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259 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What are the conventional clinical manifestation of Ischemic Heart Disease
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Angina, MI, ischemic Cardiomyopathy, sudden death
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How does aging increase your risk for HTN and CAD
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vessels have impaired Nitric oxide release from the endothelium so they become stiffer
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List 3 ways we "medically manage" ischemia perioperatively
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1. Drugs: pharmacologic manipulation of O2 supply and demand through HR control and adequate coronary perfusion pressure
2. Inhibit Thrombus formation on unstable plaque 3. IABP (last resort in terms of medical treatment) |
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What two classes of drugs are the main treatment for ischemia?
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1. beta Blockers
2. Nitrates |
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Beta blockers can worsen outcome in pt's with what?
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LV dysfunction
-Fixed defect cause decreased EF -active CHF |
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What is Syndrome X?
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Anginal CP with normal coronary angiography and lack of extracardiac etiology of the angina
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What is Hibernation?
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Impaired myocardial function in the setting of ongoing impaired myocardial blood flow is relieved following reinstitution of normal blood flow
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What arteries stem from the the Left Main Artery?
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LAD and Circumflex
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What artery supplies the posterior ventricle?
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Circumflex
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If someone has "left main equivalent" disease of the coronary arteries, what does this mean?
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High degree of stenosis of both the LAD and the Circumflex
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What are the 3 branches of the right coronary artery?
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Conus
Right Marginal Posterior Descending Branch |
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what part of the heart does the conus artery supply blood to?
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Upper right ventricle
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What is the single most common congenital heart lesion?
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Congenital valve disease
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What is the other name for the Left anterior descending artery?
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Anterior Interventricular artery
-delivers blodd to the portions of the left and right ventricles nad much of the interventriculiar septum -travels down the anterior surface of the interventircular septum towad the apex of the heart |
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What is the name of the groove that the circumflex artery travels in?
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the coronary sulcus
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What part of the heart does the circumflex artery supply blood to?
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left atrium and lateral wall ofhte left ventricle
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Define collateral arteries
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connections or anastomoses b/t 2 branches of the same coronary artery of connections of branches of the right coronary artery with branches of the left
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List some things that can affect the blood supply to the coronary arteries
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1. Autonomidc control: Sympathetics
--alpha and beta receptors, Vagus nerve 2. systolic compression |
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List some things that increase O2 demand in coronary arteries
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Increased HR
Increased Wall tension (due to increased diastolic volume or increased BP/afterload) Increased Contractility |
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What 4 things can decrease coronary blood flow?
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1. Increased HR
2. Decreased Aortic pressure (aortic root: how blood gets to rt and left cor. arteries) 3. Increased end-diastolic pressure 4. Vasoconstriction or spasm |
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what 2 things can cause decreased arterial O2 content (thus decreased O2 delivery to the cor. arteries)
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1. Anemia
2. hypoxemia |
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What 2 things can cause decreased O2 extraction (causing decreased O2 delivery to the coronary arteries)?
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1. Decreased capillary density
2. Leftward shift of Oxyhemoglobin curve (RBC's hold onto O2) |
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Which valve has the largest diameter of all the heart valve?
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Tricuspid (b/t Right Atria and ventricle)
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when blood is leaving the right ventricle, what valve does it go through?
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Pulmonic Valve
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Which valve has thinner cusps, the arotic or pulmonic vavle?
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Pulmonic
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What are the 2 semilunar valves in the heart?
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Aortic and pulmonic
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what kind of ventricular Hypertrophy develops in aortic stenosis?
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Concentric
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What systolic gradient and aortic valve area denote severe AS?
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Gradient > 50 mm Hg
area < 0.8 cm squared |
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what are the anesthetic management goals in AS
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1. Avoid Hypertension
2. Avoid hypotention 3. Maintain NSR (b.c heart is dependent on atrial Kick -- need a full Left ventricle) 4. Maintain preload |
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What is the most commn cause of sudden cardiac death in peds?
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Hypertrophic cardiomyopathy
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What is Hypertrophic cardiomyopathy?
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Ventricular hypertrophy without an obvious cause such as HTN or AS
*Sytolic dynamic obstruction ot flow |
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What are the anesthetic goals in hypertrophic cardiomyopathy?
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**Euvolemic**: they need adequate preload
-NSR and avoid a decrease in afterload |
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What are the 2 mian categories of Aortic Regurgitation?
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Primary AV leaflet disease: rheumatci fever, endocarditis, congenital bicuspid AV
Aortic root disease: Marfan's dissections, |
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what are the anesthetic goals in Aortic Regurgitation?
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Fast,
Full, Forward: Afterload reduction, Inotropic augmentation |
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What is the normal Mitral valve area?
area in severe stenosis? |
Nl: 4 cm squared
severe stenosis: < 1 cm squared |
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Which cardiac disease has incidence of 2:1 female?
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Mitral stenosis
usually caused by rheumatic fever severity of calcification correlates with the transvalvular pressure gradient |
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What condition can occur as a result of acute mitral regurgitation?
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Acute pulmonary edema
--Lft Atrium has not undergone adaptive changes that allow for compensation |
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When evaluating level of mitral regurgitation, is Left ventricle EF helpful?
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No, b.c Left ventricle ejects blood both into the aorta and back up into the left atrium
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LIst 5 last minute check prior to inductionin cardiac surgery
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1. Reassessment of pt's overall cardiopulmonary/airway status
2. Integrity of circuit and sux'n 3. availability of bllod for transufions 4. Proximity of surgeon 5. Immediate availability of emergency cardiac drugs |
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When are PA lines used in cardiac surgery?
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Ef < 40%
Left Mian CAD Right ventricle ischemia Pulmonary HTN |
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What are the 2 main goals during induction in cardiac surgery
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avoid Hypotension and tachycardia
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What is the recommended induction dose of propofol in cardiac surgery?
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1-2 mg/kg
b/c 2 mg/kg can decreased MAP by 15-40% |
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What is fast track cardiac anesthesia?
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pt is extubated wthin 8 hours
use a lower dose aof narcotic 10-15 mcg/kg (vs. 10-20 mcg/kg) |
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What is the first inciion in cardiac surgery?
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saphenous vein
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what is the most stimulating part of cardiac surgery
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Sternal split
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When should the lungs go down during cardiac surgery?
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sternal split and sternal spread
-disconnect expiratory hose and shut off vent |
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What is IMA and what position should pt be in?
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Internal Mammary Dissection
-tilt right |
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At what point during cardiac surgery do you want the BP to be low
(SBP < 90) |
when the surgeon is cannulating the aorta so it does not dissect.
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What is crucial prior to cannulation in cardiac surgery?
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pt must be heparinized
must have ACT at least 300 s to go on bypass |
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what is a normal ACT level?
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105-167 seconds
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List the factors that make weaning from CPB difficult
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Fibillation
potassium or acid/base disturbance need for pacing need for inotropic support optimal preload |
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When is there a chance of getting air in the heart during cardiac surgery?
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when the valves are being done
-Tberg and aspirate from TLC with a needle |
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what is last resort in terms of medical management in ischemic heart disease
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IABP
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what is the cornerstone of therapy in ischemic heart disease
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Nitrates
b/c vasodilate the coronary arteries, so increase O2 supply and decrease myocardial O2 demand |
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What is the treatmetn for coronary vasospasm?
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Nitroglycerin
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what is stunning?
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Brief periods of ischemia lead to subsequent myocardial dysfunction for several hours
so after bypass, the blood flow during the reperfusion phase causes stunning (dysrhythmias-- heart not working well) may last for several hours |
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How long can stunning last
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several hours (not days)
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When can pt come off bypass?
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when flow through the pump is at 1 liter flow and SBP > 90 mm Hg
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When should you strart the ventilator when coming off bypass
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When on partial bypass (flow going through the lungs)
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what is preconditioning?
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Brief intermittent periods of MI confirm protection against a subsequent larger ischemic insult and limit infarct size
-- |
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Why is left main disease the worst kind of ischemia to have?
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b/c it is the entire left ventricle
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is circumflex artery open the posterior or anterior left ventricle
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posterior
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Why is it worse for someone who is 35 yr old to have a big MI than a 65 yr old?
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b.c the 65 yr old probably has developed collateral arteries that will continue to supply the area with some blood flow
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What are the 2 things that can increase cardiac O2 demand the most
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Contractility
HR |
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What is the other name for systolic compression
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diastolic dysfunction (heart remains compressed and don't have time for diastole)
--this decreaes O2 supply b/c the coronary arteries do not have time to fill |
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What is the Rate Pressure Product
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HR x BP = more demand if either one is elevated
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what attaches the heart valves to the papillary muscles?
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chordae tendonae
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What pulls the cusps of the heart vavles together at the onset of ventricular contraction?
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papillary muscles
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What is the patho of of aortic stenosis?
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LV output is maintained by development of Left vetnricular Hpertrophy (increased afterload)
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Anesthetic management for pt with AS
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1. Avoid increased afterload (HTN)
2. Avoid hypotension 3. Maintain NSR b/c they are dependent on their atrial kick 4. Maintain preload (don't let them get dry) |
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Is hypertrophic cardiomyopathy hereditary
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Yes: autosomal dominant (1:500)
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what is the difference b/t acute and chronic mitral regurgitation?
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Acute pulmonary edema
(with chronic there is adaptive changes that allow for compensation) |
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does the LV EF a good way of measuring amount of Mitral regurge?
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no, b/c even though the EF may be normal , the blood may be going up into the right atrium
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Which heart valve can be repaired instead of replaced?
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Mitral valve
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What is the baseline cerebral Oximeter reading (normal)
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71-72%
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When does the cerebral oximeter reading go down?
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deep anethesia b/c there is decreased metabolism and decreased flow
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Is nitrous used in cardiac anesthesia?
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No, risk of air bubbles
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Do your use an OGT with cardiac surgery?
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Yes, empty stomach and then take it out right away, so can put TEE.
at the end of case put in a NGT |
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What lab do your send pre-incision in cardiac surgery?
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baseline ACT, ABG
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What do you do as soon as the chest is open in cardiac surgery?
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change the paddle plug from external to internal
10-20 joules |
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What is the Joules used for internal defibrillation?
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10-20 joules
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What must be done prior to cannulization in heart surgery?
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pt has to be heparinized
ACT must be at least 300s |
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What is ACT?
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measure the amount of time it takes blood to clot
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alzar
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to heave, to lift, to pick up, to raise (prices)
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lever, monter
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how long after you give the heparin do you draw an ACT
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2 minutes
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When do you draw up Protamine??
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no til the end of case
** very important the pt is anticoagulated for bypass, so don't have protamine drawn up so cannot be mistakenly given |
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What can happen if the BP is high during dissection?
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the aorta could dissect
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caber
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to be contained, to fit into
contenir |
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What do you do as soon as the chest is open in cardiac surgery?
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change the paddle plug from external to internal
10-20 joules |
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What is the Joules used for internal defibrillation?
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10-20 joules
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What must be done prior to cannulization in heart surgery?
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pt has to be heparinized
ACT must be at least 300s |
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What is ACT?
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measure the amount of time it takes blood to clot
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What do you do prior to pushing heparin through a central line?
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Aspirate to make sure get blood bag
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SE of Protamine
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1. sytemic hypotesnion (most common)
2. Anaphylactoid Reaction: 3. Pulmonary Hypertension and vasoconstriciton and Right Hrt Failure |
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How does Heparin work
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It binds to Antitrhombin III -- this potentiates AT III's effect of binding thrombin and removing it from the coagulation cascade
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What is the difference b/t epi and milrinone?
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Epi increases SVR and milrinone (phosphodiesterase-3 Inhibitor: Inotrope and vasodilator) does not
so epi would be appropriate if HR is normal and SVR is low |
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What is the normal SVR?
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1400 dines'second/cm squared
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SE of Protamine
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1. sytemic hypotesnion (most common)
2. Anaphylactoid Reaction: 3. Pulmonary Hypertension and vasoconstriciton and Right Hrt Failure |
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How does Heparin work
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It binds to Antitrhombin III -- this potentiates AT III's effect of binding thrombin and removing it from the coagulation cascade
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What is the difference b/t epi and milrinone?
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Epi increases SVR and milrinone does not
so epi would be appropriate if HR is normal and SVR is low |
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What is the normal SVR?
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1400 dines'second/cm squared
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What is the treatment for RV failure after cardiac surgery?
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Nitroglycerin
Inotropic support (milrinone, Dobutamine, Isoproterenol) |
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what are the advantages of minimaaly invasive coronary bypass surgery (no bypass)
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decreased transfusion requirements
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What are the disadvantages of minimally invasive coronary bypass surgery (no bypass)
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Hemodynamic instability and arrhythmias
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What is somatic pain?
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has an identifiable focal piont; (skin)
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What is visceral pain
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diffuse pain (no identifiable focal point); liver
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what is pain threshold
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The point at shichc a stimulis percieved as pain; universal
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What is pain tolerance?
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Max. intensity of pain that a person endures before they want something done about it
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what is nocioceptive pain
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results from the stimulationof nerves form a noxious stimulis
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what is the definition of nocioception
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process of transduction, transmission, and modulation of pain
results from the stimulatin of nerves from a noxious stimuli |
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Which type of pain is proportional to the stimulus
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Acute
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which is universal/uniform: pain threshold or pain tolerance?
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Threshold
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What is very different b/t individuals: pain threshold or pain tolerance?
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Tolerance
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which type of pain is neuropathic and generally exists beyond the usual course of an injury or disease
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Chronic
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what type of fibers carry Acute pain
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A delta fibers( large diameter and fast)
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What type fo fibers carry Chronic pain
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Cfibers (smaller diameter; slower)
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What causes neuropathic pain?
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abnormal processing of painful stimuli and can also be caused by spontaneous excitation of nerves
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what stimuli do A delta fibers carry?
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Noxious stimulus, temperature, touch
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What fibers carry "fast" or "first" pain
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A delta fibers
pain sensation is equal to the duration of the painful stimulus |
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When in the dorsal horn, where do the C fibers synapse?
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Lamina 2 & 3 / Substantia Gelatonosa/ "Rexed's Lamina 2"
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what changes occur in the synapses in chronic pain?
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Nerve sprouting
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Where do A delta fibers synapse in the dorsal horn?
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Lamina 1 & 5
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What tract do the A fibers and C fibers cross over in the spinal cord
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Tract of Lassaur
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What does the Substantia Gelatoanosa have in it?
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interneurons-- so this is where spinal opioids work to modulate pain
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What are the 2 types second order neurons (carry sensation up to the brain)
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Nocioceptive
Wide Dynamic Range Neurons: carry noxious and non-noxious stimuli |
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What is the Pain Pathway?
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spinal thalamic tract/ Anterior spinal thalamic tract
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what are wide dynamic range neurons capable of ?
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"wind up": during repeated stimulation, they increase their firing rate even with the same sitmulus intensity
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What is an example of " wind up"
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when pain is not treated appropriately in beginning -- will take more narcotic to control the pain
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where do the second order neurons go?
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Brain Stem
Thalamus |
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Whre do third order neurons go?
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Cerebral cortex
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What is another area of the brain that some of the afferent input goes
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Periaquaductal Gray: has an efferent pathway that inhibits pain signals
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How do IV narcotics work
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1. Periaquaductal Gray area (area in the mid brain that can inhibit pain)
2. Thalamus 3. Limbic area of brain 4. Spinal cord? |
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What are Enkephlans
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Neurotrasnmitter; body's natural opioid/endorphin
inhibit pain at the spinal cord level Found in the internuerons that the C fibers synapse within the dorsal horn; C fibers release Subtance P and enkaphlans prohibit or decrease it |
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What do opioids and enkephlans decrease at the level of the interneuron in the spinal cord
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Substance P
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How do opioids work in the subarachnoid space (spinal cord)?
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Decrease/prohibit substance P
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What is the major neurotransmitter of the A delta fibers
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Glutamate : excitatory
NMDA, AMPA |
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Is substance P excitatory or inhibitory? and what receptor does is act on?
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Excitatory
NK1 |
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What receptors do enkaphalins and endorphins work on?
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alpha, delta, Kappa (Opioid 1,2,3 receptors)
Inhibitory |
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What anesthetic drug is an NMDA antagonist
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Ketamine
useful in chronic pain syndromes |
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How does Baclofen work in treatment of myasthenia gravis (neuralgias)
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GABA Agonist (GABA inhibits pain)
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HOw is spinal analgesia mediated? (what receptors)
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Mu 2
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How is IV analgesia mediated? (what receptors
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Mu 1
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What happens at the cellular level with tissue injury and pain
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the cell depolarizes and ca is released this activates phospholipase A2 and then Arachidonick acid is produced
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Where in the brain do IV Opioids work?
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Periaquaductal gray area, thalamus, limbic
Primarily on Mu1 receptors |
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Why is the response to pain different with IV narcotics vs Spinal narcotics?
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b/c there is a cerebral component -- don't care if there is pain
IV narcotics work in mult. parts of the brain (thalamus, limbic, preiaquaductal area -- Mu1 receptors) and the dorsal horn of SC (inhibit substance P) |
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Preipheral modulation of pain can be....
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Increasing or decreaseing pain transmission
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Primary hyperalgesia refers to:
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the release of substances from damaged tissues
-enhanced response to noxious stimuli |
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what causes Primary hyperalgesia?
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the relaease of substances from damaged tissues such as phospholipase A2 and arachidonick acid
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What causes secondary hyperalgesia
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rel. of substance P -- degranulates mast cells-- causing histamine release and tissue edema
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What are two types of peripheral modulation of pain?
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Primary Hyperalgesia: results in a decrease in trheshold, an increase in frequency response to eh ame stimulus intensity, a decrease in response latency, and spontaneous firing even after cessation of the stimulus; usually mediated by the rel. of histamine following tissue damage.
Secondary Hyperalgesia: Neurogenic inflammation; due to the rel of substance P -- degranulates Histamine and leads to tissue edema |
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what is Central modulation of pain?
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Modulation of pain in the spinal cord
either facilitation or inhibition |
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what are the 3 mechanisms for central modulation/ sensitization of pain
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C fibers: chronic
1. wide dynamic range neurons "wind up" 2. Receptor field Expansion: neurons in the dorsal horn increase their receptor fields, so adjacent neurons are responsive to stimuli 3. Hyper-Excitability of Flexion reflexes |
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How do Corticosteroids work?
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stop the build up of Arachidonic Acid
(AA synthesis leads to pain due to inflammation or bradykinin and Oxygen radicals) |
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how do NSAIDs work
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inhibit cyclooxygenase pathway
(cyclooxygenase lead to bradykinins and oxygen radicals and this causes pain) |
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What is the only way improve diaphragm function when pt is having surgery near the diaphragm?
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Thoracic Epidural
-diaphragm is inhibited when there is an incision near it, so this is the only way to improve funciton.....IV narcotics will not help |
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What systmes are affected by adequate pain management
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Cardiovascular: increase HR from pain can lead to Ischemia
Pulmonary Morbidity: Thromboembolic morbidity GI morbidity stress-Response related morbidity: Increased cortisol will cause poor wound healing |
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What does TEA improve?
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Thoracic Epidural analgesia: Myocardial Oxygen supply: causes coronary artery dilation from sympathetic block
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Do Lumbar epidurals dilate coronary vessels?
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NO
segmental, so does not affect coronary vessels, but will lower the BP |
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Why is Demerol bad? contraindicated for chronic pain
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has an active metabolite: Norperidine
Do not give to anyone for > 48 hours do not give to pt on MAOI |
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What are the potential complications from clonidine
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Alpha II agonist: alpha II in the brain is inhibitory -- so alpha II agonist will decrease sympathetic outflow -- can cause hypotension and bradycardia, sedation
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potential complications of opioids in spinal/epidurals
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respiratory depression
urinary retention Pruritis (most common) N/V |
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Is Fentanyl Lipophilic or hydrophilic?
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Lipophilic
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Does Fentanyl have "Rostral spread"
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No, fentanyl does not spread to the brain b/c it is lipophilic, so it sticks to neural tissue
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Name a Hydrophilic Opioid
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Morphine
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Which opioid causes late respiratory depression when given in spinal or epidural (6-8 hours after injection)?
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Morphine, b.c it is hydrophilic so likes the CSF and spreads to the brain through the CSF
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What area of the body is typically affected in Complex REgional Pain Syndromes 1
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the extremities and typically follows minor trauma
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What area of the body is typically affected in complex regional pain syndrome 2?
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Trunk; usually gunshot wounds
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What is another name for chronic pain
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sympathetically driven pain -- b.c have more circulating norepinephrine and more sympathetic receptors
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What is a sympathetic block in the treatment of chronic pain
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use local anesthetic to block sympathetic receptors by injecting into the ganglion (bundle of nerves into)
-for chronic pain |
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How do Antidepressants help in treating chronic pain
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help sympathetically driven pain by inhibiting uptake of norepinephrine and serotonin, so have more of these nt available and they are inhibitory in the pain pathway
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How is chronic back pain treated in pain clinics?
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1. Epidural corticosteroids: decrease inflammation
2. fascit joint Injections: 1 ml of local anesthetics; can produce analgesia for up to 6 months |
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List some adjuvant drugs used for chronic pain (a drug given for other than its main purpose)
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1. Antidepressants: SSRIs (block the reuptake of serotonin and serotonin is an inhibitory Nt in the pain pathway) and tricyclics (block NMDA activity)
2. Sympatholytics: transdermal clonidine 3. Anticonvulsants: block action potentials (Clonazepam, Valproate) 4. Sodium channel blocking drugs Mexiletine (inhibit glutamine rel, by blocking Na channel) |
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What is the most important spinal nerve tract for relaying pain and temperature sensations to the brain
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Lateral spinothalamic tract
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Name the region of the spinal cord where transmission of pain impulses is modulated
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substantia gelatonosa
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What are the 4 precepts of trauma?
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1. All pts are full stomachs
2. partial airway obstruction can rapidly advance to complete airway obstruction 3. all patients are hypovolemic 4. all patients have a cervical spine injury until proven otherwise |
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what are the 3 things that the anesthetist is primarily concerned with preserving
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1. CNS function
2. Maintain adequate respiratory gas exchange 3. achieving circulatory homeostasis |
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What are the 2 main goals in the Airway assessment in Trauma?
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1. Oxygenation
2. Prevent aspiration |
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What is the most common cause of death in males younger than 40
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trauma
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What do always assume when doing your airway assessment in trauma patient
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Cervical spine injury
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what cervical injuries may require nasal intubation
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C1 and C2
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what is the best method for ruling out cervical fracture for all C spine vertebrea
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CT scan
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If injury is below the clavicle do you need to assume cervical spine injury
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YES
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List the Indications for endotracheal intubation
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1. cardiac or respiratory arrest
2. Respiratory Insufficiency: maintain ABG's 3. Airway Protection 4. Need for GA (burns 4. CO poisoning 5. Increased ICP 6. Uncooperative or Intoxicated pt |
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what trauma pt's do not get nasal intubations
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pt with Lefort II or LeFort III facial fractures
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Give 2 indications for emergent tracheostomy
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1. Pt's with massive disruption of the floor of the mouth
2. disruption of the larynx or cervical trachea |
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List the conditions that can cause compromised ventilation in trauma pt
(if unable to ventilate the pt, what could be the cause?) |
Flail chest
Obstruction of the ETT Direct pulmonary injury |
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How much O2 do you give prior to getting blood gas on a trauma pt?
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100% FiO2
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In trauma, shock is mainly a result of what?
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Hypovolemia (until proven otherwise)
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Are HCT and Hgb accurate measures of acute blood loss?
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No
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The degree of hypotension on presentation to the ER and OR correlate strongly with......
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Mortality
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What do trauma pt's have contributing to their shock that pt having elective surgery do not have?
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Massive tissue damage and peripheral somatic nerve stimulation -- these exacerbate the reduction in CO and SV seen in shock
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Where should IVs be placed in trauma pt's?
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Superior and Inferior caval systems (not periphery)
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What is Disability in the Primary survey of a trauma pt?
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Neuro status: GCS
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What is the GCS for mild TBI?
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13-15
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What is the leading cause of complications and death in trauma pts?
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sepsis
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What is the Exposure part of the primary survey in trauma pt's
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remove all clothing
lab test, ekg, CT scans, xray history and physical evaluate for surgical treatment if needed review all findings |
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when have a trauma pt, what drugs should be held until after initial neuro assessment
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sedatives and anticholinergics
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What signs and symptoms in brain injury pt precede brain herniation
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cushing's triad: HTN, bradycardia, Irregular RR
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What is the most common traumatic brain injury
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Mild TBI 13-15
may exhibit post concussion symptoms: HA, memory loss, sleep disturbances |
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which TBI has hichg rsik for mortality?
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severe: GCS <8
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If pt has a severe TBI, what should you keep their PO2 at?
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greater than 60 mmHg -- don't tolerate low PO2 or hypotension
PO2 < 60 m Hg doubles mortality |
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What is the recommended CPP level for traumatic brain injury
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70 mm Hg
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What is spinal shock?
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the loss of sympathetic vasomotor tone below the level of injury
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What are the symptoms of spinal shock?
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hypotension, bradycardia, areflexia, and GI atony
venous distension in the legs |
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what level of spinal injury eliminates sympathetic innervation of hte heart
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T1-T4
can cause bradycardia |
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what level spinal cord injury will cause apnea
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C5
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When is succinylcholine safe to give to pt with spinal cord injury
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first 48 hours
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What level lesions is autonomic dysreflexia ass. with?
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above T5
does not happen in acute period |
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nasal intubation contraindicated with...
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basilar skull fractures and mid face fractures
LeFort I and II |
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pts with panfacial fractures can have what?
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Fevers (from sinuses) need to r/o MH by lack of metabolic or respiratory acidosis
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What is a major concern when there is facial, neck or upper airway trauma?
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Airway Edema/expanding hematoma
may expand during 6-12 hours after injury |
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How is a penetrating injury to larynx diagnosed?
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by the presence of air bubbles through the penetration tract, hoarsenss of dysphonia, flattening of thyroid cartilage or protuberance
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What is the recommended position for a penetrating trauma to the neck or upper airway to prevent air embolisms
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flat or slightly head down
also positive pressure is used to increase venous pressure of the neck |
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What type of injury is common with unrestrained passengers in MVA
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Chest trauma
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what kind of chest trauma requires immediate surgical intervention?
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Thoracic aortic dissection or aneurysm
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What is a simple pneumothorax? what anesthetic is contraindicated
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an accumulation of air b/t the parietal and visceral pleura
nitrous Oxide |
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what could caseu a simple pneumothorax to develop into a tension pneumo
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Positive pressure ventilation
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What kind of chest trauma is the most severe?
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Flail chest
-chest wall can't participate in ventilation |
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what is a tension pheumothorax?
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Ipsilateral lung collapses and the trachea and mediastinum are shifted to the contralateral side
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What is the most common kind of chestr trauma in children?
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Pulmonary contusion
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What is a pulmonary contusion?
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an injury to lung parenchyma, leading to edema and blood collecting in the alveolar spaces and loss of normal lung structure and function
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which type of chest trauma can potentially lead ARDS if there is significant damage?
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pulmonary contusion
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Pulmonary contusions develop of .....hours
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24-- worsening respiratory failure over time
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When is double lung ventialtion required with chest trauma?
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Massive hemoptysis from a hemothorax
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Which type of chest trauma requires immediate chest tube before induction of GA
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subcutaneous emphysema
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If pt has a pneumothorax, which side do you put the central line in?
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same side as the pneumothorax (unless you suspect major venous injury on this side)
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The mortality rate with ARDS is
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close to 50%
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What is a good indicator of myocardial contusion in trauma patients?
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Arryhthmias
Enzyme elvations abnormal echo decreasing pulse pressure |
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What is Beck's Triad?
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S/S of Cardiac Tamponade
1. distended neck veins 2. muffled heart sounds 3. Hypotension -- need sugical treatment: thoracotomy |
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what is the treatment for pericardial tamponade?
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Thoracotomy
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can you have cardiac tamponade and not have Beck's triad?
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yes, but if have beck's triad, surgery required immediately
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What is the best diagnositc test for cardiac tamponade?
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ultrasound
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how much blood can possibly be lost in the abdomen prior to s/s being present?
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3 Liters
ave. male can lose 40% of blodo prior to change in BP |
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which type of trauma has the potential for massive blood transfusions
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Abdominal truams
-Careful about transfusion induced hyperkalemia |
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tissue necrosis occurs after how many hours of ischemia
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4-6 hours
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When do you document peripheral pulses during surgery for trauma pt?
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prior to induction and immediately after induction
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What is ptosis?
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drooping of the eyelid (seen in Horner's syndrome)
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What is miosis?
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constricted pupil (seen in Horner'ssyndrome)
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What is Horner's syndrome
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symptoms due to loss of sympathetic outflow to one side of the face
Horny PAMELa ptosis anhydrosis (no sweating on side affected) Miosis Enopthalomus (eye sunken in) loss of ciliospinal reflex (pupil reflex to pain, etc) |
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What nerve is affected in a wrist fracture
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Median nerve
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if the Humeral shaft is fractured, what nerve can be injured?
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Radial Nerve
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Myoglobinuria can occur with what type of orthopedic injury?
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crush injuries
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What type of orhopedic injuries put pt at risk of fat embolism?
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pelvic or major long bone fractures
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during orthopedic trauma surgery, wheat should be checked periodically?
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Hgb, HCT
don't let blood loss get ahead of you--set schedule to check blood loss |
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What the percentage breakdown for the body surface area in adults?
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Head: 9%
Trunk: 18 x 2 Legs: 18 x2 Arms: 9x2 |
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What is the percentage breakdown for body surface area for peds?
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Head: 18
Legs: 14 x 2 Trunk: 18 x 2 Arms: 9 x 2 |
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Burn injury pts have.......resistance to nondepolarizers (increased or decreased)
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Increased
b/c their muscle acetycholine receptors proliferate at the burn site and at sites distant to the injury |
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Acute renal failure can be.....in burn pateints
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fatal
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Why should CO poisoning pt be on 100% FiO2
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Carboxyhemolobin causes a left shift to the dissociation curve
O2 sat is inaccurate Half life of CO is inversely related to FiO2 -- dissociates in 5-6 hours in RA , 30 60 min. on 100% FiO2 |
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What si the Parkland formula for burn pt?
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4 ml LR per kg per % Total BSA burned per 24 hours
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how much anesthesia do trauma pt's require to prevent awareness
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1/10th normal dose
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hemorrhagic shock is mediated by the...
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neuroendocrine system
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the pathophys of hemnorrhagic shock begins at the ....
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macrociculatory level
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In shock, bll is shunted to preserve...
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heart brain and major organ function
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What is the "no reflow" phenomenom in shock
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fluid is trapped in the cells and interstitially, so no flow gets to the tissues, the tissues become ischemic.
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what pts are especially susceptible to cardiac failure and may not respond well to resuscitation in shock
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elderly
heart disease |
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What is the sentinel organ in MOSF in traumatic shock?
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Lungs
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Pure hemorrhage in the absence of hypoperfusion does not produce.....
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pulmonary dysfunction
--this proves that traumatic shock is more than just a hemodynamic disorder |
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what are the risks of aggressive volume replacement during early resuscitation in traumatic shock
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increasd BP
Decreased Bl viscosity Decreased HCT Decreased clotting facotr concentration Greater transfusion requirement Disruption of electrolyte blaance direct immune suppresion premature reperfusion |
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