Pharm Ii - First Exam

Front 1

List the following in order of paralysis:diaphragm, eyelids, chest, extremities, abdominal muscles

Back 1

1. eyelids
2. extremities
3. chest
4. abdominal
6. diaphragm
** opposite is order of recovery

Front 2

With TOF monitoring, what % block exists with 4 equal twitches without fade?

Back 2

Less than 70%

Front 3

IF monitoring TOF you find you have 4 twitches WITH fade-what % block do you have?

Back 3

70-75%

Front 4

Another name for Phase 1 block?

Back 4

depolarizing ( sux)

Front 5

Another name for phase 2 block?

Back 5

Nondepolarizing block

Front 6

Why does sux work top down?

Back 6

Cardiac output delivers drug to head areas first

Front 7

Which kind of block has:

*fasciculations prior to NMB
*no fade to tetanic stim
*no posttetanic stimulation

Back 7

Phase 1 block

Front 8

Which kind of block has:

* no muscle fasciculation
*tetanic fade
TOF and DBS fade

Back 8

Phase 2 block

Front 9

Which kind of NMB can be potentiated by anticholinesterase drugs?

Back 9

depolarizers ( sux)

Front 10

Which kind of NMB can be reversed by anticholinesterase drugs?

Back 10

nondepolarizers

Front 11

Can sux ever produce a phase 2 block?

Back 11

Yes-rare, but overdose >6 mg/kg

Front 12

Which is considered the gold standard for NMB recovery?
A. vital capacity
B. NIF
C. Head lift
D. sustained tetanus

Back 12

C

Front 13

How is succinylchoine metabolized?

Back 13

pseudocholinesterase

Front 14

Renal failure is a contraindication to the use of sux. T or F?

Back 14

False-if pt is dialyzed and has nl K, it is OK- it is the K level that is the contraindication

Front 15

Which of the following are contraindications to the use of sux?
A. MH
B. hyperkalemia
C. muscle trauma
D. Burns
E. muscular dystrophy

Back 15

All are correct

Front 16

What are the 2 chemical classes of nondepolarizing NMBs?

Back 16

1. benzylisoquinolines
2. Steroidal

Front 17

The major disadvantage of atracurium?

Back 17

Histamine release

Front 18

Why do all nondepolarizing NMBs have no CNS effects?

Back 18

they are quaternary ammonium compounds-they are always ionized, so they cant cross BBB (or placenta)

Front 19

Why are nondepolarizing NMBs given IV only?

Back 19

100% ionized all the time, so they can't be absorbed from GI

Front 20

Which nondepolarizer should you not give to a pt with renal disease?

Back 20

Pavulon (Pancuronium) -excreted by kidney (85%) & 15% by the liver

Front 21

Which nondepolarizer can you not give to pt. with liver disease?

Back 21

Roc (>70%), Vec (30-40%)-excreted by the liver

Front 22

Which muscle relaxant should you not give to pt with atypical cholinesterase?

Back 22

Sux

Front 23

What are the two chemical classes of nondepolarizing NMBs?

Back 23

benzylisoquinolones
steroidal

Front 24

What are the 2 general classes of NMB's?

Back 24

depolarizing
nondepolarizing

Front 25

Single twitch is?
strength of current?

Back 25

single supramaximal stimulus
.1-1.0 Hz

Front 26

Which nerve stim test, test for a series of 4 twitches at 2Hz, every 1/2 sec for 2 sec.?

Back 26

TOF

Front 27

tetanus stim test is at what strength for how long?

Back 27

30, 50 or 100 Hz for 5 sec. (use sparingly-very painful)

Front 28

which nerve stim test is easier to detect fade?

Back 28

DBS

Front 29

Which nerve stim test is 2 short bursts of 50 Hz separated by .75 sec?

Back 29

DBS

Front 30

Onset time is defined as?

Back 30

time from admin of drug to when it hits maximum effect

Front 31

Clinical duration is defined as?

Back 31

time from admin to 25%recovery of twitch response

Front 32

What % paralyzed is the pt when 25% of recovery of twitch response is present?

Back 32

75%

Front 33

Recovery index is defined as?

Back 33

time from 25%-75% recovery of twitch response

Front 34

TOF ratio is what?

Back 34

Comparison of 4th twitch of TOF with the 1st twitch

Front 35

What is an indicator of recovery with the TOF test?

Back 35

when TOF ratio is .9 ( in other words, 4th twitch is 90% of the first)

Front 36

Which muscle is most sensitive to test for onset of NMB?
A. adductor pollicis
B. orbicularis oculi
C. facial nerve

Back 36

B

Front 37

Which muscle is most sensitive to test for recovery of NMB?
A. Adductor pollicis
B. orbicularis Oculi
C. Facial nerve

Back 37

A

Front 38

Which electrode should be placed over the nerve: positive or negative?

Back 38

negative (it is a negative experience to be shocked)

Front 39

List the following in order of paralysis:

diaphragm, chest, eyelids, extremities, abdominal muscles

Back 39

1. eyelids
2. extremities
3. Chest
4. abd. muscles
5. diaphragm

Front 40

List the following in order of recovery from NMB: diaphragm, eyelids, extremities, chest, adbominal muscles

Back 40

1. diaphragm
2. abd. muscles
3. chest
4. extremities
5. eyelids

Front 41

0 twitch response means you are what % blocked?

Back 41

100%

Front 42

1 twitch response means what % blocked?

Back 42

90-95%

Front 43

2 twitch responses mean what % blockade?

Back 43

80-85%

Front 44

3 twitch responses means what % blockade?

Back 44

75-80%

Front 45

4 twitches means what % is blocked if TOFR is < 90%

Back 45

70-75%

Front 46

4 twitches with TOFR of 90% or greater means how much % blocked?

Back 46

70% or less

Front 47

Which kind of NMB produces a Phase 1 block?
A. nondepolarizer
B. depolarizer

Back 47

B

Front 48

Which type of NMB normally produces phase 2 block?
A. nondepolarizer
B. depolarizer

Back 48

A

Front 49

Which of the following are signs of Phase 1 block?
A. fasciculations
B. TOF or DBS fade
C. lack of DBS or TOF fade
D. potentiation by anticholinesterase drugs

Back 49

A, C, D

Front 50

Which of the following is characteristic of Phase 2 block?
A. fasciculations
B. TOF or DBS fade
C. reversal with anticholinesterase drugs
D. sustained response to tetanic stim

Back 50

B, C

Front 51

How is sux metabolized?

Back 51

pseudocholinesterase

Front 52

What is the name of the test used to dx atypical PseudoCholinesterase?

Back 52

Dibucaine number test or dibucaine challenge test

Front 53

What is a normal Dibucaine number?

Back 53

80

Front 54

What two things does a Dibucaine test report?

Back 54

1. dibucaine #
2. what is the % of enzyme activity

Front 55

A low Dibucaine number and normal activity will result in?

Back 55

atypical enzyme/prolonged apnea

Front 56

A normal Dibucaine # and low % activity will result in?

Back 56

normal enzyme with low levels/prolonged apnea

Front 57

A low Dibucaine # + low activity will result in?

Back 57

atypical enzyme/prolonged apnea

Front 58

A normal Dibucaine # and normal activity will result in?

Back 58

normal enzyme and mat.( In other words, there is some other reason your pt is not breathing....)

Front 59

HOw much can sux elevate K+ levels?

Back 59

.5 meq

Front 60

Which of the following are side effects of sux?
A. masseter spasm
B. MH
C. decreased ICP
D. myalgias
E. elevated intragastric pressure
F. ST depression

Back 60

A, B, D, E
(it also causes increased ICP and peaked T waves)

Front 61

Masseter spasm is important why?

Back 61

precursor to MH

Front 62

Which of the following pts should not receive sux?

A. reanl failure pt who skipped dialysis
B. pt with family hx of MH
C. Pt with 3rd deg burn on 50% of body
D. pt with CHI being emergently intubated

Back 62

None of them should!

Front 63

Matching: (drug to metabolism)

(pseudocholinesterase or non-specific esterases)
a. Succ
b. Neostigmine
c. Edrophonium
d. Atracurium
e. Cisatracurium

Back 63

succ = pseudocholinesterase
Neostig = pseudocholin....
Edrophonium = pseudocholin..

Atracurium = non-specific est.
Cisatracurium = non-specific..

Front 64

What two NMBs are metabolized by Hofmann elimination and nonspecific ester hydrolysis

Back 64

Atracurium and cisatracurium

Front 65

This NMB is metabolized predominately by non-specific ester hydrolysis and to a lesser extent hofmann elimination.

a. cisatracurium
b. atracurium

Back 65

atracurium

Front 66

This NMB is metabolized predominately by hoffman elimination and to a lesser extent non-specific ester hydrolyis

a. cisatracurium
b. atracurium

Back 66

cisatracurium

Front 67

how is rocuronium eliminated.

Back 67

> 70% liver

Front 68

What is the cardiovascular side effect (s) of Atracurium.

Back 68

cause histamine release therefore produce hypotension and tachycardia

Front 69

What is the cardiovascular side effect (s) of Pancuronium.

Back 69

is vagolytic and causes slight catecholamine release producing tachycardia

Front 70

What are the cardiovascular side effects of Succinylcholine

Back 70

sudden abrupt bradycardia may result from "repeat dosing" in adults and any dose in children.

Front 71

what drugs possibly interact with NMBs.

Back 71

antibiotics, steroids, dantrolene, magnesium and lithium....

Front 72

which reversal drug has the shortest onset of action?

Back 72

Edrophonium

Front 73

which reversal drug has the longest onset of action?

Back 73

Neostigmine

Front 74

How do the reversals work?

Back 74

blocks cholinesterase, therefore Ach can't be metabolized and it builds up and competes with the relaxant at the receptor.

Front 75

What drug do you mix neostigmine with?

What drug do you mix edrophonium with?

Back 75

neostigmine = robinul

edrophonium = atropine

Front 76

What enzyme is responsible for the synthesis of Ach

Back 76

cholineacytelases

: cholineactelases makes Ach & cholinesterase breaks it down.

Front 77

you have a patient that you are unable to reverse at the end of the case, what do you do?

Back 77

sedate, ventilate and let it wear off.

Front 78

time from drug administration to maximum effect

a. Clinical duration
b. onset time
c. total duration of action
d. recovery index

Back 78

onset time

Front 79

time from drug administration to 25% recovery of the twitch response

a. onset time
b. clinical duration
c. total duration of action
d. recovery index

Back 79

clinical duration

Front 80

time from drug administration to 90% recovery of twitch response

a. onset time
b. clinical duration
c. total duration of action
d. recovery index

Back 80

total duration of action

Front 81

time from 25% to 75% recovery of the twitch response

a. onset time
b. clinical duration
c. total duration of action
d. recovery index

Back 81

Recovery index

Front 82

Which of the following nondepolarizing NMBs are metabolized by Hoffman elimination?
A. Vec
B. cisatracurium
C. Roc
D. atracurium

Back 82

B, D

Front 83

Which of the following has histamine release?
A. atracurium
B. cisatracurium

Back 83

A

Front 84

Muscle relaxants have no CNS effects and do not cross the BBB. Why?

Back 84

They are quartenary ammonium compounds, they have a + charge all teh time, so they are always ionized.

Front 85

What NMB would you not choose to give a pt with renal disease?
A. Pavulon
B. Sux
C. Vec
D. Roc

Back 85

A, , C

Front 86

Which NMB would you not choose to give a pt with liver disease?
A. Roc
B. Vec
C. Sux
D. cisatracurium

Back 86

A, B

Front 87

Which NMB would you not give to a pt with atypical cholinesterase?
A. Vec
B. Roc
C. Sux
D. cisatracurium

Back 87

C

Front 88

Pancuronium is:
A. sympatholytic
B. vagolytic
C. parasympathomimetic
D. indirect sympathomimetic

Back 88

B, D(causes slight catecholamine release)

Front 89

Which of the following drug interact with NMBs?
A. steroids
B. antibiotics
C. volatile agents
D. Dantrolene
E. lithium
F. Magnesium

Back 89

All are correct

Front 90

Which anticholinergic agent is typically mixed with edrophonium?
A. Atropine
B. glycopyrrolate

Back 90

A

Front 91

Which anticholinergic agent is typically mixed with neostigmine?
A. atropine
B. glycopyrrolate

Back 91

B

Front 92

Which anticholinergic has the fastest onset and shortest duration?

Back 92

Edrophonium

Front 93

Which anticholinergic has the slower onset?

Back 93

neostigmine

Front 94

Which of the following are clinical signs of NMB recovery?
A. head lift/leg lift
B. cough
C. resp smooth, unlabored with adequate TV and rate
D. VC of 15 ml/kg
E. NIF of 25-35 cm H20

Back 94

All are

Front 95

What is the "MAX" dose of Neostigmine

Back 95

5 mg

Front 96

What is the "MAX" dose of Edrophonium

Back 96

1 mg/kg

Front 97

Match TOF count to minutes to recovery of reversal of intermediate relaxants:

a. Only 1 response
b. 2-3 responses
c. 4th response

1. within 5 minutes
2. as long as 30 minutes
3. 4-5 minutes

Back 97

A. 2
B. 3
C. 1

Front 98

The brief duration of Sux is due to?

Back 98

Rapid hydrolysis in plasma by cholinesterase enzyme to inactive metabolites

Front 99

Sux is broken down by plasma cholinesterase to form what?

Back 99

Succinylmonocholine and Choline

Front 100

Sux is futher broken down from succinylmonocholine and choline to what? Still by plasma cholinesterase?

Back 100

Succinic Acid and choline
Yes, still by plasma cholinesterase

Front 101

Suxs in the blood stream is broken down by?

Back 101

Plasma cholinesterase of pseudocholinesterase

Front 102

Sux is broken down in the neuromuscular synapse by what?

Back 102

Acetylcholinesterase

Front 103

What are the 2 types of cholinesterase in the body? Where are they found?

Back 103

Acetylcholinesterase- in synapse
Pseudocholinesterase - in plasma

Front 104

Pseudocholinesterase is produced where?

Back 104

Liver - pts generally develop neuromuscular symptoms at about 60% of normal activity.

Front 105

What are the 4 esterase enzymes in the body.

Think "CRAP"

Back 105

Cholinesterase
RBC esterase
Albumin esterase
Paraoxonase

Front 106

HEALTH MODELS
The narrowest interpretation of health; people are physiologic systems; health is the absence of illness.

Back 106

Clinical model

Front 107

List ester local anesthetics that are broken down by pseudocholinesterase?

one "i"

Back 107

Cocaine
Procaine
Chloroprocaine
Tetracaine

Front 108

Esmolol is an esterase dependant drug broken down by what esterase enzyme?

Back 108

RBC esterases

Front 109

Neostigmine and Edrophonium are broken down by what esterase enzyme?

Back 109

pseudocholinesterase

Front 110

True/False
Acetylcholinesterase and pseudocholinesterase are terms for ACh? The names just differentiate their location in the body?

Back 110

All true

Front 111

Esterase enzymes are metabolized by adding water, this process is referred to as?

Back 111

Hydrolysis

Front 112

True/False
Atypical cholinesterase enzyme is just considered a genetic difference in the cholinesterase enzyme?

Back 112

True, a pt with atypical enzyme is considered normal for their body, not a disease state. Counseling given once identified for future surgeries.

Front 113

Is it OK to give a patient with a severe burn sux in the first 24 hours?

Back 113

Yes, muscle damage in burn patients usually doesn't happen immediately. K+ doesn't rise for 24 hours.

Front 114

Fasciculations from sux cause what side effects?

Back 114

Myalgia, myoglobinemia, Increased intragastric pressure, ? increased ICP, increased intraocular pressure

Front 115

Can you give a patient with a muscle disorder a NDMB?

Back 115

Yes, increased sensitivity, consider decreasing dose, use nerve stimulator to evaluate response

Front 116

What are the 2 factors in Hoffman elimination that create the chemical reaction that causes molecule to break itself down?

Back 116

Change in pH and temperature

Front 117

According to Naglehout, what pH and temp does the body have to have to eliminate a drug by Hoffman elimination?

Back 117

Alive, regardless of the patient, will all break down the same.

Front 118

Prophylaxis against histamine release requires administration of both _____ and ______ receptor blockers?

Back 118

H1 (Benadryl) and H2 (Zantac, Pepcid)

Front 119

According to Naglehout, why don't you give more than 5mg of Neostigmine?

Back 119

5 mg provides 100% cholinesterase inhibition and you can't get more than 100%

Front 120

Neostigmine has an increased incidence of?

Back 120

PONV

Front 121

Glycopyrrolate may cause more or less initial tachycardia than atropine?

Back 121

less

Front 122

Why do we give Robinul with Neostigmine?

Back 122

Neostigmine builds up in the parasympathetic, causing vagal response, Robinul provides anti-muscarinic but still get nicotinic effects.

Front 123

What is the onset and duration time for Atracurium, Cisatracurium and Vecuronium?

Back 123

Onset 2-4 minutes
Duration 30-60 minutes

Front 124

What is the onset and duration for Rocuronium?

Back 124

Onset 1-3 minutes
Duration 30-60 minutes

Front 125

What is the onset and duration for succinylcholine?

Back 125

Onset 30-60 seconds
Duration 5-10 minutes

Front 126

What are some factors that may prolong the action of the relaxants

Back 126

acid base and electrolyte status, temperature, age, drug interaction

Front 127

Potent drugs have a _______ onset and the less potent have a ______ onset secondary to the amount of drug used.

Back 127

potent = slower
less potent = quicker
Higher numbers of drug molecules are able to attach to the neuromuscular junction quicker to create paralysis (have to give more of less potent so there is more available)