FINAL SCHMIDT EXAM Flashcards

Question

Why are there camps on tall mountains along the way to the summit?

Answer 1

Acclimatization to different altitudes

Answer 2

Hyperventilate initially Over a few days: expansion of hematocrit to help with oxygen delivery in low pressure environments.

Answer 3

Significantly more surface area for gas exchange in the lungs d/t more alveoli compared to someone who grew up around sea level. This is why these people are good at running marathons at sea level.. they have a huge advantage due to the increased surface area for gas exchange.

Answer 4

Kenya Ethiopia

Answer 5

Might not be in the best shape, but won't seem much different than anyone else. (because we have about 3x more lung area than we really need over the course of our life).

Answer 6

Normally is the heart, NOT the lungs. We have about 3x more lung area than we really need over the course of our life.

Answer 7

You don't. You find out when you're up there. If you find out you have altitude sickness, just don't go up the mountain. Some people elect to go up anyway and die.

Answer 8

Death valley (fun fact it's actually the shores of the Dead Sea, but that's not important for the class) This is the highest barometric pressure on earth (above water)

Answer 9

Magnifies increase in barometric pressure as water is heavier than air so more weight is above you

Answer 10

Divide the depth by 33ft, and add 1ATM to the result. i.e. 400/33 =12.121 +1 = ~13x greater atmospheric pressure Another example 166/33=5.0303 +1 = 6x greater atmospheric pressure ^Take this amplification number and multiply by 760 to get your barometric pressure

Answer 11

The entire body We need to breathe through a pressurized gas source such as a scuba tank

Answer 12

To overcome increased barometric pressure around the breather. It's not just pressurized to have more air in the tank, though that is a benefit

Answer 13

A reflection of this high pressure in the blood gas of divers

Answer 14

Nitrogen comes out of solution and becomes little air bubbles.. not immediately fatal, but if a couple bubbles mix and form a larger embolus, you're going to have a bad day

Answer 15

Don't include nitrogen in the inspired gas mixture - will eliminate decompression sickness. BUT Filling a tank with 100% oxygen will result in oxygen toxicity, and also be expensive/explosive

Answer 16

40x (note, this is if you were breathing from 100%) Normal tank? 760mmHg x 16x =12,160 mmHg Subtract 47mmHg for water vapor

Answer 17

V1 – ophthalmic (forehead) V2 – maxillary (upper mouth/nose) V3 – mandibular (mandible)

Answer 18

Base of larynx

Answer 19

10-13cm x a few cm wide

Answer 20

Their thumb width = trachea width

Answer 21

Most of the trachea is intrathoracic, while 4cm is extrathoracic (at the top of the chest in the neck) This means 4cm is extra thoracic, while 6-9cm is intrathoracic

Answer 22

Annular ligaments, which is connective tissue that connects cartilage pieces together

Answer 23

Bends and isn't brittle, won't be broken but it can be crushed. It's resilient

Answer 24

R - 10 L - 8 Note: In the left, we have 4 segments that fuse to make two during development, resulting in 8 adult segments.

Answer 25

Right - the right lung is larger in general

Answer 26

Left mainstem is more narrow and is longer as well @4-6cm. The heart is positioned here, so this mainstem routes air past the heart.

Answer 27

Right mainstem branches immediately

Answer 28

25 degrees

Answer 29

45 degrees - more horizontal

Answer 30

70 degree angle between mainstems

Answer 31

Tracheostomy Cricothyrotomy

Answer 32

any portion of the trachea exposed in the extra thoracic area, so around 4cm

Answer 33

between thyroid and cricoid cartilages at the *median cricothyroid ligament* ^Note this is a little higher than we did on pigs.. maybe this ligament goes deep to the thyroid cartilage and pops up between the thyroid cartilage and cricoid cartilage?

Answer 34

They bypass the beginning of the respiratory system, which bypasses humidification & warming. 50% air goes through the nose normally, so it's important in humidification/warming. In skipping this, the patients lungs can dry out.

Answer 35

Humidify inspired air, especially with longer term procedures.

Answer 36

Extending the neck (putting head back) stretches the trachea, making it longer. Making flexible tubes longer makes them more narrow as well (internal diameter reduced). Putting chin to chest shortens the trachea and makes the diameter larger.. which doesn't help us since we can't intubate people like this.

Answer 37

Sternal notch/angle at the top of the sternum. The balloon should be right under this area within the trachea.

Answer 38

Nasopharynx Oropharynx Laryngealpharynx

Answer 39

Cartilaginous structure that floats in the middle of the neck. It's connected to the hyoid bone superiorly, which is secured/clamped through ligaments and skeletal muscles, specifically the pharyngeal muscles.

Answer 40

Not continuous, C shaped, have a small opening in the back (facing the esophagus)

Answer 41

Helps swallow Helps cough up gunk

Answer 42

"We can put big things in the esophagus!" - Schmidt Makes sense to have a space here to allow for that

Answer 43

The connective tissue in the back of the annular ligament/trachea gets an infolding, which divides the trachea into two areas. This creates a high velocity to get rid of junk we want to get rid of.

Answer 44

We have cilia and goblet cells. Cilia sweep the gunk up, while goblet cells produce mucous. Cilia do a good job, but sometimes you need a good cough to get it all out.

Answer 45

Increases - this is the purpose of the infolding of the annular ligaments when we cough

Answer 46

Thyrohyoid membrane - connects the top of the thyroid cartilage to the hyoid bone.

Answer 47

Cricoid cartilage

Answer 48

Cricoid cartilage

Answer 49

Volcal cords

Answer 50

Transglottis space

Answer 51

Maybe if someone had severe trauma that severed the cricoid cartilage and make it an incomplete ring. Without a full ring, pressure could not be applied.

Answer 52

No, it's not a full ring, won't help

Answer 53

The thyroid cartilage is tilted forward and down, stretching/tensing the vocal cords, resulting in an increase in pitch.

Answer 54

Cords are tightened, making breathing a little harder since there's tension

Answer 55

Rima glottidis OR Rima glottis

Answer 56

#1 Cricothyroid muscle No effect on the rima glottidis Tightens the vocal folds

Answer 57

#2 vocalis muscle None Tightens the vocal folds Similar to the cricothyroid muscle, just a different location.

Answer 58

Thyroarytenoid muscle #3 Closes rima glottidis due to the arytenoid having an axis to swivel/rotate Contraction causes adduction (comes closer together) the vocal cords

Answer 59

Left - spins clockwise Right - spins counterclockwise

Answer 60

Transverse arytenoid muscle #4; think of it as a cylinder that is flexible/bendable Closes the rima glottidis Contraction adducts (makes closer together) the vocal cords Function depends on these structures being flexible*

Answer 61

Posterior cricoarytenoid muscle #5 Connects to the medial posterior side of the cricoid cartilage Contraction OPENS the rima glottidis Contraction abducts the vocal folds, meaning it makes them wider.

Answer 62

Right - clockwise Left - counter clockwise

Answer 63

Only one set of six laryngeal muscles open the vocal folds. That muscle is the Posterior cricoarytenoid muscle.

Answer 64

They have a terrible time breathing d/t not being able to keep the airway open.

Answer 65

Lateral cricoarytenoid muscle #6 Contraction closes the rima glottidis Adducts (brings closer together) the vocal cords when contracted.

Answer 66

Right - counter clockwise Left - clockwise

Answer 67

Better fuel economy as the air is less dense, leading to less friction on the airframe.

Answer 68

Airplanes are pressurized to mimic the conditions at 8,000ft. (Guyton table 44-1)

Answer 69

More pressure = more danger (both in inspired values and explosion)

Answer 70

The barometric pressure is = to that at 8000ft, so oxygen content is still a little lower. Hypoxic pulmonary vasoconstriction will be present. If vessels constrict, the right heart will have to work harder. This can exacerbate lung/heart issues.

Answer 71

There is a metal box filled with chemicals that when pulled, produces heat (exothermic) and oxygen. This oxygen is more concentrated than the environment, which helps you survive until reaching a safe altitude/atmospheric pressure. The bag won't inflate, but has enough oxygen to keep you alive. PS put your mask on before helping other people.. can't help people if you're dead

Answer 72

PO2 29mmHg Gas exchange will happen in reverse (from capillaries to the lower concentration in the cabin), leading to rapid consciousness loss. Sure, can hold your breath, but not for long.

Answer 73

No, they have a compressed 100% oxygen canister with them with a tight mask, providing oxygen + pressurization. This is why facial hair is prohibited in aviation jobs requiring flying pressurized airplanes.

Answer 74

Oxygen is pulled off of hemoglobin

Answer 75

It's an exothermic reaction. If this goes off at a bad time, can cause fire/explosions. All of these metal boxes are next to each other, which further compounds the danger. They need to be maintained regularly.

Answer 76

Compressed atmospheric air, not 100% oxygen. Reasons: Cheap, and it isn't 100% oxygen meaning that there is no risk of explosion or fire.

Answer 77

80% atmospheric pressure = nitrogen At sea level, the partial pressure of N in the alveoli will be = to the partial pressure in the blood. 569mmHg = PaN2 As pressure increases, there is still 80% nitrogen in the blood, which is why at depths the nitrogen concentration gets so high in the blood. Nitrogen gets pushed into the blood.

Answer 78

AMS & coming back to the surface rapidly Rapidly resurfacing = most concerning d/t decompression sickness

Answer 79

Pressures adjust - only way for this to happen is for nitrogen coming out of solution (blood) and forming small air emboli within the circulatory system. Can lead to a very bad day if some of these bubbles combine and travel to the left coronary artery. Some places will tolerate nitrogen, and others are lethal. "That's it for 'ya." - Schmidt

Answer 80

Ascend slowly from the ocean, make it gradual.

Answer 81

Find a Hyperbaric chamber (high pressure environment that releases pressure gradually).

Answer 82

Total recall Nitrogen coming out of solution and going under the skin. Essentially, this is what boiling blood is. ^It's the same as boiling water.. liquid turns to gas, gas escapes the solution

Answer 83

3x atmospheric pressure Military can go much higher, but is very expensive and not really needed.. also dangerous because more pressure = bigger bomb

Answer 84

Oil rigs in the gulf have active divers all the time. Regularly going to deep depths? Might be easier to just live at high pressure so the body doesn't have to adjust between dives. Downside: Expensive (both to build and to ensure practically a bomb on an oil rig).

Answer 85

Treatment of rapid decompression Diabetic wound care (problem with circulatory/immune system)

Answer 86

Uncontrolled blood sugar lead to sticky vessels, and the immune system destroys things that don't need to be destroyed while not destroying actual contaminants. As CV system gets destroyed, the ability to heal woulds gets destroyed as well as oxygen delivery isn't as good. Note that oxygen is required by the immune system. Hyperbaric chambers (or FiO2 100%) can help push air into blood, leading to beneficial oxidative stress. Bacteria/viruses don't have protection available for this, and they die.

Answer 87

Large academic hospitals. They are large, expensive, and are an insurance risk, so smaller hospitals are unlikely to carry these. Luckily, some are portable and can be moved by semi trucks.

Answer 88

Michael Jackson, as quoted by the tabloids/national enquirer

Answer 89

Expensive, not really needed.. Bomb/flammable as well Instead, little bubble head masks are put on each person. Oxygen levels are adjusted within their bubble by a nurse on staff.

Answer 90

Insoluble Hemoglobin

Answer 91

Increase PAO2 (alveolar) with a FiO2 above .21, or use a hyperbaric chamber (more environmental pressure) ^Or both. This extra oxygen is pushed into the dissolved form.

Answer 92

0.30 With general anesthesia, hypoxic pulmonary vasoconstriction and airway reactivity is goofed up. Meaning, some air might be going to areas that won't have good gas exchange. Using a higher FiO2 compensates for the loss of HPV in general anesthesia.

Answer 93

CO2 - can cause problems with vast excess

Answer 94

Superoxide (O2-) Peroxynitrite (OONO-) Hydrogen Peroxide (H2O2) Nitric Oxide (NO)

Answer 95

Has an extra electron that is unpaired and very reactive. This means it can degrade lots of compounds in the body (not great)

Answer 96

Good for relaxing blood vessels Too much in the presence of other compounds? Will form extraordinarily dangerous compounds such as peroxynitrite (OONO-)

Answer 97

Can interact and mutate DNA, damaging cells, and leading to cancer Superoxide (O2-) + Nitric Oxide (NO) = Peroxynitrite (OONO-) ^Note that this won't form if there are small concentrations of superoxide and nitric oxide. This is only a problem if there is a LARGE amount of nitric oxide and superoxide.

Answer 98

Reactive oxygen species (ROS) used as an antiseptic, helps with infections. Body uses this in some places such as macrophages and immune killer cells. These cells generate it and pump it into something it wants to degrade.

Answer 99

Peroxidases

Answer 100

Superoxide dismutase

Answer 101

Acetylcysteine

Answer 102

Reactive oxygen species

Answer 103

"funny" - Schmidt

Answer 104

A supplement used to cut down on liver damage from Tylenol overdose. It is over the counter, but the FDA wants to regulate it and make it prescription only for whatever reason. Good at destroying dangerous oxygen compounds such as superoxide, peroxynitrite, hydrogen peroxide, and nitric oxide.

Answer 105

Overwhelms the livers ability to degrade the toxin that results from CYP450 metabolism of Tylenol. All liver damage is reactive oxygen species (ROS) related. A compound such as N-Acetylcysteine can scavenge the ROS and save lots of liver.

Answer 106

Oldschool way of ventilating someone who doesn't have adequate respiratory muscle. Cylinder with a cap on the end, and a rubber/leather diaphragm that fits around the patients upper body/neck. This creates a pressure seal between the tank and the environment. The diaphragm of the iron lung is pulled outward, creating a negative pressure, which sucks air into the patients mouth/lungs assuming the airway is open.

Answer 107

1960s with polio, which is an infection that destroys the ability of the nervous system to communicate with skeletal muscle (which is needed to breathe).

Answer 108

Less trauma, and is closer to how the body normally works as opposed to PPV

Answer 109

Note: He said we don't need this, but just throwing it out there.

Answer 110

Respiratory quotient/respiratory exchange ratio, which is a ratio of how much O2 is used and how much CO2 is produced. It's not 1 for 1, but is close.

Answer 111

Arterial PCO2

Answer 112

Christopher Reeves, he has a trach with PPV, he died in a couple years from pulmonary problems as a result from PPV. Meanwhile, our Polio man on the left lived in his iron lung for 40-50 years. He was the last known living iron (lung) man living in Dallas. He was at parkland and obtained a law degree while inside the iron lung, where he then practiced as a lawyer. Spare parts were a problem.

Answer 113

Diaphragm contracts, reduces pleural pressure, and the walls of the lungs are pulled closer to the chest wall, or down when the diaphragm drops. This pulls air in in an even manner.

Answer 114

Alveoli closest to the superficial border of the lung will fill first because they're closer to the negative pressure that is pulling air into the lung. This results in deeper alveoli getting stretched out mores than the more superficial alveoli.

Answer 115

Alveoli closest to the large airway are filled first, while deeper alveoli push on alveoli between them and the border of the lungs, resulting in less air being in the deeper alveoli. This is the reverse of normal breathing.

Answer 116

PPV is mobile, while the iron lung is fixed. That being said, the iron lung is closer to normal breathing.

Answer 117

Mobility issues + comfort issues

Answer 118

7.4 7.35 - 7.45

Answer 119

Hydrogen activity (or αH+; stands for proton activity) Increase in hydrogen activity = increase in acidity

Answer 120

Concentration of hydrogen. Normally body is relatively dilute when it comes to free protons

Answer 121

It can go airborne

Answer 122

CO2 in the gas form

Answer 123

Water is everywhere in the body. CO2 can combine to form carbonic acid.

Answer 124

Example: HA = H2CO3; H being hydrogen; HCO3- being A- Proton has a positive charge A- has a negative charge A- can recombine with a proton, meaning that it is a BASE

Answer 125

Dissociate into acid and conjugate base easily. Strong acids like donating protons. Process of donating protons involves dissociation. Strong acids produce lots of protons, causing lots of potential damage to the body.

Answer 126

They want to donate them. Very weak conjugate base

Answer 127

Weak - it doesn't want to grab onto protons, just wants to donate it. Example is HCL dissociating into Cl and H. Cl doesn't want to accept protons and would rather donate it, making it a weak conjugate base.

Answer 128

Strong conjugate base - it wants to accept protons.

Answer 129

Strong Example: Carbonic acid (weak) dissociating into H+ and bicarbonate (strong Conjugate base)

Answer 130

Weak acid, because it's everywhere that water is. This means it always has the chance to combine with water and form carbonic acid.

Answer 131

Only one carbonic acid per 1,000 CO2 molecules. Carbonic acid either moves into CO2 or Bicarbonate/proton phase quickly. It's short lived. However, it is also quickly replenished by CO2 in the environment.

Answer 132

CO2 quickly combines with water in the area and replaces carbonic acid (depending on which way this equation is running). This is why we can think of CO2 a weak volatile acid.

Answer 133

No, however it can rapidly form carbonic acid which is HA (donates proton), resulting in bicarbonate production

Answer 134

Sulfuric acid Phosphoric acid Ascorbic acid Hydrochloric acid Lactic acid Salicyclic acid

Answer 135

Phosphorate

Answer 136

Salicylate

Answer 137

Can't directly turn into CO2 and be removed from the body. Kidney can take care of it or liver can turn it into something more useful.

Answer 138

Not normally. If we're unhealthy, we might produce a lot.

Answer 139

Production of non volatile acids typically involves breakdown of food, specifically protein. A low protein diet results in lower non volatile acid production.

Answer 140

small Low protein diets are one of the only things that can cause a large change in how the body works with a small behavior change. Low protein leads to less non volatile acid production You can try to be healthy and eat better, but it won't fix the underlying problem. Eat all the ice cream you want

Answer 141

Acetoacetic acid Butyric acid

Answer 142

- poor glucose management with DM - lots of alcohol consumption

Answer 143

Body can't process sugar, so different metabolic pathways are used. Acetoacetic acid is the product of that reaction.

Answer 144

Acetone; AKA, that diabetic smell

Answer 145

Alcohol is broken down in the liver by alcohol dehydrogenase. Acid aldehyde and acetoacetic acid is the byproduct. This is what makes you feel like shit after drinking too much.

Answer 146

In poor health, i.e. poorly managed DM

Answer 147

Yes - they are all proton donors. However, metabolism and removal have to be dealt with by the kidney mostly, sometimes the liver.

Answer 148

HCl Hydrochloric acid

Answer 149

Weak base - Sodium/Potassium fluoride (toothpaste; used to buffer the pH in our mouthes to prevent acid wearing out our teeth) Strong base - NaOH (sodium hydroxide); main component of drain cleaner, which is very toxic when ingested. People drink this for whatever reason

Answer 150

Vinegar Carbonic acid

Answer 151

Normal amount of protons interacting with negatively charged areas on a protein (7.4 pH)

Answer 152

Shape of protein changes, won't have a normal function Hemoglobin: The more protons that attach to Hemoglobin leads to a change in the shape, which causes oxygen to fall off (right shift on OxyHb dissociation curve)

Answer 153

Bohr effect

Answer 154

Extra protons associate with the protein, changing the structure, which slows down function of the pump. This results in K not being able to be pumped into the cell, leading to hyperkalemia.

Answer 155

Na/K ATPase pump (uses the most ATP out of anything in the body)

Answer 156

There is a class of ATPase that produces ATP within the mitochondria. They harness the electron transport train, turning energy from oxygen into ATP. This spins the ATPase pumps, which produces lots of ATP. Acidosis slows this process, which results in a reduction of ATP. The Na/K ATPase pump requires ATP to function. As a result of low levels of ATP, the Na/K ATPase pump will slow down as well, resulting in hyperkalemia and further acidosis.

Answer 157

pH of the environment

Answer 158

Increase in respiration Decrease in respiration - tissue won't work anymore

Answer 159

1; gastric acid

Answer 160

Strong base Infuse/give it slow because it's painful if you give it too fast. Easy way to remember this... phenobarbital=Peanutbutter ball You wouldn't want to chew on a large ball of peanut butter all at once, so need to take it slow.

Answer 161

Hydrochloric salt is packed into drugs to help with distribution/absorption of the drug

Answer 162

pH = -logF

Answer 163

1-14 6.9-7.8

Answer 164

Thick leathery tough lining specialized to produce/be resistant to acid

Answer 165

Pancreas (specifically the secretions) The pancreas outlet is right after the stomach empties into the duodonum.. neutralizes gastric acid so we ain't shittin' fire. Bowel is soft and fragile.

Answer 166

Metabolic acidosis - lose lots of bicarbonate that the pancreas produces

Answer 167

Pancreatic fluid Gastric content pH = 1 Pancreas conent pH = 8 This is not a 1:1 fix - need a lot more pancreas secretions to neutralize a pH of 1 and get it all the way to 7.4.

Answer 168

Person will eat, but just vomit it right back up since it can't go the other way.. constant vomiting results in loss of acids, which will lead to metabolic alkalosis

Answer 169

Logarithmic Meaning that for every one point of pH, the change is 10x for example just a basic log scale 1= 1 2 = 10 3 = 100 4 = 1,000 and so forth It looks at 1 x 10(to a certain power) For example, gastric acid with a pH of 1? 1x10(-1 superscript) = [H}] mols This will give you 0.1mol/L, which is the concentration of protons in 1L aqueous solution.

Answer 170

Strong - more likely to have a proton fall off Weak - less likely to have a proton fall off ^When a proton falls off, a conjugate base remains.

Answer 171

Strong acid - weak conjugate base because the proton doesn't want to combine with the conjugate base Weak acid - strong conjugate base because the proton wants to combine with the conjugate base

Answer 172

B- + H+ -> HB B- being a base H+ being a proton HB being a conjugate acid

Answer 173

Strong base - very likely to combine with protons Weak base - less likely to combine with protons

Answer 174

Strong base - weak conjugate acid because it doesn't want to donate the proton Weak base - strong conjugate acid because it wants to donate protons

Answer 175

Buffers (Bicarb, Proteins [Hb], Phosphates) H buffer - releases protons into the environment to help lower pH if there was a loss of protons (i.e. vomiting) This keeps our pH stable

Answer 176

No. Protons must be free and unbound to count toward acidity. Proton activity is considered low if protons are bound to proteins.

Answer 177

1 - Bicarbonate 2 - Proteins (Hb) 3 - Phosphates (Important plasma buffer despite concentration)

Answer 178

6.9-7.8 can be survived for a short period.

Answer 179

1 x 10(-6 superscript) = 0.000001 mol/L Convert to nmol by multiplying by 1,000,000,000 OR 1 x 10(9 superscript) This works out to be this (1 x 10(9 superscript)) x (0.000001) = 1,000nmol/L

Answer 180

It is cut in half, which impacts how all chemistry in the body works. Similar to cutting the BP in half - not great. Changes in pH lead to dramatic changes in proton concentration as it is a logarithmic scale.

Answer 181

Around the buffers pKa value.

Answer 182

Well, he doesn't really say.. but, it's very effective in preventing acidosis which works great because we are more concerned about acidosis than alkalosis.

Answer 183

Multiple pKas from multiple types of buffers, all of which working with/on the same pool of protons that are available to other buffers at the same time. Combined activity of buffers are much greater than any individual activity would ever be.

Answer 184

Depending on pH, they can accept or donate protons to keep the pH of the system stable.

Answer 185

Bicarbonate Proteins (Hemoglobin) Phosphate buffering system

Answer 186

Phosphate is the most important intracellular buffer, found in abundance within the cell. Used for energy storage (ATP) Despite the lack of concentration in ECF, it is an important pH buffer.

Answer 187

Used Created/released

Answer 188

Phosphorylation/dephosphorylation

Answer 189

Lungs ability to get rid of CO2. Think of the lungs as a buffer. Without proper lung function, other buffers have to work harder, resulting in poorer pH management.

Answer 190

Bicarbonate

Answer 191

Lungs getting rid of CO2 is more important. Think of the lungs as a buffer. Without the lungs, other buffers have to work harder resulting in poorer buffer function and worse pH management.

Answer 192

Other buffers have to work harder, resulting in worse buffer function and poor pH stability

Answer 193

7.4 pH 40mmHg CO2 24 mmol/L bicarbonate (this is our normal)

Answer 194

Point A, which is around 37-38mmol/L Bicarb High bicarbonate levels = low proton levels

Answer 195

More CO2 results in more bicarbonate being produced through carbonic anhydrase. Not enough to solve acidosis, but it helps

Answer 196

At a pH of 7, we have 100 nmol/L. Apply that pH is logarithmic, meaning for every point there is a 10x change. A more basic pH of 8 will have 10x less protons. pH 8 = 10nmol/L protons

Answer 197

Bicarbonate, proteins (Hb), and phosphate

Answer 198

The body has varying ability to buffer things depending on protein levels. Predominant protein we care about is hemoglobin. Note: Ignore right side of this (in mEq), Schmidt says we don't need that information

Answer 199

Buffering capacity Steeper = better Horizontal = less buffering capacity

Answer 200

Bicarbonate

Answer 201

It will increase buffering capacity note the steeper line @20 g/dL Hb

Answer 202

Ammonia compounds pH of 1 would likely not feel great for you

Answer 203

It is important, however it is relatively small compared to the amount of Hb within RBC. We have a /lot/ of Hb within RBC intracellularly.

Answer 204

It can be buffered by both plasma proteins and proteins within RBC (like Hb)

Answer 205

Osmotic pressure and keeping fluid in the CV system. Blood buffering doesn't really happen here nearly as much as on Hemoglobin.

Answer 206

0.4 For every liter of blood we have, we have 400mL of RBCs. Within these RBC, there are lots of hemoglobin normally. ^Note he said "normally." He might throw some disease process on the test.

Answer 207

0.4 hct means 400mL/L 5L blood volume 400mL x 5 = 2,000mL RBC He slightly hinted that we need to review how to find all of our volumes, be familiar.

Answer 208

The isobars get closer together. Larger variability in how much bicarbonate is available for a given pH. This means there will be better buffering ability. There will be less swings of pH, it will be more stable. More adjustment = better buffer = steeper slope of the buffer line

Answer 209

The buffer line becomes less steep/more flat, and isobars stretch further away from their original condition. Less variability of bicarbonate is available for a given pH. This means there will be worse buffering ability. There will be larger swings of pH, it will be more unstable. Less adjustment = worse buffer = less steep slope to the line

Answer 210

Steep = squished Less steep = spread

Answer 211

Lungs - blowing off CO2 (chemical buffers + protein buffers)

Answer 212

Kidneys - gets rid of protons or hangs on to protons.. same with bicarbonate

Answer 213

Reduction in the drive to breathe. Acute, kidneys haven't adjusted yet. It is purely a respiratory issue. PCO2 elevated, causing decreased pH. PCO2 will combine with water and form carbonic acid, then a proton and a bicarbonate. The proton decreases the pH. The bicarb is a weak base. Not all bicarbonate will combine with a proton, which drives the decrease in pH. Remember, weak bases are unlikely to combine with a proton. Bicarbonate is a weak base. Excess bicarbonate is in the blood as a function of having too much CO2 in acute respiratory acidosis - NOT because of the kidney.

Answer 214

Anxiety (hyperventilation) Hit their head hard Seizure Asthma attack and struggling to breathe (except maybe theyre moving more air than they think)

Answer 215

Some event leading to overventilation leads to a deficit of CO2 with a higher than normal pH. Reduction of CO2 will result in a reduction of bicarbonate and protons. (remember carbonic anhydrase equation) There are fewer protons hanging around, which results in an increase of pH.

Answer 216

In chronic conditions. Kidneys are an effective long term regulator of pH (though not perfect). Acute: small increase in bicarbonate related to CO2 concentration from carbonic anhydrase equation Chronic: LARGE increase in bicarbonate from the kidneys (think COPD)

Answer 217

More or less the amplification factor. In other words, how strongly a system reacts to a change in the system. High gain = strong reaction to change in the system

Answer 218

At least half. i.e. if BP goes from 100 to 50, one of our BP controllers would be able to get us to at least 75. Engaging more of these reflexes/systems would result in a better response.

Answer 219

pH is much higher, with a more significant reduction in arterial bicarbonate. ^This is a function of two things. 1) Less CO2 so less bicarbonate can be formed 2) Kidney stepped in and got rid of a lot of bicarb in circulation, and doesn't reabsorb bicarbonate that is filtered.

Answer 220

i.e. In chronic acidosis, the kidney can pump protons into the urine to get them out of the system. i.e. #2 In chronic alkalosis, the kidneys won't secrete protons into the urine to try to even out pH. Won't completely fix it, but can help.

Answer 221

Lungs can correct for this very rapidly. Guyton says the lungs take 3 minutes, but Schmidt says that's bologna. ^Whether 3 minutes or seconds, the lungs/controllers of ventilation in the brain step will rapidly try to fix metabolic acidosis/alkalosis.

Answer 222

Excess bicarbonate, not common Respiratory response to this is to slow breathing and shift the isobar to the left, which gives a higher blood PCO2 level.

Answer 223

To figure out what the cause of a particular acid/base problem is, and what the appropriate treatment might be.

Answer 224

Future flash cards will go through these

Answer 225

Poor lung function.- hard time getting rid of CO2, leading to a build up of CO2 in the blood This could be function, or low ventilation

Answer 226

Brainstem (i.e. hit your head and knock out the CNS results in hypoventilation d/t trauma to the brainstem)

Answer 227

Phrenic nerve injury can result in difficulty breathing.

Answer 228

C4 SCI? Diaphragmatic function would be abnormal, may cause respiratory acidosis but could move some air still. SCI to C3 and above would result in a cessation of respiration.

Answer 229

Upper accessory muscles of the respiratory system are innervated by motor nerves that arise from here. Healthy? Not much a problem. 70 y/o with clapped out lungs? You need these muscles and probably wouldn't fare well. How bad this will be = how bad the lung function is in the first place.

Answer 230

Higher Lower

Answer 231

If someone strokes (or has ischemia) in their brainstem, the respiratory center can be depressed.

Answer 232

Coronal & sagittal planes (crooked spine)

Answer 233

Crooked spine can decrease FRC and make it harder for air to get in To fix this, we might use plates, rods, and screws into the spine. This leads to better posture, easier life, and less pain. Unfortunately, this is not as flexible as a normal spine, which makes it more difficult to breathe normally as they have a decreased chest wall compliance. ^Be sure to know the compliance formula and how to calculate this.

Answer 234

More weight on chest/lungs, decreases compliance. ^Exaggerated on back when paralyzed and on the OR table.

Answer 235

Opiates (i.e. fentanyl) knock our our respiratory centers in the brain, resulting in hypoventilation. This is how people die on fentanyl ODs. ^To a lesser extent, sedatives have /some/ effect on respiratory control centers.

Answer 236

Hypoventilation and death from respiratory insufficiency.

Answer 237

Augments GABA. It's not a pure GABA agonist. They don't cause respiratory depression/death on their own, it's usually a combination of something, such as benzodiazepines + alcohol.

Answer 238

Has massive impact on respiratory centers (depressant)

Answer 239

Respiratory acidosis ...this is why we vent people

Answer 240

Phrenic nerve is close by at c3-5. Too much anesthetic can result in knocking out one side of the phrenic nerve. If we have the other phrenic nerve functional, the patient should survive just fine assuming they're healthy. Meemaw from 1875 might not be OK if you do this though. We might need to RSI and convert to general at this point (which is usually avoided in elders if able).

Answer 241

Poliomyelitis is a musculoskeletal-ish disease that prevents the nervous system from talking to the respiratory muscles, resulting in respiratory insufficiency.

Answer 242

Lockjaw However, that's not the only muscle impacted.. can have respiratory problems if the body is constantly contracted. We rely on contracting/relaxing the diaphragm to breathe.

Answer 243

Nervous system can't talk to skeletal muscle, resulting in respiratory insufficiency.

Answer 244

If we can't intubate/ventilate after paralytic administration, then they will get respiratory acidosis from respiratory insufficiency. Depending on the drug duration, they can die ^note, remember from the last test that when we give a paralytic our FRC goes down substantially, and RV is even lower. Be prepared for him to throw in lung volumes, pressures, and asking us to use the fick equation to determine how long you have before oxygen is depleted.

Answer 245

Reduction in the ability to breathe d/t decreased compliance. Less flexible = less compliance = less compliant chest wall means lower system compliance = harder to breathe.

Answer 246

COPD Asthma Scarring of tissue (Sarcoidosis; think fibrosis)

Answer 247

Pneumonia Pulmonary edema Upper airway obstruction

Answer 248

CO2 moves through water better than oxygen. Too much fluid can result in problems getting rid of CO2 though. Oxygen exchange will for sure be impaired.

Answer 249

Collapsed vocal cords Scar tissue from previous tracheostomy Upper airway tumor

Answer 250

Note: Much less common. Will go through this over the next few cards. Honorary mention to ones he didn't cover in detail: Congenital hyperventilation syndromes, Pulmonary vascular disease (PE)

Answer 251

Something shifts the nervous system into overdrive Schmidt associates nervous system overdrive with seizure of brainstem/control systems.

Answer 252

Hyperventilation will drop CO2 rapidly, especially with healthy lungs.

Answer 253

Causes problems with neural activity in the brain, resulting in hyperventilation and alkalosis.

Answer 254

Initial response of high altitude is hyperventilation in response to lower O2 tension in the air. Problem is that you blow off a lot of CO2 when you hyperventilate, which leads to respiratory alkalosis. (not a huge issue normally unless we're in an extreme environment).

Answer 255

A respiratory control cell multiplies, takes over the system, and causes problems with hyperventilation resulting in alkalosis.

Answer 256

Salicylic acid toxicity can produce respiratory overdrive, causing respiratory alkalosis

Answer 257

Progesterone surges in pregnant women. The result of this? Increase in RR to compensate for breathing for two people rather than one. SO If you have a tumor that secretes estrogen or progesterone but you're not pregnant? Or, maybe pregnant but overproducing progesterone? Will cause respiratory overdrive/alkalosis.

Answer 258

Asthma attacks are uncomfortable - people may have more air moving than they think they really do. This causes anxiety, which leads to hyperventilation, which results in low CO2, and finally respiratory alkalosis.

Answer 259

Some bozo set the respiratory rate too high, resulting in blowing off too much CO2, causing respiratory alkalosis.

Answer 260

Most causes are neuro/psych. If our patients are anesthetized, they won't be aware of anything going on which eliminates this problem. So long as you don't overventilate your patient, you won't see this most of the time.

Answer 261

Will make cards over these next

Answer 262

Losing too much bicarb Producing too much acid Consuming too many acids (food and/or drugs/infusions)

Answer 263

Methanol Ethanol Aspirin (salicylates) Ethylene glycol Ammonium chloride

Answer 264

Fermentation. i.e., moonshine

Answer 265

Acidosis and blindness d/t methanol ingestion

Answer 266

Pancreas. If you drink 30 beers, you'll spend a portion of your night in the bathroom for various reasons. Overstimulation of pancreas -> More bicarbonate produced -> poop it out via ~diarrhea~. Results in metabolic acidosis

Answer 267

Salicylate (aspirin compound) Ingestion in aspirin compounds result in metabolic acidosis.

Answer 268

Component of antifreeze that prevents your car from freezing.

Answer 269

Blue or green Random note from my brain from my RV travel days: Food safe antifreeze typically is orange

Answer 270

Europe = blue puddle Japan/America = green puddle

Answer 271

It smells sweet. Hide ya' kids, hide ya' pets. Don't want them drinking this stuff because it will produce metabolic acidosis and a very bad day.

Answer 272

No - typically only exposed if you work at a chemical plant.

Answer 273

Component of fertilizer. Not the explosive part though, but it is still dangerous as it will produce metabolic acidosis if consumed.

Answer 274

Increased gastric motility Pancreatic fistula Renal dysfunction

Answer 275

More than one output duct can produce more bicarbonate than usual, resulting in pooping your brains out and metabolic acidosis.

Answer 276

It's more of that we can't produce new bicarb, resulting in metabolic acidosis. Common in renal failure.

Answer 277

Oxidative metabolism Use oxygen + food, extract proteins and sugars, feed it into cells, metabolize it, then make 38 ATP per glucose net under ideal conditions.

Answer 278

No, have to switch over to glycolytic metabolism.

Answer 279

2 net ATP Lactate is produced in glycolytic metabolism, but not really any in oxidative metabolism.

Answer 280

Hypoxemia (generalized reduction of oxygen in the blood) OR Carbon monixide poisoning.

Answer 281

Even just one molecule of carbon monoxide on hemoglobin increases the affinity of hemoglobin for oxygen on the remaining binding sites, meaning oxygen won't want to drop off at the tissues. This results in hypoxemia and glycolytic metabolism --> metabolic acidosis.

Answer 282

BP is low and the heart is struggling here --> Inadequate volume/BP results in not being able to deliver the oxygen the tissues need. Tissues then switch to glycolytic metabolism, produces lactate, and leads to metabolic acidosis.

Answer 283

Non volatile acid More difficult for the lungs to compensate for. Lungs will compensate somewhat, but nonvolatile acids are harder for the lungs to deal with. Remember the isohydric principle. If one of our buffer systems aren't working (i.e. the lungs here), all of the other buffer systems struggle to keep the pace.

Answer 284

Lots of extra lactate accumulates, and as a byproduct there is muscle pain. High lactate = skeletal muscle pain. Can happen in skeletal muscle when they are stressed, overworked, or not conditioned to a job that we force it to do.

Answer 285

Lung problem where we can't bring enough oxygen onboard. Note that respiratory acid/base problems have to do with CO2 more, while metabolic acid/base problems tend to look more at oxygen. Low oxygen --> tissue switches to glycolytic metabolism --> creates potent acid (lactate) --> metabolic acidosis

Answer 286

Uncontrolled diabetes Non volatile gas

Answer 287

Problem delivering energy to the cells --> can't take in glucose --> switch to other forms of metabolism that can have a byproduct of keytones. Keytones shift us toward metabolic acidosis.

Answer 288

Limits the ability for the liver to regulate blood sugar over time. The liver is a large storage place for glycogen (sugar). If the liver can't store glycogen, normal metabolic pathways are not as available. This results in the production of ketone acids (or keytones, same thing) and results in metabolic acidosis.

Answer 289

He was not specific on this one - if there is no energy coming in, the body "has to do what it needs to do to stay alive," resulting in metabolic acidosis. ^Lack of food = lack of glucose Lack of glucose --> change in metabolism to fatty acid metabolism, resulting in keytone bodies, leading to metabolic acidosis per my uncle chat gpt.

Answer 290

Liver & skeletal muscles

Answer 291

If your kidney can't get rid of protons we produce, they build up in the body, leading to metabolic acidosis.

Answer 292

Metabolic acidosis.

Answer 293

Losing gastric acid (protons) through the stomach. Less acid = more alkalotic state (metabolic alkalosis)

Answer 294

Next few cards will go over it.

Answer 295

More pathways for protons to leave the stomach and exit the body leads to less protons, and thus metabolic alkalosis.

Answer 296

Majority of diuretics are K wasting. K wasting diuretics get rid of extra K floating around. There is a chance that we lose protons with this, which will reduce the acidity of the blood, leading to metabolic alkalosis. Typically, protons and K go hand in hand. If one is removed, the other follows. (think about elevated K with acidosis related to the slowing of the Na/K ATPase pump)

Answer 297

Any mineral corticoid that resembles aldosterone, such as cortisol, can look like/function like aldosterone in high enough concentration. Aldosterone gets rid of potassium. K goes hand in hand with protons. As K leaves the system, protons will follow, leading to a metabolic alkalosis.

Answer 298

Tums = calcium carbonate/bicarbonate. This is an alkaline compound to neutralize acid. An entire bottle of tums will result in metabolic alkalosis.

Answer 299

No - typically metabolic acidosis is though.

Answer 300

The next several cards will go over it.

Answer 301

Higher CO2 production in the blood, which lowers pH. Because PCO2 is high, bicarbonate will be slightly elevated despite low pH.

Answer 302

Lower PCO2 since we're blowing off too much here Causes pH to be elevated Despite low PCO2, bicarbonate will be lower than normal d/t having less CO2 in the blood (less CO2 to feed into the carbonic anhydrase reaction).

Answer 303

Compensated will have a substantial change in bicarb/proton levels

Answer 304

Bicarb is a weak base, and won't combine with all protons being produced. This means some protons are free, resulting in increased proton activity, and a drop in pH.

Answer 305

They don't really happen in practice so long as people can breathe on their own and their brainstem is intact with good lungs. This is due to rapid compensation by the lungs. If it did happen though instantly and not over time: Uncompensated metabolic acidosis would be the product of more protons d/t less bicarbonate floating around. Uncompensated alkalosis would have an increase in pH d/t reduction of protons with excessive bicarbonate in the system (more protons binding ot bicarbonate)

Answer 306

pH is low as a result of low bicarbonate and protons being high (because they don't have anywhere to bind on the lack of protons). CO2 decreased d/t partial compensation by the respiratory system (hyperventilation to blow off CO2)

Answer 307

Rare pH is elevated d/t elevated bicarb with reduced protons. CO2 is elevated d/t hypoventilation as a result of partial compensation by the lungs.

Answer 308

Will not be able to compensate as well which will result in a large pH swing and death without treatment.

Answer 309

Drop in pH from having too much CO2 (like with COPD, emphysema) Having too much CO2 leads to extra bicarbonate from the carbonic anhydrase reaction as well as the kidneys with partial compensation.

Answer 310

Ventilation decreases, leading to elevated CO2. Unfortunately, it also can lead to low PO2. With low enough PO2, glycolytic metabolism results, which increases lactate and causes other problems (though maybe your pH would even out.. not helpful if you're dead though). The lungs can only do too much before we get hypoxic.

Answer 311

Greater Lower

Answer 312

Tums would lead to metabolic alkalosis, while the anxiety attach would further this alkalosis by causing hypoventilation/loss of CO2 through the lungs. Will cause pronounced alkalosis.

Answer 313

In the blood, cations must = anions from a charge perspective.

Answer 314

Yes - you shouldn't get shocked by touching blood.

Answer 315

Yes, it does. Ohms law states that electrical charge outside of the cell will have an effect on polarity inside of the cell. ^Normally electrically neutral, but can become charged with an anion gap. Know how this works in case he asks about Vrm, etc.

Answer 316

Cation = Sodium Anion = Chloride & Bicarbonate

Answer 317

Next several cards will go through this. Note: Guytons numbers are different. Ignore guyton, go with this per daddy Honorary mention for phosphate and sulphate groups here - he doesn't cover them but does mention them.

Answer 318

142 mOsm/L H2O

Answer 319

106 mOsm/L H2O

Answer 320

24 mOsm/L H2O

Answer 321

[Na+] = [Cl-] + [HCO3] 142 = 106+24 142=130 There is a gap here of 12 These units are in mEq/L Margin of error built in here that is +/- 4 mEq/L 12 mEq/L +/- 4mEq/L

Answer 322

We have lots of "unmeasured" ions. For example, we are short on negatively charged species (remember 142=130 cations vs anions with a gap of 12). This difference is made up of proteins. Any protein can have buffering capacity, but the majority of proteins here are probably albumin related. Most proteins have a net negative charge with multiple negative charges on them. (unmeasured anion)

Answer 323

[Na+] + [unmeasured cations] = [Cl-] + [HCO3-] + [unmeasured anions]

Answer 324

Sodium must reduce, otherwise an imbalance/anion gap will result.

Answer 325

Need an increase in sodium to maintain neutrality.

Answer 326

One or both anions have to decrease to maintain electrical neutrality.

Answer 327

Either increase chloride, bicarbonate, or both to maintain electrical neutrality.

Answer 328

Chloride & bicarbonate levels

Answer 329

Typically it is increased.

Answer 330

Anion gap is a measure of metabolic anions. Acidosis produces more acid than the body can secrete (keytone, lactate, etc), decreased bicarbonate. These are all unmeasured anions, leading to an increased anion gap. Think keytoacidosis (nonvolatile acid), lactic acid (nonvolatile acid), or renal insufficiency (kidneys can't secrete protons/increase bicarbonate).

Answer 331

Non volatile acids

Answer 332

Diarrhea (No change in anion gap normally) Acidosis - If REALLY acidotic chloride can be retained, but otherwise no change in anion gap. Healthy kidneys deal with chloride by correcting bicarbonate levels. Chloride retention w/ renal tubular acidosis (Note, not always a function of a sick kidney.. could be someone just experiencing acidosis)

Answer 333

Renal insufficiency Poisons/abnormal acids (methanol, ethanol, salicylates ,ethylene glycol, ammonium chloride) Ketoacidosis and lactc acidosis

Answer 334

Diarrhea is dangerous in kids, as they don't have a fully developed kidney. This means they can't manage acid/base changes like an adult. Losing massive amounts of bicarbonate through diarrhea in kids will result in metabolic acidosis.

Answer 335

Specific formula or Breast milk

Answer 336

Yes, it's bad. Kids don't have a fully developed kidney and cannot handle the excess water. This results in fluid overload. Remember that the pediatric heart is also not as compliant (less stretch) as the adult heart. Fluid overload is a massive problem in neonates if susie dilutes her formula.

Answer 337

In the presence of bloody and/or severe diarrhea.

Answer 338

While it won't fix the diarrhea, it will make you feel a little bit better since the acidosis will be lessened with these alkaline medications.

Answer 339

In the brainstem, specifically the medulla. It is automatically regulated.

Answer 340

If someone has a loud cough, it typically means they can move about 2L of air in and out of their lungs. As people get sicker (end stage respiratory illness), their cough gets weak. This usually means not much air is moving in/out of the lungs.

Answer 341

We have sensors around the body to gather information. Some will be in the periphery, some will be in the CNS, specifically in the brainstem.

Answer 342

Changes in PO2 (oxygen), pH (protons), PCO2. Some even do BP, but no details from schmidt on that

Answer 343

Yes Typically found in the carotid bifurcation and the aortic arch

Answer 344

Aortic arch Carotid bifurcation

Answer 345

1) Protons 2) CO2 3) Oxygen

Answer 346

Changes of pH in *CSF* Peripheral chemoreceptors use arterial pH while central chemoreceptors use CSF pH, as the CNS is bathed in CSF.

Answer 347

Yes, many acids cross the BBB easily. When extra protons enter the CNS, ventilation picks up.

Answer 348

Nonvolatile acids This means that with an increase in nonvolatile acid, we will see a delay in central chemoreceptors being set off.

Answer 349

Yes, easily as it is a gas. CO2 changes result in a fast adjustment by central chemoreceptors.

Answer 350

Peripheral chemoreceptors

Answer 351

Central chemoreceptors

Answer 352

negative feedback loop

Answer 353

When we plan to do something (i.e. exercise), the cerebral cortex tells the brainstem to pick up ventilation to the exact amount needed to keep pH steady. Mechanism unclear per Schmidt. If the above system is offline, then chemoreceptors get involved to make adjustments. Sensors usually are secondary to the above with planned exercise - they only kick in when this system is offline.

Answer 354

Kidneys (acid/base corrections) Fluid shifts Buffers (Bicarbonate, Proteins [Hb], phosphates

Answer 355

Protons [H+]

Answer 356

Elevated - would set off peripheral/central chemoreceptors

Answer 357

70mmHg - this is quite the drop. Typically chemoreceptors are more sensitive to CO2 and protons.

Answer 358

Oxygen i.e. if you breathe off a lot of CO2, likely will increase O2 levels as you have more gas exchange

Answer 359

An increase/decrease in ventilation to accommodate changes in pH

Answer 360

Tidal volume Increase in RR after max tidal volume is reached.

Answer 361

Changing respiratory rate can cause increased dead space ventilation as compared to just increasing the tidal volume.

Answer 362

Inspiratory pressure is increased by ~1cm H2O. This can increase right heart workload. In patients with bad right heart failure, we might consider changing the respiratory rate first instead.

Answer 363

A stronger inspiratory signal is sent, leading to increased number of motor neurons being activated. (Reminder that respiratory muscles are skeletal muscles).

Answer 364

A alpha fibers (Large and myelinated). i.e., when you need to run from a bear, you need to do it quickly.. probably want a large fiber helping out with that

Answer 365

Governed by the interval/amount of time it takes the inspiratory and expiratory centers to fire with a brief pause in between. (Remember the 5 second respiratory cycle from prior tests).

Answer 366

C fibers A delta fibers (much larger)

Answer 367

Small sensory fibers. If you block motor function, you can pretty much count on sensory function being blocked.

Answer 368

Yes. The frontal lobe can take over respiration if we want it to. The motor cortex (higher center) can recruit different sets of muscles as well. We have pathways that connect the thinking area and motor area of the brain to the brainstem. The brainstem then changes ventilation accordingly.

Answer 369

Irritant sensors Stretch/pressure sensors

Answer 370

All throughout the lung/airways.

Answer 371

Trachea Vagus nerve (CN X). Also does the face and neck.

Answer 372

Vagus nerve (CN X)

Answer 373

Tells us that we have stuff (i.e. pollen) in the lungs that needs to get coughed up.

Answer 374

Gives brainstem feedback about lung expansion during a breath. Helps us not overfill our lungs; shuts down inspiration at a good point.

Answer 375

Pain will either increase breathing or provide brief periods of apnea, depending on the person.

Answer 376

Diaphragm External intercostal muscles Internal intercostal & accessory muscles (SCM, scalene, pec minor, abdominal muscles)

Answer 377

1-2, but really just the diaphragm.

Answer 378

Muscle coordination to make sure we are using inspiratory and expiratory muscles seperately.

Answer 379

Good in case the phrenic nerve goes down. Iron lung man: He wasn't completely paralyzed, and was able to train his secondary respiratory muscles to allow him to be outside of the iron lung for about 30 minutes a day. Without secondary breathing muscles, he would have been unable to do this.

Answer 380

When we need lots of ventilation. The diaphragm will contract more, but the secondary muscle groups will kick in. This allows for a faster rate of breathing. Normally, the passive recoil of the lung is adequate for breathing. When we need to breathe faster, need secondary muscles to get the air out faster.

Answer 381

DRG – dorsal respiratory group back side, dorsal fin like a dolphin VRG – ventral respiratory group front, like where the chest is Note: this picture is see through, which is why you can see both in the same picture. He may ask an anatomy question here requiring you to know which side of the brainstem you're looking at.

Answer 382

Nuclei (area of the CNS where we have lots of cell bodies aggregated together where we have lots of decision making)

Answer 383

Olive shaped pons

Answer 384

Medulla Pons

Answer 385

Yes, there is cross talk. This is called reciprocal inhibition. If one of these centers activates, it sends an inhibitory to the other center to make sure they don't fire at the same time. This allows for the coordination of breathing muscles.

Answer 386

PRG (Pontine respiratory group) Involved in modulating activity of the DRG/VRG

Answer 387

Caudal = tail (inferior/posterior) Rostral = Beak (Superior/anterior) Used a lot in neurosurgery in surgical descriptions.

Answer 388

Midbrain Pons Medulla

Answer 389

Motor neurons

Answer 390

Decussation of pyramids; tail end of the medulla/beginning of the spinal cord

Answer 391

Contralateral (left) Contralateral (right)

Answer 392

Generates inspiratory signals and sends inhibitory signals to the expiratory centers when active. Sends inspiratory signals to many motor nerves, of which the phrenic nerve is the most important. These signals cross at the pyramidal decussation. DRG is also the primary place where baroreceptors and gas sensors (PO2, pH, PCO2) feed into via the Vagus (CN X) and glossopharyngeal nerve (IX).

Answer 393

General area: Reticular formation Specific area: Nucleus tractus solitarius (NTS) Within this specific area: DRG located here

Answer 394

Two groups of expiratory muscles, even though they are forced expiratory muscles. Abdominal muscles Internal intercostal muscles

Answer 395

Schmidt says: Who cares, doesn't matter Dr. google days: Open to more than one interpretation/double meaning He brought this up when mentioning "retroambigualis," saying that it was a funny name

Answer 396

Don't need to know: Retrocacial nucleus Nucleus paraambigualis & retroambigualis Do know this: Botzinger and pre-botzinger complex, but call it the botzinger complex for our class

Answer 397

Controls the respiratory rate by feeding over to the DRG and controls the pace that the DRG fires. This is the site of respiratory rhythmogenesis.

Answer 398

Botzinger complex Note: The DRG controls spacing between breaths, but the VRG controls respiratory rhythmogenesis. Respiratory rate or respiratory rhythmogenesis.

Answer 399

Reciprocal innervation or feedback loop of the DRG.

Answer 400

Has some motor innervation to the skeletal muscles around the larynx, specifically the pharyngeal constrictor muscles. We don't want these tight while we are breathing, so the VRG helps keep the airways open.

Answer 401

DRG = most motor function for inspiration/expiration VRG = how open the upper airway is

Answer 402

Site of respiratory rhythmogenesis through the botzinger complex & Helps keep the upper airway open

Answer 403

Located on the border of the pons and top part of the medulla. Irritant receptors from the lungs/airway, especially the trachea, send information here via the vagus nerve (CN X). This makes us cough so we get the goop out of our lungs. Stretch sensors are also sending information to the PRG. The PRG sends information to the DRG that help limit inspiration when the stretch sensors fire off (signaling that the lung is full). Note: He said in lecture that stretch sensors are "probably" sent to the PRG, but dr google says it's sent to the DRG. I'd just go with Schmidt and maybe ask in class.

Answer 404

Inspiration will be very long, while expiration is very short.

Answer 405

Reticular formation

Answer 406

Reticular formation area, specifically in the lower parts where the medulla/inferior pons are. This lower area is called the medullary area, or medulary respiratory center. This is a broad term for a swath of tissue in the lower part of the brainstem that has groups is inspiratory/expiratory neurons.

Answer 407

Apneustic breathing, which is a death reflex. This is not great, and is a sign that something is very wrong in the CNS.

Answer 408

The phrenic nerve

Answer 409

Trigeminal nerve

Answer 410

Connections between the frontal lobe and the motor cortex modulate respiratory areas in the spinal cord

Answer 411

Glossopharyngeal nerve (CN IX)

Answer 412

Vagus nerve (CN X)

Answer 413

Decussation of pyramids

Answer 414

Opthalamic, mandibular, maxillary branches take care of a lot of the face. Since it takes up a lot of surface area, it is a large nerve. Note that it's larger than the vagus and trigeminal, meaning that the information is carried a bit faster.

Answer 415

Yes, it's a gas, no issue crossing at all. Nonvolatile acids have a hard time crossing the barrier as they are charged with protons, and charged things have trouble getting across barriers without carrier proteins.

Answer 416

Central chemoreceptors (where the actual changes happen)

Answer 417

They can influence how much CO2 we have, so the message eventually gets to central chemoreceptors. It just takes longer. This means that we will probably have a delay in the brainstem response to nonvolatile acid production.

Answer 418

Nonvolatile acids

Answer 419

Instantaneously

Answer 420

7.31 pH per Schmidt (note levitkzy uses 7.32, either fine for test) 50 PCO2 little protein, not much at all (should be clear)

Answer 421

No, unless it crosses in the form of CO2. The CNS has its own buffering system and can produce bicarbonate itself.

Answer 422

Glial cells

Answer 423

Assuming your brain is working, you produce CO2 within the CNS. Some of this CO2 will be buffered by CNS bicarbonate. There needs to be a pressure gradient for flow to occur, so it makes sense that the brain has a slightly higher CO2 (and thus lower pH) to allow for CO2 to travel down its concentration gradient to the blood, and out to the lungs to be blown off (or through carbonic anhydrase equation, etc). ---- ^Note: Remember with extreme environments when he said there was retrograde flow of oxygen with decompression? (i.e. oxygen leaving the alvoli for the lower pressure environment) He may ask a question where PCO2 is higher in the body than the CNS, maybe brainstorm some coditions where that may happen just in case. Maybe severe acidosis from a nonvolatile acid, as it won't cross the BBB as easily? food for thought

Answer 424

Higher Lower Higher CO2 in the CSF compared to blood

Answer 425

Increase Smooth muscle controls arteriolar tone of cerebral blood vessels. They dilate in response to CO2, increasing blood flow. Higher blood flow results in washing out CO2, bringing conditions closer to normal hopefully.

Answer 426

Bicarbonate is a much less effective buffer in the CSF. The CSF has its own buffering system through the glial cells. However, it doesn't make much use of proteins (Hb), as there aren't may proteins there normally to begin with. Remember the isohydric principle. When we take a buffer away, bicarbonate doesn't work quite as well without the help of other buffers. This results in a lower pH and higher PCO2.

Answer 427

Apneustic center AKA the PRG; located at the bottom of the pons, top of the medulla. Cut the link between these two? Apneustic breathing results (long inspiration, short expiration).

Answer 428

Bodies Located in the: carotid (carotid bodies) & Aortic arch (Aortic body)

Answer 429

On each side of the neck at the bifurcation of the internal/external carotid arteries.

Answer 430

Top of the aortic arch

Answer 431

Looking at the blood chemistry coming out of the left ventricle

Answer 432

Similar to baroreceptors. Aortic bodies - transmit via the vagus (CN X) nerve. Carotid bodies - transmit via the glossopharyngeal nerve (CN IX) Note: He mentioned (Harrings?) nerve, but said he would come back to this. No info yet, will come back and fix this in a future lecture.

Answer 433

Medullary (blood gas/acid information) PRG (Higher level)

Answer 434

If we're healthy, not much as all really. This is due to most of our actions resulting in an immediate pick up of ventilation (like planed exercise).

Answer 435

Ventilation will pick up (tidal volume first, then respiratory rate) ALSO, since these are both respiratory and cardiovascular sensors, there is crosstalk. CO picks up, BP elevates as a result. This helps recruit additional alveoli which increases gas exchange surface area. More surface area and more blood flow? = more gas exchange & more CO2 delivered to lungs, will blow off more CO2 as a result.

Answer 436

Increase ventilation. This will produce hypocapnia. Hypocapnia is sensed by the aortic bodies (from the blood coming out of the left ventricle), sends the information to the brainstem via the vagus nerve (CN X), and reduces cardiac output. This then reduces blood pressure. --- If you want to increase BP, just hypoventilate someone and raise their CO2 levels to do the opposite of the above.

Answer 437

Albumin has negatively charged areas that accomodate protons. A few areas will have calcium as well. If you blow off too much CO2, protons will dissociate from albumin to go through the carbonic anhydrase equation, leaving binding sites open on albumin for calcium. This leads to a reduction in ionized calcium. This will give the heart problems beating, so you might give your patient a BP of dead/dead. ^You can do this in healthy patients for a short amount of time though, just not with heart failure.

Answer 438

Oxygen (PO2) Need PO2 of 70mmHg to increase the firing frequency of chemoreceptors to the brainstem. The normal PO2 of a healthy 20 y/o patient is about 100mmHg, so 70mmHg seems pretty low. CO2 functions much better, as when it goes up respiratory drive picks up immediately. Protons have the best response, though. Schmidt said this graph isn't great, but the concept is the same.

Answer 439

The junction between the pons and medulla. Remember that the pontine respiratory group cuts inspiration off at a normal time. Leads to apneustic breathing (Long inspiratory, short expiratory).

Answer 440

It depends. Massive trauma? Probably not. Some temporary neuro thing? Maybe!

Answer 441

Attenuated, or dead virus An engineered, less potent form of active polio Both 98-99% effective.

Answer 442

Paul alexander, AKA polio Paul

Answer 443

Kids were common victims, parents wanted to protect their kids. There was no treatment, no idea how it spread, and no management other than the iron lung.

Answer 444

Virus is grown in the lab. The virus is then killed. Then, the dead virus is injected into people in hopes that the immune system would attack it and build up antibodies.

Answer 445

Some bozo didn't kill the virus in a batch of about 10,000 vaccines. Unfortunately, this caused lots of damage. The engineered/weakened virus is still on the market.

Answer 446

Sometimes mistakes are made and people can be harmed. Today, people relate autism to vaccines (looking at you RFK.....) - bogus

Answer 447

Swimming pools. People in public pools/swimming lessons (kid population usually) were impacted most. It spread in pools for ~20 years.

Answer 448

Research charity that helped find a cure for polio. People put dimes in an envelope, sent it to charity, and thus rose a ton of money.

Answer 449

Yes, outside of third world countries.

Answer 450

Child cancer. Cured through drugs, radiation, chemo, and bone marrow transplant. This survival rate is way higher than in adults. The priority was solving it in kids, not adults - money talks in research.

Answer 451

Lower surface area for gas exchange Increase lung compliance Easier to fill Harder to empty Loss of alveoli

Answer 452

While always active at any given point, overall activity should be low. This is good, as you don't want Trypsin to chew up your lungs.

Answer 453

Trypsin Also eliminates fluid problems (i.e., when someone has an infection, cells are destroyed. This releases proteins, which impact interstitial protein osmotic pressure leading to fluid problems)

Answer 454

Alveoli merge to make giant alveoli. This lowers the overall count of alveoli. This also causes a loss of elastic tissue and large lungs. Not great for breathing. Activity of digestive enzymes within the lung is increased.

Answer 455

Microbiology labs use it frequently on their samples.

Answer 456

Inherited disorders Impaired activity of alpha 1 antitrypsin via smoke Liver issues

Answer 457

We have an inhibitory enzyme called Alpha 1 Antitrypsin that floats around in our blood until it gets to the lungs, where it inhibits Trypsin to keep activity low.

Answer 458

Smoke blocks activity of alpha 1 antitrypsin. This increases trypsin activity, which then chews on the lungs, and loss of elastic recoil results.

Answer 459

"springs within the alveoli." This causes a loss of recoil pressure in the lungs. Looks a lot like an autoimmune disease, but it's not (maybe he'll throw out a question along these lines).

Answer 460

Fe++ (Ferrous) Fe+++ (Ferric)

Answer 461

No. Normally, 50% of our air is inhaled via the nose. Air is spun via the turbinates, which is then slammed against the back of the nose and down the oropharynx. Smoke particles are too small, and lack the mass/inertia to get caught in our mucous.

Answer 462

1:3,000 people have a genetic deficiency in alpha 1 antitrypsin. Results in emphysema. Without a lung transplant, the patient will die by 30 y/o. Treatment is a lung transplant, which will buy you another few years. The deficiency will remain, and the lung will be chewed on immediately.

Answer 463

At the back of the nose. Air is spun via turbinates and then slammed to the back of the nose. Most of the gunk filtered during inspiration collects there.

Answer 464

The liver is in charge of making lots of plasma proteins (coag factors, albumin, etc.) It also makes alpha 1 antitrypsin. If you have a liver problem, production decreases, resulting in increased trypsin activity. Loss of function: Congenital or alcoholism

Answer 465

Alcohol activates the liver (so it can destroy the ethanol) The liver metabolises nicotine at a faster rate because of this. This means a cigarette wouldn't last quite as long, leading to people smoking considerably more. This leads to further alpha 1 antitrypsin deficiencies (alcohol eventually causes liver problems, and smoking decreases alpha 1 antitrypsin directly as a chemical inhibitor)

Answer 466

Yes. Respiratory rate is set, and might be able to be changed from the inside by the user. Normally, acid base shouldn't be an issue as people in an iron lung don't move much. If they were sick? Would have bad acid base problems.

Answer 467

Cystic fibrosis (lung disorder) This is a result of a single mutation in a gene, so the idea was to insert a new gene somewhere other than help replace it. Sickle cell is also just related to one gene. Ideally, it should be an easy problem to fix. (i.e. take enough blood from people you could potentially isolate alpha 1 antitrypsin)

Answer 468

Capable of temporarily binding and later releasing oxygen This is the good type of iron, we like this.

Answer 469

Fe+++ (Ferric)

Answer 470

Removing an electron, which is the same as adding a positive charge. Oxidizing Fe++ leads to Fe+++, which is Ferric.

Answer 471

Methemoglobin reductase This is a reduction reaction, which adds an electron to Fe+++ making it Fe++ (adding the electron negates the extra + charge) ^It does NOT remove a positive charge, only adds a negative one

Answer 472

It can bind to oxygen/Hb just fine, but it binds permanantly. Unfortunately, this means oxygen can't be released.

Answer 473

A portion is due to the venous admixture coming off the bronchiolar circulation and mixing with the oxygenated blood in the left atrium. Other side of this is because a portion (~1.5%) of our Hb is in a state of oxidation (With Fe+++ [Ferric]) so they can't contribute much

Answer 474

Methemoglobin

Answer 475

A deficiency of methemoglobin reductase would result in increased levels of Fe+++ (Ferric, AKA methemoglobin) Fe+++ (Ferric) binds to oxygen irreversibly. This would result in decreased oxygen to the tissues, leading to anerobic metabolism (Glycolytic metabolism), the production of lactate and nonvolatile acids, and potentially metabolic acidosis. ^^He hinted at this entire card by saying that we have a small amount of Fe+++ as a result of having methemoglobin reductase around. The rest of the card is a scenario I made just to get ya' thinking. Note: PaO2 would be normal, as it would be bound to Hb. However, pulse ox would be falsely high or low, as they weren't designed to measure methemoglobin.

Answer 476

4 chains 2 alpha, 2 beta

Answer 477

4 chains Each carry 1 O2 Total = 4 O2 molecules

Answer 478

Sickle cell anemia

Answer 479

Trait: 1 Anemia: 2

Answer 480

Sickle cell anemia is far worse. Both give problems with oxygen carrying and hemolytic anemia.

Answer 481

Typically, as RBCs squeeze through capilaries, they barely fit. In fact, they have to squeeze through. The RBCs need to be flexible for this. As the RBC is pressed into the capilary wall, oxygen dissociates and goes into the tissue. With sickle cell, this results in a conformational change to a sickle shape (hence the name), which results in the RBC becoming rigid and impossible to move through the capilary. This destroys the RBC and the capillary, leading to anemia.

Answer 482

The capillary and the RBC are destroyed. The surrounding tissue requires collateral circulation. This results in CO2 problems as well, as the tissue doesn't get enough O2 and can switch to glycolytic (anaerobic) metabolism.

Answer 483

Reduce activity. If you have a lower metabolism, less oxygen is being pulled from Hb, resulting in less stuck sickle cells.

Answer 484

Very painful

Answer 485

5mL O2/dL; not typically so long as activity is limited ^Find the Guyton question about an anemia patient using more than 5mL O2/dL, he mentions this.

Answer 486

This is more than twice than normal. There will be a massive increase in sickled RBC. This is dangerous as it causes a lack of perfusion in the capillary. Then, RBC/capillaries need to be rebuilt which is time consuming.

Answer 487

Not really. Only so much can be absorbed in the blood given that O2 is not very soluble. PO2 in arterial blood at sea level won't be that high, which limits the effectiveness. **note, he emphasized "at sea level." Think through how this could be changed below sea level.

Answer 488

Replace the patients RBC with donor RBC Give the drug Hydroxyurea

Answer 489

Need an awful lot of blood for this to be effective. Blood is limited. Sometimes this is doable, but this is supply limited. Also, transfusion reaction can result, or maybe the blood could have an infectious agent in it. Transfusion is not without risk.

Answer 490

Hydroxyurea turns on some of our fetal genes. Specifically, it increases HbF (Fetal Hb). Instead of these patients having beta chains on Hb, they would swap to the fetal chain (gamma). Not a perfect fix d/t changes of affinity for oxygen (review this), but it helps.

Answer 491

Shortly after birth per schmidt, 6 months per Pelphrey

Answer 492

The sickle cell trait (not full blown sickle cell anemia) is a common mutation. Turns out, having this trait gives people an increased survivability with malaria. Sickle cell trait = more resistant to malaria.

Answer 493

HbA1C (Acetylated Hemoglobin) HbCO (Carboxyhemoglobin)

Answer 494

a = adult 1C = where the extra sugar group is attached on Hb

Answer 495

Under 5 = normal Elevated HbA1C is indicative of unmanaged diabetes

Answer 496

Sugars are sticky and like to stick to things. With uncontrolled glucose, sugars stick to Hb. This makes our HbA1C levels increase.

Answer 497

~1% of our Hb is occupied by CO. Working in the drive thru, smoking, etc.

Answer 498

Evaluate where it might have came from (maybe druve thru or smoking). The normal amount in a healthy adult is only ~1%.

Answer 499

Not really. Carbonic acid is only around for a short amount of time, but CO2 is abundant in the body. CO2 mixes with water and forms carbonic acid, which then is converted via carbonic anhydrase to H+ and HCO3-.

Answer 500

Venous: 48mL CO2/dL Arterial: 52mL CO2/dL blood Be prepared for fick equation stuff on the test.

Answer 501

Relative to one another. i.e. CO2 compared to bicarbonate? Bicarbonate is a much stronger conjugate base.

Answer 502

PO2. Remember our blood gas respiratory reflexes, and that H+ is the most important, followed by CO2, and finally O2. If CO2 and protons are always high, oxygen sensors kick in. These patients rely on feedback/regulation from oxygen. Respiratory drive is stimulated by the oxygen levels in the blood. Healthy adults rely on PCO2 for respiratory drive.

Answer 503

There is a problem with both CO2 and Oxygen.

Answer 504

CO2 buildup d/t glycolytic (anaerobic metabolism)

Answer 505

The patient lost respiratory drive. Remember than PO2 sensors look for ~70mmHg O2. If this number is surpassed, the patient will lose respiratory drive. Oxygenation would probably be fine if they don't breathe for a little bit, BUT the problem is more than they will not be blowing off CO2. This will worsen respiratory acidosis. Fix this by removing the extra oxygen, which will activate respiratory drive at ~70mmHg O2

Answer 506

Tennis court

Answer 507

More blood vessels open --> more capillaries filled with blood --> More surface area available for gas exchange

Answer 508

Oxygen is constantly being used and isn't very soluble.. need to get about 250mL O2 in each breath. 250mL O2 is a little less than a can of soda.

Answer 509

1 - Limits lung dead space. Unused alveoli won't have blood/air flow through them if systems are normal. 2 - Defense mechanism against toxins. If we don't have all alveoli functioning at all times, this limits the damage caused by a breath full of toxins. Not all alveoli would be impacted, leaving some reserve to keep us alive.

Answer 510

"A noise that someone makes, like disappointment."

Answer 511

12-15 times per hour

Answer 512

We have to take a deeper breath to allow for extra volume to be let out.

Answer 513

Inspiratory pressure is increased slightly, allowing for more air in the lungs for one single breath.

Answer 514

Maintains alveoli patency Maintains surfactant levels. Remember tat surfactant is released when we put air into the lungs.

Answer 515

Surfactant would just be put into alveoli that are already open. It won't help open the lost alveoli in the region of atelectasis.

Answer 516

Negative pressure breathing. PPV doesn't release the same level of surfactant as normal (negative pressure) breathing. Negative pressure alveoli = normal breathing Positive pressure alveoli = PPV

Answer 517

Taking a deep breath prepares the lungs for being at low lung volumes for 8 hours. Laying down (supine) to sleep decreases FRC from 3L to 2L, a reduction of 1L in FRC.

Answer 518

No.. but yawn/sighs do similar things, so you could just press the sigh button.

Answer 519

The respiratory quotient (RQ) is calculated by dividing the volume of carbon dioxide (CO2) produced by the volume of oxygen (O2) consumed during respiration. 0.8

Answer 520

25% (i.e. 5mL O2/dL blood) 75% (i.e. 15mL O2/dL blood)

Answer 521

Diffusivity

Answer 522

Early motor neurons cross at the pyramid decussation and later become the phrenic nerve. This motor neuron that crosses over is called the intermediate neuron.

Answer 523

Alpha 1 antitrypsin

Answer 524

Less; Less Eventually, this patient will go into right heart failure. Given that there are fewer capilaries, pulmonary pressure increases. This increases right ventricular afterload.

Answer 525

Neutrophil elastase; this is the digestive enzyme that breaks down proteins/springs in the alveoli.

Answer 526

RV decreases a lot VT is a bit smaller IRV is a little smaller ERV is smaller IC is smaller FRC is lower Everything is lower^

Answer 527

Obstructive lung disease - emphysema This disease expands RV, which is the main reason for increased TLC. As the lungs get bigger, RV increases by squeezing ERV and IRV, eventually making IRV = VT. VT is a little larger overall as a result of alveolar dead space.

Answer 528

50% Filtration, warmth, humidification

Answer 529

Emphysema - larger VT as a result of alveolar dead space.

Answer 530

Turbinates (concha) spin the air in the nose Air is slammed against the inside of the nose against mucous, where they will get stick Air then makes a hairpin turn toward the larynx, where large particles can get stuck against the back of the throat, where they then can get swallowed into the GI system where it can get recycled.

Answer 531

Smoke It doesn't have much mass, meaning is has less inertia. Because of this, there is less momentum to slam the particles into the back of the throat or nose to get stuck in mucous. Smoke makes it down to the lungs.

Answer 532

Jaw bone, aka mandible

Answer 533

Trigeminal nerve

Answer 534

Suprahyoid muscles - connect above hyoid Inferior hyoid muscles - connect below hyoid

Answer 535

V1 – ophthalmic (headaches) V2 – maxillary – top part of face/nose V3 – mandibular – Jaw line

Answer 536

We have irritant receptors in out nose that send information to the brainstem through the maxillary (V2) division of the trigeminal nerve to alert us to contaminants in the air, aka a dusty environment. This causes us to sneeze.

Answer 537

The ability to reduce pain signals by applying pressure to the injured area We can use lateral inhibition to block our sneeze reflex. Since the sneeze reflex is through V2 around our nose, we can shut down this signal through lateral inhibition.

Answer 538

Drinking water - stimulates sensors in the mouth Pinching the upper lip - also fed through the V2 pathway. A hard enough pinch will stop the sneeze.

Answer 539

The vagus nerve on each side of the body A portion will go to the heart and lungs as well.

Answer 540

Right recurrent laryngeal nerve (at the hairpin turn) Inferior laryngeal nerve [right] (after the hairpin turn). Called inferior since it's coming from below the larynx.

Answer 541

Left recurrent laryngeal nerve Inferior laryngeal nerve (left)

Answer 542

Loops anterior to posterior

Answer 543

The right recurrent laryngeal nerve is more superior than the left.

Answer 544

They are the two nerves that control the ability to speak.

Answer 545

First attemt: Trying to not damage the recurrent laryngeal nerves so the patient can speak normally. Recurrent cancer? - they'll be more aggressive with treatment

Answer 546

Cricothyroid muscle w/ the median cricothyroid ligament.

Answer 547

Inferior laryngeal nerve

Answer 548

Superior laryngeal nerve (external branch) This is the branch of the superior laryngeal nerve that provides motor input to the cricothyroid muscle. If this is contracted, intubation is difficult. We wantit relaxed.

Answer 549

Superior laryngeal nerve (internal branch) Tells us if we have something stuck/if we need to cough.

Answer 550

Galen's anastomosis This is where the superior and inferior laryngeal nerves meet. The signals aren't meaningful here - they just so happen to meet up together in most people during development. If we need to send info through the inferior laryngeal nerve, it won't be sent back up through the superior laryngeal nerve - the anastomosis is not functional for that.

Answer 551

Inferior laryngeal nerve

Answer 552

Yes - they are all under voluntary control. This means we need motor neurons to innervate all of these muscles if we want to speak. This is a result of the inferior laryngeal nerve.

Answer 553

The vagus nerve The early trachea is through branches of the inferior laryngeal nerve.

Answer 554

Two - one internal, one external. Internal (inside the larynx) - helps us know if we need to cough something up or if something is stuck. External - provides motor input to the cricothyroid muscle.

Answer 555

Foramen for superior laryngeal nerve This is located within the thyrohyoid membrane

Answer 556

Above Below

Answer 557

The pharyngeal muscles (8), split into superior, middle, and inferior. Want these relaxed so we can get an airway.

Answer 558

Direct connection with the top of the hyoid bone and the small projection behind the ear called the Styloid process which is just in front of the mastoid process.

Answer 559

99% of the time, the styloid process will be broken off. It's very fragile.

Answer 560

Hyoid bone (floating bone in the neck)

Answer 561

1a - Diagastric muscle (anterior belly) 1b - Diagastric muscle (Posterior belly) 2 - Stylohyoid 3 - Mylohyoid 4 - Geniohyoid

Answer 562

Two (anterior + posterior)

Answer 563

3 2; bellies (anteior & posterior)

Answer 564

Helps fasten the hyoid bone to the mandible

Answer 565

Helps connect the hyoid bone to the mastoid process (which is the same place as the SCM attachment)

Answer 566

It hangs out in the floor of the mouth - attaches inside the mandible to the top part of the hyoid bone

Answer 567

Geniohyoid muscle (the big muscle that runs midline) Attaches inside the mandible to the top MIDDLE part of the hyoid bone

Answer 568

Geniohyoid muscle (4)

Answer 569

A connective tissue sling loops around the middle tendon of the diagastric muscle, anchoring it to the hyoid bone.

Answer 570

Intermediate tendon

Answer 571

Green - Geniohyoid Blue - Mylohyoid

Answer 572

Stylohyoid muscle

Answer 573

Sternohyoid muscle

Answer 574

Hyoid bone to the sternum

Answer 575

Thyrohyoid muscle It's a skeletal muscle

Answer 576

Thyrohyoid muscle

Answer 577

Sternothyroid muscle

Answer 578

Sternothyroid muscle

Answer 579

Thyroid cartilage & sternum

Answer 580

Omohyoid muscle

Answer 581

Two parts Superior & Inferior bellies

Answer 582

Blue - Diagastric muscle (posterior belly) Green - Diagastric muscle (Anterior belly)

Answer 583

Thyrohyoid Sternothyroid Sternohyoid Omohyoid (superior and anterior bellies)

Answer 584

Intermediate tendon, tied down "somewhere in the middle of the thorax." ^Schmidt said during the review session that it is tied down to the CLAVICLE. This makes it useful when we're moving the hyoid bone around.

Answer 585

Diagastric muscle (anterior & posterior bellies) Stylohyoid Mylohyoid Geniohyoid

Answer 586

Anterior view

Answer 587

Left lateral

Answer 588

The thick part called the body

Answer 589

Posterior view

Answer 590

Four total, two sets on each side of the hyoid bone. Lesser horn is more anterior, while the greater horn is more posterior

Answer 591

Cheyne-stokes breathing Periodic bursts of inspiration, progressively larger and deeper, then it slows down with a period of apnea. The cycle then continues. Seen with brain damage or blunt force trauma.

Answer 592

Abnormally slow breathing

Answer 593

Apneustic breathing + Cheyne-Stokes breathing

Answer 594

Attached to the hyoid bone and top of the thorax. It's anchored down to the clavicle by a connective band over the intermediate tendon.

Answer 595

J receptors Responsible for shutting down inspiration when the lung gets to a certain volume.

Answer 596

Abnormally rapid breathing

Answer 597

Kussmaul breathing, often seen during diabetic ketoacidosis. This is typically hyperventilation since it's in excess of metabolic requirements. Very high RR with large tidal volumes. Brainstem tries to do this to get rid of CO2 and buffer out acids produced by ketoacidosis. The acid is hard to breathe off, as it is a nonvolatile acid. Won't make you pass out typically since there's an underlying acidosis.

Answer 598

Hyperventilation is often rapid or deep ventilation in excess of metabolic demands. You can be tachypnic and still not exceed metabolic demands (i.e. exercise) OR Be tachypnic and exceed metabolic demands (anxiety attack), which would be hyperventilation

Answer 599

Chemoreceptors, gas receptors, stretch receptors

Answer 600

Will have inappropriately sized respirations d/t stretch sensors saying that the lungs are full.

Answer 601

Hering-breuer reflex (inhalation reflex)

Answer 602

Biot breathing Common with opiate overdose. Breathing is irregularly interspersed with low volumes (low rate, low depth)

Answer 603

+ pregnancy, MH, burping

Answer 604

Increased temperature = increased metabolism, which increases CO2 production

Answer 605

Think about the carbonic anhydrase equation. A portion of bicarbonate will turn into CO2, which will elevate the waveform.

Answer 606

If you had a tourniquet on a limb for 45min and suddenly released it, the limb will get lots of perfusion. Since the limb was under perfused, the vessels will be wide open, which will allow for lots of flow. This will cause an increase in the CO2 waveform.

Answer 607

More blood through the lungs = more CO2 unloaded. This isn't a sustained change, because at some point we will blow off the extra CO2 via the lungs. Increased BP is similar to increased CO in that it will lead to more flow through the lungs. While vascular resistance is involved, Schmidt says think about BP relating to CO. "When CO goes up, BP goes up, which results in more flow."

Answer 608

Not blowing off as much CO2, will have a higher concentration per breath

Answer 609

Massive increase in muscle activity/metabolism generates a boatload of CO2

Answer 610

Body is producing CO2 for two. The brain tries to buffer this, but can only do so much in late pregnancy. Late pregnancy has an elevated CO2 waveforms with increased rate and depth. Lung volumes are lower overall given abdominal contents push the diaphragm up. Will see a tiny spike at the end of the waveform (only if they are not intubated).

Answer 611

Pregnancy (spike at the end of the waveform) Burping after having something carbonated (Spike when you burp d/t high concentration of CO2) Single lung transplant

Answer 612

If the sensor is disconnected, the CO2 waveform will abruptly drop to zero.

Answer 613

Lower body temperature (like in the OR) slows metabolism, reducing CO2.

Answer 614

Less blood through the lungs = less CO2 dropped off at the lungs to be breathed out Hypotension is similar here.

Answer 615

If blood isn't going through a part of the lung, the CO2 will acutely decrease

Answer 616

More CO2 is removed from the system, leaving less to be breathed out.

Answer 617

If you remove the tube out, the sensor will read environmental air. This is effectively zero.

Answer 618

A breath that takes a long time to expire CO2 will decrease the waveform. (i.e. a piece of meat in the throat)

Answer 619

All alveoli are connected to one another. If one capilary is blocked, while another is not, this air will still mix and mingle on the way out in an expired breath. This will drop the average CO2 in the sample, decreasing the CO2 waveform.

Answer 620

Alveolar (A) is equal or higher than arterial (a) oxygen

Answer 621

Arterial (a) is greater or equal to alveolar (A) PCO2

Answer 622

We might get a few breaths of CO2 (decreasing with every breath), but it will dissapear and be flat. This is from gastric insufflation during mask bagging the patient.

Answer 623

Normal capnograph and EKG

Answer 624

Ventilation that does not meet metabolic requirements. Expect to see higher than normal waveform since there's a higher PaCO2. Normal shape.

Answer 625

Ventilation in excess of what's needed for metabolism. Will see lower waveforms on capnography, as there is a lower PaCO2. This is common in the OR.

Answer 626

If the heart isn't pumping adequately, less blood with CO2 will make it to the lungs, progressively lowering CO2 on capnography waveforms. This could be indicative of MI. The ability to offload CO2 is reduced. Will see a difference in blood work vs capnograph.

Answer 627

Malignant hyperthermia Sux holds SR calcium channels open, leading to muscle rigidity. The first warning sign is an abrupt spike in EtCO2 d/t increased metabolic demand, which leads to overheating.

Answer 628

Dantrolene - a calcium channel blocker.

Answer 629

Genetics. Important to get family history pre-op.

Answer 630

Increasing CO2 with every breath since the heart is pumping blood through the lungs after successfuly CPR.

Answer 631

Bronchospasm - uneven emptying of the lungs

Answer 632

Esophageal intubation vs mechanical failure. Esophageal intubation - might have a few waveforms, but they will decrease. This is CO2 coming from the stomach from mask ventilating the patient. Mechanical failure - maybe a luer lock on the Y piece tubing fell off, power is cut off, the patient self extubated, etc. Abrupt drops to zero don't happen other than mechanical failures such as this. All other problems are gradual.

Answer 633

Lower than normal (800-1000cc) RV d/t abdominal contents pushing against diaphragm, which is exacerbated by obesity. Anterior pleural pressure is -13 cm H2O Posterior pleural pressure is +4 cm H2O Airflow will want to go where it is more negative, so anteriorly. Blood flow will follow gravity, so posteriorly, creating a VQ mismatch (especially in the posterior lung since there is not much airflow) To correct this, keep extra air in the lungs between breaths. The more full the lung is, the more will be directed to the posterior part of the lung. ^This is why we use PEEP.

Answer 634

Prevents airway collapse and helps us get better VQ matching while sedated, paralyzed, supine, and intubated. Especially helps in people with bad lungs or long procedures.

Answer 635

At the end of expiration, pressure should be low normally. With PEEP, pressure is elevated. This increases the workload on the right heart. This can be dangerous in someone with right heart failure, so we have to be more careful there.

Answer 636

2L, which is 1L lower than normal. This is due to abdominal contents pressing against the diaphragm.

Answer 637

Posterior fills first, as the anterior part of the lung is kind of full. This means that the posterior lung is more compliant in this case. Blood flow will be greatest posteriorly, which gives us decent VQ matching since most of the airflow is also going there.

Answer 638

They are similar.

Answer 639

Boyle's Law P1V1 = P2V2 @ constant temperature Body Plethysmography (we don't have to know much about this per Schmidt)

Answer 640

Boyle's Law (gas is compressible)

Answer 641

How fast gas diffuses across a barrier

Answer 642

Basis for the partial pressure of a gas formula (PPGas = [Gas] x Ptotal) The pressure one gas exerts is independent of what gasses in the mixture are doing.

Answer 643

Poiseuille's Law Daltons law Grahams law Henrys law Ficks law of diffusion Ohms Law Page 295 @appendix in the back of our pulmonary book has all of the definitions.

Answer 644

Flow Resistance Pressure Voltage

Answer 645

If we have gasses with similar solubilities, the movement of these gasses are dictated by how large the molecule of gas is (i.e. oxygen vs CO2)

FINAL SCHMIDT EXAM Flashcards

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