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116 Cards in this Set

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what are the 6 pre-op Orders and to check
• MI history (last 6 mo): ischemia=> arrhythmia- check EKG
• Heart failure - check EKG, CXR
• Uncontrolled seizures - check electrolytes
• Uncontrolled HTN - check BP
• Bleeding disorders - check PT/PTT/Platelets
• Occult infection: spreads to lungs and urine- check CBC, UA, CXR
what are the 6 Relative Contraindications to surgery and what should be checked?
• Low Mg: cripple all your kinases (need this for ATP to wake up)
• Hypothyroid: check TSH
• Hypoglycemia: check glucose
• Risk of arrhythmias: check EKG
• Abnormal K+ levels: check electrolytes
• Anemia (⇩02 carrying content already) - check CBC
NYHA Classifications:
1 =
2=
3=
4=
NYHA Classifications:
1 = Asymptomatic
2= Symptoms with moderate exertion
3= Symptoms with minimal exertion
4= Symptoms at rest
Informed Consent: must understand the following (7)
• What the procedure entails in layman's terms in the patient's language
• Risks/Benefits of procedure
• Alternatives to the procedure (including those not available at your hospital)
• Consequences of not having procedure done
• Voluntary/ Competent
• Patient can change their mind at any time before receiving anesthetic
• Can't act on any intra-op unexpected findings unless it is life threatening
4 Confidentiality Exceptions:
Harm to self/ others
Child/ elder abuse
Communicable diseases
Knife/ gunshot wounds
Pediatrics Without Parental Consent: (7)
Emergency situation
Pregnancy/Abortion (most states)
oral contraceptives (> 15y/o)
STDs
Psychiatric patient (ward of the state)
Drug/EtOH detoxification
Emancipated minor (<13 y/o living on own >1y/o, in military, married)
when is "No Consent" applicable to treat someone:
• emergency situations if there is no medical personnele at the scene
• You were trained to perform that procedure
an intoxicated man refuses tx. what should you do?
Intoxicated people have the right to refuse tx
(state can enforce if they have dependants)
3 rules for jehovas witness
children when can you give blood?
adult when not to or give blood?
• Can give children blood if it is an emergency (get court order if non-emergent)
• Can give children blood if one parent agrees
• Do not give blood to adults if they are dying and they have documentation
Pre-Operative Medications:
taking medications
anti-platelets/NSAIDs
warfarin/heparin
smoking
Take normal meds with sip of water
• Stop anti-platelets 2 wks pre op, stop NSAIDs 1wk pre-op
• Stop warfarin, start heparin drip, stop heparin 1hr before surgery
• Stop smoking: 8 wks pre-op
Pre-Operative Medications:
diabetics
steroid
antibiotics
SBE prohylaxis
Diabetics: check glucose, start insulin drip in OR,
don't give am dose/ restart 2 days later
• Give stress-dose steroids if pt had Prednisone
for at least 3 weeks over the past year
• Antibiotics: 1 dose 1 hour before surgery to
decrease bacteremia
• SBE prophylaxis: for heart dz except
mitral prolapse (Tx: 3g Amoxicillin or Vanc)
Pre-Operative Medications:
pulmonary secretions
feedings
advance directives
Pulm secretions Tx: muscarinic blockers: Atropine or Glycopyrrolate
• NPO: at least 6 hrs to prevent aspiration
• Get advanced directives
Directives: in order
1) Advanced directives
• Living will: put in writing what you want done
• Durable power of attorney: choose someone to make that decision
2) Spouse
3) Closest kin (amount of time spent with patient)
4) Doctor (if no one else)
Fever after Surgery:
Day 1
Day 3:
Day 5:
Day 7:
Day 10:
anytime:
"LUIDA"
Day 1: Lungs "Wind" Pnemonia, Atelectasis (early skin infection is Clostridium or Strep)
• Day 3: Urine "Water" Urinary tract infection
• Day 5: Infection "Wound"
• Day 7: DVT "Walk"
• Day 10: Abdominal Abscess
• Drugs: H2 blockers, Pre-op antibiotics
Post-op Issues:
DVT Prophylaxis:
Heparin (add Warfarin for hip/knee surgery)
Post-op Issues:
Stress Ulcer Prophylaxis
H2 blocker
Post-op Issues:
Pneumonia Prophylaxis
Incentive spirometry, chest percussion therapy
Post-op Issues: Oliguria
do fluid challenge (dehydration gets better, renal failure doesn't)
Post-op Issues: Urinary retention
Tx: muscarinic agonist: Bethanechol, Carbachol
Post-op Issues:
Adrenal insufficiency:
hypotension, hypoglycemia, Δmental status
(Tx: Cortisol)
Post-op Issues:
Alcohol withdrawal: and tx
tremors, Δ mental status
(Tx: benzodiazepine: chlordiazepoxide)
Post-op Issues:
Delayed post-op healing:
obesity (fat is poorly vascularized and holds stitches poorly)
Anesthesia Concepts:
Induction:
the faster gas dissolves => smaller coefficient, quicker induction
Anesthesia Concepts
Potency:
how long it will keep patient knocked out=> need coefficient to be high
Anesthesia Concepts
Minimal Alveolar Concentration "MAC":
concentration gradient to get into your brain
what are the 5 Actions of Anesthetics:
when should a patient be extubated?
what is the only anesthetic that does NOT sensitize myocardium to NE?
1) Anesthesia: total loss of sensory input (vision, taste, hearing, smell)
2) Analgesics: no pain transmission
3) ⇩CNS activity: groggy, delirium, no gag reflex (don't extubate until brain function returns)
4) Muscle relaxation: atelectasis; aspiration pneumonia, can't poop/pee, DVT /PE
5) Sensitize myocardium to NE (except Isoflurane)
Topical Anesthetics:
Esters:
Amides:
Topical Anesthetics Esters: name all
Cocaine
Benzocaine
Procaine
Tetracaine
Novacaine
if the patient has allergy to lidocaine, what can be used?
Procaine use if allergic to Lidocaine
Cocaine
MOA
administration
blocks reuptake of NE, don't need Epinephrine
Topical Anesthetics:
Esters t1/2 is short. tell me about its
solubility, metabolized by what organ
what do you need to add with it? and its contraindications?
Short t1/2
• Water soluble: needs Epi to localize it (don't use Epi on fingers/toes/penis/nose)
• Metabolized by kidney
Topical Anesthetics:
Esters: short t1/2
nephrotoxic/hepatoxic, GFR or p450 dep (mngmt) and Vd
how do you get rid of the drug faster?
Nephrotoxic
• Dependant on GFR (give 'em fluid to get rid of it)
• Small Vd
Topical Anesthetics:
Esters: t1/2 is short
tell me about its.. induction, recovery time, MAC and blood/oil gas ratios
Water soluble:
⇧MAC (concentration gradient to get into your brain)
• Blood/Gas ratios
• Slow induction (has a hard time getting across lipid BBB)
• Fast recovery (wants to get out of there fast)
Topical Anesthetics:
Amides: "two i's" name all
Lidocaine
Prilocaine
mepivacaine
Bupivacaine
why is lidocaine give always with epinephrine
Lidocaine (fat soluble, distributes) with Epi (vasoconstricts to hold it)
Topical Anesthetics:
amides long t1/2
tell me about its solubility, metabolized by what organ
Iong t1/2
Fat soluble: still needs Epi to localize it
metabolized by liver: If metabolized to NH4 =>⇧GABA
Topical Anesthetics:
amides: tell me about its..
nephrotoxic/hepatoxic, GFR or p450 dep (mngmt) and Vd
Hepatotoxic
Dependant on P45O
Large Vd
Topical Anesthetics:
amides: tell me about its..
induction, recovery time, MAC and blood/oil gas ratios
⇩MAC (concentration gradient to get into your brain)
• Oil/Gas rations
• Fast induction
• Slow recovery
X-rays:3
Coarctation
X-rays: Boot
RVH
Banana shaped xray
HCM
Egg x-ray
TGA
Snowman: xray
TAPVR
what are the 3 Inhaled General Anesthesia and its MOA
blocks Na channels from inside! (ionized base inside neuron)
• Nitrous oxide
• Halothane
• Isoflurane
Nitrous oxide
class
SE
Inhaled General Anesthesia
diffusion hypoxia
Halothane
class
SE
contains what?
Inhaled General Anesthesia hepatitis, has bromine
Isoflurane
class
when is it used
contains what? SE
Inhaled General Anesthesia
used in heart surgery, has fluoride (inhibits enolase in glycolysis)
what are the 6 IV General Anesthesias
• Barbiturates·
• Benzodiazepines
• Opioids·
• Propofol
• Ketamine
• Succinylcholine
Propofol
class
solubility
what is it good for?
IV General Anesthesia
lipid soluble
good for induction
Ketamine
class
SE (3)
IV General Anesthesia
dissociative amnesia
stimulates heart
colorful nightmares on recovery
Succinylcholine
type of anesthesia
SE and tx
IV general anesthesia
malignant hyperthermia
Tx: Dantrolene
Unresponsive pt
''ABC"
airway
breathing
circulation
Airway:
call, listen for noise:
1) Endotracheal Tube placement
2) Cricothyroidotomy:
endotracheal tube placement
when is it indicated?
calculate ET tube size.
procedure of placement (4 steps)
• For p02 <50 or pC02 >50
• ET Tube size: (8+age)/2
• Lift jaw, push tube straight in just past vocal cords
• Listen to breath sounds
• Blow up ET Tube balloon
• Tape in place
Cricothyroidotomy:
take cut in trachea right under "Adam's apple" and insert straw
Breathing:
listen to chest
Circulation:
color and capillary refill (extremity temperature)
1) IV Access 2) IV Fluids
Circulation: IV Access: in adults and kids
• Adults: femoral
• Kids: interosseus
Circulation: IV Fluid
normal saline vs. lactate ringers
how much NaCl does each has?
what does it do?
what is it go for?
• NS: 164mEq/L NaCl
⇨ forces kidney to waste bicarb
(good for hypovolemic alkalotic pts.)
• LR: 130 mEq/L NaCl
⇨ causes lactate to convert into bicarb
(good for bleeding-acidic pts)
types of wounds:
• Clean cases
• Clean-contaminated
• Contaminated
Clean cases wounds: define and tx
groin vessels, open heart, prosthetics, bladder, eye
(Tx: 1g Cefazolin or 1g Vanc)
Clean-contaminated wounds. tx
abdomen, gallbladder
(Tx: 1g Cefazolin or 1g Vanc)
Contaminated wound tx
colorectal, appendectomy
(Tx: Gentamycin +Amp or Vanc)
stages of bed "sores" ulcers
Stage I
Stage II
Stage III
Stage IV
Stage I: non-blanching erythema
Stage II: partial thickness, blisters
Stage III: full thickness, deep crater
Stage IV: muscle/bone exposed
worse position for bed soars
worst position is Head of Bed at 45°
Shock: define and Dx when a patient does not respond to fluids
state of hypoperfusion
do not response to fluid
= > cardiac tamponade, internal bleed, or neurogenic shock
CVP
average volume in RA
CO:
how much blood can come out of heart: 5L/ min
TPR
resistance in arterioles
Hypovolemic Shock:
Sx, CVP, CO, TPR, PCWP
Tx:
Sx: pale, cold, tachycardic, bleeding (low preload)
⇩CVP, ⇩CO, ⇧TPR, ⇩PCWP (preload)
Tx: volume
Cardiogenic Shock:
Sx
CVP, CO, TPR, PCWP-(preload)
Tx: Low HR and High HR:
chest pain, peripheral edema, Sx: big liver, heart's not pumping
⇧CVP, ⇩CO, ⇧TPR, ⇧PCWP-(preload)
Tx: Low HR/not hypotensive: dobutamine (β1 agonist)
and High HR/hypotensive: dopamine (D2)
Neurologic Shock:
Sx: (6)
Tx:
CVP, CO, TPR
Sx: warm, flushed, can't move or feel; ⇩BP / ⇩pulse,
vasodilates
⇩CVP, ⇩CO, ⇩TPR
Tx: phenylephrine (α1 vasoconstrict)
Anaphylatic Shock:
CVP, CO, TPR
Tx:
antigen exposure
⇩CVP, ⇧CO, ⇩TPR
Tx: "Phenylephrine (α1 vasoconstrict)
Septic Shock:
Sx
CVP, CO, TPR
Tx:
Sx: Gram(-) endotoxin dilates vessels (NO), FEVER
⇩CVP, ⇧CO (due to⇧HR), ⇩TPR
Tx: Antibiotics
Amyloid: AA
Any chronic disease
Amyloid: AB:
Brain (Alzheimer's)
Amyloid: AB2:
β2 microglobulinemia (renal failure)
Amyloid: AE:
Endocrine (medullary CA of thyroid)
Amyloid: AL:
Light chains (multiple myeloma)
Hypotension+ Bradycardia Dx
=> neurologic or cardiogenic shock
Hypotension +Tachycardia Dx:
=> Hypovolemic or
Anaphylatic or Septic shock
Hypertension+ Tachycardia
=> Severe pain
Hypertension+ Bradycardia
=> increased intracranial
pressure
during Heart Failure, what hormone is released?
BNP released due to change in ventricular filling pressures
Left-side HF "systolic dysfunction":
pathogenesis and mngmnt
Sx
Ex
heart not squeezing, S3, do TEE
Sx: Fluid backup into lung: crackles, pleural edema, dyspnea on exertion (DOE), paroxysmal nocturial dyspnea (PND), SOB, orthopnea, decreased renal perfusion
• Ex: dilated cardiomyopathy, HTN, coarctation of aorta
Tx: Left-side HF
TxE:
⇩Preload: Furosemide,
⇩Afterload: ACE-I
⇧Inotropy (contraction): Dopamine, Dobutamine, Digitalis
Discharge meds for left sided heart failure
1) Digitalis: blocks K of the Na/K pump to ⇧contractility
2) ACE-I: dilates arteries/veins, blocks Aldo
3) β-blocker: ⇩mortality
4) Aldosterone blocker: Spironolactone or Epleranone
Right-side HF "diastolic dysfunction":
pathogenesis, s3/s4, mngmnt, Sx
patho: heart can't relax, S4,
mngmnt: do TEE
• Fluid backup into tissue:
leg edema, JVD, hepatomegaly,
pulm HTN, nocturia, ascites
stabbed at the right chest: Dx
• pneumothorax
• hemothorax
Right-side HF "diastolic dysfunction":
examples
most common cause
tx
• Ex: ventricular hypertrophy, amyloidosis, 1° pulm HTN
• Most common cause: Left-side HF
• Tx: Digoxin (slows AV node to ⇧diastolic filling),
CCB (⇧preload via vasodilation)
Stab left chest:
• pneumothorax
• hemothorax
• tamponade
Types of Hemorrhage: affects from waist down
Anterior cerebral artery
Types of Hemorrhage: affects from waist up
Middle cerebral artery
Types of Hemorrhage: affects eyes
Posterior cerebral artery
Types of Hemorrhage: locked-in syndrome
Basilar artery
Basilar skull facture trauma: "raccoon eyes"
Bleed-around eye
Basilar skull facture: "battle sign"
Bleed around mastoid
Basilar skull facture: "hemotympanum"
Bleed behind eardrum
Basilar skull facture: leak CSF into nose or ears
Break cribiform plate
Complication of basilar skull fracture
infection (meningitis)
basillar skull fracture test and mngmnt
o Test: put discharge on tissue, CSF will cause yellow-orange ring around blood
o mngmnt: CT of head to see how big crack in skull is
Epidural hematoma:
pathogenesis
sx
mngmnt
tx
temple trauma to MMA (baseball helmets cover MMA)
Sx: intermittent consciousness
CT: elliptical "football" or "lenticular" shape
Tx: Immediate surgery
Intracerebral hemorrhage:
blood vv. pop (at basal ganglia, internal capsule) due to HTN
Intraventricular hemorrhage
bleed into ventricles due to prematutrity
• Frail medial wall of lateral ventricles
• 02 releases free radials
Lacunar hemorrhage:
lenticulostriate aa. pop (supply internal capsule) due to HTN
"Lakes of blood"
Lobar hemorrhage:
define
example
amyloid deposition in cerebral aa.
• Ex: Creutzfeldt-Jakob Disease (spongiform encephalopathy) = >kills
Retinal hemorrhage:
shaken baby syndrome
Subarachnoid hemorrhage:
define
location of berry aneurysm in PCKD
Sx
test
tx for vasospasm
tx to prevent seizures
berry aneurysm emboli at anterior communicating artery
• Posterior communicating artery in PCKD
• Sx: "worst headache of my life" in occipital area, blood in CSF, loss of consciousness
• CT scan: white CSF, xanthochromia
• Tx: Nimodipine (for vasospasm), Phenytoin (prevent seizures)
Subdural hematoma:
pathogenesis
test
tx
bridging veins
• Headache occurs 3-4 weeks after trauma
• Crescent/ concave shape, crosses suture line
• Tx: Glucocorticoids
Xanthochromia: causes (2)
Subarachnoid hemorrhage
HSV encephalitis
Subgaleal hemorrhage:
pathogenesis and two types
trauma to scalp=> prolonged jaundice
• Caput succedaneum
• Cephalohematoma
Caput succedaneum
under scalp (edema crosses suture lines)
Cephalohematoma
under bone (blood not cross sututre lines)
Concussion:
⇩vision, ⇩multitasking ability, olfactory hallucinations, hard to find words
Brain Death: tell me about their
GS, brain stem reflexes, DTRs, pupils and breathing
GCS = 3
No brainstem reflexes (may have DTR)
Nonreactive pupils
No spontaneous breathing
Brain Death: tell me about their
heart beat, life support, limb movement, reflexes
Heart may be beating
Can remove life support
Isolated limb movement = spinal reflex
freshly dead people still have good reflexes