Ppal99 Dissecting The Usmle 1,2,3 Surgery/trauma/anesthesia

Front 1

what are the 6 pre-op Orders and to check

Back 1

• 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

Front 2

what are the 6 Relative Contraindications to surgery and what should be checked?

Back 2

• 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

Front 3

NYHA Classifications:
1 =
2=
3=
4=

Back 3

NYHA Classifications:
1 = Asymptomatic
2= Symptoms with moderate exertion
3= Symptoms with minimal exertion
4= Symptoms at rest

Front 4

Informed Consent: must understand the following (7)

Back 4

• 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

Front 5

4 Confidentiality Exceptions:

Back 5

Harm to self/ others
Child/ elder abuse
Communicable diseases
Knife/ gunshot wounds

Front 6

Pediatrics Without Parental Consent: (7)

Back 6

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)

Front 7

when is "No Consent" applicable to treat someone:

Back 7

• emergency situations if there is no medical personnele at the scene
• You were trained to perform that procedure

Front 8

an intoxicated man refuses tx. what should you do?

Back 8

Intoxicated people have the right to refuse tx
(state can enforce if they have dependants)

Front 9

3 rules for jehovas witness
children when can you give blood?
adult when not to or give blood?

Back 9

• 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

Front 10

Pre-Operative Medications:
taking medications
anti-platelets/NSAIDs
warfarin/heparin
smoking

Back 10

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

Front 11

Pre-Operative Medications:
diabetics
steroid
antibiotics
SBE prohylaxis

Back 11

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)

Front 12

Pre-Operative Medications:
pulmonary secretions
feedings
advance directives

Back 12

Pulm secretions Tx: muscarinic blockers: Atropine or Glycopyrrolate
• NPO: at least 6 hrs to prevent aspiration
• Get advanced directives

Front 13

Directives: in order

Back 13

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)

Front 14

Fever after Surgery:
Day 1
Day 3:
Day 5:
Day 7:
Day 10:
anytime:

Back 14

"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

Front 15

Post-op Issues:
DVT Prophylaxis:

Back 15

Heparin (add Warfarin for hip/knee surgery)

Front 16

Post-op Issues:
Stress Ulcer Prophylaxis

Back 16

H2 blocker

Front 17

Post-op Issues:
Pneumonia Prophylaxis

Back 17

Incentive spirometry, chest percussion therapy

Front 18

Post-op Issues: Oliguria

Back 18

do fluid challenge (dehydration gets better, renal failure doesn't)

Front 19

Post-op Issues: Urinary retention

Back 19

Tx: muscarinic agonist: Bethanechol, Carbachol

Front 20

Post-op Issues:
Adrenal insufficiency:

Back 20

hypotension, hypoglycemia, Δmental status
(Tx: Cortisol)

Front 21

Post-op Issues:
Alcohol withdrawal: and tx

Back 21

tremors, Δ mental status
(Tx: benzodiazepine: chlordiazepoxide)

Front 22

Post-op Issues:
Delayed post-op healing:

Back 22

obesity (fat is poorly vascularized and holds stitches poorly)

Front 23

Anesthesia Concepts:
Induction:

Back 23

the faster gas dissolves => smaller coefficient, quicker induction

Front 24

Anesthesia Concepts
Potency:

Back 24

how long it will keep patient knocked out=> need coefficient to be high

Front 25

Anesthesia Concepts
Minimal Alveolar Concentration "MAC":

Back 25

concentration gradient to get into your brain

Front 26

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?

Back 26

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)

Front 27

Topical Anesthetics:

Back 27

Esters:
Amides:

Front 28

Topical Anesthetics Esters: name all

Back 28

Cocaine
Benzocaine
Procaine
Tetracaine
Novacaine

Front 29

if the patient has allergy to lidocaine, what can be used?

Back 29

Procaine use if allergic to Lidocaine

Front 30

Cocaine
MOA
administration

Back 30

blocks reuptake of NE, don't need Epinephrine

Front 31

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?

Back 31

Short t1/2
• Water soluble: needs Epi to localize it (don't use Epi on fingers/toes/penis/nose)
• Metabolized by kidney

Front 32

Topical Anesthetics:
Esters: short t1/2
nephrotoxic/hepatoxic, GFR or p450 dep (mngmt) and Vd
how do you get rid of the drug faster?

Back 32

Nephrotoxic
• Dependant on GFR (give 'em fluid to get rid of it)
• Small Vd

Front 33

Topical Anesthetics:
Esters: t1/2 is short
tell me about its.. induction, recovery time, MAC and blood/oil gas ratios

Back 33

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)

Front 34

Topical Anesthetics:
Amides: "two i's" name all

Back 34

Lidocaine
Prilocaine
mepivacaine
Bupivacaine

Front 35

why is lidocaine give always with epinephrine

Back 35

Lidocaine (fat soluble, distributes) with Epi (vasoconstricts to hold it)

Front 36

Topical Anesthetics:
amides long t1/2
tell me about its solubility, metabolized by what organ

Back 36

Iong t1/2
Fat soluble: still needs Epi to localize it
metabolized by liver: If metabolized to NH4 =>⇧GABA

Front 37

Topical Anesthetics:
amides: tell me about its..
nephrotoxic/hepatoxic, GFR or p450 dep (mngmt) and Vd

Back 37

Hepatotoxic
Dependant on P45O
Large Vd

Front 38

Topical Anesthetics:
amides: tell me about its..
induction, recovery time, MAC and blood/oil gas ratios

Back 38

⇩MAC (concentration gradient to get into your brain)
• Oil/Gas rations
• Fast induction
• Slow recovery

Front 39

X-rays:3

Back 39

Coarctation

Front 40

X-rays: Boot

Back 40

RVH

Front 41

Banana shaped xray

Back 41

HCM

Front 42

Egg x-ray

Back 42

TGA

Front 43

Snowman: xray

Back 43

TAPVR

Front 44

what are the 3 Inhaled General Anesthesia and its MOA

Back 44

blocks Na channels from inside! (ionized base inside neuron)
• Nitrous oxide
• Halothane
• Isoflurane

Front 45

Nitrous oxide
class
SE

Back 45

Inhaled General Anesthesia
diffusion hypoxia

Front 46

Halothane
class
SE
contains what?

Back 46

Inhaled General Anesthesia hepatitis, has bromine

Front 47

Isoflurane
class
when is it used
contains what? SE

Back 47

Inhaled General Anesthesia
used in heart surgery, has fluoride (inhibits enolase in glycolysis)

Front 48

what are the 6 IV General Anesthesias

Back 48

• Barbiturates·
• Benzodiazepines
• Opioids·
• Propofol
• Ketamine
• Succinylcholine

Front 49

Propofol
class
solubility
what is it good for?

Back 49

IV General Anesthesia
lipid soluble
good for induction

Front 50

Ketamine
class
SE (3)

Back 50

IV General Anesthesia
dissociative amnesia
stimulates heart
colorful nightmares on recovery

Front 51

Succinylcholine
type of anesthesia
SE and tx

Back 51

IV general anesthesia
malignant hyperthermia
Tx: Dantrolene

Front 52

Unresponsive pt

Back 52

''ABC"
airway
breathing
circulation

Front 53

Airway:

Back 53

call, listen for noise:
1) Endotracheal Tube placement
2) Cricothyroidotomy:

Front 54

endotracheal tube placement
when is it indicated?
calculate ET tube size.
procedure of placement (4 steps)

Back 54

• 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

Front 55

Cricothyroidotomy:

Back 55

take cut in trachea right under "Adam's apple" and insert straw

Front 56

Breathing:

Back 56

listen to chest

Front 57

Circulation:

Back 57

color and capillary refill (extremity temperature)
1) IV Access 2) IV Fluids

Front 58

Circulation: IV Access: in adults and kids

Back 58

• Adults: femoral
• Kids: interosseus

Front 59

Circulation: IV Fluid
normal saline vs. lactate ringers
how much NaCl does each has?
what does it do?
what is it go for?

Back 59

• 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)

Front 60

types of wounds:

Back 60

• Clean cases
• Clean-contaminated
• Contaminated

Front 61

Clean cases wounds: define and tx

Back 61

groin vessels, open heart, prosthetics, bladder, eye
(Tx: 1g Cefazolin or 1g Vanc)

Front 62

Clean-contaminated wounds. tx

Back 62

abdomen, gallbladder
(Tx: 1g Cefazolin or 1g Vanc)

Front 63

Contaminated wound tx

Back 63

colorectal, appendectomy
(Tx: Gentamycin +Amp or Vanc)

Front 64

stages of bed "sores" ulcers
Stage I
Stage II
Stage III
Stage IV

Back 64

Stage I: non-blanching erythema
Stage II: partial thickness, blisters
Stage III: full thickness, deep crater
Stage IV: muscle/bone exposed

Front 65

worse position for bed soars

Back 65

worst position is Head of Bed at 45°

Front 66

Shock: define and Dx when a patient does not respond to fluids

Back 66

state of hypoperfusion
do not response to fluid
= > cardiac tamponade, internal bleed, or neurogenic shock

Front 67

CVP

Back 67

average volume in RA

Front 68

CO:

Back 68

how much blood can come out of heart: 5L/ min

Front 69

TPR

Back 69

resistance in arterioles

Front 70

Hypovolemic Shock:
Sx, CVP, CO, TPR, PCWP
Tx:

Back 70

Sx: pale, cold, tachycardic, bleeding (low preload)
⇩CVP, ⇩CO, ⇧TPR, ⇩PCWP (preload)
Tx: volume

Front 71

Cardiogenic Shock:
Sx
CVP, CO, TPR, PCWP-(preload)
Tx: Low HR and High HR:

Back 71

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)

Front 72

Neurologic Shock:
Sx: (6)
Tx:
CVP, CO, TPR

Back 72

Sx: warm, flushed, can't move or feel; ⇩BP / ⇩pulse,
vasodilates
⇩CVP, ⇩CO, ⇩TPR
Tx: phenylephrine (α1 vasoconstrict)

Front 73

Anaphylatic Shock:
CVP, CO, TPR
Tx:

Back 73

antigen exposure
⇩CVP, ⇧CO, ⇩TPR
Tx: "Phenylephrine (α1 vasoconstrict)

Front 74

Septic Shock:
Sx
CVP, CO, TPR
Tx:

Back 74

Sx: Gram(-) endotoxin dilates vessels (NO), FEVER
⇩CVP, ⇧CO (due to⇧HR), ⇩TPR
Tx: Antibiotics

Front 75

Amyloid: AA

Back 75

Any chronic disease

Front 76

Amyloid: AB:

Back 76

Brain (Alzheimer's)

Front 77

Amyloid: AB2:

Back 77

β2 microglobulinemia (renal failure)

Front 78

Amyloid: AE:

Back 78

Endocrine (medullary CA of thyroid)

Front 79

Amyloid: AL:

Back 79

Light chains (multiple myeloma)

Front 80

Hypotension+ Bradycardia Dx

Back 80

=> neurologic or cardiogenic shock

Front 81

Hypotension +Tachycardia Dx:

Back 81

=> Hypovolemic or
Anaphylatic or Septic shock

Front 82

Hypertension+ Tachycardia

Back 82

=> Severe pain

Front 83

Hypertension+ Bradycardia

Back 83

=> increased intracranial
pressure

Front 84

during Heart Failure, what hormone is released?

Back 84

BNP released due to change in ventricular filling pressures

Front 85

Left-side HF "systolic dysfunction":
pathogenesis and mngmnt
Sx
Ex

Back 85

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

Front 86

Tx: Left-side HF

Back 86

TxE:
⇩Preload: Furosemide,
⇩Afterload: ACE-I
⇧Inotropy (contraction): Dopamine, Dobutamine, Digitalis

Front 87

Discharge meds for left sided heart failure

Back 87

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

Front 88

Right-side HF "diastolic dysfunction":
pathogenesis, s3/s4, mngmnt, Sx

Back 88

patho: heart can't relax, S4,
mngmnt: do TEE
• Fluid backup into tissue:
leg edema, JVD, hepatomegaly,
pulm HTN, nocturia, ascites

Front 89

stabbed at the right chest: Dx

Back 89

• pneumothorax
• hemothorax

Front 90

Right-side HF "diastolic dysfunction":
examples
most common cause
tx

Back 90

• 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)

Front 91

Stab left chest:

Back 91

• pneumothorax
• hemothorax
• tamponade

Front 92

Types of Hemorrhage: affects from waist down

Back 92

Anterior cerebral artery

Front 93

Types of Hemorrhage: affects from waist up

Back 93

Middle cerebral artery

Front 94

Types of Hemorrhage: affects eyes

Back 94

Posterior cerebral artery

Front 95

Types of Hemorrhage: locked-in syndrome

Back 95

Basilar artery

Front 96

Basilar skull facture trauma: "raccoon eyes"

Back 96

Bleed-around eye

Front 97

Basilar skull facture: "battle sign"

Back 97

Bleed around mastoid

Front 98

Basilar skull facture: "hemotympanum"

Back 98

Bleed behind eardrum

Front 99

Basilar skull facture: leak CSF into nose or ears

Back 99

Break cribiform plate

Front 100

Complication of basilar skull fracture

Back 100

infection (meningitis)

Front 101

basillar skull fracture test and mngmnt

Back 101

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

Front 102

Epidural hematoma:
pathogenesis
sx
mngmnt
tx

Back 102

temple trauma to MMA (baseball helmets cover MMA)
Sx: intermittent consciousness
CT: elliptical "football" or "lenticular" shape
Tx: Immediate surgery

Front 103

Intracerebral hemorrhage:

Back 103

blood vv. pop (at basal ganglia, internal capsule) due to HTN

Front 104

Intraventricular hemorrhage

Back 104

bleed into ventricles due to prematutrity
• Frail medial wall of lateral ventricles
• 02 releases free radials

Front 105

Lacunar hemorrhage:

Back 105

lenticulostriate aa. pop (supply internal capsule) due to HTN
"Lakes of blood"

Front 106

Lobar hemorrhage:
define
example

Back 106

amyloid deposition in cerebral aa.
• Ex: Creutzfeldt-Jakob Disease (spongiform encephalopathy) = >kills

Front 107

Retinal hemorrhage:

Back 107

shaken baby syndrome

Front 108

Subarachnoid hemorrhage:
define
location of berry aneurysm in PCKD
Sx
test
tx for vasospasm
tx to prevent seizures

Back 108

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)

Front 109

Subdural hematoma:
pathogenesis
test
tx

Back 109

bridging veins
• Headache occurs 3-4 weeks after trauma
• Crescent/ concave shape, crosses suture line
• Tx: Glucocorticoids

Front 110

Xanthochromia: causes (2)

Back 110

Subarachnoid hemorrhage
HSV encephalitis

Front 111

Subgaleal hemorrhage:
pathogenesis and two types

Back 111

trauma to scalp=> prolonged jaundice
• Caput succedaneum
• Cephalohematoma

Front 112

Caput succedaneum

Back 112

under scalp (edema crosses suture lines)

Front 113

Cephalohematoma

Back 113

under bone (blood not cross sututre lines)

Front 114

Concussion:

Back 114

⇩vision, ⇩multitasking ability, olfactory hallucinations, hard to find words

Front 115

Brain Death: tell me about their
GS, brain stem reflexes, DTRs, pupils and breathing

Back 115

GCS = 3
No brainstem reflexes (may have DTR)
Nonreactive pupils
No spontaneous breathing

Front 116

Brain Death: tell me about their
heart beat, life support, limb movement, reflexes

Back 116

Heart may be beating
Can remove life support
Isolated limb movement = spinal reflex
freshly dead people still have good reflexes