BASICS Exam 3 Flashcards
airway, uro/ortho/robot, POCUS, monitoring, vents
1
Q
what is the #1 reason for anesthesia related deaths/morbidity
A
difficult airway
2
Q
what condition makes patients difficult to mask
A
obesity
3
Q
what do you do if you cant ventilate/ cant intubate
A
wake up
emergent cric
4
Q
what do you add to ETT for long procedures to avoid heat loss
A
HME, passive evaporation heat loss prevention, takes 1 hour to be effective
5
Q
how much higher is resistance in nasal intubation when compared to oral intubation
A
2x, can be higher in deviated septum
6
Q
what is the the airway space behind the nose
A
nasopharynx
7
Q
what is the airway space behind the mouth
A
oropharynx
8
Q
when does the nasopharynx end
A
soft palate
9
Q
when does the oropharynx end
A
epiglottis
10
Q
what is the name of the space from the glottis down
A
hypopharynx
11
Q
what the area below the eipiglottis where CRNAs do alot of airway manipulation
A
subglottic opening
12
Q
what is the purpose of the nose
A
warm and humidify air during oral breathing
13
Q
how much moisture does the nose add to air a day
A
1 L to 10,000L of air per day
14
Q
what is the space between tongue and epiglottis
A
vallecula
15
Q
what innervates the anterior nose
A
V1 opthalmic division of Cranial nerve 5- trigeminial-
anterior ethmoidal nerve
16
Q
what innervates the mid nose and hard/soft palate
A
V2 maxillary division of cranial nerve 5- trigeminial- sphenopalantine nerve
17
Q
what innervates the anterior 2/3 anterior tongue (sensation)
A
V3 Mandibular division of cranial nerve 5- trigeminial- lingual nerve
18
Q
what innervates the posterior 1/3 tongue, oropharynx, and soft palate
A
cranial nerve 9, glossopharyngeal
19
Q
what innervates the glotis/subglottic space, hypopharynx and trachea above the vocal cords
A
cranial nerve 10- vagus- internal laryngeal nerve
20
Q
what innervates the trachea below the vocal cords
A
cranial nerve 10- vagus- recurrent laryngeal
21
Q
what innervates the nasal mucosa
A
opthalmic and maxillary divisions of cranial nerve 5-trigeminal
22
Q
what can happen with mouth breathers/ intubated patients
A
mucous gets thick and dry, add humidifier
23
Q
what is a passive humidifier
A
HME
24
Q
what innervates the hard and soft palate
A
palantine nerves from sphenopalatine ganglion
25
what is the innervation of the gag reflex
glossopharyngeal,
vagus,
spinal accessory nerves
26
what three nerves innervate all the muscles of the pharynx, larynx, and soft palate
glossopharyngeal (9)
vagus (10)
spinal accessory (11)
27
what carries the gag afferently to the medulla
glossopharyngeal
28
what carries the gag reflex efferently from medulla
vagus nerve
29
what nerves have synapses with the glossopharyngeal nerve to carry the gag reflex afferently towards the medulla
vagus
spinal accessory
30
what are the borders of the pharynx
back of tongue to nose
31
what are the three divisions of the pharynx
nasopharynx, oropharynx, laryngopharynx
32
what separates the nasopharynx and oropharynx
soft palate
33
what inervates the nasopharynx
trigeminal nerve- CN5
34
what are the borders of the oropharynx
soft palate to superior edge of epiglottis
35
what innervates the oropharynx
CN 9- glossopharyngeal
36
what are the borders of the hypopharynx
superior border of epiglottis to inferior border of cricoid cartilage
37
what innervates the hypopharynx
CN 10 (vagus) through internal superior laryngeal nerve
38
what does the R recurrent laryngeal nerve go under
innomanite artery/ brachiocephalic artery
39
what does the L recurrent laryngeal nerve go under
aorta
40
what procedures do the recurrent laryngeal nerve get damaged in
thoracic,
mitral valve,
aortic,
tumor
41
the recurrent laryngeal nerve innervates all muscles of the larynx except the
cricothyroid
42
what are risks of recurrent laryngeal nerve damage
hoarseness,
vocal cord palsy
43
what does the recurrent laryngeal nerve innervate in hypopharynx
sensory innervation from vocal cords down through trachea
motor function to all muscle of larynx except cricothyroid
44
what does the internal superior laryngeal nerve inervate in hypopharynx
sensory innervation of hypopharynx above vocal cords, base of tongue, epiglottis, arytenoids (above glottic opening)
45
what does the external superior laryngeal nerve inervate in hypopharynx
motor function to cricothyroid muscle of larynx
46
what do you block for awake intubation
superior laryngeal nerve at bifurcation
47
what nerve perforates the cricothyroid membrane
external laryngeal branch of superior laryngeal nerve
48
when do you use airway blocks
awake intubation with fiberoptic intubation
49
what does unilateral damage to the superior laryngeal nerve do
minimal effects
50
what does bilateral damage to the superior laryngeal nerve do
hoarseness
tiring of voice
51
what does unilateral damage to recurrent laryngeal nerve do
hoarseness
52
what does bilateral acute damage to recurrent laryngeal nerve do
stridor, Resp dx
53
what does bilateral chronic damage to recurrent laryngeal nerve do
aphonia
54
what does unilateral damage to vagus nerve do
hoarseness
55
what does bilateral damage to vagus nerve do
aphonia
56
where is larynx located on cervical spine
C3-C6
57
what is the narrowest part of the adult airway?
vocal cords
58
what part of airway anatomy modulates sound
larynx
59
what seperates the trachea from esophagus when swallowing
larynx/epiglottis
60
What is the larynx composed of?
muscles
ligaments
cartilage
61
what is size of vocal cords in males
23mm
62
what is the size of vocal cords in females
17mm
63
what is the smallest part of pediatric airway
glottic opening
just past vocal cords
64
what is the range of the glottic apertrue
60-100mm
65
what does the posterior cricoarytenoid do?
what innervates it?
abducts (opens) the vocal cords
recurrent laryngeal nerve
66
what does the lateral cricoarytenoid do?
what innervates it?
adducts (closes) the arytenoids, closing the glottis
recurrent laryngeal nerve
67
what does the transverse arytenoid do?
what innervates it?
adducts (closes) the arytenoids
recurrent laryngeal nerve
68
what does the oblique arytenoid do?
what innervates it?
closes the glottis
recurrent laryngeal nerve
69
what does the aryepiglottic /aryearritnoid do?
what innervates it?
closes the glottis (apperture)
recurrent laryngeal nerve
70
what does the vocalis do?
what innervates it?
relaxes the cords
recurrent laryngeal nerve
71
what does the thyroarytenoid do?
what innervates it?
relaxes tension int he vocal cords
recurrent laryngeal nerve
72
what does the cricothyroid do?
what innervates it?
tenses and elongates the vocal cords (tone of voice)
external branch of superior laryngeal
73
what is the first thing you see when doing DL
epiglottis
74
what is the second thing you see when doing DL while lifting
arytenoid cartilage
75
what is the third you see when doing DL while lifting
vestibular folds (false vocal cords)
76
what is the fourth thing you see when doing DL while lifting
true vocal cords
77
where do you put MAC blade
vallecula
78
where do you put the Miller blade
under the epilglottis
79
what is doorway to the airway
epiglottis
80
what is the epiglottis attached to
bottom of the tongue
81
which arytenoid cartilages are most medial/ at the bottom of DL view
corniculate
82
which arytenoid cartilages are most lateral/ at the sides of DL view
cuneiform
83
where is trachea in relation to cervicle and thoracic vertebrae
C6-T5
84
where is carina on thoracic vertebrae
T5
85
when does trachea end
carina
86
what is the most cephalad cartilage of trachea
cricoid
87
what cartilage of trachea is a full ring
cricoid
88
what is the shape of most tracheal cartilage
horse shoe/ C shaped
89
what is the first "grade" view you see when intubating and then
Cormack-Lehane
grade 4- soft tissue
grade 3- epiglottis
grade 2- vestibular folds/arytenoids
grade 1- vocal cords, arytenoids, everything
90
what is visible in Cormack-Lehane grade 4
soft tissue
91
what is visible in Cormack-Lehane grade 3
epiglottis
92
what is visible in Cormack-Lehane grade 2
vestibular folds
arytenoids
+ grade 2
93
what is visible in Cormack-Lehane grade 1
everything
true vocal cords
arytenoids
epiglottis
94
can you do an airway assessment pre op
no, have to stick scope down throat
95
when doing airway assessment do you say "ah"
no, raises soft pallate and makes it too easy
96
What is Mallampati class 1
most of glottis visible
- hard palate, soft palate, uvula, fauces, tonsillar pillar
97
what is Mallampati class 2
hard palate,
soft palate,
uvula,
fauces (usually only base of uvula visible, non tonsilar pillars)
98
what is Mallampati class 3
hard and soft palate, very base of uvula
99
what is Mallampati class 4
hard palate only
100
What does the Mallampati score evaluate?
difficulty of intubation
how much room you have in mouth to displace tissue
101
where do we do cricothyrotomy
cricothyroid membrane, right above cricoid cartilage
102
what is prayer sign
if cant press palms together, have arthritis of joints, probably arthritis of neck, hard to move neck to view airway
also arthritis of arytenoids
103
what neck circumference leads to difficult intubation
43 cm
104
what neck circumference/thyromental distance (NC/TMD) is difficult intubation
>5cm
105
having OSA is indicitive of difficulty ___________
masking
soft tissue flaps
106
what percent of pregnancy has Difficult intubation
8%
107
what in pregnancy leads to Diff Intubation
swelling of airway
friable airway
smaller airway
lots of edema
(lay out lots of tubes to go down in size if needed)
108
what are large incisors indicitive of in airway assessment
decreased room, increased injury
109
what is large tongue indicitive of in airway assessment
large wide tongue will get in way of ETT
will cover airway making mask ventilation difficult
110
what is facial hair indicitive of in airway assessment
cant seal mask
111
how can you get a seal with facial hair
opsite dressing
water based lube
use two hands and use machine to ventilate
112
why dont you use petroleum based lubricant on face with intubation
airway fire
113
what is small mouth opening (<3cm) indicitive of in airway assessment
difficult airway
114
what is decreased mobility or pain or N/T with neck flexion and extension indicitive of in airway assessment
movement- cant get good angle for intubation
N/T- cervical compression, double crush syndrome watch with how you turn head
115
what is the upper lip bite test
vermillion border test
bite with lower teeth as far up upper lip/gums as possible
116
what does upper lip bite test test for
checks for retrognathia,
basically no chin with big overbite (mandible in and overbite)
117
what is lemon technique?
L-look externally
E-evaluate 3,3,2
M-mallampati
O-obstruction or obesity
N- neck mobility
118
What is the 3-3-2 rule in airway assessment?
3 fingerbreaths between incisors
3 fingerbreaths between mentum (tip of chin) and hyoid bone (chin-neck junction)
2 fingerbreaths between hyoid bone and thyroid notch
119
what decreases somebodys incisor distance
TMJ
120
how do you get help with patient with TMJ
ask them tricks of how they open jaw, or have them open jaw then stick gaurd in
121
what shape of palate is a predictor of difficult airway
highly arched or narrow
122
what neck shape is a difficult airway
short thick neck
123
what neck movement predicts Diff intubate
cannot touch chin to chest OR patient cannot extend neck
124
what female specific thing can lead to Diff intubation
large breasts, shift up and put weight on chest/airway, cant move tissue
ramp patient up to sniffing position
125
what is thyromental distance
distance between mental area and thyroid cartilage
126
what does thyromental distance help determine
how readily laryngeal axis will fall in line with pharyngeal axis
how acute the angle will be
127
what should thyromental distance be
> 3 fingers or > 6 cm in adults
128
what is thyromental distance is less than 3 fingers or >6 cm
acute pharyngeal/laryngeal angle = Diff intubation
129
what is the most important airway skill
masking
130
What is the goal of airway management?
move air
131
where should mask lay on patient
bridge of nose/between pupils, lateral nasolabial folds, between lower lip and chin
132
what can a large mask that goes under the chin cause
leak
compression of soft tissue
133
how can we minimize gastric insufflation with masking
pressure under 20 cm H20
give gradual not sudden breath
134
what does gastric insufflation cause
vomit
135
what do you do if you have to use high pressure (<20 cm H20) in mask patient
OG tube and suck air out
136
what is the CE technique
2 fingers (thumb and index) on mask in C
2 fingers (middle and ring) on jaw bone
1 finger (pinky) performing jaw thrust on mandible
137
what happens if you put fingers on soft tissue while mask ventilating
compressing airway
138
what are techniques for difficult mask
two handed- beards or difficult seal seal
opsite dressing/lube- beards
oral/nasal airway
mask straps
139
where do you but fingers in two handed ventilation
thumbs on mask, middle finger under mandible jaw thrusting
140
why do you not want hands on patients face while falling asleep
makes patient nervous
141
what size of mask is for Premis
00
142
what size of mask is for infant
0
143
what size of mask is for child
1
144
what size of mask is for a small adult
2
145
what size of mask is for medium adult
3
146
what size of mask is for large adult
4
147
what size of mask is for extra large adult
5
148
what size mask for adult is most common
3 or 4
149
what hand do you hold larygoscope handle with
left
150
what hand do you hold ETT with
right
151
what is shape of miller
straight
152
what shape is a mac
curved
153
how does mac open airway
goes in valecula and indirectly lifts epiglottis
154
how does miller open airway
goes under epiglottis and directly lifts it
155
which blade do you knock out teeth more
miller
156
what is MAC technique for intubation
R side of mouth
displace tongue to left
157
what is miller technique for intubation
avoid tongue
go down back side
under epiglottis
158
What is a stylet used for?
rigid wire inside tube used to shape ETT
usually in indirect laryngoscopy
159
what is 00 miller blade for
premi
160
what is 0 miller blade for
infant
161
what is 2-3 miller blade for
most adults
162
what is a wisconsin blade
super straight long miller
163
what is pediatric size MAC
1
164
what increases as you go up with MAC size
length and width
165
what is the most used MAC size
3-4
166
what is Dr Rices perfect mac blade
3.5 ceramic
167
What is the sniffing position?
It is the optimum intubation position
35 neck flexion, 15 face plane extension
head elevated 8-10 cm
168
how can you lift head for intubation sniffing position
pillows
stomach
chest
169
where do you put pillows for sniffing posistion
shoulder blades
head
170
what is goal of sniffing position
align oral, pharyngeal, laryngeal axis for straight line visualization of glottis
171
how high should patient be for intubation
CRNAs xiphoid
172
what is the scissor techique
2 gloves on R hand
using R thumb and R index/middle finger on maxillary teeth to push mandible and lip away
173
what percent of peoples mouth are opened automatically
20%
174
where on patients body do you aim when lifting laryngoscope
patients left foot
175
how do you insert laryngoscope blade
insert blade slightly to right of tongue
sweep leftward and upward
aim for patients left foot
176
how does wrist move during intubation
it doesn't, lock it in place, lift with arm tucked in to body
177
what is BURP manuever
manipulation of trachea to find epiglottis with cricoid pressure
Backward
Upward
Rightward
Pressure
178
ETT is sized according to __________ diameter
internal
179
what is the increment of size for ETT
0.5mm
180
where do lengthwise centimeter markings start at on ETT
distal end to assist in placement depth
181
how does ETT react to body temp
the polyvinyl chloride plastic softens with body temp
182
how high above carina do you want ETT
3-5 cm
183
why do you not want ETT on carina
cause cough reflex
184
where are cough receptors in lungs
carina
185
what is normal ETT depth at incisors for females
21 cm
186
what is normal ETT depth at incisors for males
23 cm
187
what is formula for ETT depth
(body height in cm/5) - 13 to the R mouth angle (cm)
188
what is method for proper ETT placement depth
intubate, inflate cuff, pull tube till meet resistance, this is right on the other side of vocal cords
189
what type of tube cuffs do we usually use
high volume low pressure
190
how many ccs can ETT hold
90ccs
191
what is normal cause of "cuff leak"
migration of tube up vocal cords
192
should you squeeze little ballon on ETT
no, doesnt tell you anything, very painful
193
what can you do to determine if their is a cuff leak
leak test
194
how do you do leak test
put air in cuff
put valve thing on
put at 40-30-20
should leak at 40 and 30
should stop and 20
if leaks at less than 20 then needs more air
195
what other device measures cuff pressure
sphygomometer or something, monometer
196
what can overfilled ETT cuff lead to
tracheal stenosis
197
what are methods of confirming intubation
condensation in ETT
bilateral chest rise
continuous EtCO2
direct visualization of ETT through cords
lung sounds
198
how many EtCO2 readings do you need before know in lungs
>4
199
what makes false EtCO2 reading in esophagation
bictra anaticid
its Sodium Bicarb
200
how do you check for R mainstem
breath sounds
PIP
unilateral chest rise
decrease volume
decreased SpO2
201
what is an LMA an example of
supraglottic airway
202
what does LMA stand for
laryngeal mask airway
203
T/F you can aspirate with LMA
TRUE
204
Is the LMA a secure airway?
NO
205
what is a device that "lets us mask patient without hands"
LMA
206
Where does the LMA seal the airway
hypopharynx
207
what size LMA do you use for an infant weighing <5 kg
what is the cuff volume
1
up to 4ml
208
what size LMA do you use for a child weighing 5-10 kg
what is the cuff volume
1.5
up to 7ml
209
what size LMA do you use for a child weighing 10-20 kg
what is the cuff volume
2
up to 10 ml
210
what size LMA do you use for a small adult weighing 20-30 kg
what is the cuff volume
2.5
up to 14ml
211
what size LMA do you use for a normal adult weighing 50-70 kg
what is the cuff volume
4
up to 30
212
what size LMA do you use for a large adult weighing 70-100 kg
what is the cuff volume
5
up to 40
213
what size LMA do you use for <5kg
1
214
what size LMA do you use for 70-100 kg
5
215
what size are most adults in LMA
3-4
216
what does supreme LMA have
catheter to suction in esophagus
217
where does the tip of LMA sit
esophagus
218
where is opening of LMA
over glottic opening
219
what can fast track LMA do
ETT can slide in through LMA
can also use fiber optic bronchoscope with cook exchange catheter
220
what can LMA be used for
airway on its own
time before intubation
as an "introducer" for ETT/bronchoscope intubation
221
what is the approach for video laryngoscopy
midline approach
222
what can be difficult in video laryngoscopy and anterior airway
can see it, but have to hook ETT up to get airway, have to twist it
223
what is a benefit of video larygoscope intubation wise
more room in mouth
224
what do you do if you cant ventilate with mask
wake up or intubate
1) oral airway
2) nasal airway
3a) paralyze and intubate OR 3b) LMA
225
what do you do if initial intubation is unsuccessful
1) call for help
2) return to spontaneous respiration
3) wake the patient
4) MASK
226
what do you do if face mask ventilation after failed intubation is inadequate
attempt SGA (LMA)
227
what do you do if LMA fails after face mask ventilation after failed intubation is inadequate
emergency invasive airway (cric)
228
at anypoint in pathway if you cant ventilate where do you jump to
emergency airway pathway
229
in needle cric do you ventilate patient?
NO,
just pushing oxygen in,
too small to ventilate
230
if multiple failed attempts to intubate but can mask ventilate what do you do
end surgery
231
what does waveform on anesthesia machine mean
pressure changes, not always ventilating
232
how long do patients last before desat
6 min in perfect patient
233
how long does propofol last
2-5 min
234
what is a bougie for
poor view,
hard tip goes into airway and you feel hard bumps of tracheal rings
235
if you use a bougie and it is smooth where are you
esophagus
236
what are some complications of intubation
ETT malposition
laryngospasm
dental trauma
soft tissue trauma
vocal cord damage
237
what is common ETT malposition
R main stem
-PIP
-low volumes
-decrease sats
-lung sounds
238
What is a laryngospasm?
vocal cords clamp closing the airway
239
when does laryngospasm usually happen
stage 2 anesthesia
240
what are steps to treat laryngospasm
100% O2 with continuous PP
jaw thrust so air hits cords
if complete
1-2 ccs succs
-bag them till succs wears off
241
what is a partial laryngospasm? how does it resolve?
usually resolve on own
use 100% O2 with continous PP
242
what happens if you breathe against a closed glottis
negative pressure pulmonary edema
negative pressure against closed airway pulls fluid from vasculature into lungs
243
how do you treat negative pressure pulmonary edema
cpap/bipap 12-24 hours (push fluid back out)
possible diuretic
244
how long does it take to develop negative pressure edema
5-6 breaths
few minutes
245
what kind of risk is dental trauma in anesthesia
normal risk
246
how can you cause vocal cord damage with stylet
pushing stylet through vocal cords- causes vocal cords palsy
never put stylet through vocal cords
247
what happens if you break a tooth
have to get it out
248
what do you do for C-spine anesthesia
hold c-spine
log roll
hold cspine while intubaing,
use glidescope or fiber optic to keep neck in line
DOCUMENT cspine held
249
what do you document with Cspine
Cspine help
fiber optic
no flexion/extension
preexisting issues
anything to show you didnt cause worse symptoms
250
when do you use jet ventilation
airway or tracheal procedures (tracheal stents)
251
what is rate of jet ventilator inspiration/expiration
1-2 sec inhale
5-6 sec exhale
252
is jet ventilator ventilation?
no only oxygenating
253
what is common issue with jet ventilator
increased CO2
254
can you run gasses in jet ventilation case
no all IV
255
what psi jet ventilator do you use for adults
what is limit
start at 20 psi, increase until adequate chest rise
< 50 psi
256
what psi jet ventilator do you use for children
what is limit
start at 5-10 psi, increase until adequate chest rise
<30psi
257
what rate do you use for jet ventilator
20 bursts per minute
258
how do you minimize barotrauma in jet ventilation
adequate expiratory phase
259
what do you do if surgeon is using bovie during jet ventilator
<30% O2, us air blender
260
if you are using 100% O2 with jet ventilator and surgeon decides to use bovie how long do you wait for O2 to diminish
3 min
261
what are disadvantages of jet ventilation
does not provide protection against secretions/aspiration
incomplete control
specialized training
262
are jet ventilators laser safe
NO
263
can you accurately monitor gas exchange in jet ventilation
No
use abgs
264
how are pH and CO2 affected in jet ventilation
low pH
high CO2
265
what are complications of jet ventilation
aspiration
Gi insufflation
bleeding
pneumothorax
subcutaneous emphysema
inadequate ventilation
barotrauma
266
what is the most common performed urologic procedure
cystoscopy
267
what are indications for cystoscopy
hematuria
recurrent urinary infection
renal calculi
urinary obstruction
268
what are some procedures using cystoscope
bladder biopsies
retrograde pyelograms
resection of bladder tumors
extraction of lithotripsy or renal stones
placement of manipulation of ureteral stents
269
what are anesthesia considerations for ureteral stents
patient cannot move
NMBD- ETT
270
what position are most cystoscopy in
lithotomy
271
how do you move legs in lithotomy
move legs together, avoid dislocating hip
272
what are anesthetic considerations for lithotomy
deep sedation, dont want movement to prevent nerve damage
273
what is risk of an OR bed where the foot of the bed lowers
if arms are tucked fingers can get cut off by bed
274
what neves can be damaged in lithotomy
common peroneal nerve
saphenous nerve
obturator and femoral nerve
sciatic nerve
275
how can common peroneal nerve be damaged in lithotomy
lateral knee/calf rests on strap support
276
how does common peroneal nerve injury manifest
loss of dorsiflexion of foot (foot drop)
277
How does a saphenous nerve injury present?
numbness along medial calf (nerve runs along medial thigh)
278
how does obturator and femoral nerve injury occur in lithotomy
excessive flexion of thigh against groin, panus/obesity
279
how does the sciatic nerve get injured in lithotomy
extreme flexion at thigh can stretch sciatic
280
how does lithotomy position affect lungs
FRC decrease, especially in large/pregnant patients
increased peak pressures
LMA may not be a good choice cause of pressure requirements
281
how does lithotomy position affect heart
increased venous return from leg elevation
exacerbate CHF,
increases MAP but not CO
lowering legs can cause a drop in pressure
282
what are contraindications for LMA
reflux,
obese,
diabetic,
lengthy procedures,
gastroporesis,
longer than 2 hours,
laparoscopic, some lithotomy
283
what can prolonged use of LMA cuase
nerve damage
284
why do you not always use neuraxial anesthesthesia in cystoscopy
cystoscopy usually 15-20 min and spinal is multiple hours
285
what level do you do spinals at for cystocopy
T10
286
what kind of neuraxial do you use for cystoscopy usually
spinal
287
NMBD are usually not needed for cystocopy unless you are doing what
going in ureters
288
what level do you spinal at for csection/OB
T6
289
what is preffered anesthesia tool for elderly or high risk patients in cystoscopy
spinals
290
what is an elderly complication for spinals
arthritis
use larger needle
291
what is a TURP
transurethral resection of the prostate (BPH)
292
what is age of most turps
>70 so lots of comorbidities
293
what type of anesthesia is preferred for TURP
neuraxial/spinal
294
why is spinal preferred for TURP
less neuro depression, can detect TURP syndrome better
295
what are common side effects of TURPs
clots,
hematuria,
UTI,
failure to void
296
what evaluations do you do for preop eval for elderly turp patient
cardiac- aortic stenosis (loud systolic murmur)
297
why are spinals bad in aortic stenosis
rely of SVR to maintain CO, if SVR is decreased by spinal vasodilation, then blood cant get to coronaries or rest of body
also increased HR makes it worse
298
when do you do type and screen for TURP
anemia
>40g prostate gland removal
long procedures=more bleeding
299
what is average blood loss for TURP
3-5ml/min
avg 200-300
300
how much is 1 gm of tissue loss in TURP blood wise
15cc blood loss per gram
301
what length and mass of removal may require transfusion of TURP
>90 min
>40grams
302
besides bleeding what can cause a decrease in TURP hct
hemodilution from absorption of irrigating fluid
303
how does TURP syndrome occur
-prostate has lots of venous sinuses, irrigant is hypotonic
-this cuases hyponatremia
304
when does confusion occur with hyponatremia
<120 Na
305
what are s/s TURP syndrome
HA,
restlessness,
confusion,
cyanosis,
dyspnea,
arrhythmias,
hypotension,
seizures due to hyponatremia,
fluid overload,
solute toxicity
306
how much fluid absorption is related to TURP syndrome
>2L
307
what lab do you draw to check TURP syndrome
BMP (Na)
308
what solutions are used for turp irrigation
glycine,
sorbitol,
mannitol,
nothing with Na because it conducts electricity
309
what two factors increase fluid absorption in turp
bag height (irrigant pressure)
time of procedure
310
besides hyponatremia, what other electrolyte imbalance occurs in TURPs
hyperglycemia from absorption of solutions
311
what vision change can occur in TURP
temporary blindness from hyperglycinemia (from glycin)
312
what is treatment for TURP syndrome
-recognition-constant check neurostatus
-fluid restrictions/loop diuretics
-hyponatremia- 3% saline
-seizures- versed/prop
-intubation- prevent aspiration
313
how does turp affect temp? what is risk?
-hypothermia-irrigant, shivering can dislodge clots and cause bleeding
314
how fast do you give 3% saline
100cc/hr
315
how do you prevent hypothermia in TURP
bair hugger, warm blankets, fluid warmers, humidifier for circuit
316
what bleeding disorder can occur with TURP
DIC- r/t thrombaxane release blood cell lysis
317
what infection can occur with TURP
septiciemia- treat with gentamycin maybe prophylactic
318
besides aortic stenosis, what other condition is contraindicated for spinal in TURP
cancer with spinal metastasis
319
what is an ESWL procedure
extracorporeal shock wave lithotripsy
320
what is the first line therapy for renal and upper 2/3 of ureter stones
lithotripsy
321
what kind of anesthesia for ESWL procedures
general
322
what positioning considerations for ESWL
hole in bed, dont let them fall through
323
what other procedure can be done with EWSL
stents
cysto
324
what are contraindications for ESWL
-pregnancy
-lungs away from shcok
-aortic aneurism
-coagulopathy
-arrythmias
-ICD/pacemaker (have magnet)
-urinary obstruction below stone
325
what is ESWL shock timed with
HR so no shock on R wave
326
what medication is given to increase speed of ESWL shocks
robinol/glycopyrolate (speed up HR)
327
what are anesthesia considerations for ESWL
-want patient intubation (no LMA)
-time shocks during expiration so lungs arent close to wave
-bradycardia prolongs procedure
-patients with arrythmia hxs are at higher risk for dysrhythmias
328
what do you need to know with cancer patient
mestastasis, malignancy
329
what is position for prostectomy
-extreme trendelenburg with robot
-arms tucked
330
what are anesthesia considerations for prostectomy
-long procedure (4-6 hours)
-2 IVs
-decreased FRC, increased PP (peak pressure_
-OG to suction patient
-pressure mode for ventilator
-EBL 100-300 usual
331
what are preoperative considerations for radical nephrectomy
-degree of renal impairment
-size of tumor
-underlying diseases (HTN, DM)
-COPD, CAD
-most are anemic and may need preop transfusion
-cooler of blood in room
332
what is a well documented risk for renal tumors? what are other risk factors associated with this
smoking
emphysema
333
what are intraop considerations for radical nephrectomy
SEVERE BLEEDING (Type and cross, 2 large IVs, a-line, CVC)
-positioning/approach
-mannitol to preserve renal function
-use lots of narcotics
-adrenal gland= BP swings, have nitro ready
334
what is it called when tumor extends outside of renal capsule
thrombus
335
what is a level one renal tumor
into IVC below liver
336
what is a level 2 renal tumor
up to liver below diaphragm
337
what is a level 3 renal tumor
above diaphragm in to R atrium
338
what test can you do pre-op to check for preexisting embolization and thrombus of renal carcinoma(into diaphragm)
VQ and TEE
339
what lines/blood products do you use for a radical nephrectomy with tumor thrombus
invasive monitoring (swan, TLIJ)
multiple large IVs
10-15-50 units PRBC
use platelets, FFP, cryo
340
what is risk of swan placement with tumor thrombus of renal carcinoma
contraindicated in level 3 throbus due to potential of dislodgement of tumor
-causes stroke
341
what do you do if renal carcinoma tumor covers >40% of right atrium
cardio-pulmonary bypass (perfusionist)
342
do you use cell saver for radical nephrectomy
no, spread cancer cells
343
what are serious potential complications of radical nephrectomy with tumor thrombus
pulmonary embolism of a tumor piece
344
what are s/s PE
sudden dysrhythmias,
arterial desaturation,
profound hypotension
345
what does a high CVP during a radical nephrectomy with tumor thrombus point towards
venous obstruction by the thrombus
346
what is polymethylmethacrylate
bone cement
347
what kind of reaction is bone cement
exothermic, gives off heat
348
what is a risk of bone cement
expansion, leads to emboli, like fat (called intermedullary HTN-the force that pushes the fat out)
349
what is a serious side effect of bone cement
DIC
350
how can you prevent emboli in orthopedics
100% O2 prior to cement
drill a vent hole in bone
use non-cementing prothesis
351
what are some diseases/procedures that have DIC risk
amniotic fluid emboli,
bone cement
fat emboli,
bone cement emboli,
sepsis,
TURP syndrome,
crystalloids,
ARDS
352
what happens in DIC caused by bone cement emboli
release of tissue thromboplastin,
platelet aggregation,
microthrombus formation in lungs,
cardiovascular instability,
EtCO2 emboli pattern
353
what do you set pressure on tourniquet to
100mmHG over systolic BP
150mmHg over systolic BP for thigh
354
how does anesthesia help create a bloodless field
decrease BP
355
how long can you have tourniquet inflated for
2 hours
if it goes longer deflate for 20 min then can go for 2 more hours
356
what can deflation of tourniquet lead to
acidosis,
hyperkalemia,
myoglobinemia,
renal failure
increased EtCO2
357
When does tourniquet pain occur?
around 60 min
358
what is tranexamic acid (TXA)
inhibits fibrinolysis
plasminogen to plasmin inhibitor
359
what sx can you not use tourniquet in? what do you use instead
joints like hips and shoulders
use TXA
360
when do you give TXA periop
beginning of case and before tourniquet inflation or at closing
361
what are the main anesthesia issues with ortho
clots and bleeding
362
what are the neurological affects of tourniquet use
-30 min = decreased somatosensory evoked potentials and nerve conduction
-60 min = tourniquet pain and HTN
-2 hrs = postop neuropraxia
-nerve injury
363
what are the muscle changes of tourniquet use
-2 min= cellular hypoxia
- decreased cellular creatinine
-cellular acidosis
-2hrs= endothelial capillary leak
364
what are the systemic effects of tourniquet inflation
-increased arterial and pulmonary arterial pressure
-more severe without volatile anesthetics
365
what are the systemic affects of tourniquet release
-decrease in temp
-metabolic acidosis
- decrease central venous O2
-thromboxane release
-decrease in pulm and arterial pressures
-increase in eTCO2
366
what nerve fibers cause tourniquet pain
c fibers
367
what can happen anesthesia wise with tourniquet release
increase CO2 leads to spontaneous breathing
kinda wake up a bit
368
what nerve fibers are associated with tourniquet pain
c fibers
369
what kind of fractures have fat emboli
long bone fractures- nearly 100%
370
what is Fat embolism syndrome triad
dyspnea,
confusion,
petechia (of chest and upper extremities)
371
what is the differentiating symptoms of fat embolism vs amniotic fluid, VAE
petechia of chest and upper extremities
372
what are life threatening complications of Fat embolism syndrome
ARDS,
neurodamage via edema,
DIC
373
what does fat from long bone fx come from
medullary vessels
374
what are the two complications for beach chair position in shoulder sx
VAE,
decreased cerebral perfusion pressure
375
in sitting position, what is difference between BP in head and in arm
about 20mmHg
376
what is treatment for VAE
Position- Left lateral, trendelenburg
flood sx site with NS
central catheter to suck VAE out
DC N2O
100%O2
377
what are risk factors of DVT/PE
>60 yo,
>obesity,
>tourniqet,
>>30 min procedure,
>>lower extremity fx,
>>immobilized >4 days
378
how do you prevent DVT
pneumatic compression devices, pharmocological methods
379
how does neuraxial anesthesia affect thromboembolitic events
decreased them
380
what are anesthetic considerations for old people
-decrease doses for induction agents
-high mortality
-dehydration, malnourishment
-increased blood loss
-increased comorbidities
381
what bleeds more intracapsular or extracapsular hip fxs
extra
382
what is an anesthesia method to decrease mortality of hip fx patients
neuraxial
spinal
epidural
combo
383
how long does spinal last
about two hours, so if longer do combo
384
what is replaced in total hip
ball and socket, usually due to osteoarthritis
(longest hipp procedure so use spinal/epidural combo)
385
what is replaced in hemiarthroplasty
only ball (shorter procedure)
386
what is used in gamma nail
nail to fixate fracture
387
what positions are shoulder sxs done in
lateral or sitting
388
what is positioning considerations for lateral shoulder
head and neck in neutral position
axillary roll -protects brachial plexus
389
what are risks of beach chair CV wise
vasodilation,
increased HR,
BP swings (mix neo)
390
anesthesia considerations for shoulder sx
higher blood loss
GETA with regional block
low visualization of ETT after draping
consider a-line
391
what does gas insufflation do anesthesia wise
increased intrathoracic pressure
increased PP (peak pressure)
harder to breathe
absorb CO2, causes acidosis so increase MV to breathe it off
392
what type of anesthesia technique for laprascopic technique
general ETT anesthesia
393
what is pneumoperitoneum
increased pressure caused by insufflation of CO2 in laparoscopic technique
394
CO2 insulflation affects
395
what are factors leading to subcutaneous emphysema (crepitus)
-insufflation
-intraabdominal pressure >15mmHg
-multiple attempts at the abdomen entry
-needle or cannula outside peritoneal cavity
-cannula seal not snug
-use of >5 canulas
-laparoscope used as a lever
-canula acting as a flucrum
-long arm of laparoscope
-compromised tissue integrity by repetitive movements
-structural weakness caused by repetitive movements
-improper cannula placement
-soft tissue dissection and fascial extension
-procedure >3.5 hours
-etCO2>50 mmHG
396
how do you manage subcutaneous emphysema
-decrease intraabdominal pressure
-dc NO2
-100%fiO2
-evaluate pneumothorax
-increase MV to treat hypercarbia
-evaluate ETCO2 and PaCO2
-assess chest wall and lung compliance
-assess airway to rule out compression prior to extubation
397
what is celiac reflex
vagal nerve stimulation from traction or structures within peritoneal and thoracic cavities
-causes severe brady, asystole
398
how do you treat celiac reflex
robinol/glycopyrolate
atropine
decrease CO2 pressure in abd
399
what are causes of gas embolisms
trocar insertion into vessel,
open intravascular vessels with lower pressure than intraabdominal pressures
hit liver with trocar
c section
400
how do you treat VAE
left lateral,
100% O2,
discontinue N2O,
flood field with NS,
place CVC
401
what is positioning for lap cholecystectomy
trendelenburg and airplane left
402
what is positioning for lap appendectomy
Reverse trendelenburg and airplane left
403
what is positioning for robotic prostatectomy
steep trendelenburg
404
what are some open abdomen procedure considerations
evaporative fluid loss
heat loss
blood loss
decreased bowel function
405
how do you decrease bowel function issues
ERAS,
reduce opioids,
consider regional blocks,
406
what are some ERAS (enhanced recovery after surgery) protocol recommendations preop
PREOP
preadmin counseling
fluid and carbo loading
eliminate NPO status
no/selective bowel prep
antibiotic prophylaxis
thromboembolism prphylaxis
eliminate routine use of premedicating
407
what are some ERAS (enhanced recovery after surgery) protocol recommendations intraop
INTRAOP
short acting anesthetic agents
epidural use
avoid sx drains
avoid salt/water overload
maintain normothermia
408
what are some ERAS (enhanced recovery after surgery) protocol recommendations post-op
POSTOP
epidural anesthesia
avoid NG tubes
PONV prophylaxis
avoid salt/water overload
early ambulation
early oral nutrition (gut motility)
early catheter removal
409
how does gas affect evoke potentials
decrease them, so <1/2 mac
410
if doing muscle evoke potentials what do you do anesthesia wise
dont paralyze, use succs to intubate
411
how do you keep patient from moving in spinal anesthesia when you cant use NMBDs
OVERSEDATE if not paralyzed
412
where do you put hands and how do you roll patient for prone
log role kinda, one head on top of face on on back of head, secure tube, CRNA in charge of movement
413
anterior ethmoidal nerve
1
414
sphenopalentine nerve
2
415
lingual nerve
3
416
glossopharyngeal nerve
4
417
superior laryngeal nerve
5
418
internal laryngeal nerve
6
419
recurrent laryngeal nerve
7
420
superior laryngeal nerve
1
421
internal laryngeal nerve
2
422
external laryngeal
3
423
carotid artery
4
424
vagus
5
425
left recurrent laryngeal nerve
6
426
right recurrent laryngeal nerve
7
427
recurrent laryngeal nerve
8
428
epiglottis
1
429
hyoid bone
2
430
thyroid cartilage
3
431
cricothyroid membrane
4
432
cricoid cartilage
5
433
cervical sympathetic ganglion
6
434
inferior ganglion of vagus nerve
7
435
superior laryngeal nerve
8
436
internal laryngeal branch
9
437
external laryngeal branch
10
438
vagus nerve
11
439
recurrent laryngeal nerve
12
440
innominate artery
13
441
hard palate
1
442
soft palate
2
443
nasopharynx
3
444
oropharynx
4
445
hypopharynx (laryngopharynx)
5
446
epiglottis
6
447
vocal cords
7
448
larynx
8
449
trachea
9
450
valleculae
1
451
epiglottis
2
452
aryepiglottic folds
3
453
trachea rings
4
454
true vocal cords
5
455
vestibular folds
6
456
arytenoids (corniculates)
7
457
nasopharynx
1
458
oropharynx
2
459
epiglottis
3
460
hypopharynx
4
461
vocal cord
5
462
larynx
6
463
trachea
7
464
esophagus
8
465
tongue
9
466
epiglottis
10
467
vocal cords
11
468
trachea
12
469
epiglottis
1
470
aryepiglottic folds
2
471
true vocal cords
3
472
corniculate cartilage
4
473
cuneiform cartilage
5
474
Cormack and Lehane grade 4
soft tissue only
475
Cormack and Lehane grade 3
epiglottis
476
Cormack and Lehane grade 2
vestibular folds
arytenoids
477
Cormack and Lehane score grade 1
true vocal cords
478
Cormack and Lehane grade 4
soft tissue only
479
Cormack and Lehane grade 3
epiglottis
480
Cormack and Lehane grade 2
vestibular folds
arytenoids
481
Cormack and Lehane score grade 1
true vocal cords
482
mallampati class 4
hard pallate only
483
mallampati class 3
hard and soft palate
base of uvula
484
mallampati class 2
hard and soft palate
uvula
fauces
485
mallampati class 1
hard and soft palate
uvula
fauces
tonsilar pillars
486
what is the distance from the subclavian vein to the R atria
right 15 cm
left 25cm
487
what is the distance from the R IJ to the R atria
15 cm
488
what is the distance from the L IJ to the R atria
20 cm
489
what is the distance from the right Femoral vein to the R atria
40cm
490
what is the distance from the R median basilic vein to the R atria
40 cm
491
what is the distance from the L median basilic vein to the R atria
50 cm
492
What does CVP measure?
right atrial pressure
493
what is normal CVP
1-10mmHg
494
what does CVP estimate
preload
495
in a CVP waveform what does the a wave denote
atrial contraction
496
in a CVP waveform what does the c wave denote
tricuspid valve closure (pressure pushed against valve at closure)
497
in a CVP waveform what does the v wave denote
passive filling of RA (coranaries, IVC, SVC)
498
where does the a wave of the CVP waveform correlate to the EKG
comes after P wave
499
where does the c wave of the CVP waveform correlate to the EKG
during QRS
500
where does the v wave of the CVP waveform correlate to the EKG
t wave/ repolarization
501
what causes an elevated a wave in CVP waveform
(increased contractile force)
junctional rhythm (atria pushing on closed tricuspid valve)
PVCs
tricuspid stenosis
ventricular pacing
502
what causes an elevated C wave in CVP waveform
(pushing against tricuspid valve)
pulm htn
mitral insufficiency (regurge)
503
what are causes of elevated CVP
(elevated preload)
RV failure
tricuspid stenosis or regurge
cardiac tamponade
constrictive pericarditis
volume overload
pulmonary htn
LV failure (chronic)
504
how does hypovolemia affect CVP waveform
hides abnormalities
505
what causes a large V wave in CVP waveform
(increased filling pressure)
increased preload
high volume of fluid given
506
what happens to CVP waveform when you give alot of volume
up and plateaus
507
what condition causes a lack of a waves in CVP waveform
a fib
508
with a swan, what is the distance from the Rt IJ to the RA
15-25 cm
509
with a swan, what is the distance from the Rt IJ to the RV
25-35 cm
510
with a swan, what is the distance from the Rt IJ to the PA
35-45 cm
511
what is the approx normal pressure of the RA
5
(no systolic, same as CVP)
512
what is the approx normal pressure of the RV
25/5
(gain systolic, diastolic mimics RA)
513
what is the approx normal pressure of the PA
25/10
(systolic same, diastolic increase)
514
what does a thick line on a swan represent
50 cm
515
what does a thin line on a swan represent
10 cm
516
what is the thermistor port on a swan for
CO
CI
517
what color is the CVP port on a swan
blue
518
what color is the balloon port on a swan
red
519
how many ccs go in a swan balloon
1.5 ccs
520
what color is the PA port on a swan
yellow
521
what is used to introduce a swan? how big is it? where is it usually placed?
cordis
9 french
Rt IJ
522
when do you inflate the swan balloon during insertion
RA
523
what is a common dysrhythmia when inserting a swan
PVCs
524
if you insert swan from the L side IJ instead of the R how much distance do you add
10 cm
525
how can you tilt bed to help with swan insertion
R and trendelenburg
526
what is the A wave on a PAOP or wedge
left atrial contraction
527
what is the C wave on a PAOP or wedge
mitral valve closure (bulge)
528
what is the v wave on a PAOP or wedge
filling of L atria
529
what causes a large a wave on PAOP
mitral stenosis
530
what causes a large v wave of PAOP
mitral regurg
531
what causes an elevated PA pressure
LV dysfunction
mitral stenosis/insufficiency
L-R shunt
ASD/VSD
pulm htn
532
what causes an elevated PAOP
LV dysfunction
cardiac tamponade
constrictive pericarditis. (chronic pericarditis, mimics tamponade)
Ischemia
533
what three pressures are the same in a patient with cardiac tamponade
PAD
PAOP
CVP
534
What is the Frank-Starling law of the heart?
the more the heart fills with blood during diastole, the greater the force of contraction during systole (to a point then it fails)
535
when do you read a PA mean in a spontaneous breathing patient? a ventilated patient
patient peak- diastolic pressure during expiration
vent valley (or just make them apnic)
536
what does PAOP approximate
LVEDP
537
PA pressure is and indirect measurement of
ventricular function
538
what is normal CVP, PADP, PAOP
cvp 1-10
PADP- 5-15
PAOP- 4-12
539
what causes CVP, PADP, and PAOP to be low
hypovolemia, or misplaced transducer
540
what causes normal or high CVP, High PADP, and high PAOP
LV failure
541
what causes high CVP, normal or low PADP, and normal or low PAOP
RV failure
Tricuspid regurge
Tricuspid stenosis
542
what causes normal or high CVP, High PADP, and normal or low PAOP
PE
543
what causes high CVP, High PADP, and normal PAOP
Pulm HTN
544
what causes high CVP, High PADP, and high PAOP
tamponade,
ventricular interdependence,
transducer not at phlebostatic axis
545
what causes normal CVP, normal High PADP, and high PAOP
LV myocardial ischemia
MR?
546
what causes low CVP, High PADP, and normal PAOP
ARDS
547
how do you calulate CO
CO=SVxHR
548
what is normal CO
5-6 L/min
549
how do you calculate CI
CI= CO/BSA
550
what is normal CI
2.8-3.6 L/min
551
what helps us calculate CO, CI on a swan
thermodilution +/- 5-10%
552
how does thermodilution work
inject 10ccs ns/d5,
computer reads temp change and when it returns to normal
553
why is mixed venous drawn from PA
has SVC and IVC blood
554
what is normal mixed venous
65-77%
555
what does mixed venous tell us
measurement of O2 delivery, can be an indicator of low CO
556
what needs to be documented every 5 mins for all anesthetics
BP
HR
RR
557
what reading does methemoglobin give and why
85%, absorbs red and infrared light equally
558
if you intubate too deep, where is tube most likely to go
right lung, shorter straighter
559
how can temperature affect blood loss
big temp change can increase blood loss
560
what needs to be monitored continuously on all pediatric (<12) patients receiving general anesthesia and when indicated on other pts
body temp
561
what monitors are necessary
lung sounds-stethoscope
inspired o2 concentration- gas analysis
expired gas analysis
spo2
pulmonary/chest wall mechanical function
562
what does pulmonary chest wall mechanical function include
inspiratory pressures, respiratory volumes
563
what should be monitored continuously on all patients
oxygenation
564
what are the three ways of verify intubation listed on standard 9
auscultation,
chest excursion,
confirmation of co2 in expired gas
565
what should be continuously monitored during controlled or assisted ventilation with any artificial airway support
end tidal CO2
566
what is recommended by standard 9 for alarms
have threshold and variable pitch audible alarms
567
how many breaths at minimum are needed for etco2 to avoid misinterpretation
6 breaths
568
what prevents 93% of anesthetic mishaps
pulse oximetry and capnography
569
how is co2 analysis helpful in gas monitoring
assesses ventilation and detects equipment/patient problems
570
what co2 analysis is ph sensitive, co2 presence changes color, and used most often by ems
colorimetric co2 analysis
571
if you intubate and get color change after 1 breath, what could be a problem
could be co2 from stomach
572
what does a galvanic cell play a role in analyzing
O2 analysis
573
what law explains pulse oximetry
lambert beer law
574
what instrument uses a mathematical means of expressing how light is absorbed by matter
pulse ox
575
what are two main types of oximetry
fractional
functional
576
what kind of oximetry measures arterial oxygen saturation (Sao2)
fractional oximetry
577
what kind of oximetry is only measurable by arterial blood sample
fractional ox
578
what absorbs more red light and what is the light wavelength
deoxyhemoglobin- 660
579
what absorbs more infrared light and what is light wavelength
oxyhemoglobin 940
580
if you are seeing more red light than infrared light what is happening with oxygen
higher oxygen- more infrared light being absorbed means higher oxygen content
581
if you are seeing more infrared light, what is happening to oxygen
decreasing oxygen- more red light being absorbed into deoxyhemoglobin means less oxygen content
582
what is the formula for fractional oximetry
oxyhemoglobin/
(oxyhemoglobin+deoxyhemogobin
+methemoglobin+carboxyhemoglobin)
583
in 100% pulse ox, which light will you see most of
red light- infrared has been absorbed into oxyhemoglobin
584
what kinds of light flash hundreds of times per second in pulse ox
red and infrared light
585
what does a pulse ox rapidly sample from each pulse wave
peak and trough
586
what is a trough in pulse ox
vascular bed has arterial, capillary, venous blood, and tissue density
587
what is a peak in pulse ox
all of blood from trough + additional arterial blood
588
when is pulse ox inaccurate
methemoglobin, methylene blue, carboxyhgb messes up pulse ox- do abg for real oxygen reading
589
what is it called when neither red or infrared light is emitted from pulse ox
off period
590
what are causes of low etco2
hyperventilation,
decreased co2 production,
alveolar dead space
591
how does a cerebral oximeter work
does not require pulsatile flow, gets readings from vascular beds- also tries to measure arterial though
parabolic arch
592
below what reading is pulse ox not reliable
below 70%
593
what happens during off time in pulse ox
reading of ambient light is read and subtracted from sequences
594
where do you put pulse ox probe to detect changes faster
centrally place
peripheral=slower
595
what are some pulsatile vascular beds you can attach pulse ox to
finger, cheek, ear, toe, nose,
596
what are some pulsatile vascular bed you can attach pulse ox to on infant
palm, forefoot, wrist
597
when is pulse oximeter accurate to within 5%
70-100%
598
what happens when pulse ox is below 70%
readings are extrapolated and unreliable
599
what conditions affect accuracy of pulse ox
raynauds,
movement,
vasoconstriction,
poor circulation d/t low co,
improper placement,
hypothermia
600
what are dyes that can cause false high/low readings in pulse ox
methylene blue,
indigo carmine
601
exposure to what can cause false high/low pulse ox reading
smoke or fire
602
what causes fire/smoke to give overestimate of pulse ox
carboxyhemoglobin
603
what can fluorescent light cause in pulse ox reading
false high- red light isn't getting absorbed because of same wavelength 660
604
what can drugs cause that makes pulse ox have false high/low reading
methemoglobinemia -doesn't release oxygen
85% reading
605
name some drugs that can induce methemoglobinemia
nitrates,
locals such as prilocaine,
chlorates,
sulfas,
metochlopramide
606
what are two disease that can cause false high/low pulse ox reading
anemia,
sickle cell (vaso-occlusive crisis),
dyes
607
what kind of light can interfere with pulse ox
fluorescent light
608
what happens if esophageal stethoscope enters lungs
makes a leak in cuff, bellows collapse
609
what can inhibit passage of light through finger
nail polish- black henna or dark blue
610
what is placed in nasall/orally and is only used in intubated patients
esophageal stethoscope
611
when is esophageal stethoscope contraindicated
esophageal varices/strictures
612
when should temperature be carefully monitored according to standard 9
pediatric (<12), or when significant temp change is intended/anticipated/suspectd
613
what is a late sign of malignant hyperthermia
increased temp
614
what does hypothermia triple the incidences of
cardiac complications and surgical wound infections
615
what impact does hypothermia have on blood loss
increases it
616
what is heat production and how is it brought about
thermogenesis- shivering and non shivering
617
what is heat loss
thermolysis
618
what is normal range of temp
36-37.5 c
619
where is thermoregulation controlled
hypothalamus
620
what is total body heat a combination of
zone temperatures- peripheral and core zones
621
what is more important than maintenance of individual temps
maintenance of total body heat
622
what is the peripheral temp zone made up of
skeletal muscle, subcut tissue, skin
623
what is core temp zone made up of
trunk and head- holds more heat and releases more heat
624
how does body respond to cold exposure
increases heat production, reduces heat loss
625
how does body reduce heat loss
vasoconstriction of peripheral vessels,
increased metabolic rate,
layering w/clothes
626
Why do peds lose heat more quickly than an adult?
bigger core zone than peripheral zone-
627
is hypothermia or hyperthermia more cmmon
hypothermia- body naturally vasoconstricts to increase temp but anesthetics gases cause vasodilation
628
what can you give for shivering
demerol
629
what is shivering indirectly controlled by
catecholamines
630
how much heat can you lose in the first hour aka phase 1
1-1.5 degrees c
631
what is phase 3 of heat loss
equilibriate, plateau, produce same heat you are losing after 4 hours
632
what is phase 2 of heat loss
still declining but plateauing, losing more heat than you can generate for next 2-4 hrs
633
how can hypothermia influence ekg
increase pr/qrs/qt
increase or decrease st segment
634
what is the extra wave from hypothermia in ecg
j wave aka osborn wave
635
cricothyroid muscles
tense vocal cords
**c**ords **T**ense
636
thyroarytenoid muscle function
relaxes vocal cords
**t**hey **r**elax
637
posterior cricoarytenoid muscles
ABducts vocal cords
Please Come Apart
638
lateral cricoarytenoid muscles
ADDuct vocal cords
Lets Close Airway
639
what nerve innervates the cricothyroid muscles?
Superior Laryngeal Nerve
640
what muscles does the Right Laryngeal nerve innervate
vocalis
thyroarytenoid
lateral cricoarytenoid
posterior cricoarytenoid
aryepiglottic
interarytenoid
641
642
What can cause a loss of a waves or only v waves
Afib
Ventricular pacing
643
What causes giant a waves aka cannon a waves
Junctional rhythms
Complete AV block
PVCs
Ventricular pacing
Tricuspid/ mitral stenosis
Diastolic dysfunction
Myocardial ischemia
Ventricular hypertrophy
644
What can cause large V waves on cvp
Tricuspid/ mitral regurg
Acute increase in intravascular volume
645
What can cause elevated CVP
Rv failure
Tricuspid stenosis/regurg
Cardiac tamponade
Restrictive pericarditis
Volume overload
Pulm HTN
LV failure
646
What can cause elevated PAP
LV failure
Mitral stenosis/regurg
L to R shunt
ASD or VSD
Volume overload
Pulm HTN
Cather whip
647
What causes elevated PAOP
LV failure
Mitral stenosis/ regurg
Cardiac tamponade
Constrictive pericarditis
Volume overload
Ischemia
648
What can cause overestimated thermodutjln CO
Low injectate volume
Injectate too warm
Thrombus on thermistor of PAC
Partially wedged PAC
649
What can cause underestimates of thermodultion CO
Excessive injectate volume
Too cold injectate
650
After induction of general anesthesia, if initial attempts at intubation are unsuccessful, which of the following is NOT advised as a potential “next step”:
Invasive airway access
651
ASA guidelines suggest equipment in a portable storage unit for difficult airway management should include (Check all that apply): Select one or more
Rigid laryngoscope blades of alternate design and size
Tracheal tube guides (e.g., ventilating tube changer, light wands, forceps designed to manipulate the distal portion of the tracheal tube)
Supraglottic airways (e.g., LMA) equipment
e. Equipment suitable for emergency percutaneous or surgical airway access
652
Follow-up care for the patient with a difficult airway includes all of the following:
Informing the patient or responsible party of the airway difficulty that was encountered
Providing a description of the airway difficulties that were encountered
Providing a description of the various airway management techniques that were used
Evaluation and follow-up with the patient for potential complications of difficult airway management
653
If awake intubation is unsuccessful in a patient with a known difficult airway, the following management options are recommended, EXCEPT
A rapid sequence intubation
654
In the emergency situation in which the patient cannot be ventilated and cannot be intubated, which of the following is recommended
Awakening the patient
Supraglottic airway (SGA) ventilation
Jet ventilation
Percutaneous airway access
Surgical airway access
655
Strategies to deliver supplemental oxygen throughout the process of difficult airway management include oxygen delivery by
Nasal cannula
Face mask
Supraglottic airway (SGA) Insufflation
656
An airway history should be conducted, whenever feasible, before the initiation of anesthetic care and airway management in all patients. Examples of at-risk history include all but which one of the following
History of episodic, mild snoring in 10 year old child
657
A two-year old pediatric patient with an anticipated difficult intubation should be considered a candidate for which of the following management strategies?
Spontaneous ventilation following induction with volatile anesthetic.
Intravenous induction aiming to maintain spontaneous ventilation.
658
What is sniffing position
35 degree neck flexion
15 degree face plan extension
Head elevation 8-10cm
659
What is sniffing position
35 degree neck flexion
15 degree face plan extension
Head elevation 8-10cm
660
What grade view do you visualize most of glottic opening and epiglottis
Cormack-Lehane Grade 1
661
What view has partial view of vocal cords and full view of posterior laryngeal cartilages
Cormack-Lehane grade 2a
662
What view has only the posterior portion of the glottic opening can be visualized
Cormack lehane grade 2b
663
What view only the epiglottis can be visualized; no portion of the glottic opening can be seen
Cormack lehane grade 3
664
What view is epiglottis cannot be see ; only view is of the soft palate
Cormack lehane grave 4
665
What is the formula to get ETT depth
Body height (cm) / 5 -13
666
Pierre robin syndrome
Retrognathia
Micrognathia
Glossoptosis
Cleft palate
667
Treacher Collins syndrome
Mandibular hypoplasia
Micrognathia
Facial bone hypoplasia
Choanal atresia
Cleft palate
668
L in lemon
look externally
facial trauma
large incisors
beard or mustache
large tonge
669
e in lemon
evaluate 3-3-2
incisor distance 3 finger breadths
hyoid mental distance 3 fingers
thyroid to mouth 2 fingers
670
m in lemon
mallampati score
671
o in lemon
obstruction
epiglottitis, abscess, trauma
672
n in lemon
neck mobility
673
Goldenhar syndrome
Hemifacial microsomia,
mandibular hypoplasia;
vertebrae may be incomplete, fused, or missing
674
Mucopolysaccharidosis
Macroglossia,
odontoid hypoplasia,
dental anomalies,
675
Klippel-Feil syndrome:
Short neck,
fusion of two or more cervical vertebrae,
limited range of neck motion
676
Down syndrome:
Macroglossia,
flattened nose,
cervical spine abnormalities,
obstructive sleep apnea,
dental anomalies
677
Acquired Conditions Associated With Difficult Airway Management
*Morbid obesity: Thick neck with redundant airway tissue, obstructive sleep apnea
*Acromegaly: Macroglossia, prognathism, vocal cord swelling
*Ludwig angina: Infection at the floor of the mouth, trismus
*Abscesses (oral, retropharyngeal): Distortion or stenosis of the airway tissues, trismus
*Laryngeal papillomatosis: Viral infection causing tumors or papillomas within the larynx
*Epiglottis: infection causing swelling of the epiglottis, laryngeal edema
*Croup: infection causing laryngeal edema and subglottic edema
*Rheumatoid arthritis: Limited cervical spine range of motion, temporomandibular joint ankylosis, cricoarytenoid arthritis
*Ankylosing spondylitis: Cervical spine ankylosis, decreased chest expansion
*Tumors involving the airway: Distortion or stenosis of the airway, fibrosis with fixation from irradiation
*Trauma (airway, cervical spine): Distortion, edema, hemorrhage of the airway
678
what size lma for >100 kg
6 LMA classic only
up to 50ml
679
what LMA size and volume for 30-50 kg
3
up to 20 mL
680
acute inferior wall MI
681
afib with moderate ventricular response
682
early repolarization (a normal variant)
683
ectopic atrial rhythm, non specific T wave abnormalities
684
acute anterolateral MI
685
NSR with old inferior MI
686
left atrial abnormality ( left atrial enlargement)
687
left posterior hemiblock
688
left bundle branch block
689
-60
690
atrial flutter with low voltage
691
left ventricular hypertrophy
692
what is criteria used for LVH diagnosis
The R in lead I plus the S in lead III is greater than 25mm
the R wave in aVL is greater than 11 mm
Left atrial abnormality (enlargement)
left axis deviation
693
evidence of old anteroseptal MI
694
sinus rhythm, frequent PVCs, early transition
695
right bundle branch block with left anterior hemiblock
696
ST depression- consistent with ischemia
697
sinus rhythm, type I second degree AVB, LVH with strain
698
there is a normally functioning single chamber ventricular pacemaker that started competing with the sinus rhythm
699
pre excitation (WPW)
700
What nerve injuries can result from masking
Stretch facial nerve (drool, sag)-jaw thrust
CN7 compression (buccal branch)- face mask
Supraorbital nerve compression (ETT in face)
701
What nerve injuries can result from masking
Stretch facial nerve (drool, sag)-jaw thrust
CN7 compression (buccal branch)- face mask
Supraorbital nerve compression (ETT in face)
702
What degree of AO extension indicates difficulty with DL
<23 degrees
703
What are the 4 treatments for hereditary angioedema
C1 esterase concentrate
FFP
Ecallantide
Icatibant
704
Anatomical borders for LMA
Sides: pyriform sinuses
Distal end: upper esophageal sphincter
Proximal end: base of the tongue
