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110 Cards in this Set
- Front
- Back
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List physical signs that correlate with fluid loss.
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skin turgor
mucous membranes orthostatic changes urine output HR BP |
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Late signs of hypervolemia
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tachycardia
pulmonary crackles wheezing cyanosis pink, frothy pulmonary secretions |
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Early signs of hypervolemia
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pitting edema - presacral in the bedridden pt or pretibial in an ambulatory pt
increased urine output in pts with normal heart, liver and kidney function |
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What's the difference between a crystalloid and colloid solutions?
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Crystalloids are low molecular wt ion (salt) solutions with or without glucose. Equilibrate and distribute out into the ECF.
Colloids contain high molecular wt substances like proteins or lg glucose polymers. Maintain plasma colloid oncotic pressure and remain intravascular. |
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Crystalloid or colloid solutions can more rapidly correct a severe intravascular fluid deficit?
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Colloids
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Rapid infusion of crystalloid or colloid solutions is more commonly associated with tissue edema? Why?
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Crystalloids because those solutions tend to equilibrate and distribute in the ECF whereas colloids tend to remain intravascular.
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When do we use crystalloids as the initial resuscitation fluid?
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in pts with hemorrhagic and septic shock
burn pts pts with head injury to maintain CPP pts undergoing plasmapheresis and hepatic resection |
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What is the most commonly used fluid to replace intraop isotonic fluid losses?
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LR
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When given in large volumes, what type of acid-base disturbance is associated with normal saline admin?
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hyperchloremic acidosis
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What replacement fluid is used to replace pure water deficits?
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D5W
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What is the intravascular half-life of a crystalloid solution?
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20 -30 minutes
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What is the intravascular half-life of a colloid solution?
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3 - 6 hrs
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List the blood derived colloids.
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plasma protein fraction (5% solution)
albumin (5% & 25% solutions) they are heated to 60C for 10hrs to decrease risk of transmitting hepatitis and other viral diseases. |
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List the synthetic colloids.
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dextrose starches such as Dextran and Hetastarch
gelatins |
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Which of the following statements is FALSE?
a. the net intracapillary pressures are greater than the surrounding interstitial pressures to ensure adequate drainage of fluids. b. the net interstitial pressures are greater than the intracapillary pressures to ensure adequate drainage of fluids. c. There is a slow continuous flow from the capillaries to the interstitium. d. ECF compartment encompasses the plasma and interstitium. |
b. the net interstitial pressures are greater than the intracapillary pressures to ensure adequate drainage of fluids.
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Ideally, when should fluid deficits be replaced, pre-, intra- or post-op?
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pre-op
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What is the ratio of replacing fluids to blood loss?
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Crystalloids 3ml to 1ml blood loss
colloid is 1:1 ratio until the transfusion pt is reached, at that time it is a unit for unit lost w/PRBCs |
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If a pt is exsanguinating and you don't know the blood type, what is the safest blood type to transfuse? State type and Rh factor.
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type O
Rh-negative |
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What is the most frequent acid-base abnormality after massive blood transfusion?
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metabolic alkalosis
even though stored blood is acidic due to the citric acid anticoagulant and accumulation of RBC metabolites (CO2 and lactic acid), once transfused the RBC metabolites are converted to bicarb by the liver. |
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During quiet breathing, where is resistance the greatest in the resp. system?
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nasal passages accounts for 2/3 of total airway resistance
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sensory innervation of nasal mucosa is from which nerve?
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branches of the trigeminal (CNV)
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Gag reflex is which nerve?
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cranial nerve X - vagus
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What is the valeculae?
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space between epiglottis and tongue;very sensitive area & sympathetic nervous system is stimulated when this area is touched
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Describe the pharynx.
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extends from the posterior aspect of the nose to the cricoid cartilage (C5/6)
has 3 parts: nasopharynx, oropharynx, laryngopharynx |
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What is the main source of oropharynx obstruction?
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the TONGUE
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sensory innervation to the tongue?
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glossopharyngeal
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motor innervation to the tongue?
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glossopharyngeal
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Why isn't nasal intubation used often?
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Don’t nasally intubate often because it bleeds like hell, blood goes down the pharynx, blood can cause laryngospasm
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What is the location of a child's cricoid cartilage? an adult's?
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C3 in a child
C5-6 in an adult |
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The unpaired cartilages found in the larynx.
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cricoid
thyroid epiglottis |
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The paired cartilages found in the larynx.
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arytenoid
corniculate cuneiform |
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At what vertebral level is the hyoid bone located?
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C3
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Which pair of cartilages is responsible for changing the shape of the vocal cords in phonation?
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arytenoids
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What nerve innervates the larynx?
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vagus
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What are the branches of the nerve that innervates the larynx?
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superior laryngeal
inferior laryngeal recurrent laryngeal |
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Which nerve supplies motor innervation to all of the muscles of the larynx? Which muscle(s) doesn't it innervate?
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recurrent laryngeal nerve
except the cricothyroid muscle, which is the external branch of the superior laryngeal |
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Describe the motor innervation of the larynx.
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SLN - cricothyroid
RLN - all other muscles |
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What does the external SLN innervate?
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anterior subglottic mucosa
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What does the internal SLN innervate?
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epiglottis
base of the tongue supraglottic mucosa thyroepiglottic joint cricothyroid joint |
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What happens when you stimulate the vallecula?
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sympathetic nervous system response
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At what level does the trachea start?
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C5/6
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How long is the trachea?
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10-15 cm
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How long is the esophagus
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25 cm
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At what vertebral level is the bifurcation of the trachea?
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T5
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What is the narrowest part of the trachea?
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the glottis
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What shape does the infants larynx look like?
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funnel shaped
that's why uncuffed ETTs are used in children <6yrs |
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Which is better:
a larger ETT with less air in the cuff or a smaller ETT with lots of air in the cuff? Why? |
larger with less air
That way you don't compress the surrounding structures causing ischemia and breakdown of tissue |
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absolute indications for intubation
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inability to oxygenate = hypoxia
inability to ventilate = hypercarbia airway protection |
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What nerve injuries can occur when mask ventilation is used for long periods of time?
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trigeminal and facial nerve injuries
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relative indications for intubation
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combative pt
inability to clear secretions anticipate airway edema (C-spine, inhalation injury) anticipate worsening lung function (ARDS,atelectasis, pneumonia) anticipate respiratory fatigue |
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curved blade.
Mac or Miller? |
Mac
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When properly inserted, where does the Mac blade go? What can be a consequence of this?
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it goes into the vallecula, indirectly lifting the epiglottis
this can result in sympathetic nervous system stimulation |
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What are the 3 axis that need to be alligned for intubation?
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oral
pharyngeal laryngeal |
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What kinds of 'mishaps' occur with intubation?
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failure to recognize esophageal intubation
failure to successfully establish the airway |
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From the oral cavity, how many centimeters to the carina?
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40cm
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signs that may predispose a pt to being a difficult intubation
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small mouth
receding mandible overbite/buck teeth large tongue <6cm from mandible to thyroid prominence short, bull neck neck mass body wt head and neck movement |
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Where does most of the head movement for intubation occur? (at what joint)
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occipito-atlantoaxial joint
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some diseases that might limit the movement of the head/neck for intubation.
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morquio syndrome (lysosomal storage disorder char. by skeletal malformations)
klippel-feil syndrome (char by short neck, low hairline and limited neck movement) dysproportionate dwarfism Down's syndrome RA ankylosing spondylitis |
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most common site of airway obstruction?
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oropharynx
it's usually the tongue falling back as the jaw relaxes |
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indicators that a pt might be difficult to mask ventilate.
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age > 55 yrs
snores beard overweight (BMI > 26) CPAP at home |
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What is the Mallampati system?
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grading system that compares the relative size of the tongue to the oral cavity
stages I - IV |
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How do you position the patient to apply the Mallampati scoring system?
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pt should be sitting, with their mouth open and tongue sticking out
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How big should the mandibular compartment size be for a potentially easy intubation?
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the mandibular compartment size extends from the inferior border of the mandible to the superior border of the thyroid cartilage (aka thyromental distance which should be 6cm minimum)
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When is an esophageal intubation considered a bad intubation?
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when it's not recognized!
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Why is positive pressure mask ventilation a poor choice for a pt with a full stomach?
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the positive pressure may force gas into the stomach and cause the pt to aspirate prior to intubation
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What part of the brain controls 'automatic' breathing?
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medulla
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What role does the pons play in respiration?
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stimulates the pneumotaxic center, which inhibits the apneustic center and inhibits respiration
the apneustic center is also located in the pons and is responsible for inspiration |
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What is the stimulus for normal respiratory drive?
In what pts is this not true? What is their stimulus? |
CO2 levels in normal pts
This is not true of COPD pts, whose drive comes from O2. |
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How is the respiratory drive stimulated in a COPD pt?
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stimulated by O2 concentration and the carotid bodies respond to this.
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Define minute ventilation.
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RR x TV
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What's the difference b/t oxygenating and ventilating?
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oxygenating is gas exchange
ventilating is the movement of CO2 into and out of the lungs |
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Can you have oxygenation without ventilation?
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yes. an example would be the apnea test on neuro pts.
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Describe west zone 1.
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zone at the upper lung field where:
PA>Pa>Pv this means the alveoli are so big that the capillaries collapse, limiting gas exchange |
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Describe west zone 2.
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the middle lung field where:
Pa>PA>Pv which means both capillaries and alveoli are open and exchanging gas. This is the ideal zone. |
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Describe west zone 3.
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the lower area of the lung where:
Pa>Pv>PA which means the capillaries are so engorged that the alveoli collapse and so minimal gas exchange occurs |
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In which West Zone would you expect to have dead space ventilation?
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zone 1
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Causes of hypoxia & hypercapnia
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ventilation without perfusion (deadspace ventilation)
diffusion abnormality perfusion without ventilation (shunting) hypoventilation decreased or inadequate FiO2 |
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What is shunting?
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perfusion without ventilation
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What is the normal V/Q ratio?
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0.8
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What can cause increased dead space ventilation?
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low cardiac output
increased PEEP PE (air, fat, amniotic fluid) |
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What percentage of the airway is not involved in gas exchange? Why?
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30%
because it lacks blood supply |
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What can resulting in shunting?
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anything that collapses the alveoli such as:
pneumothorax pulmonary hemorrhage pulmonary edema pneumonia atelectasis (obesity, pregnancy, ascites) |
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causes of hypoxemia
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hypoventilation
low FiO2 V/Q mismatch diffusion impairment right to left shunt |
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which way does the oxyhemoglobin curve shift when a pt is hypermetabolic (fever)?
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to the right, which means the oxygen requirement for that pt is increased
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which way does the oxyhemoglobin curve shift when a pt is alkylotic?
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to the left
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What is the respiratory quotient?
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ratio CO2 produced to O2 consumed
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normal O2 consumption in a resting adult?
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3-4 ml/kg/min
or 250ml/min |
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normal O2 consumption in a resting child?
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6-7 ml/kg/min
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What is the total lung capacity in a normal adult?
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6L
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What is vital capacity?
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IRV + TV + ERV
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What is FRC? What is the significance with intubating?
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functional residual capacity = ERV + RV
decreased with obesity, ascites, pregnancy, PEEP We focus on the FRC because when we pre-oxygenate a pt, we want the oxygen to diffuse into the reserve areas to carry them through an intubation |
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What decreases FRC?
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"P-A-G-O-N-S"
Pregnancy Ascites General anesthesia Obesity Neonates Supine position |
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What is closing volume?
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volume needed in the lungs at end expiration to keep the alveoli open
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What is closing capacity and what affects it?
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it is the closing volume + residual volume
it's affected by chronic bronchitis, age, liver failure, surgery, smoking, obesity |
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effects or stages of anesthesia
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sedation ->analgesia -> anesthesia -> neuromuscular block
in a supine pt, it results in the diaphragm moving cephalad |
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What is the purpose of PEEP?
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prevent atelectasis and promote alveolar recruitment
there is a point at which PEEP will no longer be an effective recruitment method |
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What is the rate of PaCO2 rise during apnea? Why is this significant?
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6 mmHg the 1st minute
3-4 mmHg every minute thereafter If you have a ventilated pt from the OR and you want to extubate, they sat 100% with etCO2 of 35, turn of the machine and wait to bag them for at least 2minutes so their CO2 will rise to give them the stimulus to breath. |
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What is the first physiologic effect of hypoxia?
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CV effect = excitatory and vasoconstrictive
increased HR and BP |
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What are the main cations of ICF?
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potassium
magnesium |
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What are the ECF compartments?
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interstitium
plasma transcellular |
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What are the anions of ICF?
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proteins
phosphates |
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What are the main anions in ECF?
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chloride
bicarb |
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How much volume expansion is expected after infusing 1L of a hypertonic solution?
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2.5 times
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How much of a 1L isotonic solution remains in the vasculature after 2hrs?
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200ml
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What are the key points with cryoprecipitate?
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it precipitates from thawed FFP
must be used within 4hrs will raise fibrinogen levels 50mg/dl contains factors I, III, fibrinolectin, von Willebrand's |
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What is the hct of a unit of PRBCs?
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70-80%
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25% albumin draws how many mls per ml of albumin?
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3-4ml
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What is the maximum dose of hespan per day?
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1L
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What is the maximum dose of dextran to avoid bleeding?
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1.5-2g/kg (Units are per Dale's notes)
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Which dextran is used for volume expansion?
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dextran 70
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