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47 Cards in this Set

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Should positioning be delayed if pt is hemodynamically unstable?
duhhhh
ya
What are the effects of gravity to respiratory system?

(2)
1. increases perfusion to posterior (dependent) lung segments
2. decreases FRC (abdominal viscera against diaphragm)
In horizontal supine postition does MAP stay stable?
Yes
venous return affected only from intrathroacic pressure changes from respirations
Which position increase pressure in cerebral veins, inc ICP/CVP/IOP, inc preload, and causes nasal congestion?
Trendelenburg
What nerves cause inc preload, activate aortic and carotid baroreceptors to inc parasympathetic flow and dec HR, CO?
Vagus
Glossopharyngeal
Trendelenburg positon causes swelling where?
head
neck
possible airway obstruction
What happens when abdominal viscera moves cephalad in trendelenburg position?
decreased FRC
decreased pulmonary compliance
atelectasis
V/Q mismatch (shunting)
What does reverse trendelenburg cause?
1. venous pooling to lower ext.
2. decreased preload, co, perfusion
3. increased FRC, less work of spont. breathing
Name 2 uses for trendelenburg position.
1. improve surgical exposure
2. prevent venous air emboli
(not really useful in hypotension)
What works better for hypotension than trendelenburg (per lecture)?
raising legs increases MAP without affecting CO, pulmonary fx, or ICP
In standard lithotomy position how is pt positioned?
thighs flexed approx 90 deg.
knees bent parallel to floor
legs well padded
arms tucked or on armboards <90 angle
Common injury with lithotomy position?
peroneal nerve injury from fibula pressing against candy canes
What does standard lithotomy postition do to cardiac/resp?
1. inc preload and CO
2. dec. vital capacity, FRC, TV
3. possible hypotension when legs come down to supine
How far are hips flexed in low lithotomy position?
30-45%
allows simultaneous access to perineum and abdomen
Why use high lithotomy position?
Where are thighs in this position?
improve access to the perineum

thighs flexed 90 degrees over trunk, legs almost fully extended suspended from sling
Explain exaggerated lithotomy position.
1. thighs flexed over trunk
2. lower legs aimed skyward
3. symhysis ubis parallel to floor
4. may restrict ventilation
5. uphill gradient for perfusion of legs --> can cause hypotension
Which position is associated with high incidence of lower extremity compartment syndrome?
exaggerated lithotomy

can cause ischemia and edema
What are the complications of dorsal decubitus positions?
(supine, frog leg, lithotomy)
(5)
1. postural hypotension
2. pressure alopecia (use donut)
3. ischemic necrosis under bony areas
4. backache
5. nerve palsies
Most common peeps that get peroneal nerve injury.
smokers
low body mass index
long surgeries (>2 hrs)
also with candy canes
Complications of lithotomy position
1. peroneal nerve injury
2. compartment syndrome
3. digit amputation
What is lateral decubitus?
-turned to one side
-down side knee bent, pillow between the legs
-axillary roll caudad from axilla to raise thorax and prevent shoulder compression
Why use an axillary roll in lateral decub position?
to raise the thorax and prevent shoulder compression and brachial plexus injury
under GETA dependent lung gets MORE/LESS perfusion than ventilation
MORE

decreased compliance/atelectasis
under GETA non-dependent lung gets MORE/LESS ventilation than perfusion
MORE

underperfused, overventilated
Most accurate NIBP is in dependent/non-dependent arm
(in lateral position)
dependent
What is lateral jackknife position?
-intended to widen intercostal spaces
-pt down-side iliac crest over the hinge
-table is flexed so the thighs become lateral to the trunk
-chassis of table re-oriented so that flank and thorax become horizontal
What is different about the kidney lateral jackknife?
elevation of the "kidney rest" under dependent iliac crest to increase lateral flexion
Complications of lateral decub positions
(5)
1. backache/neck pain
2. compartment syndrome
3. contusion "folding" ear
4. Inc IOP, ischemia to dependent eye
5. stretch injury to suprascapular nerve (too much rotation of non-dep arm)
What surgical access is possible with prone position?
posterior fossa of skull
posterior spine
buttocks
perirectal area
posterior lower extremities
In what postion can you have compression of the great vessels? why does this matter?
Prone
b/c decreased preload
Improper prone positioning can cause abdominal pressure.. why does this matter?
increased abdominal pressure can cause
decreased preload
cephalad movement of the diaphragm
decreased FRC and compliance
increased peak airway pressure
What can extreme head flexion cause in the prone position?
may impede cerebral venous return
Complications of prone position
1. ischemic optic neuropathy
2. central retinal artery occulsion
Which are you more likely to recover vision from?
Ischemic otic neuropathy
Central retinal Art. Occulsion
ION
Risk factors for blindness with prone position?
(surgery risk fx)
prolonged spinal procedures
massive blood loss
intra-op hypotension
excessive crystalloid use
anemia or hemodilution
venous congestion
edema of the head
(higher MAP in spine room)
Risk factors for blindness with prone position?
(pt risk fx)
HTN
DM
morbid obesity
atherosclerosis
smoking
Complications of prone position
1. periorbital, conjunctival edema (keep HOB at lvl of heart of higher)
2. brachial plexus injury
3. impaired cerebral perf
4. breast injury
What is sitting position for?
posterior cervical access
posterior fossa access
shoulder operations with upper torso rotations
Describe the sitting position.
semireclining
legs above heart lvl
head flexed ventrally
distance b/w chin and suprasternal notch (2 fingerbreaths)
Hemodynamic effects of sitting postion
1. venous pooling - hypotension
2. dec. atrial filling activates RAAS
3. MAP reading at circle of willis more accurate (CPP)
Complications of sitting postion
1. postural hypotension
2. air embolus
3. Midcervical tetraplegia
4. edema of face, tongue, neck
5. pneumocephalus
Who is ulnar neuropathy more common in?
older males

can have delayed onset (3-4 days)
Wrist drop, weakness of abduction of thumb, loss of sensation b/w thumb and index finger, inability to extend the distal phalanx of the thumb
radial nerve injury
inability to completely extend elbow, numbness over dorsal and palmar areas of the distal phalanges of the 1 and 2nd fingers. caused by AC trauma s/p IV attempt.
Median nerve dysfunction
What is Median nerve and artery damage caused by?
tight arm restraint
ischemic injury that resembles compartment syndrom and requires surgical decompression
Sensory neuropathy
usually resolves 5 days
motor neuropathy
neurologist should be consulted
EMG studies done