True Learn Flashcards

Question 1

Q

Post thoracotomy multi modal pain management

Answer

A

Paravertebral vs epidural local anesthetic
PCA morphine
Tylenol

Question 2

Q

Brachial artery line cannulation risks

Answer

A

Median n runs with brachial artery, usually insertion site is proximal to antecubital fossa and medial to biceps tendon
- nerve damage
- Distal ischemia from thrombosis formation
- Central line infection

Question 3

Q

Pathophysiology of rhabdo in muscular dystrophies

Answer

A

Succinylcholine can trigger cellular lysis from contraction of already weakened myocyte cytoskeleton from dystrophy

increase in potassium, myoglobin, phosphate, CPK

Hyperkalemia leads to peaked t wave and subsequent wide QRS and eventual v fib

Question 4

Q

Fibromyalgia diagnosis

Answer

A

Dx of exclusion, rule out inflammatory diseases

Complex pain syndrome assoc with widespread pain, sleep disturbance, and depression

Can benefit from SSRI/SNRI, neuropathic meds

Rheumatoid arthritis is 3+ joints for more than 6 weeks

Question 5

Q

Treatments of cyanide poisoning

Answer

A

Hydroxycobalamin: combines with cyanide to form cyanocobalamin (aka vit B12), rapid onset and low risk profile

Amyl nitrite: can be used as inhaled agent if patient does not have IV access

Sodium nitrite: risk of hypotension

Sodium thiosulfate: significantly slow onset if action

Question 6

Q

How to dose succinylcholine and rocuronium (wt based) and also RSI dose

Answer

A

Succinylcholine is total BW and 1.5mg/kg

Rocurconium is ideal BW and 0.6mg/kg (1.2mg/kg RSI)

Question 7

Q

A1c goal prior to elective surgery, hyperglycemia post surgical effects

Answer

A

Goal 6-8% a1c which correlates to avg 125-180 mg/Dl

Must decrease insulin dose prior to surgery due to NPO status

Risk of poor wound healing and infection post op (leads to poor chemotaxis and phagocyte activity)

Question 8

Q

Nerve innervation of gag reflex

Answer

A

Afferent - glossopharyngeal N

Efferent - vagus nerve

Question 9

Q

What is strong ion difference and how does it pertain to high volume fluid infusion (NS vs half NS)

Answer

A

cation (Na, K, Ca) - anion (Cl, lactate) = SID (bicarb, phos, albumin, unmeasured anion)

SID usually is 40mmeq

large infusion of NS (ie SID = 0) will increase Chloride which in turn will cause bicarb to diffuse into cells to even out negative charge causing acidosis

large infusion of 1/2 NS (SID = 0) will cause metabolic acidosis because it will dilute the SID anions

***decrease SID will decrease pH

Question 10

Q

What electrolyte abnormalities occur with CKD?

Answer

A

hyperkalemia (impaired clearance)
hyponatremia (hypotonic)
hypermagnesemia (exogenous admin)
hyper/hypocalcemia (tertiary HPT vs low Vit D)
hyperphosphatemia

all the above will prolong QRS or QT except:
hypercalcemia will decrease QRS and QT
hyperphos has no effect on ECG

Question 11

Q

pathophys of myasthenia gravis and MOA of tx, what are considerations of NMB in these patients

Answer

A

pathophys: antibodies against nicotinic Acetylcholine receptor in the NMJ leading to reduced number of receptors

Tx: pyridostigmine inhibits butyrylcholinesterase (plasma cholinesterase) preventing the break down of acetylcholine

patients with MG who take pyridostigime prior to surgery: can render neo/glyco less effective, potentiate succinylcholine due to decreased breakdown by plasma cholinesterase, and potentiate non -depolarizing NMB

Question 12

Q

What do B lines of lung US represent

Answer

A

interstitial lung disease: Pna or contusion/ bleed

Question 13

Q

What is ficks principle and what is the equation

Answer

A

Describes relationship between uptake if a substance, blood flow, and the gradient of that substance

Used to measure CO

CO = VO2/(CaO2-CvO2)

VO2 is total oxygen uptake by measure difference of inhaled and expired O2
Ca/Cv O2 is the o2 content of arterial or venous blood, which is calculates by taking saturation x hgb x carrying capacity of blood which is 1.36 g O2/ml

Question 14

Q

Moa of methylergometrine and risks

Answer

A

Ergot alkaloid causes intense vasocontriction, given IM and onset is 10 min lasting 3-6hrs

Watch out for pre-eclampsia or hx HTN, can lead to strokes!

Last line tx in hemorrhage for uterine atony

Question 15

Q

What is moa of carboprost and misoprostol

Answer

A

Both are prostaglandin

Increases force and frequency of uterine contraction

If oxytocin does not work for uterine atony then use carboprost up to 8 doses, then try misoprostol

Question 16

Q

What types of nerve blocks produce highest serum peak local anesthetic concentration?
How does epinephrine affect this process?

Answer

A

“BICEPS”
Bier block > intercostal > caudal > epidural > brachial plexus > subcutaneous

Uptake phases
Phase 1 is installed rapid fluid phase which is slowed by epinephrine and phase 2 is slow resolution into high lipid compartments

Epi slows phase 1 and allows for lower peak serum levels and greater blockade at block site

Question 17

Q

What other anomalies are assoc with tracheoesophalgeal fisutlas?

Answer

A

VACTERL anomalies

Vertebral
Anal
Cardiac
TEF
Esophageal atresia
Renal
Limb

Question 18

Q

Mild vs severe bronchospasm treatment ladder

Answer

A

100% FiO2 and hand ventilate

Mild (smaller but adequate TV)
- Deepen anesthetic, gas vs propofol vs ketamine
- Albuterol if able to move air

Severe (no tidal volume)
Epi
Glycopyrrolate takes 20 min
Magnesium sulfate for refractory
Glucocorticoid takes 4-6 hr

Question 19

Q

Fasting recommendations:
Clear liquids
Breast milk
Infant formula
Nonhuman milk
Light meals
Fatty meals

Answer

A

Clear liquids 2hr
Breast milk 4hr
Infant formula 6hr
Nonhuman milk 6hr
Light meals 6hr
Fatty meals 8hr

Question 20

Q

Premedications that don’t affect intraocular pressure?

Which medications are contraindicated in ocular trauma?

Answer

A

Midazolam - no effect on IOP
Precedex - can prevent increase in IOP if succhincholine is being used

C/I
Etomidate - decreases IOM but can cause myoclonus and contraction of EOM
ketamine - nystagmus and blepharospasm
Nitrous oxide
Succinylcholine - risk of vitreous expulsion and vision loss

Question 21

Q

Physiologic response following ECT

Answer

A

Transient parasympathetic response including bradycardia followed by sympathetic response including hypertension and tachycardia

Etomidate increases seizure duration
Methohexital and ketamine do not effect seizure duration

Question 22

Q

Mechanism of aldosterone

Answer

A

Mineralocorticoid

Activates RAA in response to hypovolemia and renal hypoperfusion

Upregulates N/K pumps in distal renal tubules to reavsorb na and secrete k to retain fluid

Question 23

Q

Level of conus medularis in neonates vs adults

Answer

A

L3 neonates
L1-L2 adults

Question 24

Q

Nerves for sensory innervation to these parts of the leg:
Medial leg
Lateral leg
Anterior thigh/knee
Medial knee
Lateral thigh
Medial ankle
Lateral ankle

Answer

A

Medial leg- saphenous
Lateral leg- superficial fibular n
Anterior thigh/knee- femoral n
Medial knee- obturator n
Lateral thigh/hip- Lateral femoral cutaneous n
Medial ankle- saphenous
Lateral ankle- sural

Question 25

Q

Nerves for sensory innervation of these parts of the leg:
Medial thigh
Posterior thigh
Posterior calf
Lateral foot
Heel

Answer

A

Posterior thigh- Posterior cutaneous nerve of thigh
Medial thigh- obturator
Posterior calf- sural n
Lateral foot- sural n
Heel- tibial

Adductor canal block for saphenous block, pure sensory, common for total knee

Question 26

Q

Deep peroneal nerve innervation type

Answer

A

Mixed sensory and motor

Foot dorsiflexion
Cutaneous innervation to skin between 1st and 2nd toes

Lateral knee injury can cause deep peroneal n damage and result in foot drop

Question 27

Q

Superficial peroneal nerve innervation type

Answer

A

Motor: foot eversion
Sensory: lateral lower leg and most dorsum of foot

Question 28

Q

Effects of the following on metabolism:
Starvation
Insulin
Glucagon
Catecholamines

Answer

A

Starvation 24-48 hr: glycogenolysis, lipolysis, proteolysis
Insulin: glycolysis and glycogen synthesis, lipogenesis, protein synthesis
Glucagon: glycogenolysis, gluconeogenesis

Catecholamine: beta stimulation > lipolysis (TGs turn into glycerol and FFAs)

Substrates for gluconeogenesis include glycerol, lactate, and some amino acids

FFA undergo hepatic conversion into ketone bodies in setting of low Insulin or lack of glycogenolysis

Brain does not use amino acids only ketone and glucose

Question 29

Q

How to determine level of consciousness?
Minimal, moderate, deep, general

Answer

A

Depends on purposeful movements to specific stimuli, NOT airway

Minimal- normal response to verbal stimulation
Moderate- Purposeful response to verbal or tactile stimulation
Deep- response to repeated painful stimulation
General- no response to repeated painful stimulation

Question 30

Q

What are contraindications for LMA

Answer

A

High aspiration risk: delayed gastric emptying, hiatal hernia, gerd, full stomach, intestinal obstruction

Low Lung conpliance: restrictive lung disease, glottic or subglottic airway obstruction, limited mouth opening

Question 31

Q

How does placental abruption present and what are risk factors for it?

Answer

A

Painful vaginally bleeding, uterine tenderness, nonreassuring fetal heart rate pattern

Rfs: materal/paternal smoking, trauma, hypertension, advanced material age, parity

Question 32

Q

What is the composition of Normal Saline and its effect on pH at high doses?

Answer

A

154mmeq/L of Na and Cl
No potassium
Isotonic

Excess chloride causes impaired bicarbonate reabsorption, causing decreased serum bicarbonate. This creates electroneutrality resulting in non-ion gap metabolic acidosis with hyperchloremia

In terms of strong ion difference, sharp increase of chloride as compared to sodium increase will decrease the strong ion difference. Smaller SID will create an acidosis.

Question 33

Q

Milrinone MOA and effects

Answer

A

Phosphodiesterase 3 inhibitor

Positive inotrope and causes peripheral vasodilation

(Good for right heart failure but need to add vasoconstrictor to support peripheral bloodpressure/perfusion ie vasopressin to prevent pulmonary constriction)

Question 34

Q

Phases of emergence

Answer

A

Phase 1: cessation of gen anes, antagonism of NMB, increased CO2, spontaneous respiration returns
Phase 2: recovery of airway tone and pharygeal muscles, ETT becomes noxious stimulus, defensive posture, gagging, coughing, salivation, tachy, HTN
Phase 3: responds to verbal command, return of cortical function, eye opening

Question 35

Q

Areas sensing and response to hypoxia and hypercapnia

Answer

A

Carotid body chemoreceptor > aortic arch chemoreceptor for inducing ventilatory response to hypoxia

Central chemoreceptors more sensitive to hypercapnia

Carotid sinus has baroreceptors ro manage blood pressure

Question 36

Q

Spironolactone mechanism and effects on electrolytes

Answer

A

Competitive aldosterone antagonist, potassium sparing, wastes Na

Aldosterone usually upregukstes ENACs at the distal tubule with pumps in Na and in return potassium is usually dumped

Question 37

Q

Equation for total oxygen content in arterial blood

Answer

A

(1.36 mL O2/g hb x hgb value x oxygen saturation) + (0.003 mL O2/dL/mm Hg × partial pressure of oxygen)

Question 38

Q

NMB of muscles in relation to diaphragm
- corrugator supercilii
- adductor pollicis
- flexor hallucis

Answer

A

Adductor pollicis muscle is supplied by ulnar nerve and lags behind diaphragm recovery

Flexor hallucis is innervated by posterior tibial n on Medial side posterior to Medial maleolus, similar to adductor pollicis

Corrugated supercilii innervated by facial nerve and resembles laryngeal adductor but not reliable for diaphragm recovery

Question 39

Q

What is standard error of mean?

Answer

A

Describes the standard deviation and measures the precision with which a sample mean represents a population

SEM = standard deviation / Sq root of (n)

As the sample size increases the standard error decreases

Compared to standard deviation which is a description of sample data compared to sample mean and quantifies the variation or dispersion of the data

Question 40

Q

How much does MAC change per decade of life?

Answer

A

Decreases by 6% per decade of life starting after age 40

Question 41

Q

What is MOA of TCAs causing cardiac toxicity?

Answer

A

sodium channel blockade which causes QRS prolongation (>100ms) along with inhibition of potassium efflux during repolarization which flattens the T wave, QT is also prolonged but patients are often sinus tachycardic during TCA overdose.

Question 42

Q

post-op considerations after carotid endarterectomy

Answer

A

damage to carotid body can lead to low hypoxic induced ventilatory drive

damage to the carotid sinus can lead to hypertension or hypotension

risk of thromboembolism, cerebral hypoperfusion, and neck hematomas

Question 43

Q

difference between nicotinic and muscarinic cholinergic receptors

Answer

A

cholinergic receptors are a part of the parasympathetic system

nicotinic receptors are excitatory and are located in between the pre and post ganglionic neurons

muscarinic receptor activation depends on subtype. M1-3. M1 and M3 are excitatory, M2 is inhibitory and works on the heart.

Question 44

Q

what is the function of alpha-2 adrenergic receptors and where are they located?

Answer

A

inhibitory role when activated and located in presynaptic terminal betwee neurons of the sympathetic nervous system often in the CNS and peripheral blood vessels, act as a negative feedback system.

ie. clonidine is alpha-2 agonist and is used for both lowering blood pressure both peripherally and centrally which helps with migraines.

Question 45

Q

What type of patients are at risk of upregulated nicotinic acetylcholine receptors?

What is the difference between myasthenia gravis and guillaine Barre syndrome?

Answer

A

risk is increased in low mobility, nerve damage, or neuromuscular disorders

burn (1 day up to 1-2 yrs), stroke, spinal cord injury (worse after 16 days), muscular dystrophy, GBS, ALS, MS

MG is auto antibodies targeting nicotinic acetylcholine receptors
vs.
GBS is autoimmune destruction of myelin sheath of neuronal axons

Question 46

Q

excretion of NMB and acetylcholinesterase inhibitors in CKD

Answer

A

both are excreted by kidneys and will be prolonged in patients with CKD. extended duration of neostigmine provides a safety margin for the prolonged NMB.

No dose changes are indicated in CKD for neostigmine, glycopyrrolate, or rocuronium.

Question 47

Q

what is the target of an inter scalene block and what are the risks? What are limitations?

Answer

A

aimed at blocking ventral rami of C5-7 which covers the shoulder and proximal arm, but spares the distal arm and hand since C8-T1 is often not blocked

Common risks include almost 100% hemidiaphragm due to involvement of C5 that contributes to phrenic nerve, hoarseness if recurrent laryngeal n is blocked, and horner syndrome from sympathetic blockade

Question 48

Q

renal changes in pregnancy

Answer

A

increased cardiac output and increased blood volume leads to GFR and renal plasma flow increases by about 50% along with decreased tubular reabsorption leading to glycosuria

BUN and Cr are decreased and usually lower than pre-pregnancy levels

Question 49

Q

technical spinal cord level of injury classifying paraplegia vs quadriplegia

Answer

A

Above T1 vertebrae (C1-8) is quadriplegia

Below T1 vertebrae (T1-L5) is paraplegia

Question 50

Q

What are minimum criteria when following up a post-op patient in pacu (standards)

Answer

A

mental status
respiratory function
cardiovascular function
temperature
pain
hydration status

Question 51

Q

how does blood volume and CBC lab values change in pregnancy

Answer

A

blood volume increases by 45% by sodium retention through RAA system

Hemoglobin only increases by 30% but usually hgb will be above 11. CO increases in order to increases oxygen delivery to tissues.

oxygen dissociation curve shifts to the right in order to help facilitate offloading to the fetus

Question 52

Q

what dictates changes in baseline fetal heart rate tracing? What is normal range?

Answer

A

accel or decel lasting more than 10 minutes dictates a change in baseline FHRT

normal range is 110-160bpm

Question 53

Q

What is FHR baseline variability and what are the different types? what is sinusoidal pattern?

Answer

A

irregular fluctuations in peak/ trough of heart rate

absent
minimal <5bmp
moderate 6-25
marked >25

sinusoidal pattern is undulating fluctuations that occur 3-5 times per minute and last more than 20 minutes and is an ominous sign of placental abruption

Question 54

Q

FHR Accels/Decels and pathology:

Variable Decel
Early Decel
Accel
Late Decel

Answer

A

V = cord compression
E = head compression
Accel = ok
Late = placental insufficiency

Question 55

Q

what makes a carbon dioxide absorbent high risk of producing CO

Answer

A

Containing high amounts of strong bases like NaOH or KOH

Baralyme (discontinued) and sodalime both have higher amounts of strong bases

Desflurane breaks down into CO and sevoflurane breaks down into Compound A when ran thru carbon dioxide absorbents

Question 56

Q

If patient has symptomatic bradycardia what is the ACLS algorithm?

Answer

A

HR < 50

place ECG/cardiac monitoring, IV access

check for HD stability and signs of shock including angina, AMS, dizziness

atropine IV 1mg q3-5min for maximum 3 doses
transcutaneous pacing or dopamine gtt @5-20mcg/kg/min or epinephrine gtt @ 2-10mcg/min
transvenous pacing/expert consult

Question 57

Q

how does partial pressure of desflurane gas change when elevation changes?

Answer

A

partial pressure decreases as elevation increases

sea level atmospheric pressure is 760mm hg (1 atm)

Question 58

Q

how does desflurane storage/delivery differ from other halogenated gases (ie sevo)

Answer

A

Desflurane has high vapor pressure and will boil at temp above 22C therefore must be pressurized and delivered via dual-gas blender which is calibrated at a certain elevation and will deliver anesthetic based on the change in elevation that it is currently at compared to storage

All other gases can be delivered through variable bypass vaporizer which delivers similar MAC at higher and lower elevations

Question 59

Q

Relevant structures when performing a femoral nerve block?

Answer

A

medially are the femoral artery and vein

nerve lies deep to the fascia lata and fascia iliaca with the sartorius muscle more lateral

nerve sits on top of the iliopsoas muscle

Question 60

Q

These structures are perfused by which branches of the coronaries:

anterior left ventricle
AV node
lateral right ventricle
posteromedial papillary
interventricular septum (thirds)
SA node
bundle of HIS
cardiac apex
posteroinferior wall

Answer

A

anterior left ventricle = Lateral anterior descending a.
AV node = AV nodal a.
lateral right ventricle = Right marginal a.
posteromedial papillary = Posterior descending a.
interventricular septum (thirds) =
- anterior 2/3 = LAD
- posterior 1/3 = PDA
SA node = SA nodal a.
bundle of HIS = AV nodal a.
cardiac apex = RMA + LAD
posteroinferior wall = PDA

Question 61

Q

what is first line txs for afib with RVR if HD is stable, and what are their mechanisms of action

Answer

A

beta blocker or CCB

avoid beta blocker in patients with reactive airway diseases. Esmolol/metoprolol is cardioselective for B1 anatagonism, esmolol would be more indicated in rapid correction of dysrhythmias ie HD instability

diltiazem better for HD stable patients. inhibits influx of Ca in cardiac and smooth muscle cells causing negative inotropy and vasodilation of cerebral, periphery, and coronaries

digoxin has low therapeutic window

Question 62

Q

mechanism of action of barbiturates and what are their function? How do they affect ventilation?

Answer

A

bind to GabaA receptors and increase the duration of opening of the chloride ion channels. They provide anesthesia by increasing inhibitory transmission and decreasing excitatory transmission (CNS depression). They do not produce analgesia.

Depresses the ventilatory center of the brain stem which blunts ventilatory response to hypoxia and hypercarbia.

Question 63

Q

mechanism of Vasopressin

Answer

A

aka antidiuretic hormone

released from the hypothalamus and transported into the posterior pituitary

release is triggered by hypovolemia or hyperosmolality

will activate V2 receptors in the collecting ducts of the kidney which increases free water reuptake via aquaporins

and will activate V1 receptors of peripheral vessels which causes vasoconstriction

Question 64

Q

how are ester vs amide LAs metabolized

Answer

A

ester = plasma cholinesterase
amide = hepatic metabolism

Answer 65

A

prevent spontaneous bleeding = >10k
minor procedure = 20-30k
major procedure = 50k
neurosurgery/neuraxial procedure = 100k

**take into account clinical context, platelet dysfunction can occur in times of acidosis or hypothermia (ie trauma/cardiac arrest)

Answer 66

A

cushing = hypercortisolism
moonfacies, hyperglycemia/diabetes, osteoporosis, central obesity, easy brusing

addison’s = hypocortisolism
weight loss, fatigue, hypercalcemia, hyponatremia, hyperkalemia (via hypoaldosteronism)

Answer 67

A

hydrophilic (morphine, dilaudid)
slower onset, longer duration, greater CSF bioavailability and CSF spread, delayed respiratory depression

lipophilic (fentanyl)
faster onset, shorter duration, fat redistribution > systemic, less CSF spread/bioavailability

Answer 68

A

density, velocity, and size of tube are all directly associated with Re (reynolds number) and inverse with viscosity

Re <2000 = laminar
RE >4000 = turbulent

Answer 69

A

chronic HTN is elevated BP prior and up to 20 weeks of gestation

gestational HTN is elevated BP after 20 weeks gestation without severe features

Pre-clampsia is HTN after 20 weeks accompanied by proteinuria or severe features (think HELLP syndrome stuff, headache, migraine, RUQ pain, elevated liver enzyme, kidney dysfunction, thrombocytopenia, pulm edema)

control BP to prevent maternal stroke, Mg sulfate for neuroprotection from seizures

Answer 70

A

L3 = medial knee
L4 = medial malleolus and anterior knee
L5 = dorsum of foot and 2nd/3rd digit
S1 = lateral foot and lateral malleolus

FYI C1 does not have dermatome
C2 covers posterior scalp and anterior neck under chin

Answer 71

A

posterior tibial nerve (1cm posterior to medial malleolus and posterior tibial artery) branches from tibial n and provides motor and sensory to plantar aspect of foot

Saphenous n (1cm anterior to medial malleolus) is a terminal branch of the femoral nerve and provides sensory to the medial ankle

Sural n (lies 1 cm distal to lateral malleolus) branches from both peroneal and tibial and provides sensory to the lateral foot and 4th and 5th digits

Deep peroneal n is medial of the dorsum of the foot while superficial peroneal n is more lateral on dorsum of the foot

Alternatively, sciatic (popliteal fossa) and saphenous n blocks will coverall the nerves in an ankle block as well

Answer 72

A

woods x80 = dynes

normal SVR 800-1200 dyne
normal PVR 30-180 dyne

Answer 73

A

Ca O2 = (1.39 x SaO2 x Hgb) + (0.003 x PaO2)

Answer 74

A

reversible inhibition of Na/K pump in cardiac muscle producing high intracellular Na
there is a Na/Ca exchanger which will retain Ca as Na leaves the cell
this causes increased contractility and decreased conduction via AV and SA nodes, which helps in heart failure and for SVTs

eliminated mostly by kidneys, must be dose adjusted for renal function

toxicity is from slowing heart too much ie bradycardia, AV block, and PVCs and delirium and visual changes and is promoted by electrolyte abnormalities like hypoK, hypoMg, hyperCa

Tx is digoxin specific antibodies

Answer 75

A

initiating treatment with clonidine or betablockers prior to non-cardiac surgery had increased risk of clinically relevant hypotension and nonfatal cardiac arrest compared to placebo

ok to continue if patient is chronically on betablocker or clonidine

Answer 76

A

NMDA r antagonist in thalamus and indirectly affects reticular activating system

All other sedatives or anesthetics directly affects RAS including gas, etomidate, opioids

Answer 77

A

Fasle positive is type 1 or alpha error (incorrectly reject null)

False negative is type 2 or beta error (incorrectly accept null)

Answer 78

A

Sedative hypnotic effect via alpha2 receptor agonist in the locus ceruleum and also can cause hypotension

Answer 79

A

Absolute: measure of gaseous water in gas and is reported as mass of water per unit area of gas, temp directly associated with maximum absolute humidity

Relative humidity is amount if water vapor in gas relative to temperature of the gas itself and is reported as a percentage of the maximum absolute humidity at a given temp

Lower ambient relative humidity results in more rapid water evaporation from skin

Recommended humidity in OR is 20-60% (lower limit for electrical equipment and upper limit for sterile barrier integrity)

Answer 80

A

Embryonic tumor of kidneys can often metastasized thru IVC into right atrium and high risk of PE

Usually present with hypertension but volume down

Often have hematuria and chronic kidney dysfunction, excess renin release from mass compression of renal artery

Present with severe anemia and thrombocytopenia and acquired vWB disease but may be asymptomatic

Preoperative chemo therapy

Answer 81

A

21% O2
78% nitrogen

Answer 82

A

Holding breath while submerged
water in hypopharynx causes laryngospasm
hypercarbia from lack of ventilation
release of laryngospasm from hypoxia
aspiration of water causes washout of surfactant, decrease lung compliance, VQ mismatch
multiorgan failure from global hypoxemia

Answer 83

A

Sensory: recurrent laryngeal is sensory to larynx from vocal cords and downward while superior laryngeal supplies above vocal cords

Motor is from recurrent laryngeal which supplies al intrinsic laryngeal muscles except the cricothyroid muscle

Circothyroid M is innervated motor by superior laryngeal n which tenses the vocal cords for pronation but has minimal disruption

Answer 84

A

Increase in stroke volume by 10-15% after 500cc bolus IV

Often volume depleted causes low preload and low CO.

Positive pressure Vent causes increases intrathoracic pressure and decreases venous return/preload of right ventricle. If LV stroke volume changes with cyclic vent then then ventricles are preload dependent

Stroke volume variation can be calculated from arterial pressure waveform when arterial compliance and SVR are known or can be determined by doppler

Must be paralyzed, Supine, ventilated with larger tidal volume >8cc/kg and in NSR with closed thorax and normal lung compliance

Answer 85

A

Wide spread Coagulation cascade activation thrombo-hemorrhagic disorder

Lab findings will commonly show thrombocytopenia

Presents with diffuse thrombosis leading to multi organ failure, consumption coagulopathy, and bleeding

Answer 86

A

Loss of fetal station due to loss of uterine tone
Pain uncontrolled by epidural analgesia
Vaginal bleeding
Abnormal change in fetal heart rate
Acute shoulder or abdominal pain

Answer 87

A

Iliac crest inferior
Latissimus dorsi posteriorly
External oblique anterior

Answer 88

A

Mostly thru biliary system, but partially thru kidneys
Has active metabolite which has 80% potency and is also eliminated via kidneys

Prolonged duration in kidney failure and elderly

Answer 89

A

HIV 0.3%
HEPC 0.5%
HEPB 30%

Answer 90

A

Gr1 epiglottis, entire vocal cords, arytenoids
Gr2a epiglottis, partial posterior aspect of VCs, arytenoids
Gr2b epiglottis and aryteboids, no VCs visualized
Gr3 only epiglottis no arytenoids
Gr4 only soft tissue no epiglottis

Answer 91

A

Propagation speed and density of mediums

Answer 92

A

Need 2/3:
Altered mental status
SBP < 100
RR > 22/min

Answer 93

A

Sepsis with persistent hypotension

Requiring pressors to maintain map >65

Lactate > 2 despite adequate volume resuscitation

Answer 94

A

Increases

Fibrinogen levels double to limit postpartum hemorrhage

Increase in factors

Dilution if platelets, often <150k
Dilutions anemia, plasma vol increases by 40-50%

Answer 95

A

Hemorrhage - avoid hypertension
Ischemia from vasc steal- avoid hypotension
Normal perfusion pressure breakthru - inability to vasoconstrict after AVM removal
Occlusion hyperemia
Seizures

Avoid hypertension by mix of 0.5 Mac gas and opioid anesthesia especially on induction

Answer 96

A

Male: 65-70cc/kg
Female: 60-65cc/kg

Answer 97

A

tamponade showing pericardial effusion on echo

esophageal thermal injury , detectable with temp probe

MI can be detected on ECG, often in right coronary distribution

phrenic nerve damage, can detect with fluoro while stimulating phrenic nerve

Answer 98

A

somatosensory evoked potential provide information on the integrity of ascending neurons during stimulation of peripheral or cranial nerves and measuring resulting cortical impulse on EEG

SSPE quantifiable by amplitude and latency of signal (aka delay between stim and signal)

decrease in amplitude or increased latency can indicate direct damage to nerve or ischemic insult (significant is 50% lower amp or 10%inc latency)

signal is worsened by inhaled volatile gases (keep mac below 0.5 and use multimodal anesthetic i.e. propofol)

other types of SSPE are brainstem auditory evoked potential and visual evoked potential

often used during spine surgery

Answer 99

A

evaluate integrity of descending motor neuron pathways. Generate motor impulse by stimulating motor cortex and receiving signal from distal muscle groups

Require that NMB not be used to receive motor signals

inhaled volatile gases can reduce signal but not as sensitive as SSPE

Answer 100

A

anterior to C7 transverse process but safer to block at C6 (below is risk of unprotected vertebral artery)

part of the sympathetic chain receiving T1-4 outflow and can be used for CRPS in the upper extremities

Answer 101

A

fat is metabolically active and therefore requires increase in total blood volume

excess blood volume leads tto increase cardiac output with inc SV and ventricular dilation resulting in deleterious hypertrophy of ventricles

also eventually develop hypertension due to increased sympathetic NS leading to increased SVR which contributes to cardiac hypertrophy and eventual failure

Answer 102

A

in fetus, immobilized, burns, or motor neuron injury, sepsis

associated with larger efflux of potassium from depolarizing paralytics

they contain gamma subunit instead of mature epsilon one

Answer 103

A

anticonvulsant and for neuropathic pain (DM, TGN, phantom limb)

inhibits alpha2 voltage gated calcium channel by decreasing release of glutamate

SFX: sedation, dizziness, ataxia, nystagmus, edema, weight gain

Answer 104

A

decreased risk of perioperative MI but increased risk of stroke and increased mortality

recommended to start BB atleast week prior to surgery and continue taking chronically

Answer 105

A

CPP = AoDP - LVEDP

diastolic fillingtime/HR also contributes

Answer 106

A

High risk = intrathoracic, intraperitoneal, suprainguinal vascular procedure, aortic/major vessel vasc surgery

Moderate risk = head neck, carotid, orthopedic, urological, gynecologinal, EVAR

low risk = superficial, outpatient, breast, endoscopic, eye, thyroid

consider per-op ECG for cardiac/CVA risk factors and for moderate to high risk procedures

Answer 107

A

all plasma factors involved in hemostasis

can be used to urgently reverse warfarin, in DIC, liver dysfunction

recommended dose is typically 10-15ml/kg which obtains level of 30-40% factor activity which is about INR 1.4-1.7 (INR1.0 is 100% factor function)

can calculate by equation:
Amt FFP needed (mL) = (target functional percent - present percent) * Kg

stored frozen and warmed prior to use

single unit is about 200-250 mL

usualy to reach INR 1.5
INR 2.5 needs 4u
INR 2.0 needs 3u
INR 1.8 needs 2u

Answer 108

A

arm: 50 above systolic
leg: 100 above systolic

up to 2 hours at a time before compression injury

changes after deflation:
metabolic acidosis
increased CO2
drop in systemic BP

Answer 109

A

left shift means at a given pO2 there is more Hgb saturation which means higher affinity and less unloading

right shift means less saturation at a given pO2 which means less affinity and more off loading

Answer 110

A

less CO2 or H+
lower temp
less DPG
alkalinity (higher pH)
met-Hgb
CO-Hgb
fetal-Hgb

Answer 111

A

increased pCO2
increased temp
increased DPG
acidosis (lower pH)

Answer 112

A

first letter: chamber paced
(A,V, Dual)

second letter chamber sensed
(O none, A, V, Dual)

third letter response to sensing
(O none, I inhibit, T trigger, Dual)

*inhibits pacemaker not actual heart

asynchronous modes are DOO,VOO,AOO
and often used in perioperative setting where electro cautery is being used and patient is pacemaker dependent such as complete heart block, often set between 80-100bpm

Danger is posed with patient’s intrinsic HR is greater than pacemaker rate and has chance of R on T phenomenon and can lead to VT or VF

safe if intrinsic heart rate is less than mode set

DDD is most commonly used since it can pace both chambers and also inhibit itself if detecting increase intrinsic hr

Answer 113

A

Zone 1: all freely accessible public areas outside MR environment

Zone 2: interface between uncontrolled zone1 and strictly controlled zone 3, acts as holding area for unscreened patients

Zone 3: strict access to screened patients and equipment includes control room outside the scanner

Zone 4: MR magnet scanner room, restricted access to screened patients under constant supervision of MR personnel and MRI compatible equipment

Answer 114

A

Total mass is about 60% water

intracellular fluid 2/3
Extracellular fluid 1/3 (mostly interstitial about 3/4 and rest is CSF and intravascular fluid about 1/4)

neonates have higher total body water than adults about 3x (particularly ECF)

obesity has lower TBW, adipose tissue contains much less water compared to other tissues

Answer 115

A

when oxygen tension is low:

peripheral resistance decreases/vasodilates

pulmonary resistance increases (hypoxic pulmonary vasoconstriction) often in focal lung diseases to shunt blood to better oxygenated alveoli, diffuse constriction can lead to pulmonary hypertension

Answer 116

A

age >3
duration of surgery >30min
type of surgery (eye, tonsil)
PMH and FHX of PONV

adequate hydration and reduce opioids, consider regional where able

Answer 117

A

enlarged internal organs
Heart failure
macroglossia
sleep apnea
epiglottis enlargement
HTN
DM
CAD
peripheral neuropathy

Answer 118

A

increased mortality in GCS<13 patients with TBI who received albumin 4% compared to normal saline

Answer 119

A

Risk: UOP < 0.5cc/kg over 6 hours
Injury: UOP <0.5cc/kg over 12 hours or GFR decrease by 50% or rise of Cr x2
Failure: UOP < 0.3cc/kg for 24hr, dec GFR by 75%, rise Cr by3x, or 12hr anuria

Loss: persistent renal failure lasting 4 weeks
End stage: needs renal replacement therapy

Answer 120

A

transplanted hearts are dennervated and there is minimal baroreceptor reflex to counterbalance

need to use direct adrenergic agents (beta 1) such as isoproterenol which is nonselective beta agonist, can also use epi, norepi, dobutamine, and glucagon but save epi/norepi for reserve since baroreceptor reflex is severed and can have unopposed tachycardia

reinnervation of vagus nerve of the donor heart can take up to 24months to be re-established

Answer 121

A

chi square evaluates multiple categorical data sets while ANOVA analyzes the variance between multiple nominal or ordinal data

Answer 122

A

Prop gtt, succ: total BW

thiopental, fentanyl, prop push: lean BW

roc/vec: ideal BW

Answer 123

A

premature infant: 90-105cc/kg
fullterm infant: 80-90 cc/kg
infant 1-12 months: 70-80cc/kg
child 1yo-12yo: 70-75cc/kg

adult male: 65-70
adult female: 60-65

Answer 124

A

ABL = EBV x (HCTi - HCTf)/HACTavg

means maximum blood loss prior to transfusion

Answer 125

A

TLV = total lung volume
TV = tidal volume
VC = vital capacity (IC + ERV) what you can maximally inhale and exhale
RV = what is remaining after forced exhale
ERV = forced exhalation volume after tidal exhale
IC = tidal volume with forced inhale
FRC = remaining volume after exhaled tidal volume

Answer 126

A

Hepatic artery buffer response is the increase or decrease in Adenosine that will contract or dilate hepatic arterioles when portal blood flow changes

Answer 127

A

1mg Intrathecal = 10mg epidural = 100mg IV = 300mg oral

Very hydrophilic drug which means if given intrathecal, it will stay for long duration

It will occur to smaller extent if given epidural

Lipophilic drugs like fentanyl will redistribute back into fat, so shorter duration

Answer 128

A

shortened QT interval

Normal qtc is 350-450ms

Answer 129

A

CaO2 = [(SaO2 * Hgb * 1.34 ml O2/gm Hgb, O2 carrying capacity of Hgb) + ( 0.003, O2 solub in plasma * PaO2)

SaO2 is fraction of Hgb saturated with O2
PaO2 is partial pressure of O2

Answer 130

A

benzocaine, dapsone, inhaled nitric ozide

Answer 131

A

no evidence to show anesthesia affects long term course of MS

higher chance of relapse in the few months following pregnancy

Answer 132

A

converts grounded power supply from electrical company into ungrounded isolated power for OR use

Answer 133

A

checks integrity of the isolated (ungrounded) power supply and measures current flow from isolated power to the ground

Answer 134

A

GCFI prevents shocks from occurring in a grounded power system by detecting differences in current between the hot and neutral wires to immediately interrupt the power supply

Answer 135

A

macroshock is electrical shocks that traverse the skin and can cause muscle contractions or even Vfib at higher currents

microshock is electrical shocks that are applied directly to the heart (ie from indwelling catheters, pacing wires, or from leakage current)

Answer 136

A

alpha 1 and 2 blocker
causes vasodilation but also increase in catecholamine release from alpha 2 block (unihibits release of norepi)

Answer 137

A

nonselective vasodilator working on veins and arteries causing decrease preload and SVR

Answer 138

A

alpha 2 agonist which activates negative feedback that decreases sympathetic outflow in CNS and causes vasodilation in periphery

Answer 139

A

nonselective beta and alpha 1 blocker through competitive inhibition, with more beta than alpha about 4:1

onset of 10minutes and lasts 2-6hours

Answer 140

A

venodilator which functions when it is turned into nitric oxide

first line therapy for MI since it also causes dilation of epicardial coronary arteries

immediate onset of action and lasts up to 5 minutes

Answer 141

A

medial side includes median nerve, brachial artery, and basilic vein (brachial artery will split into the ulnar and radial arteries distal to the antecubital fossa and runs lateral to median nerve)

lateral side is the cephalic vein and the radial nerve

midline of the fossa deep to the biceps tendon is the musculocutaneous nerve

posterior/medial is the ulnar nerve near the olecranon (funny bone)

Answer 142

A

maintains own nervous function separate from recipients but will not receive parasympathetic innervation

direct beta agonists and blockers will work on the denervated heart

parasympathetic-blocking meds such as glyco and atropine will not affect the HR

resting HR of a transplanted denervated heart is usually between 90-110

Answer 143

A

Rocuronium: 30% renal, mostly biliary
Vecuronium: 10-50% renal
Cisatracurium: hoffman elimination and ester hydrolysis
Succinylcholine: plasma cholinesterases

Answer 144

A

normally 35-65% is normal fetal O2 saturation

Below 30% is considered to cause metabolic acidosis

This can be measured with fetal pulse oximetry but Fetal heart rate monitor is more often used where decreases in heart rate are thought to be due to fetal hypoxia and correlates with fetal distress

Answer 145

A

fascia lata is most superficial layer that encases all musculature

fascia iliaca is second layer that encases the femoral nerve

femoral nerve is lateral to the femoral artery and femoral vein (most medial)

lateral muscle structure us the sartorius with the iliopsoas being deep to the femoral nerve

Answer 146

A

pantoprazole/omeprazole: directly inhibit H+ atpase channels in gastric parietal cells which ceases acid release, takes about 1hr for onset

famotidine/cimetidine: histamine-2 receptor blockers which partially prevents parietal cells from release acid (but other mechanisms are still unblocked), requires about 30min for onset

sodium citrate immediately increases pH of gastric fluid but also increases amount of fluid in the stomach

Answer 147

A

originates from S2-4

sensation to clitoris/head of penis, labia, external anal sphincter

Answer 148

A

stage 1 is divided into latent and active phases
latent is variable in time and includes onset of contractions and persistent dilation
active phase is when contractions are regular at 2-3 minutes and lasting about a minute and ends at complete dilation of 10cm
(can use paracervical block) Pain comes from inferior hypogastric plexus to the uterus and cervix (T10-L1)

stage 2 starts with complete cervical dilation and ends with delivery of fetus
(can use pudendal block) Pain comes from S2-4 and T12-L1 to the vaginal wall

stage 3 is delivery of the placenta

Answer 149

A

lasts 90 minutes

IV adult dose is 0.4mg to 2mg can repeat q2-3minutes until reversal of respiratory depression

Answer 150

A

10 min to double and 30min to triple

this occurs because N2O has MAC 105% and very insoluble in blood (ie has a low blood:gas coefficient) and thus will come out of solution

Answer 151

A

1/radius^2

ie if exposure is 8mrem/s, and if you move 2 feet away, then it reduces exposure by 1/4 resulting in 2mrem/s

Answer 152

A

divide number of apnea episodes with hypoxia that last at least 10 seconds by the number of hours slept

normal is 0-4
mild is 5-14
moderate 15-29
Severe is 30+

Answer 153

A

increased levels of progesterone will relax the lower esophageal sphincter

can give antacid (non particulate), H2 blocker, and metoclopramide (reglan) for patients >16weeks gestation

Answer 154

A

30-35cm from incisors which will reach about level T5-6, this is where esophagus and descending thoracic aorta are in close proximity

you can also see the mid-esophageal 4 chamber view here with views of the thoracic aorta when you rotate left

Answer 155

A

exenatide
semaglutide (wegovy/ozempic)
liraglutide

administered as injectables

while DPP4 inhibitors (sitagliptin/januvia) and SGLT2 inhibitors (empagliflozin/jardiance) are oral

Answer 156

A

hepatic arterial buffer system

adenosine is a byproduct of the liver and causes vasodilation

blood flow through the portal vein will determine how much adenosine is washed out from the liver, if blood flow is low then high amounts of adenosine will dilate hepatic artery to increase blood flow and the opposite will occur if high portal blood flow resulting in adenosine washout and less arterial dilation

Answer 157

A

repercussion syndrome:

acidosis from influx of hydrogen ion, can give 25 meq of bicarb preemptive

influx of potassium can result in peaked t waves and arrhythmia - preemptive CaCl (500mg-1gm) administration can stabilize myocyte membranes

increase preload and right heart strain

hypothermia due to organ being cooled to prevent organ ischemia

coagulopathy due to wash out of TPA when organ is reperfused

Answer 158

A

uncuffed is age/4 + 4

cuffed is age/4 +3.5

ie for a 2yo use a size 4.5mm uncuffed or 4mm cuffed

Answer 159

A

sinus tach has p waves present and rate is typically less than 150 for adults

SVT has either absent or abnormal pwave emorphology with rates usually >160

For SVT attempt vagal maneuver or adenosine then try cardioversion

sinus tach: treat underlying cause

Answer 160

A

presence of beard
BMI >30
edentulous
age > 55
hx of snoring (occlusion present)

also, male and mallampati 3-4

Answer 161

A

aspirin only needs to be held prior to operations that involve increased risk of bleed in to confined spaces ie intraocular, middle ear, intramedullary
hold for 7 days

P2Y12 inhibitors ie ticagrelor or clopidogrel are stronger antiplatelets and generally are held 5-7 days prior to surgerys with high bleed risk

usually DAPT is given 6-12onths after PCI stent and then recommended to wait 3-6mo after stent placement for elective surgery

resume anticoagulants immediately after surgery

Answer 162

A

pulmonary artery systolic pressure >35, or mean PA pressure >25 at rest or >30 during exercise

Answer 163

A

keep tidal volumes low (6-8cc/kg)

avoid excess PEEP which can increase vascular resistance, increase RV afterload from inc intrathroacic pressure

avoid permissive hypercapnia which will result in increase pulmonary vascular resistance and possible right heart failure

Answer 164

A

Group 1: primary pulmonary artery hypertension (ie collagen disease, portal HTN, drugs/toxins)

Group 2: left side heart disease

Group 3: lung disease (ie COPD, OSA)

Group 4: chronic thromboembolic disease (PE or sickle cell)

Group 5: other (ie sarcoidosis, henolytic anemia)

Answer 165

A

prominent incisor length
large overbite
poor prognath ability
<3 cm interincisor distance

mallampati 3 or 4
narrow or high arched palate
stiff mandible

<3 finger breaths thyromental distance
short neck
thick neck
limited neck flexion or extension

Answer 166

A

paravertebral block or thoracic epidural

PCA with IV opioid has higher risk profile and less analgeisa efficacy

Answer 167

A

6-7% per each degree celsius

deep hypothermic cardiac arrest, temp target is around <25C

Answer 168

A

central venous pressure 0-7
right atrial pressure 0-7
RV sys pressure 15-25 (systolic presence)
RV end-dia pres 3-12
Pulm A systolic pres 15-25
Pulm A end-dia pres 8-15 (dia step up)
mean pulm A pres 10-22
pulm cap wedge pres 6-15

Answer 169

A

Hgb > 7
PT/PTT <1.5 (give FFP)
Fibrinogen >300 (give cryo)
Platelets >50,000

Answer 170

A

PaO2 = FiO2(Patm-Ph2o) - (PaCo2/R)

patm sealevel = 760
Ph2o = 47
R quotient - 0.8

Answer 171

A

febrile nonhemolytic transfusion reaction

Mechanism is cytokine build up in stored blood

Answer 172

A

increases ICP by increasing CMR and cerebral blood flow

Answer 173

A

methohexital: no change
propofol: decreases
midazolam: decreases
etomidate: increases
remifentanil: no change

Answer 174

A

fentanil is metabolized by the liver and is better for ESRD

dilaudid has metabolite and can cause seizures in ESRD

Answer 175

A

preganglionic parasympathetic > Ach >nicotinic R
preganglionic sympathetic > Ach > nicotinic R
postganglionic parasympathetic > Ach > muscarinic R
postganglionic sympathetic > Norepi > adrenergic R
motor neurons > Ach > nicotinic R

Answer 176

A

it is a intermediate in glycolytic pathway and increasing 2,3DPG will shift the curve to the left

Answer 177

A

Carbamazepine
Phenytoin
Rifampin
Ethanol
Barbiturates

Answer 178

A

Fluconazole
Valproic acid
Metronidazole
Cirpofloxacin

Answer 179

A

Wide awake - beta
Drowsy awake - alpha
Stage 1 light sleep - theta
Stage 2 deep sleep - sleep spindles k complex
Stage 3 and 4 (deep non rem) - delta
Rem sleep - beta

Bis is simplified eeg
Isoelectric = Bis < 40

Answer 180

A

Host antibodies against donor leukocytes
Or accumulation of cytokines in donor blood during storage

Most common transfusion reaction and incidence can be reduced by leuko reduction

Answer 181

A

Egfr < 15 (esrd)

Answer 182

A

gingko - inhibit platelet activating factor (inc risk bleed)

ginseng - lowers glucose, antiplatelet (risk bleed, hypoglycemia)

kava - sedation/anxiolysis (increases anes req)

st john wort - used for depresison (induces Cytp450

ginger - anti-emetic/antiplatelet (inc risk of bleed)

Answer 183

A

Ab against alpha-subunit of the muscle-type nicotinic acetylcholine receptors

symptoms include diplopia, ptosis, dysarthria, and proximal limb muscle weakness that worsens with activity

Answer 184

A

hold 4-6 hr before and can restart 1 hr after both insertion and pull

Answer 185

A

hold 12 hr before and resume 12 hour after insertion or 4 hr after removal

Answer 186

A

hold 4-6hr prior and can resume immediately after insertion and pull

Answer 187

A

bicarb increases about 4-5mEq per 10 mm Hg inc in PaCO2

Answer 188

A

transpulmonary pressure are highest in restrictive lung disease due to a decrease in lung compliance

Answer 189

A

S1 closure of mitral and tricuspid valves
S2 closure of pulm and aortic valves
S3 (after S2) early ventricle filling
S4 (before S1) atrial contraction

Answer 190

A

glycopyrrolate
heparin
nondepolarize NMB
succinylcholine
phenylephrine
sugammadex

Answer 191

A

0.5mEq/L in healthy and in renal failure patients

(not in spinal cord, burn or neuromuscular disease)

Answer 192

A

kiwi, bananas, and avocados (many fruits)

Answer 193

A

protamine

Answer 194

A

increase in progesterone leads to increase in minute ventilation by increasing tidal volumes

Answer 195

A

activity level (0, 2, 4 extremities)

respiration (deep breath, shallow breath, apneic)

circulation (>20, >20-50, >50% pre-anes bp)

consciousness (fully, arousable, unconscious)

o2 sat (92% on RA, O2 supp for >90%, <90% on support

Answer 196

A

PADSS also incorporates nasua/vomiting, pain, and surgical bleeding

also requires patient have a driver

Answer 197

A

myasthenia gravis is Ab against postsynaptic nicotinic Ach receptors

LE is Ab against presynaptic Ca channels

Answer 198

A

20 cm H2O

Answer 199

A

initial bolus of 2.5mg/kg and maintenance of 1mg/kg q6hr for 1-2 days

Answer 200

A

3+ attempts and taking longer than 10 min

Answer 201

A

flumazenil has quick onset 1-3 min but only lasts 45min

midazolam is shortest duration of all benzos and lasts 1-2hr

patient must be continuously monitored for resedation when given flumazenil to reverse benzos due to half life discrepancy

Answer 202

A

decreased lung compliance
increased inspiratory pressure
increased VQ mismatch from atelectasis
hypercarbia from CO2 insufflation and reduced ventilation

Answer 203

A

For low dose:
4-6hours from last dose OR normalization of PTT. Can dose while catheter is in place immediately after placement

For high dose wait 12 hrs before insertion and avoid giving while catheter is in

For both doses, can immediately resume next dose of subQ heparin ppx catheter removal

Answer 204

A

hold 4-6hrs AND normalization of PTT prior to catheter insertion and removal

Can resume heparin IV dosing 1 hour after procedure/removal

Answer 205

A

BID dosing lovenox must wait 12 hours before insertion and wait 12 hours after to restart dosing. Can wait 4 hours after catheter removal but cannot be within 12 hours from insertion (ie catheter was inserted but removed within 12 hours)

daily dosing must wait 12 hours before insertion. Avoid dosing daily while catheter is in. wait 12 hours after single shot and can similar wait 4 hours after catheter removal but no sooner than 12 hrs after insertion

therapeutic dosing wait 24hrs (longest) after last dose prior to insertion. Avoid administering while catheter is in place. Can resume dosing after removal 4hrs after and must be atleast 24hrs since initial insertion.

Answer 206

A

wait 24hrs before insertion AND have normalization of PTT. Do not administer while catheter is in place. Can resume immediately after removal.

Answer 207

A

loss of chloride causes hypochloremic metabolic alkalosis
hyponatremia
hypokalemia
hypercalcemia

Answer 208

A

mechanically ventilated, no PEEP, 6=8cc/kg TV, ECG = SR, supine

PPV>13% is likely fluid responsive

Answer 209

A

correlates directly with lipid solubility of that gas (meyer overton study). higher potency means less drug is needed to attain therapeutic effect. high lipid solubility means a high oil:gas parition coeffecient which resutls in a lower MAC of that gas. (ie higher potency)

This also gives reason that partial pressure of a gas describes its potency (ie MAC) and not percent of gas volume. given different atmospheric pressures, a given percent gas volume can be more or less potent than at sea level. higher elevation ie -0.5atm means half the number of gas molecules per volume in a similar percentage

Answer 210

A

MACamnesia = 0.25
MACunconscious = 0.5
MACbar = 1.3

Answer 211

A

transverse process: nose
pedicle: eye
ears: superior articular process
inferior articular process: front legs
pars interarticularis: neck
opposite superior/inferior articular processes: tail/hindlegs
spinous process/lamina: body

fractured pars interarticularis from spondylolysis will show a white band on scotty dog neck

Answer 212

A

LE is antibodies against VG Ca channels at the terminal end of motor neurons which prevents vesicles from fusing and release acetylcholine (paraneoplastic syndrome sometimes seen when small cell lung cancer)

MG is antibodies against acetylcholine receptors at the motor end plate rendering transmission less sensitive

Dantrolene prevents the release of calcium from the sarcoplasmic reticulum in skeletal muscles, depressing the excitation-contraction coupling

Answer 213

A

MAP is most accurate as this is what is directly measured

Systolic is the most inaccurate and is often overestimated especially in HTN

Answer 214

A

Stage 1:
- cessation of anesthetics
- reversal of NMB
- transition of respirations from apnea to irregular to regular (reactivation of respiratory centers of medulla and pons)
- increase in CO2 levels

Stage 2:
- Return of autonomic responsiveness (ie tachycardia, HTN iso recent surgical trauma and ETT stimulation), sensory and motor brainstem pathways recovery (ie reaching for tube)
- tearing, grimacing, salivating (return of CN 7, 9, 10 in pons and upper medulla)
- airway tone improves when pharyngeal muscles recover (risk of laryngospasm here)

Stage 3
- following commands denotes recovery from general anesthesia (shows recovered integration of higher brain functions along with CN8)
- however spontaneous eye opening is usually the last physiologic response to recover despite patient following verbal commands

Answer 215

A

metoclopramide is a dopamine antagonist (along with antipsychotic like haloperidol, and even antinausea/antiemetic promethazine (phenergan) which can result in tremors and dyskinesias

caution sympathomimetics (ephedrine, ketamine) when patient is on levodopa therapy which can precipitate severe hypertension

avoid meperidine if patient is on selegiline (MAOis) due to risk of serotonin syndrome (rigidity, hyperautonomic state)

if patient is taking acetylcholinesterase inhibitor like rivastigmine or donepezil for parkinsons dementia, administration of succinylcholine can be prolonged and patient can be more resistant to nondepolarizing NMB

prone to dyskinesias with propofol and rigidity with opioids (morphine/fentanyl)

Answer 216

A

minor surgery:
continue ASA thru surgery
noncardiac surgery:
prescriber and surgeon must discuss bleed risk vs MI risk
elective CABG:
continue ASA thru surgery
prior PCI with upcoming CEA:
continue ASA thru surgery unless risk of bleed > risk of MI
periph vasc disease s/f pop art endovascularization:
continue ASA thru surgery (better outcomes)

**If holding ASA or P2Y12 blocker, must stop 5-7 days prior to the surgery

Answer 217

A

L1 - femoral crease
L2 - anterior mid thigh
L3 - medial KNEE (THREE)
L4 medial maleolus
L5 top of fore foot
S1 lateral foot

Answer 218

A

COPD patient s/p single lung transplant
healthy lung is initial peak and diseased lung is the second elongated peak

Answer 219

A

incompetent inspiratory valve which results in the inspiration of CO2.
extended expiratory plateau due to the detection of CO2 during inspiration phase

blunted and shortened inspiration wave

ETCO2 may or may not return to 0 during inspiration

Answer 220

A

ETCO2 does not return to 0 due to incompetent expiratory valve which results in rebreathing expired air

Answer 221

A

via histamine release
this will lower end diastolic volume and thus pressure in the ventricles
this will assist in coronary perfusion

Answer 222

A

anterior: V3-4
Septal: V1-2
Lateral: I, aVL, V5-6
Inferior: II, III, aVF

Answer 223

A

pupillary light: II, III

corneal: V1 (ophthalmic), VII

jaw jerk: V3 (mandibular), V3 (masseter)

gag: IX (GPN, tongue base, post. pharynx wall), X (contract post. pharyngeal musc.)

oculocephalic: VIII, III/IV/VI

Answer 224

A

two acetylcholine bound together

binds to the alpha subunit on nicotinic acetylcholine receptors

Answer 225

A

ulnar nerve injury

numbness/pain in the 5th/4th digits of hand and weakness on wrist flexion and thumb abduction

ensure adequate padding of medial epicondyle and supination of upper extremities

Answer 226

A

baricity

hypobaric: sterile water
hyperbaric: dextrose

(volume will determine spread for EPIDURAL injection)

Answer 227

A

MAP 60-150

Answer 228

A

gases: potentiate blockade

antibiotics: potentiate blockade except for penicillin and cephalosporins (ceftriaxone)

antiepileptics: potentiate blockade

electrolytes
Ca: decreases blockade
Mg and Li: potentiate blockade

Answer 229

A

initially due to veins supplying nearby organs such as jugular or inferior thyroid veins

large bleed multiple months out is due to tracheoinnominate fistula bleed where there is a fistula between trachea and the brachiocephalic trunk coming off the aorta

Answer 230

A

dihydropyridine calcium channel blocker mainly causing arteriolar vasodilation with minimal effects on cardiac inotropy (this allows for easier control of BP as compared to medications that cause both venous and arterial vasodilation like nitroglycerin)

short half life of about 3-14min

Answer 231

A

290 mOSM/kg

Answer 232

A

increased body plasma osmolality which triggers ADH release to retain more free water

Answer 233

A

TACO: transfusion associated cardiovascular overload is volume overload that appears several hours after large volume transfusion and presents with dyspnea, tachycardia, hypertension, with bilateral infiltrates but is afebrile

TRALI: TR acute lung injury is an immune response where donor antibodies trigger recipient neutrophils to cause damage to pulmonary vascular capillaries leading pulmonary edema. Presents with fever, chills, hypotension, hypoxia, and frothy airway secretions

Answer 234

A

they increase the conductance of chloride across the channel while GABA is bound to the receptor, therefore benzos are allosteric positive modulators of the receptor and not direct agonists

(flumazenil is the opposite and is considered a negative allosteric modulator)

Answer 235

A

TENS = transcutaneous nerve stimulation and provides analgesia by activating A-beta mechanoreceptors which will inhibit A-delta and C nociceptive fibers (pain fibers)

Answer 236

A

immature and mature nACHr upregulate starting 1-2 days after initial burn and becomes safe 1-2years after the initial injury

Answer 237

A

aminoamides have preservatives (ie methylparaben) that can sometimes cause allergies but rarely cause anaphylactic rxn themselves

aminoesters break down into PABA which can induce anaphylaxis

Answer 238

A

atropine is a tertiary structure that is able to cross both BBB and placental barrier and can be used to prevent neonatal bradycardia from neostigmine for reversal of NMB

glycopyrrolate (quaternary structure) does not cross the blood brain barrier and minimally crosses the placental barrier (often used during reversal of NMB to prevent the side effects of neostigmine (ie bradycardia)

scopalamine can cross the blood brain barrier and placental barrier, allowing for CNS effects like antinausea along with the potential adverse effect of central anticholinergic toxicity (AMS)

Answer 239

A

physostigmine since it is a tertiary structure and is able to cross the BBB unlike neostigmine and pyridostigmine

neostigmine can cross the placental barrier and has potential for neonatal bradycardia

pyridostigmine is used to treat myasthenia gravis but does not cross BBB

Answer 240

A

0.2mAmp - 0.5mAmp

less indicates risk of intraneural injection and too close proximity

greater than 0.5 means needle may be too far for LA to provide adequate block after injection

Answer 241

A

glucocorticoids affect glucose metabolism, glycogen deposition

mineralocorticoids are for sodium and water retention

hydrocortisone is a naturally produced glucocorticoid that has a 1:1 ratio (standard equivalent benchmark)

Prednisone, prednisolone, methylprednisolone are all glucocorticoids with very minimal mineralocorticoid function with ratio approx 4-5:0.5-0.8

dexamethasone only has glucocorticoid function and has a ratio of 30:0 and is long acting

Answer 242

A

hyperglycemia from increased gluconeogenesis

muscle wasting used to feed gluconeogenesis

fat metabolism and redistribution centrally

anti-inflammatory by decreasing prostaglandins which takes away protective stomach lining leading to peptic ulcers

immunosuppression leading to infections and oral thrush

sodium and water retention causing edema and hypertension

negative feedback on adrenal gland causing secondary adrenal insufficiency

osteoporosis/fractures

Answer 243

A

> 20mg prednisone for 3+ weeks, especially for moderate and major surgeries

give 100-150mg hydrocortisone during induction

Answer 244

A

plasma: 291
NS: 308
LR: 280
Plasmalyte: 284

Answer 245

A

plasma: 4-5
NS: 0
LR: 4.5
Plasmalyte: 5

Answer 246

A

goal directed means to use IV fluids to improve prelaod and to utilize fluid responsiveness measurements to track response such as pulse pressure variation, cardiac output and oxygen perfusion then once adequately euvolemic, fluid is restricted

zero balance is where euvolemic weight is minimized and IF fluids are used to replete 3rd space losses and avoid overhydration and weight gain

no differences have been identified in terms of outcomes between the two methods

Answer 247

A

supplemental oxygen
racemic inspired epinephrine
non-invasive PPV (BiPAP, CPAP, or HFNC)
humidified air
Heliox (laminar flow 70%helium, 30% oxygen)
Steroids

Answer 248

A

primary hemostasis involves a vasospasm to reduce bleeding area and the aggregation of platelets of exposed collagen at a damaged vascular endothelial site to form a platelet plug

secondary hemostasis involves the coagulation cascade purposed to create activated fibrin polymers to form a fibrin mesh that will strengthen the platelet plug

Answer 249

A

the start of the common pathway is the activation of factor X. Xa along with Va will activate the prothrombin activator complex which activated prothrombin into thrombin which will activate fibrinogen into fibrin

intrinsic and extrinsic pathways lead to the activation of factor X

fun facts:
- Ca is also known as Factor IV
- tissue thromboplastin is part of the extrinsic pathway and is known as Factor III

Answer 250

A

tissue damage causes a release of tissue thromboplastin (aka factor III) which activates factor VII into VIIa which then activates X into Xa, starting the common pathway.

this is very quick to activate (approx 30 secs) since there is a high amount of factor VII available.

Answer 251

A

tissue damage/inflammation leads to activation of Factor XII then factor XII which activates Factor IX then factor VIII which directly activates factor X of the common pathway

this is a slower but more robust cascade that takes a few minutes but produces more fibrin than the extrinsic pathway

Answer 252

A

PT/INR measure extrinsic pathway by measuring Factor VII, X, V, II (prothrombin), and Factor I (fibrinofgen)
INR is a standardized way of expressing PT across different countries
Warfarin is monitored using INR

aPTT measures intrinsic pathway and common pathway by measuring all factors excpet for VII
Heparin is monitored using PTT (or ACT)

(both drugs affect both pathways but each is more sensitive for a particular drug)

Answer 253

A

present in both primary and secondary hemostasis

Primary hemostasis: in the creation of platelet plug, VWF is used for platelet adhesion to the exposed collagen of the damaged endothelium, without vWF platelets cannot adhere and therefore cannot activate and therefore cannot aggregate

Secondary hemostasis: VWF acts as a carrier of Factor VIII and significantly extends the half-life of it, without VWF, you will have extended PTT

DDAVP will increase the amount of VWF expressed by the subendothelial tissue

Answer 254

A

peripheral vasodilation
decreased cardiac contractility
coronary vasodilation (especially isoflurane)
cardiac preconditioning (decrease loading of Ca into myocardial cells)

Answer 255

A

Propofol works as an anesthetic by potentiating the GABAa receptor

quick onset and termination are due to its lipid solubility allowing for quick re-distribution into other body compartments

dose dependent associated decreases in tidal volume and eventual apnea

bronchodilation

increases sensitivity of hypoxic vasoconstriction

Answer 256

A

epinephrine increases the duration of the block by causing vasoconstriction and decreasing uptake of the LA

sodium bicarb will decrease the pH and allow for more LA to be in the nonpolarized form which allows for faster onset via faster diffusion across cell membranes

increased lipid solubility equates to more potent medication and denser block

Answer 257

A

5HT3 (serotonin)
Histamine
Dopamine
muscarinic M1
Substance P/Neuokinin 1

Answer 258

A

ABL = [EBVx(starting Hct - minimum Hct)]/starting hematocrit

minimum Hct is about 20-25 for healthy adults/kids and 30 for active cardiac comorbidities

Answer 259

A

occurs when there is not enough time for adequate exhalation of lung volumes before the start of next inspiration

this is often due to inappropraite settings on the ventilator I:E time and frequency in patients with increased lung compliance suchas COPD where it takes longer for the chest to recoil and exhale to remove lung volumes

this leads to progressive build up of end inspiration and expiration lung volumes

auto/intrinsic PEEP is the notable by the presence of persistent end expiratory flow at the end of expiration and is due to hyperinflation of the lungs generating pressure moving outwards

Answer 260

A

consciousness
activity (moves extremities)
O2 saturation (>90%/supp req)
respiration (quality of resp)
circulation (BP)

Answer 261

A

superior laryngeal nerve originates from the vagus nerve (CN X) and divides into the external and internal branches

External provides motor function to the cricothyroid muscle which tenses the vocal cords

Internal branch provides sensory innervation to laryngeal/epiglottic structures above the vocal cords

Answer 262

A

almost entirely by the liver (even with liver function at 50%, can metabolize 100% of propofol) however this means propofol metabolism is also dependent on adequate hepatic blood flow

about 30% of propofol is extrahepatic at the site of the kidneys

Answer 263

A

940nm (infrared) more absorbed by oxyhemoglobin

660nm (red) more absorbed by deoxyhemoglobin

Answer 264

A

opioid agonist, NMDA antagonist, and serotonin reuptake inhibitor

metabolized by liver enzyme CYP3A4

can cause QT prolongation that can progress into torsades de pointes
(normal QTc is 350-450ms)

Answer 265

A

epi does not increase duration of bupi or ropi for either peripheral nerve blocks or neuracial blocks

dexamethasone and clonidine have both been shown to increase duration of block for both ropi/bupi

dicarbonate is thought to increase speed of onset of local anesthetic block but it has the potential to cause LA precipitation at higher pH

Answer 266

A

occurs due to recipient antibodies targetting minor antigens on donor red blood cells (rhesus, kidd, kell) and hemolysis usually presents days to weeks after transfusion with mild or minimal symptoms (ie mild fever, jaudice or back pain)

Answer 267

A

-60 to -90 mV and is largely due to K why it is negative

Answer 268

A

Bohr effect pertains to the shift in the oxygen-hemoglobin dissociation curve due to changes in CO2 and pH

Haldane effect pertains to hemoglobin’s ability to carry more CO2 in the deoxygenated state

Answer 269

A

Air = yellow
Oxygen = Green
CO2 = grey
NO = blue
Nitrogen = black
Helium = brown

Answer 270

A

2 x Na + Glucose/18 + BUN/2.8

normal gap is <10

increased gap can be due to solutes that are unmeasured such as ethanol, mannitol, sorbitol, lactate, ketones

Answer 271

A

temperature: directly related to cerebral blood flow and will decrease with decrease in temp (CMRO2 decreases by 6% with every drop in 1 degree)

blood pressure is connected to blood flow thru the cerebral perfusion autoregulation curve that exists between maps of 50-150

PaO2: cerebral blood flow is inversely related t oPaO2 when < 50, does not change when PaO2 is > 50

PaCO2: increases in PaCO2 will result in increased cerebral blood flow

Answer 272

A

citrate = anticoagulant
phosphate = pH buffer
adenine = ATP source and maintains membrane integrity
dextrose = sugar source

Answer 273

A

halothane = 2.5 (very soluble)
iso = 1.4
sevo = 0.6
nitrous = 0.47
des = 0.42 (not soluble)

Answer 274

A

increase the most in highly soluble gases (ie halothane then second is isoflurane)

Answer 275

A

subcostal, ilioinguinal, and iliohypogastric nerves which provide sensation to lower abdominal walls

Answer 276

A

lowers cerebral metabolic rate, cerebral blood flow, and intracranial pressure

Answer 277

A

cricothyroid muscle adducts the vocal cords and is innervated by the external branch superior laryngeal nerve

all other intrinsic muscles are innervated by the recurrent laryngeal nerve (along with sensation below the vocal cords, internal branch of SLN provides sensation above the vocal cords)

both of these nerves provide efferent innervation of the laryngospasm

Answer 278

A

bilirubin, albumin, prothrombin time (PT or INR)

fatigue, nausea/vomiting, jaundice, dark urine, biliary colic, ascites, encephalopathy

Answer 279

A

enzyme-independent reaction of breakdown that occurs in the plasma which allows for a relatively predictable offset time especially in liver failure patients (this can be affected by acidosis or hypothermia). cisatracurium and atracurium undergo this elimination route.

Answer 280

A

200mg of fibrinogen per unit of cryoprecipitate which will tend to raise the serum levels by about 70mg/Dl

in addition to fibrinogen, cryo has high concentrations of Factor VIII and XIII and vWBF

Answer 281

A

relaxes airway tone,, depresses airway reflexes, and attenuates hyperconstrictive responses to bradykinin and acetylcholine

Answer 282

A

anticholinergics such as atropine or glycopyrrolate

short acting beta agonist inhaler (albuterol)

magnesium

epinephrine

glucocorticoids

Answer 283

A

factors that increase tendency for turbulent flow include velocity, density, and length of travel (tubing)

while viscosity decreasing tendency of turbulent flow

Answer 284

A

both augment antithrombin III which inhibits factor Xa and thrombin

however in order to inhibit thrombin, the heparin molecule must be long (ie unfractionated heparin) while LMWH will preferentially only inhibit factor Xa which allows for lower risks of HIT and platelet dysfunction due to the role of thrombin in inflammatory and immune pathways

Answer 285

A

sever hyponatremia is < 120 mmeq

give hypertonic saline if severe or symptoms are present

correct by 1-2mmeq per hour with maximum 12 per day due to risk of pons demyelination syndrome

Answer 286

A

it allows for the preferential use of the higher pressured pipeline oxygen source (50 psig) over the lower pressure oxygen tank (40psig) source

using oxygen flush can allow high flow that lowers pipeline pressure below tank pressure

second stage regulators reduce pressure to just above atmospheric and provide constant flow to downstream components

Answer 287

A

Prerenal:
BUN:Cr >20
Urine Na <20
FENa <1%

Renal:
BUN:Cr <20
Urine Na >20
FENa>2%

Answer 288

A

centrally acting alpha2 agonist which decreases sympathetic activity in the medulla oblongata (vitals control)

this reduces the production of renin and catecholamines in plasma

withdrawal presents with rebound hypertension, tachycardia, flushing, agitation, palpitations

Answer 289

A

emergent = risk of life or limb if not operated within 6 hours
urgent = within 24 hrs
time sensitive is from 1 week to months
elective = within a year

Answer 290

A

incompetent inspiratory valve will show an extended down stroke due to inappropriately allowing CO2 back into the inspiratory limb

incompetent expiratory valve will show residual CO2 during inspiration phase, such that EtCO2 will not return to baseline of 0.

Answer 291

A

ETCO2 will not return to 0 during inspiration phase

it lies after the expiratory valve and APL valve and just before the inspiratory limb (exhausted absorbent will cause CO2 to spill over into the inspiratory limb)

Answer 292

A

primarily class 3 antiarrhythmic by blocking potassium channels

also acts as blocks calcium, sodium channels and to lesser extent alpha and beta adrenergic receptors

it can be used to treat ventricular arrhythmias and sustained SVT such as afib

Answer 293

A

adult: 3-5 ml/kg/min
infant 7-8 ml/kg/min

Answer 294

A

desflurane 0.42
nitrous oxide 0.46
sevoflurane 0.65
isoflurane 1.46 (much more soluble)

“DNSI = Desflurane Not Soluble In..blood”

Answer 295

A

thiazides = hypercalcemia
loop = hypocalcemia

Answer 296

A

activates GCPRs to increase adenylyl cyclase and increases cAMP and causes increased inotropy and chronotropy in cardiac cells and which also leads to counter effects to insulin which increases blood sugar by increasing glycogenolysis and gluconeogenesis, and inhibiting glycogen synthesis in the liver

Answer 297

A

sevoflurane: 167
isoflurane: 238
desflurane: 669
nitrous oxide: 38000

vapor pressure increases and boiling point decreases

“SID-NEE has lots of vapor from aquatics”

Answer 298

A

anterior = sartorius
lateral = vastus medialis
posteromedial = adductor longus (superior portion), adductor magnus (inferior portion)

contents include saphenous nerve, femoral artery and vein

ultrasound halfway between ASIS and patella

Answer 299

A

standard pressure is 2000 psig and volume is 625L

convert the new remaining pressure in to a volume and divide it by the flow rate

ex. 1500psig/2000psig = X/625L
then divide the new volume by the flow rate to get time in minutes

Answer 300

A

nitrous oxide will be partially liquid and partially vapor when it reads pressure of 745psig. At this point only by weighing the tank will tell how much gas is left. Once <75% is remaining then the amount of nitrous oxide will parallel the decrease in pressure

Answer 301

A

intubation dose: 0.1-0.15mg/kg and lasts 30-60min with half life about 25min

undergoes hoffman degradation dependent on temperature and pH (not kidney or liver)

Answer 302

A

MELD predicts mortality in mortality in End stage liver disease but is purely objective criteria and components compared to childs-pugh and can be used to prioritize patients for transplant

MELD: “I crush several beers daily = INR, Cr, Sodium, bilirubin, dialysis

Childs-pugh: “Pour Another Beer At Eleven” = prothrombin, ascites, bilirubin, albumin, encephalopathy

Answer 303

A

morbid obesity
uncontrolled GERD
recent GI surgery
improper NPO
> 14 weeks pregnant
hiatal hernia
delayed gastric emptying (opioids, diabetes)

Answer 304

A

if the following is present:
0 twitches = 95% blocked
1 twitch = 90% blocked
2 twitches = 80% blocked
3 twitches 75% blocked
4 twitches = 0-60% blocked

Answer 305

A

phase 1 is polarizing with the addition of polar side groups (uses CYP enzymes to undergo oxidation/reduction etc)

phase 2 is addition of endogenous compounds to enlarge the molecule and uses transferase enzymes

Answer 306

A

PSNS is both cholinergic

SNS is cholinergic for preganglionic (including the single synapse to the adrenal gland) and postganglionic is all adrenergic including organs and smooth muscle (except for sweat glands which is cholinergic)

Answer 307

A

increased inotropic and chronotropic effect by increasing adenylyl cyclase in cardiac muscle cells (similar to catecholamines) but bypasses any inhibition by beta blockers (which is why it is considered Betablocker reversal)

dose is 1-5mg IV bolus followed by infusion

Answer 308

A

roc 0.6mg/kg, 1-2min

vec 0.12mg/kg, 3-5min

cis 0.2mg/kg, 2-3 min (hoffman degradation)

Answer 309

A

urine will be concentrated but Na content will be low due to the body attempting to reuptake Na to retain voume

BUN:Cr ratio > 20:1
FENa <1%
UrNa < 20meq
Urine osm > 400

Answer 310

A

for recent MI, stroke, or TIA that occurs more than 3 months ago is considered ASA3 and within 3 months is considered ASA 4

Answer 311

A

D2-antagonist used for antiemetic

can cause QT prolongation and is C/I in anyone with prolonged QT, patients with hypomagnesemia have higher risk of prolonged QT and developing torsades

other potential sideeffects include anxiety, restlessness, dystonia

Answer 312

A

30% of total blood output

3/4 blood flow to liver is thru the portal vein, 1/4 is thru the hepatic artery (origin celiac trunk)

50/50%

Answer 313

A

sensitive = anti-platelet factor 4 antibody

specific = serotonin release assay

Answer 314

A

when heparin binds to platelets and exposes platelet factor 4, then antibodies develop to PF4

10x more likely from UF hep compared to LMWH

presents 4-10 days after initiating heparin and often has reduction of 50% of pre-heparin platelet levels

other risk factors include surgical patient > medicine, UF heparin, appropriate timing, and thrombosis

Answer 315

A

hypokalemia will potentiate effects of digoxin

MOA: digoxin binds to K spot on the Na/K ATPase and causes inhibition. this leads to higher levels of Na in the cardiac cells. Higher levels of intracellular Na will then be exchanged outward in return for Ca to increase in the cell. This causes increased contractility (inotropy) and slower electrical conduction (decreased HR)

By decreasing K levels in the state of hypokalemia, there will be less competition for digoxin in the binding of ATPase

Answer 316

A

4ml x total body weight x %SA burn

half of this should be given over the first 8 hrs then the second half over the next 16hrs

Answer 317

A

ventricle dilation leads to increased afterload (higher volume to push), wall stress and also increased O2 consumption.

thick walled hypertrophy will develop a smaller ventricle chamber and will have lower wall stress

wall thickness is inversely related to wall tension. as chamber radius increases along with wall pressure then wall tension increases (thin dilated walls have high tension). when the chamber radius is decreased and wall thickness is increased then wall tension decreases

Answer 318

A

give calcium gluconate and increase pH with bicarb to immediately cause intracellular shift of K into cells
insulin takes 15min, albuterol takes 30min to shift potassium intracellularly
dialysis/RRT can be ordered, lasix can be given but must be euvolemic, polystyrene helps with GI excretion but takes days

Answer 319

A

patient pathologies
- morbid obesity
- improper NPO or high aspiration risk
- difficult airway/intubation
- neck immobility, recent H/N radiation
- inability to lay flat/lay still for duration of surgery (anxiety/tremors/coughing)

2.type of surgery
-accessibility to airway (180 turn/prone)
- high pain stimulation surgery
- need for paralysis
- fire risk

Answer 320

A

eyes (4), mouth (5), movement (6)

Eyes:
4 = spontaneous eye movement
3 = opens to command
2 = opens to pain
1 = no response

mouth/verbal:
5 = spontaneous conversation
4 = confused speech
3 = incongruent speech
2 = incoherent speech
1 = no response

movement:
6: spontaneous movement
5: localizes painful stimuli
4: withdraws from pain
3: decorticate (flex) posture
2: decerebrate (extended) posture
1:no response

Answer 321

A

cerebral blood flow is 50ml/100g/min
cerebral perfusion pressure is 80-100mmhg
ICP is <10mmhg

Answer 322

A

anticonvulsants such as carbamazepine and phenytoin wil induce the CUP450 system which increases metabolism of NMBs, shortening the duration

aminoglycosides prevent the release of acetylcholine in alpha neurons and potentiate NMB duration

hypercalcemia antagonizes NMBs
hypermagnesemia will prolong NMBs
hypokalemia will prolong NMBs

Answer 323

A

1 point each:
high risk surgery, hx of ischemic heart disease, congestive heart failure, cerebrovascular disease, DM2 requiring insulin, Cr >2

score equates to risk of major cardiac event
0 = 0.4%
1 = 1%
2 = 2.4%
3+ = 5%

Answer 324

A

initially causes both decrease in CBF and CMR, but above 1.1 MAC it will cause vasodilation that increases CBF while decreasing CMR

Answer 325

A

Paired t test is for when comparing outcomes from a single group who acts as their own control

Unpaired t test is used to compare nonordinal outcomes of two groups

Answer 326

A

lidocaine plain: 5
lidocaine w epi: 7
bupivicaine plain: 2.5
bupi w epi: 3
ropivicaine: 3
chloroprocaine: 12

Answer 327

A

low: outpatient, superficial, breast, eye, endocrine (thyroid)

moderate: head and neck, orth, uro/gyn, endovascular (aneurysm), carotid endarterectomy

high: intrathoracic, intraperitoneal, suprainguinal endovascular, large vessel (ie aorta)

Answer 328

A

Urine:serum > 1.5 , meaning the kidneys preserve the ability to concentrate the urine

Answer 329

A

“PEA”: phenytoin, ethanol, aspirin

Answer 330

A

total volume is 1590L of N2O at a pressure of 745psig much of it contained in liquid form under high pressure (actual internal volume of the cylinder is 5L)

pressure will continue to read the same until about 16% volume left or 250L, this is when all liquid N2O is used up

Answer 331

A

unpaired: cricoid, thyroid, epiglottis

paired: arytenoid, cuneiform, corniculate

Answer 332

A

starts at the cricoid cartilage C6 and ends at the carina T5

has 15-20 U-shaped cartilage rings with the posterior wall consists of the posterior trachealis muscle that aids in expectoration

lined with ciliated pseudostratified columnar cells

Answer 333

A

Oxygen consumption of myocardium factors: wall tension, heart rate, and contractility

LaPlace Equation:
Wall tension = (Pxr)/2H, where H is wall thickness

from increased systemic pressure ie AS or HTN, wall tension increases from an increase in afterload pressure. The heart will hypertrophy the LV walls to increase thickness and subsequently decrease wall tension and thus decrease O2 consumption

Deleterious effects of this change is that the ventricles become less compliant and can develop diastolic dysfunction and becoming more reliant on left atrium kick to maintain LV end diastolic volume for adequate CO.

Brainscape's Knowledge GenomeTM

True Learn Flashcards

Brainscape's Knowledge Genome^TM