FINAL ASSESSMENT Flashcards
(240 cards)
1
Q
Difficult intubation
A
External anatomic features
• ↓ Head/neck movement (atlanto-occipitaljoint)
• Jaw movement (temporo-mandibular joint), mouth opening, and subluxation of the mandible
• Receding mandible
• Protruding maxillary incisors
• Obesity
2
Q
Other Predictors
A
Thyromental distance • Sternomental distance • Visualization of the oropharyngeal structures • Anterior tilt of the larynx • Radiographic assessment
3
Q
Mouth opening predictors of difficult intubation
A
A mouth opening (distance between incisors) limited to 3.5 cm or less will contribute to difficult intubation
4
Q
Other predictors of difficult intubation incision
A
Protruding maxillary incisors can interfere with
laryngoscope placement and ETT passage
5
Q
BAG mask ventilation MOANS
A
Mask seal Obese Age No teeth Snores or stiff
6
Q
LEMON Laryngoscopy and intubation
A
L: Look externally ➢ E: Evaluate 3-3 (3 fingers between teeth, 3 fingers chin-neck to thyroid notch) ➢ M: Mallampati class ➢ O: Obstruction ➢ N: Neck mobility
7
Q
Predictors of a Difficult Airway
A
➢ High Mallampati Classification ➢ Small mouth opening ➢ Prominent Incisors ➢ Thyromental Distance <6 cm ➢ Decreased neck extension ➢ Neck Circumference
8
Q
Predictors of Difficult Face Mask Ventilation
A
➢ Age >55 y.o. ➢ BMI >26-30 kg/m2 ➢ Beard ➢ Snoring ➢ Lack of teeth ➢ Mallampati III or IV ➢ Limited mandibular protrusion
9
Q
What is the Single most important predictor for both Difficult mask ventilation and difficult intubation
A
Limited mandibular protrusion
10
Q
Predictors of Impossible Face Mask Ventilation
MBONM
A
➢ Male ➢ Beard ➢ Obstructive Sleep Apnea ➢ Mallampatie III or IV ➢ Neck radiation changes
11
Q
Awake fiberoptic intubation can be performed
A
without atlanto-occipital extension
12
Q
What can be left in place with awake fiberoptic intubation
A
Any head and neck stabilizing device can be left in place to prevent movement of c-spine
13
Q
Awake intubation should be the technique of choice when?
A
if there is any reason to believe that maintaining a patent airway after induction of anesthesia may be difficult
14
Q
Tracheal intubation in patients with an
A
unstable neck should be done with extreme caution.
15
Q
Avoid movement that can
A
cause spinal cord compression and damage
16
Q
Most conservative approach when difficult airway is
known or suspected
➢ Be careful
A
Awake intubation
➢ Must explain to the patient and coach through the
procedure
–> with sedatives
17
Q
Topical anesthesia is the
A
KEY to successful awake intubation
18
Q
During awake intubation, important to use
A
Important to use glycopyrrolate to dry mucous
membranes prior to topical LA (at least 20 min before)
19
Q
To numb airway
A
➢ Nebulized LA, LA swish and swallow, LA spray
(hurricane spray), bilateral lingual nerve block, superior
laryngeal nerve block, transtracheal LA injection
20
Q
Awake vs sleep intubation
A
Consider presence of at least 3 factors predictive of difficult or impossible to mask ventilate
21
Q
COPD can lead to
A
Possible right-sided failure, cor pulmonale
• Peripheral edema
• Increased hepatojugular reflux
22
Q
Can lead to cor pulmonale
A
COPD
23
Q
Chronic Instrinsic pulmonary disorder In late stages, signs
A
signs of right ventricular failure/cor pulmonale
24
Q
Treat cor pulmonale
A
– diuretics, dig, oxygen
25
Interpreting pulmonary funcitons: CLASS
FEV/FVC = <0.8 (80%)
26
Restrictive FEV/FVC
Both reduced, ratio is normal or high
27
Obstructive FEV/FVC
Low ratio , less than 70%
28
FEF25–75%:
forced expiratory flow over the middle one-half of the
| FVC
29
FEF 25-75% is the
Average flow from the point at which 25% of the FVC has been exhaled to the point at which 75% of the FVC has been exhale
30
VC, TLC, RV in restrictive
Decreased
31
Signs of EARLY asthma attack
Alteration of expiratory plateau on capnography
32
Adventitious lung sounds
Crackles (rales)
■ Wheezes
■ Friction rubs
■ Rhonchi
33
What is crackles
| – Late = pneumonia, CHF, atelectasis
Series of individual clinking or popping noises in an area
34
May sound like hairs rubbing together, Velcro, or a
| crumpling piece of cellophane
Crackles
35
Sounds are caused by opening of small airways or alveoli that have been collapsed or decreased in volume during expiration because of fluid, inflammatory exudate
Crackles
36
Heard in both phases of resp
Crackles
37
Chronic bronchitis and crackles.
– Early inspiratory/expiratory crackles =
38
Fine vs. coarse
Fine Crackles =
–
brief, discontinuous, popping lung sounds that
| are high-pitched
39
– Wood burning in a fireplace
Fine crackles
40
Coarse Crackles =
discontinuous, brief, popping lung sounds
41
Compared to fine crackles , coarse =
louder, lower in pitch, last longer
42
Bubbling sound, rolling strands of hair between fingers near ears?
Fine crackles
43
Can be inspiratory or expiratory
Wheezes
44
■ High-pitched continuous sounds that are generated by airflow through narrowed airways
Wheezes
45
Caused by airflow obstruction from edema, smooth muscle constriction, secretions
Wheezes
46
Low-pitched wheezes
– Continuous in both phases
| – Snoring, gurgling, rattle-like quality
47
■ Occur in bronchi!
Rhonchu
48
■ Most commonly used to describe sounds generated by secretions in airways, usually clear after coughing
Rhonchi
49
Can also be used to describe coarse crackles from airway secretions
Rhonchi
50
Sound generated by inflamed or roughened pleural surfaces rubbing against each other during respiration (both phases)
Pleural rub
51
■ Series of creaky or rasping sounds heard during inspiration & expiration
Pleural rub
52
– Sounds like cat purring, walking on fresh snow
Pleural rub
53
Caused by inflammatory disease: pneumonia or pulmonary infarction
Pleural rub
54
– Not cleared by coughing
Pleural rub
55
– Localized, may be transient
Pleural rub
56
Pleural rub stops when_______if it continues.
holding breath, if it continues, it might be a pericardial friction rub (pericarditis!)
57
Stridor mostly
Inspiratory
58
Stridor associated with
Epiglottis
Foreign body
Laryngeal edema and croup
59
```
Lung Sounds (B, V, BV)
– Vesicular
```
– inspiration/expiratory ratio of 3 to 1 or I:E of 3:1
60
■ Over most of both lungs (V, B, BV)
Vesicular
61
■ Inspiratory sounds last longer then expiratory (V, B, BV)
Vesicular
62
■ NORMAL Soft sound with relatively low pitch (B, V, BV)
Vesicular
63
Mixture of the pitch of the bronchial breath sounds
heard near the trachea and the alveoli with the vesicular
sound (B, V, BV)
Bronchovesicular
64
Inspiratory & expiratory almost equal (V, B, BV)
Bronchovesicular
65
– Medium intensity(B, V, BV)
| – Medium pitch
Bronchovesicular
66
– Heard between scapula & in 1st & 2nd interspaces
| anteriorly (B, V, BV)
Bronchovesicular
67
Abnormal in the lung periphery and may indicate an
| early infiltrate or partial atelectasis (B, V, BV)
Bronchovesicular
68
– Hollow, tubular(B, V, BV)
Bronchial
69
– Expiratory sounds last longer than inspiratory (1:3)(B, V, BV)
Bronchial
70
```
Loud intensity (B, V, BV)
– High pitch
```
Bronchial
71
Normal over trachea (B, V, BV)
Bronchial
72
```
Bronchial breath sounds other than close to the trachea
may indicate (B, V, BV)
```
pneumonia, atelectasis, pleural effusions
73
Distinct pause between I/E (B, V, BV)
Bronchial
74
Vital Capacity in obstructive
Normal or decreased
75
TLC in obstructive
Normal or increased
76
RV in obstructive
Increase
77
FEV/FVC
Decreased
78
Maximum midexpiratory flow rate
Decreased
79
Maximum breathing capacity
Decreased
80
Primary Survey
```
A – Airway with C-spine
B – Breathing
C – circulation with hemorrhage control
D – disability
E – Exposure / Environment
```
81
Secondary Survery
```
A – allergies
M – medications
P – past medical history
L – last meal
E – events/environment related to injury
```
82
Even in smokers with no chronic lung
| disease
smoking increases carboxyhemoglobin levels, decreases
| ciliary function, increases sputum production, stimulates CV system
83
Smoke-free interval of
12-18 hours shows significant declines in carboxyhgb & normalization of oxygen-HGB dissociation curve
84
CO Hb < 15-20
Headache, dizzins and occasional confusion
85
CO Hb 20-40
N/V, disorientation and visual impairment
86
CO Hb 40-60
Agitation, combativeness, hallucinations, coma, and shock
87
CO Hb > 60
Death
88
Early complications
```
Carbon monoxide poisoning
Airway obstruction
Pulmonary edema
1-5 days post-injury
ARDS
```
89
Late complications
Pneumonia
Atelectasis
Pulmonary emboli
90
Tension pneumothorax
Immediate threats to life=>Tension pneumothorax
91
Pneumo and CXR
No time for CXR!
92
Tension PNeumo Treatment:
14 gauge angiocatheter at 2nd intercostal midclavicular line or 4th intercostal midaxillary line
93
Anesthesia Considerations for Burns
No easy way to induce – slow & steady
94
Hypovolemia and/or depleted catecholamines
lead to hypotension with all agents
95
Burns and succ
No succinylcholine after 1st 24 hrs, and for up to 2
| yrs
96
Burn pts and NDNMB
are resistant to nondepolarizers
| Up to 5X normal dose!
97
Opioid requirements and BURNS
increased
98
Regional and
is an option unless electric burn
99
Cardiac Tamponade
Beck’s triad
Electrical alternans
May need to drain under local before general
induction
100
Beck's Triad
JVD, Hypotension, Muffled heart sounds
101
C-collar
Manual in-line stabilization – 2 people
No traction
2nd person will stabilize both shoulders
Remove anterior C-collar
102
C-Collar 1 person
1 person stabilizes and aligns head in neutral position
| WITHOUT cephalad traction
103
Greater than 1 MAC
increase CBF , • Ketamine, > 1 MAC volatiles
104
Normal ICP =
5-15 mm Hg
105
ICP waveform Lundberg A wave
“plateau waves”
| Worst
106
ICP waveform Lundberg B wave
Sharp, brief
107
ICP wavefrom C wave
Benign
108
o CBF and CBV
1mm Hg increase = 2ml /100g/min increase in CBF
109
o PaO2 below 50 =
vasodilation = increase in CBF
110
Increase ICP Meds:
mannitol, Lasix, corticosteroids, acetazolamide,
111
Central neurogenic hyperventilation –
spontaneous and severe, PaCO2 may decrease to less than 20 mm Hg
112
Related to
cerebral thrombosis, embolism, or closed head injury
113
Ataxic breathing (Biot’s breathing)
completely random pattern of tidal volumes related to disruption of medullary neural pathways by trauma, hemorrhage, or compression by tumors
114
Apenustic breathing –
prolonged end-inspiratory pauses maintained for as long as 30 seconds, related to lesions in the pons or basilar artery infarct
115
Cheyne-Stokes –
breaths of progressively increasing and then decreasing tidal volume (crescendo-decrescendo pattern), followed by periods of apnea lasting 15-20 seconds related to basal ganglia or cerebral hemispheres brain injury
116
Central neurogenic hyperventilation –
spontaneous and severe, PaCO2 may decrease to less than 20 mm Hg Related to cerebral thrombosis, embolism, or closed head injury
117
Post hyperventilation apnea –
awake apnea following moderate PaCO2 decreases related to frontal lobe injury
118
Brain compression and its signs and symptoms
(pupils, movement, posturing, etc)
119
• Patients with diffuse brain dysfunction
above the level of the diencephalon will react with purposeful or semi purposeful movements toward the painful stimulus
120
• Decorticate responses to pain includes
flexion of elbows, adduction of the shoulder, and extension of the knee and ankle = diencephalic dysfunction
121
• Decerebrate responses include
extension of the elbow, internal rotation of the forearm, and leg extension = more severe brain dysfunction
122
• No response =
pontine or medullary lesions
123
Chiari malformation =
displacement of the cerebellum
| s/s = HA extending to shoulders/arms, pain w/ coughing/ head movement, syringomyelia
124
Chiari Class 4 –
cerebellar hypoplasia, no displacement of posterior fossa content
125
Chiari Class 2 –
displacement of cerebellar vermis
126
Chiari Class 1 –
displacement of cerebellar tonsil down over cervical spinal cord
127
Chiari Class 3 –
displacement of cerebellum into occipital encephalocele
128
Forces that affect cerebral blood flow
```
CMRO2
ICP
Drugs
CPP
PaCO2-Pao2 tension
Intracranial anomalies
CO
SNS and PNS
Cerebral autoregulation
```
129
Brain herniation 3 =
tonsillar herniation
130
Brain herniation 2 =
transtentorial (uncal) herniation
131
Brain herniation 4 =
bad day = transcalvarial
132
Valve lesions and their corresponding murmurs
MS –Apex, holodiastolic decrescdeno with opening snap , tx – maintain preload, avoid tachy and acidosis
133
MR –
pansystolic murmur
134
AS –
systolic crescendo decrescendo
135
AR –
early diastolic decresncdo murmur
136
PS –
crescendo decrescendo, increases with deep inspiration
137
PR –
decrescendo diastolic murmur
138
TR –
pansystolic highpitched increases with inspiration
139
TS –
diastolic
140
Accentuated S1
| Mild mitral stenosis
* Shortened PR interval
| * Leaflets have less time to drift back together; forced shut from wide distance
141
Accentuated S1 which stenosis
Mild mitral stenosis
142
Accentuated S1 and blood flow
• Impeded flow → prolonged diastolic pressure gradient → keeps leaflets farther apart during late diastole → loudly forced shut from far apart during systole
143
* High CO states or tachycardia
| * Shortened diastole, less time to drift back together
Accentuated S1
144
• Diminished S1
• Lengthened PR interval
145
• More time to float back together before systole • Mitral regurgitation
Diminished S1
146
Leaflets do not fully come together when they close •
Diminished S1
147
Severe mitral stenosis
Diminished S1
148
• Higher than normal ventricular pressure at end of diastole → leaflets drift together more rapidly → close from a smaller than normal distance during systole
Diminished S1
149
• Leaflets are nearly fixed in position • Stiff left ventricle
Diminished S1
150
Abnormalities in S2
| Intensity =
velocity of blood flow toward valves with sudden arrest by closing valves
151
Diminished S2
Severe AS or pulmonic stenosis → valve nearly fixed in position = Dim S2
152
Accentuated S2
Systemic HTN/Pulmonary artery HTN → greater diastolic pressure → increased velocity of blood flow
153
Abnormal splitting patterns of S2: A2 and P2
widened, fixed, paradoxical • Widened
| Increased time interval between A2 and P2; noticeable even during expiration and becomes wider on inspiration
154
Abnormal splitting patterns of S2
Delayed closure of pulmonic valve (RBBB)
155
Occur shortly after S1 and coincide with opening of aortic/pulmonic valves
Ejection clicks
156
Presence of aortic/pulmonic valve stenosis or dilatation of pulmonary artery or aorta Sharp, high-pitched
Ejection clicks
157
Mid/late extra systolic heart sounds
Usually from systolic prolapse of mitral or tricuspid valves
158
Ejection Click: Leaflets bulge abnormally from
ventricular side of the AV junction into the atrium during ventricular contraction
159
Commonly associated with valvular regurgitation
Extra diastolic heart sounds: opening snap (OS), third heart sound (S3), fourth heart sound (S4), pericardial knock
160
Commonly associated with valvular regurgitation
Extra diastolic heart sounds: opening snap (OS), third heart sound (S3), fourth heart sound (S4), pericardial knock
161
early diastole following opening of AV valves during ventricular filling due to tensing of chordae tendineae during rapid filling/expansion of ventricle
S3 (ventricular gallop
162
Normal in children and young adults, Suggests dilated ventricle (heart failure) or advanced mitral/tricuspid regurgitation in middle- aged/older
S3
163
occurs late in diastole coinciding with contraction of the atria and flow of blood into a stiffened ventricle (CAD)
S4 (atrial gallop)=
164
S4, S1, S2, S3 Tachycardia →
shortened duration of diastole, S3 and S4 coalesce = summation gallop
165
Pericardial knock
Seen in severe constrictive pericarditis
Appears early in diastole after S2
High-pitched
166
Quadruple rhythm/summation gallop
S4 (atrial gallop)=
167
Eye opening response
```
4 = spontaneous
3 = to verbal command,speech shout
2 = to pain (not applied to face)
1 = NO eye openin g
```
168
Verbal response
5= Oriented
4= Confused converstation, but able to answer questions
3= Inappropriate responses, words discernable
2= Incomprehensive sounds or speech
1=NO verbal response
169
3 areas Glasgow Coma scale measure
Eye opening
Verbal response
Motor response
170
Motor Response
6=obeys commands for movement
5= purposeful movement to painful stimulus
4=Withdraws from pain
3= Abnormal flexion, decorticate posture2=
2= Extensor rigid response, decerebrate posture
1= NO motor response
171
Trunk burn %
9%
172
Back burn %
9%
173
Legs each burn %
9%
174
Arms each back and front burn %
4%
175
Head front and back burn %
4 1/2%
176
Penis or genital burn %
1%
177
Right axis Deviation RALeftPO
Right axis deviation
Acute R heart strain
Left Posterior Fascicular Block
178
Left Axis Deviation
Inferior wall MI
Left anterior fascicular Block
Left axis deviation
179
Ataxic Biot breathing location
MEdulla
180
Pattern of ataxic
Unpredictable sequence of breaths varying in rate and tidal volume
181
Apneustic breathing location
Pons
182
Pattern of Apneustic
Gasps and prolonged pauses at full inspiration
183
Cheynes stokes breathing
Cyclic crescendo-decrescendo tidal volume pattern interrupted by apnea
184
Cheynes stokes breathing pattern
Cerebral hemispheres
185
Cheynes stokes breathing what conditions
CHF
186
Central neurogenic hyperventilation Pattern
Marked hyperventilation
187
Site of lesion/conditions with neurogenic hyperventilation pattern
Cerebral thrombolism
| Embolism
188
Post hyperventilation apnea breathing
Awake apnea following moderate decreases in PaCo2
189
Location of post hyperventilation apnea
Frontal lobes
190
Region of compression : Diencephalon
| pupillary examination
Small pupils ;reactive to light
191
Region of compression : Diencephalon
| response to oculocephalic or cold caloric testing
normal
192
Region of compression : Diencephalon
| Gross motor findings
Purposeful semi-purposeful or DECORTICATE (flexor ) posturing
193
Region of compression : Midbrain
| Pupillary examination
Midsize pupils; UNREACTIVE To light
194
Region of compression :Midbrain
| response to oculocephalic or cold caloric testing
May be impaired
195
Region of compression : midbrain
| Gross motor findings
Decerebrate (extensor) posturing
196
Region of compression : PONS or MEDULLA OBLONGATA
| Pupillary examination
Midsize pupils: UNREACTIVE TO LIGHT
197
Region of compression : PONS or MEDULLA OBLONGATA
| response to oculocephalic or cold caloric testing
Absent
198
Region of compression : PONS or MEDULLA OBLONGATA
| Gross motor findings
No response
199
Systolic ejection murmurs associated with
Aortic stenosis
| Pulmonic Stenosis
200
Aortic stenosis murmur characteristics
Radiates to the neck
201
Pansystolic mumur is associated with
MR and TR
202
Mitral Regurgitation murmur characteristics
Location at apex and radiates to Axilla
203
Tricuspid Regurgiation murmur characteristics
Left Lower sternal border--> R Lower sternal border
204
Late systolic associated with
MVP
205
MVP murmur at
Apex radiates to Axilla
206
Early diastolic murmur are
Aortic Regurgitation
| Pulmonic Regurgitation
207
Mid to late systolic
Mitral stenosis
208
Mitral stenosis heard at
Apex
209
CVA risk factors : Systemic Hypoperfusion
Hypotension
Hemorrhage
Cardiac arrest
210
CVA risk factors : Embolism and Thromboembolism
| MIS PDW
```
Male gender
Ischemic heart disease
Smoking
Peripheral vascular disease
Diabetes Mellitus
White race
```
211
CVA risk factors : Subarachnoid hemorrhage and Intracerebral hemorrhage
```
Often none
HTN
Coagulopathy
Drugs
Trauma
```
212
'OFTEN NONE" risk factors
SAH
213
Early phase of burn CV System
Increase HR,Increase PVR and SVR
Decrease CI
Decrease SV
Decrease contractility
214
LATE phase of burn CV System
```
Increase HR, Increase CI
Normal or Increase SV
Decrease SV
Decrease contractility
Decreased SO2
```
215
Early Phase of burn: Blood
Increase hematocrit
216
Late Phase of burn: Blood
Decrease Hematocrit
217
Early Phase of burn: Lungs
Pulmonary Edmea
Bronchospasm
Bronchorrhea
218
Late Phase of burn: Lungs
Pneumonia
ARDS
Atelectasis
219
Early Phase of burn: Kidneys
Myoglobinuria
Oliguria
Fena <1%
220
Late Phase of burn: Kidneys
Increase GFR
| Decrease Tubular Function
221
Both Early and LATE Phase of burn: Brain
Possible Cerebral Edema
Increase Pain response
Altered mental status
222
Early Phase of Burn : Endocrine and metabolic function
Increase aldosterone and Cortisol
223
Late Phase of Burn : Endocrine and metabolic function
Increase insulin resistance
Increase O2 consumption and Co2 production
Muscle catabolism
224
Left axis deviation is
< -30 degrees
225
Moderate left axis deviation
30-45 degrees
226
Marked degrees
-45 - (-90 degrees)
227
Broached Notched R or slurred R waves in lead
LBBI, aVl, V5 and V6
| Occasional rS pattern in V5 and V6 or V1
228
Right Axis deviation
> + 90
229
Right axis deviation moderate
90-120 degrees
230
Right axis Marked
120-180 degrees
231
Rhythm common under anesthesia
Junctinal escape rhythm
232
V3, V4
Anterior LAD
233
V1, V2
Septal LAD
234
II, III, aVF
Inferior RCA
235
I, aVL, V5, V6
Lateral Circumflex only V6 is just lateral
236
Axis when Lead I and AvF upright
normal axis
237
Axis when lead I up and avF down
Left axis
238
Axis when lead I Down, and AvF up
Right Axis
239
Predictors of difficult video laryngoscopy
* Scarring
* Radiation
* Masses
* Large neck circumference
* TMD < 6 cm
* Limited neck mobility
* Operator experience
240
Brain Herniation 1
Subfalcine (cingulate) herniation
