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Extra From Class Flashcards

1
Q

What are the four DAS plans?

A

A: face mask ventilation and tracheal intubation
B: maintain oxygenation - SAD
C: face mask ventilation
D: emergency front of neck access

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2
Q

What is DAS plan A?

A 
Face mask ventilation and tracheal intubation
- optimise position
- pre O2
- adequate NMB
- direct/video laryngoscopy (3+1)
- external manipulation (BURP)
- bougee
- remove cricoid
- maintain O2 and anaesthesia
Success --> confirm capno
Fail --> declare failed intubation
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3
Q

What is DAS plan B?

A 
Maintain oxygenation: SAD
- 2nd generation 
- change device or size (max 3)
- O2 and ventilate 
Success --> wake, intubate via SAD, proceed on device, Trache/crico
Fail --> declare failed SAD
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4
Q

What is DAS plan C?

A 
Face mask ventilation
- if can't - paralyse
- final attempt
- 2 person technique with adjuncts
Success --> wake
Fail --> declare CICO
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5
Q

What is DAS plan D?

A

Emergency front of neck access

  • scalpel bougee
  • call for help
  • 100% O2
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6
Q

How is a scalpel bougee technique performed?

A 
Help
100% O2 upper airway
Ensure NMB
Position to extend neck
Laryngeal handshake to ID membrane
Transverse stab with scalpel
Turn blade 90 degree caudal (sharp)
Slide bougee tip along blade into trach
Railroad lubricated 6.0 Parker ET
Ventilate, cuff up and confirm
Secure in place
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7
Q

What is is a scalpel bougee pack?

A

Scalpel size 10
Bougee
6.0 Parker tip
Chlorhexidine swab

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8
Q

How is the scalpel bougee technique handled in a non-palpable neck?

A

8-10cm vertical incision caudad to cephalad
Blunt dissect with fingers to separate tissue
ID and stabilise larynx
Continue as with palpable neck

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9
Q

What is the post op care following a DI?

A 
Make airway management plan
Monitor for complications 
Complete airway alert form
Explain to patient
Send report to GP
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10
Q

What is the post op care following cricothyroidotomy?

A

Postpone surgery unless life threatening
Urgent surgical review of site
Document and follow up as in DI

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11
Q

What is the cuff and collar system?

A

On a sleeve index system
Ring placement and diameter is individualised for each gas on the gas hose and bollard connector
Outlet sleeve and corresponding groove on hose can couple

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12
Q

What must you know about the anaesthetic agent in order to make a safe vaporiser?

A

SVP: in order to know what splitting ratio is required

MAC: in order to know range for the dial

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13
Q

How does ET control differ from simply setting a vaporiser?

A

On ET the machine varies the amount of vapour delivered so that the ET is always the same even if the exhaled amount or circulating flow changes. If simply set then the same amount is constantly delivered but may differ in circulation due to changing flow rates. You may deliver much less.

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14
Q

Why is ET better measurement than Fi?

A

ET reflects patient blood level well and is easier to measure.

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15
Q

What are the valves on an ambu bag?

A

End:
+p valve (outside) to relieve
-p valve to entrain
One way valve so gas goes forward when squeezed
Front:
Duckbill valve: open on insp and close once delivered, pulls back on refill to prevent air entrainment and ensure expiratory gases flow out peep valve. One way valve prevents expiratory gas entering bag.

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16
Q

How does the aisys anti hypoxic system work?

A

Programmed not to allow a mix of less than 25% O2
Electronic system
Cannot select a mixture less than 25%
Gas analyser alerts if occurs

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17
Q

What is a total spinal?

A 
High dose LA in the CSF causing it to travel high and block vital pathways. Intercostals/diaphragm get blocked
Tingling arms/hands
Dyspnoea
Hypoxia
Hypotension
Blocked nose (sympathetic vasoD)
Reduced conscious state
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18
Q

What is intra osseous?

A 
Into bone marrow
Non-collapsible
Systemic venous access
Compares to IV for dosing
For emergencies, difficult IV and paediatrics 
Lasts 24 hours
Can deliver drugs and fluids 
Hand bolus or P bag fluids
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19
Q

What are the general principles to placing an IO?

A 
Prep skin prior
Consider LA
Appropriate needle
Push needle through skin to bone 
The IO hub has a black line which should be visible above the skin prior to penetrating the bone (good size)
Pull trigger and apply pressure until a change in R is felt 
Remove stylet; needle should be firm
Secure with supplies dressing
Attach flushed EZ connector
Aspirate for marrow/blood
Flush IO before use (ensure no oedema) 
Need pressure bag for fluids
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20
Q

How is an IO placed for proximal tibia?

A 
Adult:
3cm below patella
2cm medial along flat aspect
Paed:
1cm below and 1cm medial along flat aspect
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21
Q

How is an IO placed in the proximal humerus?

A

Place patient hand on abdomen to get 90degree at elbow
Palpate for “ball”
Locate surgical neck (ball on tee)
1-2cm higher than the neck is the greater tubercle and this is insertion point
Aim 45 degree down and drill until hub meets skin

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22
Q

What areas can the IO be placed?

A

Antero-medial tibia
Distal tibia
Distal anterior femur
Proximal humerus (superior site for speed and flow rate)

Proximal/distal ends of long bones where spongy bone exists
Sternum not ideal!!!

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23
Q

What are the risks of IO?

A 
Extravasation of fluid or drug into tissue 
Compartment syndrome 
Necrosis
Infection
Fracture
Growth plate injury
Fat microemboli
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24
Q

What are the contraindications of IO?

A 
Fracture in bone 
Absence of landmarks
Infection at site 
Previous attempt on same bone within 48 hours 
Osteoporosis or other bone disease
Elderly high risk fracture
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25
What is an AED?
Delivers electrical energy to heart to simultaneously depolarise cells to allow stable rhythm to establish Automated external defibrillator
26
What are the properties of modern AED?
DC energy: more effective, less damage, less arrhythmia Transformers (to increase V) converters (turn AC to DC) and capacitor (store) Biphasic: electrical current in one direction for set time then reverses for remaining time. Optimal delivery. Uses less peak current so low damage
27
What is a cheat drain?
Into the pleural space Drains air, blood and reinflates lung Air tight system with underwater seal allows air exit without re-entry Chamber kept 100cm below cheat to maintain -P If lifted, fluid can siphon into chest Oscillations indicate patency. Absence may indicate blocked, kinked, lost -P or lung has fully re-expanded
28
How does a paediatric airway and respiratory system differ to an adult?
``` Narrow at cricoid vs glottis Large structures Larynx C2-C3 anterior vs C3-C6 Fast/slow and deep/shallow cycle 7-10ml/kg vs 10ml/kg Low FRC High RR: 24- (age/2) 2x the metabolic rate ```
29
How does the paediatric CVS system differ to that of an adult?
``` Higher compliance Large blood volume (80ml/kg vs 70) More TBW (75-80% vs 55-60%) Higher hb >130 Higher HR >60 Lower BP (sys= 80 + (agex2) Higher CO ```
30
Why do paeds desaturated quickly?
``` Reduced alveolar cluster Underdeveloped intercostals CC within TV Low FRC High metabolic rate ```
31
What other body systems are considered in paeds for anaesthetic?
``` Immature liver and kidney function Low carb stores so hypoglycaemia occurs BBB more permeable to agent Thermoregulation: high SA to volume Minimal SC fat Reduced vasoC and shiver mechanism Brown fat metabolism in infants to produce heat - high energy and O2 use ```
32
What are the paediatric emergency drug doses?
Suxamethonium 1-2 mg/kg (-3 for IM) Atropine 10-20 mcg/kg (-30 for IM) Adrenaline 10 mcg/Kg IV/IM
33
What is the normal CO2 range?
35-45 >45 is hypercarbia <35 is hypocarbia
34
What can cause a high CO2?
``` Hypoventilation Hyperthermia/sepsis Tourniquet release High CO Bronchial intubation Soda lime exhausted ```
35
What can cause a low CO2?
Hyperventilation Reduced CO (caution not treading to arrest/PE) Hypothermia System leak
36
What can cause an inclined plateau on CO2 trace?
Obstructive lung disease Blocked airway/tube Aspiration, spasm, anaphylaxis
37
What can cause a raised CO2 baseline?
``` Exhausted like Rebreathing Sticky valves Insufficient FGF Excessive dead space ```
38
What can cause decreasing co2?
PE Cardiac arrest Tamponade
39
What does oesophageal and bronchial intubation look like on CO2?
Oesophageal: Small ETCO2 dropping off Bronchial: A bifid wave noticed in phase III
40
What are the phases of CO2 tracing?
1 is the baseline and is end inspiratory phase 2 is the upstroke and is expiration 3 is the alveolar plateau 0 is the downstroke and is the beginning of next inspiration
41
What are the problems and considerations for prone patients?
High IOP Difficult airway access Risk optical nerve/retinal damage resulting in blind Reduced abdominal compliance limiting diaphragm movement High airway pressure/reduced vent Neutral neck position Neutral shoulders and elbow position Pressure: genitals, breasts, knees, feet, nose and eyes
42
What are the problems and considerations for patients in lithotomy or Lloyd Davis position?
``` Reduced perfusion to legs Increased venous return Pooling/DVT legs Compartment syndrome legs Pressure: peroneal, sciatic nerves Hips should be >90 degrees to body ```
43
What are the problems and considerations for patients in lateral position?
``` Care with lower shoulder - axillary roll for brachial plexus Front and back support at hips to protect and away from abdomen Support upper arm in neutral position Lower arm in neutral/safe position Pillow between knees Pad lower foot Neutral neck Limited airway access ```
44
What are the problems and considerations for patients in beach chair position?
``` Air embolism Stroke/brain injury hypoxic BP reading inaccurate: head is higher than heart Neutral and strapped head/neck Limited airway access Ensure eyes well taped Arm supports padded and at correct height Sciatic nerve Pooling/DVT in legs Reduced venous return ```
45
What are the problems or considerations when a patient is head down?
Good venous return Good brain perfusion Aspiration protection Reduced ventilation/high pressures Low FRC, atelectasis, V/Q mismatch Likely regurgitation High ICP/IOP
46
What are the problems and considerations for head up positions?
Optimal lung compliance Low CO Brain injury risk DVT/pooling in legs Air manolis M
47
What is the range for a cuff pressure monitor?
14-24 cmh2o | Keep below 30
48
Why are uncuffed tubes better in paeds historically?
The narrowest point of the paed airway is the cricoid cartilage and this is where the cuff sits. If damage occurs then swelling could occur I.e causing narrowing of the already narrowest point!! Small airway means small swelling causes closure. In an adult the narrowest point is the cords and the cuff sits below this therefore doesn't matter so much
49
Why is PCV best for paediatrics?
(12-15cmH2O) Less trauma risk Compensate for a leak around an uncuffed tube
50
What is the chest depth, bpm and joules for CPR?
1/3 chest 100 bpm 200J (360 next shock)
51
What are the differentials to MH?
Sepsis Thyroid storm Drug use Inadequate anaesthesia
52
How do you change gas cylinder?
``` Slowly close valve Release remaining P and close Wipe new cylinder; clean hands Check content via label Ensure cylinder restrained Check regulator valve matches cylinder Remove seal and crack cylinder Check intact heat detection tag Ensure regulator clean and attach it Open slowly to full position then closed one quarter turn ```
53
What is the process for body fluid exposure and needle stick injury?
``` Report to coordinator Wash area with soap and water Obtain testing kit Complete the form Test staff members blood Test patients blood (CONSENT) Complete lab forms for tests - send Complete accident form Entry in patients notes (If known HIV+ contact infectious diseases for prophylaxis) ```
54
What is an example of isbar?
``` Identify Self, patient and site Situation What is going on? (DI) Background Clinical background (op, stats) Assessment What do I think problem is Recommend What I recommend, assign responsibility, any risks ```
55
What are the 10 standard precautions?
``` Hand hygiene Gloves Gown/apron Face protection (mask, goggle) Care with sharps Respiratory hygiene/cough etiquette Environmental cleaning Linen Waste management Reprocessing reusables ```
56
What are three examples of supine?
Mastectomy AAA Appendix
57
What are three examples of lateral?
Lobectomy THJR Nephrectomy
58
What are three examples of prone?
Spinal fusion/decompression Posterior fossa surgery Percutaneous stone removal Achilles' tendon repair
59
What are three examples for beach chair?
Total shoulder replacement Craniotomy ORIF humerus
60
What are three examples of Lloyd Davis?
Hartmans Anterior resection Vaginal hysterectomy
61
What are three examples of lithotomy?
Haemorrhoidectomy TURP Ureteroscopy
62
Draw a circle circuit.
-
63
What is normal Hb?
115-155 g/L
64
What is normal ACT?
80-120 seconds | >480 for bypass
65
What is normal CVP?
0-8 mmHg
66
What is normal glucose?
4-8 mmol/L
67
What is normal INR?
0.8-1.2 The higher the number the thinner the blood
68
10 things to consider for a known MH case.
``` First on list TIVA Remove triggers Flush machine Replace consumables Vapour free filter Keep high flows for 90min MH box in theatre Insert temp probe Team awareness/plan ```
69
10 things to consider for blood administration.
``` Consent X match sent? Correct form complete 2 person checking Product correct, in date, viable Warming Filter Document correctly Rate of infusion Standard precautions:glove, biowaste ```
70
Who is susceptible to latex allergy?
``` Healthcare workers Cerebral palsy Spina bifida Atopic people Allergy to banana, kiwi, avocado ```
71
What are physical indicators?
Part of the steam steriliser | Record readings from inside
72
What are chemical indicators?
Patches/tape which are heat or chemical sensitive and change colour when the conditions are met Eg Bowie Dick in the steam steriliser
73
What are biological indicators?
Inoculated strip on non-pathogenic bacteria with similar life conditions to those harmful
74
What are methods of disinfection?
Thermal wash: Jets of hot water/soap Chemical: Eg glutaraldehyde Pasteurisation: High heat
75
Why hand hygiene before and after glove use?
Maybe punctured Hot and moist hands breed organisms Can contaminate upon removal
76
When do gloves need changing?
Between procedures Between patients When defected When going from dirty to non-contaminated area (patient to drug trolley)
77
Why use gowns or eye protection?
If in close contact occurs When splashes of fluids may occur
78
What are transmission based precautions?
To be used in addition to standard precautions when a patient is confirmed or suspected to be colonised by organisms transmissible via contact, droplet or airborne routes
79
What are contact precautions?
Spread by direct or indirect contact with patient or environment MRSA Scabies Excessive wound drainage Noro or rotavirus
80
What are droplet precautions?
Spread by close respiratory or mucus membrane contact with respiratory secretions Flu Pertussis Meningococcal
81
What are airborne precautions?
Remain infectious over long distances when suspended in air and transmitted by inhaling those airborne particles Chicken pox Measles TB
82
What are isolation precautions?
For patients who are immune suppressed | Eg bone marrow transplant patients
83
What is the PPE for contact precautions?
``` Anti microbial soap or alcohol hand rub Gloves Gown Red linen bag (water soluble liner) Infectious waste - inside room Alert receiving area Disinfect environment ```
84
What is the PPE for droplet precautions?
``` Normal soap or alcohol hand rub Gloves Gown as per standard precautions Surgical mask on entry and exit Red linen bag Infectious waste - inside room Disinfect environment Alert receiving area - pt wear mask ```
85
What is the PPE for airborne precautions?
``` Normal soap or alcohol hand rub Gloves Gown per standard precautions Particulate respirator mask (N95) on prior to entry and remove after leaving Normal linen Normal waste Alert receiving area - pt wear mask Normal environment cleaning ```
86
What is the PPE for protective isolation?
``` Normal soap or alcohol hand rub Gloves Gown as per standard Don't need mask Normal linen Normal waste Alert receiver - pt wear N95 Clean equipment before use ```
87
What are some other points to consider in transmission precautions?
``` Minimise entry/exit Minimum people Minimum equipment Minimise time in the room Have a 'clean' helper ```
88
What is the general rule for where to put on and remove PPE?
Put on outside and remove inside prior to leaving Except for N95 mask Hand hygiene before exit If transporting body fluid, wait and remove in sluice room
89
What is important about the N95 mask?
It must be fitted correctly | Ensure this prior to entering room and do not remove until exited
90
What is the sequence for PPE on?
Gown Mask Goggle Glove
91
What is the sequence for PPE off?
Glove (treat outside of glove as dirty, roll into a ball) Goggles (remove by ends of handles) Gown (unfasten and pull away from neck touching inside only, turn inside out and roll up) Mask (only touch the ties)
92
What solution should be used for cleaning?
Disinfection only required for contact or droplet precautions Use presept or chlorwhite
93
What is MRSA?
Methicillin resistant staphylococcus aureus Skin and mucus mems May cause infected skin lesions Any patient having a procedure should be screened Decolonisation treatment exists Hospital elsewhere within 2 years treated as precautions 3 sets of swabs must be clear (24hr between)
94
What is ESBL?
Extended spectrum beta-lactamase producing organism GI inhabitants Inactivates penicillin Low risk (standard precautions) High/mod risk: any incontinence, stoma, catheter, large wounds, trache Any ESBL klebsiella - high risk
95
What is VRE?
Vancomycin resistant enterococci | Intestine inhabitants
96
What is the age of consent?
Not defined Must be competent and have the capacity to do so and it is assumed that near 16 they are Depends on procedure, risks and maturity of person
97
Why is subtenon better than peribulbar?
More appropriate in long axial length and anticoagulated patients
98
How long should hand hygiene take?
30s ABHR 60s soap and water
99
What's the default P setting for jet vent?
1 bar or 15 psi | 1 bar = 100 kPa (1 kPa = 10 cmH2O)
100
What's the amps for a manual nerve stimulator?
About 70 mA | 30-80 mA in Oxford
101
What can be done if the spinal or epidural for a Caesarian section is not sufficient?
Prior to start: Either re-site an epidural or repeat the spinal. Otherwise try the other technique or GA Intra op: N2O, IV opioid, surgical infiltration or GA
102
Why is GTN useful in obstetrics?
It relaxes the uterus making surgery easier
103
What are the bougee sizes?
14 Fr 10 Fr 6 Fr
104
What is in the sign in?
Lead by anaesthetist Before induction ``` Confirm pt, procedure, site and side Allergies Difficult airway G&S/blood available Special equipment available ```
105
What is in the time out?
Lead by surgeon After position; before incision ``` Team introductions Reconfirm pt, procedure, site and side Correct imaging Other drugs Intra-op DVT prophylaxis Concerns/anticipated events ```
106
What is in the sign out?
Lead by nurse Before patient leaves ``` Count correct Correct procedure recorded Specimens labelled/sent Post operative DVT Equipment issues Concerns for post-op management ```
107
What is in the obstetric sign in?
Lead by anaesthetist after OT arrival (nurse for cat1) ``` Patient confirms ID, procedure, consent Category displayed NICU called Allergies Difficult airway G&S or blood available ```
108
What is in the obstetric time out?
Lead by surgeon before incision Team intro Reconfirm pt and procedure AB given? Concerns or anticipated events
109
What is in the obstetric sign out?
Lead by nurse before pt leaves ``` Counts correct Correct procedure recorded Specimens labelled/sent Post-op VTE prophylaxis Equipment issues Post-op concerns ```
110
How do u fit an N95 mask?
Wash hands Cup in hand and place on face - under chin to nose Top elastic on then bottom one Mould metal around nose With hands covering front of mask perform leak test by breathing out sharply and feeling for any leak around nose or sides. Reposition/pinch nose piece and repeat seal test
111
What is the alternate oxygen control?
Turns on when there is an electronic gas mixer failure. It has an independent pathway via the vaporiser to the circle with gas being controlled by the alternate flowmeter manually. AA may be useable depending on the nature of the failure. Also use in an ASD screen fail Automatic and manual activation
112
What is HIV and the precautions?
Human immunodeficiency virus Transmission via blood/body fluid Standard precautions
113
What is hepatitis and the precautions?
Inflammation of the liver Viral Transmission via blood/body fluid or faeces Standard precautions Contact for type A incontinence
114
What is CJD and the precautions?
Creutzfeldt -Jacob disease Affects brain tissue Transmission via contact with CNS tissue Normal reprocessing; yellow waste; disinfect Mask, glove, apron with yellow gown over, visor
115
What are the common problems with one lung ventilation?
A shunt Hypoxia Adjust settings to optimise O2 and CO2 PEEP to lung to optimise Ongoing hypoxia not appropriate
116
What products cannot be put through the rapid infuser?
Platelets and cryoprecipitate
117
What are arytenoids and faucial pillars?
Arytenoids are cartilage which help cords move Faucial pillars are muscle folds which help swallowing
118
What is bipap?
Bilevel positive airway pressure Set level on pressure on inspiration with less pressure on expiration so expiring is easier
119
What do u need for an epidural?
``` Sterile PPE Spinal tray Skin prep LA, syringe and filter needle Saline 2xIV3000 and mefix ```
120
How is laryngoscope blade cleaned?
Disassembled Thermal wash Autoclave
121
What is hellp?
Associated with pre eclampsia Haemolysis, elevated liver enzymes, low platelets
122
How does Das for obstetrics differ?
RSI 2+1 for plan A Plan B is SAD (Max. 2) or face mask Plan C is CICO (exclude laryngospasm first)
123
What are some factors which determine whether to proceed or wake an obstetric patient?
``` Maternal condition Fetal condition Expertise of anaesthetist Obesity Surgical risks Fasting status ```
124
What are the general steps to Das extubation?
``` Plan Prepare Low risk (awake or deep) or high risk algorithm (Awake only or postpone/Trache) Recovery HDU / ICU ```
125
What does RACE stand for?
Rescue/remove Activate alarm Confine Extinguish/evacuate
126
What is allens test?
To assess arterial supply prior to cannulation Hand is held up and clenched for 30 seconds Both arteries are occluded Hand open - should appear blanched Ulnar pressure released while maintaining radial pressure Colour should return otherwise don't cannulate this radial artery
127
What is on the anaesthetic assistant MH task card?
``` MH box Art line CVL Soda lime Restock drugs ```
128
Trauma set up
See notes
129
Obstetric set up
See notes
130
Paediatric set up
See notes
131
Regional block set up
See notes
132
MH case set up
See notes
133
Write out the MTP algorithm
See notes
134
What is the standard for SOP?
Work within SOP Responsible for the safety of others ANZCA/NZATS Promote quality assurance Practise that protects from harm
135
What is the standard for professionalism?
Responsible for own practice Promote equality Comply with HDC, treaty and cultural needs
136
What is the standard for roles and responsibilities?
Provide dedicated professional, technical and clinical assistance. Work in partnership Systematic approach
137
What is the standard for Professional development?
Be committed to CPD Attend education Member of professional group
138
What are the four nzats standards?
Professionalism SOP Professional development Roles and responsibilities
139
What is critical, semi-critical and non-critical?
Critical: penetrates the skin, membranes or vascular network or parts normally sterile - STERILISE Semi: contact with membranes/body fluid - DISINFECT/STERILISE (ours!!) Non: touched in tact skin only
140
10 considerations for MRSA
``` Last on list Signs outside OT Alert PACU Reduce equipment in room Reduce people in room Get a clean helper PPE on before contact; off before exit Yellow waste Water soluble linen bags Disinfect environment ```
141
What is in a suxamethonium ampoule?
100mg in 2ml | 50mg/ml
142
What is in a atropine ampoule?
600mcg in 1ml
143
What is in an adrenaline ampoule?
1mg in 1ml OR 1mg in 10ml (100mcg in 1ml)
144
Why are the blood universals the way they are?
RBC is O- These have no surface antigens for the recipient to attack Plasma is AB These have no antibodies that will attack the recipient
145
How long can fluids be in the warmer and what's the purpose of the outer packet?
2 weeks To show that it hasn't been tampered with
146
Why is CJD extra concerning and what should be done regarding cleaning?
It has prions which are very hard to destroy Destroy all instruments and consumables
147
What is high vs low level disinfection?
Low level cannot kill mycobacterium High level will kill everything except the spores
148
What's the process for unconsented emergency blood?
Two doctor consent but should attempt to obtain the views of the patient
149
What are the steps to a blood product check prior to transfusing?
Two person check: - Patient ID Wrist bracelet against the consent and product form - Consent Consent is correct and agreed - Blood product Correct patient, product, type, batch number, expiry date and looks good
150
What does the guardian of the box do?
Signs to receive the box on the card attached Checks the forms match the ID on the box Selects products for checking
151
How long do charcoal filters last and what's the flush time for preparation vs crisis?
12 hours Machine preparation flushing is 10 L/min Crisis flows are 15 L/min
152
What are the 'during CPR' considerations?
``` IV/IO Airway adjunct Oxygen Capnography Minimise interruption ```

Anaesthesia (8 decks)

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