney recipients |
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Cause of ST depressions |
MI Non-infarction ischemia (unstable angina) Digoxin use Hypokalemia |
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Multiple myeloma pathology and sxs |
Plasma cell cancer causing abnormal antibody production due to inc in RANKL protein See inc osteoclasts activity, inc Ca, renal failure, pathological fxs, infections and anemia |
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Syndrome X |
Insulin resistance resulting in inc insulin without hypoglycemia, dec HDL with inc artherosclerosis and HTN |
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Sxs of acute intermittent porphyria Drug to avoid Tx |
- abd pain, n/v, arrhythmia from lyte derangement, autonomic instability, m weakness with respiratory failure, seizure - etomidate, nifedipine, NSAIDs - beta blocker for inc HR, replace lytes, IVF and 10% glucose in NS to dec porphyrin synthesis Hematin is last resort after several days of supportive therapy |
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When is ST analysis inaccurate? |
LBBB WPW Digoxin used Hypokalemia Pericarditis |
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RF for post op delirium |
1-5yo Pre op anxiety Breast or abd surgery Long surgery Pain Bladder distension |
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Obesity hypoventillation syndrome |
Obesity + daytime hypercapnea + polycythemia + nocturnal hypoxia |
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Complications and contraindications to ECMO |
CI: <2g, <34wk, ICH, congenital heart defect Complication: pulm hemorrhage, ICH, embolism, infection |
