Assessment Exam II Flashcards
(217 cards)
1
Q
What is the preferred pathway for the passage of nasal air devices?
A
Inferior Meatus
2
Q
What makes up the anterior 2/3rds of the of the mouth?
A
Hard Palate
3
Q
What are the subdivisions of the pharyx? Which one gives us the most problems?
A
- Nasopharynx
- Oropharynx
- Hypopharynx
Oropharynx
4
Q
What is one of the primary causes of upper airway obstruction during anesthesia?
A
Loss of pharyngeal muscle tone
5
Q
What is a common site of airway obstruction in both awake and anesthetized patients?
A
Velopharynx
6
Q
What joins the nasal and oral cavaties with the larynx and esophagus?
A
Pharynx
7
Q
What counteracts the collapse of the pharyngeal airway?
A
Chin lift with mouth closure
8
Q
Where is the end of the cricoid cartilage?
A
6th cervical vertebra
9
Q
What are the unpaired laryngeal cartilages?
A
Thyroid
Cricoid - complete ring
Epiglottis
10
Q
What are the paired larygneal cartilages?
A
Arytenoid
Corniculate
Cuneiform
11
Q
Extends from the inferior cricoid membrane to the carina
A
Trachea
12
Q
What is normal tracheal diameter?
A
10-15 cm
13
Q
What is more valuable than any test?
A
History
14
Q
What are the basic decisions?
A
Can I ventilate/intubate??
15
Q
What’s the most predictve factor of a difficult airway?
A
Previously documented difficult airway
16
Q
A neck greater than ______ cm indicates a difficult intubation.
A
43 cm
17
Q
What’s the preferred inter-incisor distance?
A
> 6 cm (3 finger breadths)
Less than this is indicative of a difficult airway
18
Q
What is macroglossia?
A
enlarged tongue
19
Q
What teeth are the most frequently injured during endotracheal intubation?
A
Anterior maxillary central and lateral incisors
20
Q
What causes negative pressure pulmonary edema?
A
Pulling enough pressure on the tube by putting it down that it causes pulmonary edema
21
Q
What is the anatomical position for sniffing position?
A
Cervical flexion and atlanto-occipital extension
22
Q
What structures does sniffing position align?
A
Aligns oral, pharyngeal, and laryngeal axis
Want all three in perfect alignment
23
Q
What is the perferred distance for sternomental distance?
A
> 12.5 cm
24
Q
What are the most common risk factors for ischemic heart disease?
A
- Age
- Male
25
Most common reason for impaired coronary blood flow resulting in angina?
Atherosclerosis
26
What are the (3) primary stressors that induce angina?
1. Physical exertion
2. Emotional tension
3. Cold weather
27
Chest pain that does NOT change in frequency or severity in a 2-month period.
Chronic stable angina
28
Chest pain increasing in frequency and/or severity without increase in cardiac biomarkers.
Unstable angina
29
What is the A-OK protocol?
Treats amniotic fluid embolism with zofran and toradol.
30
Who is the typical gallbladder patient?
Fat, fertile, female
31
Which test allows us to directly visualize coronary perfusion?
Nuclear stress imaging
32
Size of perfusion abnormality = ?
significance of CAD detected
33
How long does aspirin inhibit the platelet?
Lifespan of the platelet (7-14 days)
34
Why are nitrates contraindicated in patients with AS and hypertrophic cardiomyopathy?
Need to maintain afterload in patients with AS
35
What is the only drug that prolongs the life of CAD patients?
B-blockers
| Decreases risk of death and reinfarction in MI patients
36
What are the 3 principal effects of beta blockers?
1. Anti-ischemic
2. Anti-hypertensive
3. Anti-dysrhythmic
37
Which cardiac drug is also used as an anxiolytic?
Propranolol
38
What is one of the primary differences between Ca2+ blockers and B-blockers?
Ca2+ blockers have more vascular smooth muscle tone relaxation
39
What is the primary downside of ACE-Is?
Patients taking ACE-Is have an exagerated response to systemic changes (hypo, hypertension)
40
What are the 3 types of ACS?
1. STEMI
2. NSTEMI
3. Unstable angina
41
Emergency CABG is reserved for what type of patients?
Failed angioplasty
Ventricle rupture
Mitral Regurg
Anatomy that inhibits PCI
42
What is the most significant predictor of stent thrombosis?
P2Y12 inhibitor discontinuation
43
How long do patients need to wait for elective surgery after drug-eluting stent placement?
1 year
44
How long do patients need to wait for elective surgery post CABG?
At least 6 weeks; 12 weeks is preferred
45
What are the 2 non-cardiac diseases we need to worry about for cardiac patients?
1. Diabetes
2. Hypertension
46
Which B-blocker can reduce anesthetic requirements?
Esmolol
47
Which drug is given for refactory hypotension?
Vasopressin
48
What two drugs can be used to treat excessive bradycardia caused by B-blockers during the perioperative period?
Atropine or glycopyrrolate
| Glycopyrrolate is preferred/better
49
What are the 6 independent predictors of major cardiac complications in the RCRI?
1. High-risk surgery
2. Ischemic heart disease
3. CHF
4. CVA/TIA
5. Insulin-dependent DM
6. Preoperative serum creatinine > 2mg/dL
50
What drug would you give a hypotensive AS patient?
Phenylephrine
51
What is the benefit of volatile anesthetics with ischemic heart disease?
Decrease myocardial oxygen requirements and may precondition the myocardium to tolerate ischemic events
52
What is the dentrimental effect of volatile anesthetics with ischemic heart disease?
Lead to a decrease in blood pressure and an associated reduction in coronary perfusion pressure.
53
Why is glycopyrrolate preferred over atropine?
Less chronotropy and central effect than atropine
54
What are the two most commonly used leads for monitoring? Why?
II, V5 because it gives us the best picture of the heart.
55
What are the leads for the circumflex?
I, aVL
56
What are the leads for the RCA?
II, III, aVF
57
What are the leads for the LAD?
V3-V5
58
Name several criteria associated with difficult airway?
1. Large upper incisors
2. Strong overbite
3. Inability to protrude mandible
4. Small-incisor distance (<6 cm)
5. Mallampati 3 or 4
6. Large tongue
7. Narrow or high-arched palate
8. Short thyromental distance (<6.5 cm)
9. Excessive mandibular soft tissue
10. Short, thick neck
11. Decreased cervical ROM
59
What four things would warrant an awake intubation?
1. Suspected difficult ventilation with face mask/supraglottic airway
2. Significant increased risk of aspiration
3. Increased risk of rapid desaturation
4. Suspected difficult emergency invasive airway
60
What should you do first if you cant ventlate or intubate?
Put in a supraglottic airway
61
In what 3 situations would you alwayas intubate early and quickly?
1. Bullets (neck trauma)
2. Bites (anaphylaxis)
3. Burns (thermal and caustic airway injury)
62
Which blade goes in the vallecula? Which blade goes on the epiglottis?
MAC ; Miller
63
What can you do to improve your view?
Ventilate
64
What does the black stripe on the bougie indicate?
25cm at the lips = mid trachea in an adult male
65
What views does the bougie help intubate?
Epiglottis only views (class 3 & 4 mallampati)
66
Etomidate is contraindicated in which patients or conditions?
1. Sepsis
2. Hemorrhagic Shock
3. Epilepsy
67
What are contraindications for ketamine?
1. Hypertensive
2. Tachycardic
3. High ICP
68
Ketamine is indicated for which patients and conditions?
1. Reactive airways
2. Asthmatics
3. Hypotension/sepsis
4. IM RSI
69
What are the 3 physiologic killers?
1. Hypotension
2. Hypoxemia
3. H+ (metabolic acidosis)
70
What BP should we shoot for before intubating?
SBP > 140 mmHg
71
What is the dose for rocuronium?
1.6 mg/kg
72
What is NO DESAT? How is it performed?
Nasal Oxygen During Efforts Securing A Tube; NC at 15 LPM + NRB at 15 LPM
73
What is intervention 2? What is it for?
Delayed Sequence Intubation
1. Give 0.5-1 mg/kg Ketamine
2. Preoxygenate
3. Paralyze
4. Apneic Oxygenation
5. Intubate
| Used for uncooperative, hypoxic, and critically ill patients
74
What is intervention one?
NC 15 LPM + BVM 15 LPM + PEEP (APL) Valve 5-15 cmH2O
75
What is intervention three?
Back Up-Head Elevated (BUHE); Don't insist on laying everyone supine
76
When do you not move the neck to intubate?
Diagnosed (CT/MRI) cervical spine injury. Use fiberoptic scope and then direct larygnospy as a 3rd choice.
77
Before doing RSI on patients with high aspiration risk (GI bleed, SBO, Vomitting), what should we do?
NGT prior to intubation and put it to suction
78
What are the two interventions for acidosis?
1. Bicarbonate
2. Ventilator Assisted Pre-oxygenation (VAPOX)
79
What's the first sign of MH?
Increased ETCO2
80
What are the key differentials that mimic MH?
CATS
1. Catecholamine tremor from pheochromocytoma
2. Acute porphyria crisis
3. Thyrotoxicosis (Thyroid storm)
4. Sepsis
81
How do we manage MH?
SHADE
1. Stop inhaled agent
2. Heat control - cold IV fluids,
3. Activated charcoal to remove residual agents from aneshetic work station
4. Dantrolene
5. Electrolytes (check!)
82
What is CREST syndrome?
Calcionosis - Ca2+ deposits in skin
Raynaud's - spasm of blodo vessels in response to cold or stress
Esophageal dysfxn - acid refleux, decrease in motility of esophagus
Sclerodactyly - thickening and tightening of fingers and hands, skin taut
Telangiectasias - dilation of caps causing red marks on surface of skin like freckles
83
What are some unique S/S of scleroderma?
1. Limited mobility/contractures
2. Trigeminal neuralgia
3. Keratoconjuctivitis sicca
84
How do treat a vasospasm in the small arteries of the fingers?
Localize the area, Na+ channel blockade to prevent spasm
Give lido or NS
85
What is the Edrophonium/Tensilon test?
Improves myasthenic crisis and makes cholinergic crisis worse
86
What muscleoskeletal disease would you avoid succinylcholine and do regional over GA?
Pseudohypertrophy Muscular Dystrophy (Duchenne's)
87
What muscleoskeletal disease will have a serum CK 20-100x normal and weakened respiratory muscles and cough, poor reserve, and OSA?
Psuedohypertrophy Muscular Dystrophy
88
What muscleoskeletal disease is associated with fatty infiltration, waddling gait, and primarily affects boys?
Duchenne Muscular Dystrophy
89
Degenerative process affecting articular cartilage, pain relieved by rest
Osteoarthritis
90
Which musckeloskeletal disease is degenerative and has Heberden nodes?
Osteoarthritis
91
What type of arthritis affects proximal interphalangeal and metacarpophalangeal joints?
Rheumatoid arthritis
92
What type of arthritis affects weight bearing and distal interphalangeal joints?
Osteoarthritis
93
What joints does rheumatoid arthritis not affect?
T and L spines are unaffected
94
What characterizes an acute cricoarytenoid arthritis?
Swelling and redness of the arytenoids
95
What characterizes chronic arytenoid arthritis?
High risk for upper airway obstruction
96
What musculoskeletal disease is characterized by symmetrical arthritis, polyarthritis, avascular necrosis, and no spinal involvement?
Lupus
97
Thromobombolism, thrombocytopenia, and hemolytic anemia characterize what musculoskeletal disease?
Lupus
98
C1-C4
Cervical plexus
99
C5-C7
Interscalene
100
L4-S4
Sacral Plexus
101
How long are troponin levels elevated for?
Initial bump is in 3-4 hours and remains elevated for up to 2 weeks.
102
Which chest pain differential has tearing back pain with EKG changes?
AAA
103
What substances stimulate cardiac nociceptive and mechanosensitive receptors resulting in chest pain in angina pectoris?
Adenosine and bradykinin
104
What medications are examples of glycoprotein IIb/IIIa receptor antagonists?
Abciximab, eptifibatide (Integrillin), tirofiban
105
What medication is uniquely effective for decreasing frequency/severity of spasm in Prizmental's/variant angina?
Ca2+ channel blockers
106
What medications are used in reperfusion therapy?
tPA, streptokinase, reteplase, or tenecteplase
107
How long do do patients need to wait for elective surgery post angioplasty without stenting?
2-4 weeks
108
How much is 1 MET?
3.5 mL/kg/min
109
What are the two principal issues related to PCI with stent placement?
1. Thrombosis
2. Bleeding due to DAPT
110
When should thromboyltic therapy be initiated?
Within 30-60 minutes of hospital arrival and within 12 hours of symptom onset.
111
What is the specific pharmacologic antagonist for excessive B-blocker activity?
Isoproterenol
112
What 2 things result from the neuroendocrine stress response from surgery?
1. ↑ Heart rate
2. Metabolic changes
113
What 2 things result from the inflammatory response from surgery?
1. Hypercoagulable state
2. Plaque rupture
114
The ACC/AHA algorithm recommends that a patient with a functional capacity of ____ or more METs should proceed directly to surgery.
4
115
Which types of vWF disorder cannot be treated by DDAVP?
2B, 2N, and 3
116
What are the CNS and ECG changes at a Na+ level of 110?
Seizures, coma; Vtach or Vfib
117
What are the CNS and ECG changes of a Na+ level of 115?
Somnolence, nausea; Elevated ST segment, widened QRS
118
What are the CNS and ECG changes associated with a Na+ level of 120?
Confusion, restlessness; widening of the QRS
119
What is the normal dose for DDAVP?
0.3 mcg/kg in 50mL NS ovr 15-20 minutes
120
What clotting labs are normal in patients with vWF disease?
PT and aPTT are normal in patients with vWD
121
What does vWF do?
Plays a critical role in platelet adherence/adhesion
122
What is one of the major side effects of DDAVP?
Hyponatremia
123
Which blood product has an increased risk of infection?
Cryoprecipitate; Not submitted to viral attenuation
124
1 unit of Cryo increases fibrinogen levels by how much?
50 mg/dL
125
How long before surgery should DDAVP be given?
60 minutes
126
What drugs are antifibrolytic?
1. Transexamic Acid
2. Amiocaproic acid (Amicar)
3. Aprotinin
127
What blood disease has a resistance to activated protein C?
Factor V Leiden
128
What diagnosis should be entertained for any patient experiencing thrombosis or thrombocytopenia during or after heparin administration?
HIT
129
How long do PF4/heparin immune complexes clear from the circulation?
Within 3 months
130
What is the universal donor? Recipient?
O- ; AB+
131
What are the components of whole blood?
cells, platelets, clotting factors, and plasma
132
What are the components of packed red blood cells (PRBCs)
RBCs and some plasma
133
What are the components of FFP?
Plasma, a combination of fluids, clotting factors, and proteins
134
What are the components of platelet-rich plasma (PRP)?
platelet rich plasma.
135
What is added to blood to preserve it?
CPDA-1
1. Citrate
2. Phosphate
3. Dextrpse
4. Adenine
136
How much does Hgb and Hct increase after 1 unit?
1. Increase Hgb 1g/dL (10g/L)
2. Hct by 3%
137
What is the dose for FFP?
10-15 mL/kg
138
How much does 1 unit of FFP increase the clotting factors?
2-3%
139
What is cryoprecipitate?
Protein fraction taken off the top of FFP when being thawed
140
What factors does cryo contain?
1. VIII: C
2. VIII: vWF
3. XIII
4. Fibrinogen
141
How much does 1 unit of platelets increase platelet count?
5,000-10,000
142
How much cryo is required to raise fibrinogen concentration by 100 mg/dL?
2 units / 10kg of body weight
143
What is the pH of plasmalyte/normosol?
7.4
144
When would whole blood be indicated?
Actively bleeding > 20% of body blood volume
145
What mediates a nonhemolytic febrile transfusion reaction?
A/b to HLA Class I Ag
146
What are the mediators of hemolytic transfusion reactions?
IgM A/b (ABO), complement
147
What is the primary symptom of noncardiogenic pulmonary transfusion reaction?
Noncardiogenic pulmonary edema
148
What blood products is TRALI typicaly associated with?
FFP, platelets, PRBCs
149
What are the 5 criteria for TRALI?
1. Acute onset hypoxemia
2. Ratio of PaO2/FiO2 < 300 or spO2 < 90% on RA.
3. Occurs within 6 hours of transfusion
4. B/L diffuse pulmonary infiltrates
5. No evidence of LA hypertension
150
What is TACO?
Transfusion Associated Circulatory Overload
151
Iron Overload
Transfusion-induced hemosiderosis
152
What is the volume of blood loss (mL and %) in a class I hemorrhage?
750mL; 15%
153
What is the volume of blood loss (mL and %) in a class II hemorrhage?
750-1500 mL; 15-30%
154
What is the volume of blood loss (mL and %) in a class III hemorrhage?
1500-2000 mL; 30-40%
155
What is the volume of blood loss (mL and %) in a class IV hemorrhage?
> 2000 mL; > 40%
156
What is LTOWB?
Low-Titer O Whole Blood
157
What is the definition of MTP?
Replacement of total blood volume in 24 hours.
158
What are the fibrinogen levels of LTOWB, FFP, and Cryo?
LTOWB - 1000mg
FFP - 400mg
Cryo - 250mg
159
What Rh is the product of choice for males?
Rh+
160
What's the difference between Ca2+ gluconate and Ca2+ chloride?
3x the amount of elemental Ca2+ in chloride than gluconate.
161
Where is citrate metabolized?
Liver
162
What decreases citrate metabolism?
Liver injury
Hypothermia
163
How much Ca2+ do you give for a patient recieving blood transfusions?
1g Ca2+ for every 4-8 products
164
TEG Interpretation: R
**Reaction** time, first significant clot formation
**How long does it take to clot**
165
TEG Interpretation: a-Angle
**Kinetics** of clot development
How **significant** the clot becomes
166
TEG Interpretation: K
Achievement of certain clot **firmness**
167
TEG Interpretation: MA
Maximum amplitude - **maxiumum strength of clot**
168
TEG Interpretation: LY30
Percent lysis 30 minutes after MA
**How long does it stay in place**
169
TEG Interpretation: R time > 10 mins indicates a need for what type of blood product?
FFP
170
TEG Interpretation: K time > 3 min indicates a need for what blood product?
Cryo
171
TEG Interpretation: TEG-ACT >140 sec indicates a need for what blood product?
FFP
172
TEG Interpretation: a-angle < 53° indicates a need for what blood product?
Cryo +/- platelets
173
TEG Interpretation: MA < 50 mm indicates a need for what blood product?
platelets
174
TEG Interpretation: LY30 > 3% indicates a need for what?
Tranexamic Acid
175
A heart murmur that is primarily due to physiologic conditions outside the heart, as opposed to structural defects in the heart itself
Functional, physiologic, or innocent
176
What murmur merges with S1 and S2?
Holosystolic murmur
177
What murmur occurs between S1 and S2?
Midsystolic murmur
178
What murmur follows S2?
diastolic murmur
179
Auscultatory sites: Aortic
2nd ICS RSB
180
Auscultatory sites: Pulmonic
2nd ICS LSB
181
Auscultatory sites: Erb's Point
3rd ICS LSB
182
Auscultatory sites: Tricuspid
5th ICS MCL
183
Auscultatory sites: AS
right upper sternal border
184
Auscultatory sites: AR
left sternal border
185
Auscultatory sites: MS
Apex
186
Auscultatory sites: MR
Apex
187
Auscultatory sites: TR
lower left sternal border
188
What inhibits views on an echocardiogram?
ASD
VSD
Vegetation
Obese
189
The most frequently encountered cardiac valve lesions produce ______ overload or ________ overload on the left atrium or left ventricle.
pressure; volume
190
Symptoms of a compensatory increase in sympathetic nervous activity may manifest as _______, ________, and resting ________.
anxiety, diaphoresis, and resting tachycardia
191
What are 3 assessment findings that are indicative of heart failre?
1. Basilar rales
2. JVD
3. 3rd Heart Sound
192
What valvular problem is associated with atrial fibrillation?
Mitral Stenosis
193
What murmurs are heard during diastole?
1. Stenosis of the mitral or tricuspid valves
2. Incompetence of the aortic or pulmonic valves
194
What murmurs are heard during systole?
1. Incompetence of the mitral or tricuspid valves
2. Stenosis of the aortic or pulmonic valves
195
What does enlargement of the left atrium result in?
Elevation of the left mainstem bronchus
196
What does a midsystolic murmur indicate?
Aortic Stenosis
197
What does a holosystolic murmur indicate?
Mitral Regurgitation
198
Discontinuation of anticoagulant therapy puts patients at an increased risk of thromboembolisum due to a what?
Rebound hypercoaguable state
199
What valvular problem pimarily affects women?
Mitral Stenosis
200
What is the normal mitral valve orifice area? At what size would symptoms develop?
4-6 cm2 ; <2 cm2
201
What valvular problem is indicated by a rumbling diastolic mumur at the apex and an opening snap early in diastole?
Mitral Stenosis
202
What's the anesthetic goal for mitral stenosis?
1. Normal HR
2. Normal volume
3. Normal aterload
203
What is the primary pharmacological treatment for MS?
1. Rate control - b-blockers, Ca2+ channel blockers, digoxin
2. Left atrial pressure - diuretics
3. Anticoagulation
204
What two drugs do we avoid in mitral stenosis?
1. Ketamine
2. Histamine releasing NMBs (Pan, atra)
205
What 4 heart issues is mitral regurgitation associated with?
1. IHD
2. Ruptured papillary muscle
3. Mitral valve prolapse
4. Cardiomyopathy
206
What is the goal of anesthetic considerations for mitral regurgitation?
1. Improve forward LV SV
2. Decrease regurgitant fraction
207
What is the normal valve area of the aortic valve? What area would be considered severe AS?
2.5-3.5 cm2 ; < 1 cm2
208
What's the hallmark symptom of AS?
Syncope
209
Thickening of the LV d/t chronic pressure overload is known as
concentric hypertrophy
210
What ECG changes indicate possible AS?
1. ST depression
2. T wave inversion
211
Cardiopulmonary resuscitation is typically ineffective in patients with what valvular disorder?
AS
212
What are the goals of anesthetic considerations for AS?
Prevention/avoidance of hypotension
Prevension/avoidance of decreased CO (preload dependent)
Maintain NSR
213
What decreases the magnitude of aortic regurgitation?
1. Tachycardia
2. Peripheral vasodilation
214
What substances can lead to morpholgy changes in the leaflets that leads to AR?
Anorexigenic drugs (phentermine, methamphetamine)
215
What valvular problem is indicated by an early or mid-diastolic murmur and a low pitched diastolic rumble?
AR
216
What are the three most common AR symptoms?
Hyperdynamic circulation
1. Widened pulse pressure
2. Decreased DBP
3. Bounding pulses
217
What is the primary anesthestic goal for AR?
Maintain forward foward LV SV
FAST FORWARD FULL
