Hyper focus Flashcards
1
Q
Phases of ventricular action potential
A
2
Q
What is the threshold potential for the ventricular action potential? RMP?
A
TP = -70
RMP = -90
3
Q
Event and Ion movement for phase 0 of the ventricular action potential?
A
Event - Depolarization
Ion - Na moves in
4
Q
Event and Ion movement for phase 1 of the ventricular action potential?
A
Event - Initial repolarization
Ion - Cl- moves in and K moves out
5
Q
Event and Ion movement for phase 2 of the ventricular action potential?
A
Event - Plateau
Ion - Ca+ in and K moves out
6
Q
Event and Ion movement for phase 3 of the ventricular action potential?
A
Event - Final repolarization
Ion - K moves out
7
Q
Event and Ion movement for phase 4 of the ventricular action potential?
A
Event - Resting phase
Ion - ATP pump activated
8
Q
SA node action potential
A
9
Q
SA node action potential, RMP and TP?
A
TP = -45
RMP = -60
10
Q
Event and Ion movement for phase 4 of the SA node action potential?
A
Spontaneous depolarization
NA and CA in the cell
11
Q
Event and Ion movement for phase 0 of the SA node action potential?
A
Depolarization
CA into the cell
12
Q
Event and Ion movement for phase 3 of the SA node action potential?
A
Repolarization
K out of cell
13
Q
Is it easier or harder to depolarize the cell when RMP and TP are close?
A
Easier to depolarize
14
Q
What are three ways to manipulate the HR?
A
Rate of phase 4 depolarization increases
TP becomes more negative
RMP becomes less negative
15
Q
Goals for AS
A
HR - Slow/normal
Preload - increased
Contractility - 0
SVR - 0/ increase
PVR - 0
16
Q
Goals for Mitral stenosis
A
HR - Slow/normal
Preload - 0
Contractility - 0
SVR - 0
PVR - Avoid increase
17
Q
Goals for aortic insufficiency
A
HR - Increase
Preload - 0/increase
Contractility - 0
SVR - Decrease
PVR - 0
18
Q
Goals for mitral insufficiency
A
HR - Increase
Preload - 0/increased
Contractility - 0
SVR - Decrease
PVR - Avoid increase
19
Q
2 major classes of CCB?
A
Dihydropyridines
Non- dihydropyridine
20
Q
Examples of Dihydropyridines? How do they work?
A
- Mainly on the smooth vascular muscle
- Decreases SVR through vasodilation
Ex: anything that ends in “pine”
Clevidipine, amlodipine, nicardipine
21
Q
Examples of Non-Dihydropyridines? How do they work?
A
Work in the myocardium - decreases chronotropy, inotropy, dromotropic
Ex:
verapamil (phenylalkylamine)
Diltiazem (benzothiazepine)
22
Q
Stent Chart
Angio without stent?
Bare metal?
Drug eluting?
CABG?
A
23
Q
Which type of nerve is the first to be blocked?
A
B Fibers (preganglionic ANS fibers)
24
Q
What do A alpha nerves do?
A
Skeletal muscle - motor
Proprioception
Last to be blocked
25
What do A beta nerves do?
Touch and pressure
26
What do A gamma nerves do?
Skeletal muscle - tone
27
What do A delta nerves do?
Fast pain
Temp
Touch
28
What controls Postganglionic ANS fibers?
C fibers
29
Rank the nerve fibers in their block order
Most sensitive (easiest to block)
1. B fibers
2. C fibers
3. Small A fibers (gamma+delta)
4. Large A fibers (alpha+beta)
30
If the pKa is closer to the pH, is the onset faster or slower?
Exception?
If pKa is closer to pH, the onset is faster
Chloroprocaine is the exception because such a large dose is given
31
What determines local anesthetic potency?
1. Lipid solubility
2. Intrinsic vasodilating effect
32
What determines local anesthetic duration of action?
1. Protein binding (the more protein bound, the longer the duration)
2. Lipid solubility and intrinsic vasodilating activity
The more lipid soluble, the longer the duration
The more blood flow, the shorter the duration
33
Which local has 0 protein binding? Which also is very low?
Chloroprocaine - 0
Procaine - 6
34
Rank the ester locals
35
Rank the amide locals
36
Which amide has the lowest protein binding?
Prilocaine
37
Rank injection sites of plasma concentrations of locals
38
Max dose of AMIDES
39
Max dose of ESTERS
40
What is the most common sign of LAST? What is the exception
seizure
Bupivacaine - cardiac arrest
41
Which two local anesthetics cause methemoglobinemia? What way does the OxyHgb curve shift?
Prilocaine and benzocaine
Leftward shift
42
Which drugs can cause methemoglobinemia?
Benzocaine
Cetacaine
Prilocaine
EMLA (lido+prilocaine)
Nitro
Sulfonamides
Phenytoin
43
Which local anesthetic reduces opioids effectiveness?
Chloroprocaine
44
Which conditions increase extrajunctional receptors?
-Upper or lower motor neuron injury
-Burns
-Sepsis
-Spinal cord injury
-Tetanus
-Muscular dystrophy
45
Do you need more or less NonD NMB with more extrajunctional receptors?
You need more medicine
46
Which TOF ratio correlates with a full recovery from NMB?
>0.9
47
Where is the best location to monitor onset and recovery of NMB?
Onset - orbicularis with facial muscle
Recovery - adductor pollicis or flexor hallucis with the ulnar nerve or posterior tibial nerve
48
What is a normal dibucaine test?
70-80 which means dibucaine inhibited 80% of pseudocholinesterase
49
How is K shifted into cells?
1. Hyperventilation
2. Glucose + insulin
3. Bicarb
4. Albuterol
50
Which NMB have a histamine release?
SAM has histamine
Succ
Atracurium
Mivacurium
51
Which NMB has a vagolytic effect?
Pancuronium
52
Which NMB causes the most anaphylaxis?
Succ
53
Pairings?
Edrophonium
Neostigmine
Pyridostigmine
Edrophonium - Atropine
Neostigmine - Glyco
Pyridostigmine - Glyco
54
Which AchE passes through the BBB?
Physostigmine (tertiary amine)
55
Which Anticholinergic (antimuscarinic) does not pass through the BBB?
Glyco because it is a quaternary amine
Scopolamine and Atropine cross because they are tertiary amines
56
Which fibers transmit slow pain? What about fast pain?
Fast - A delta
Slow - C
57
Which tract is pain transmitted on? What are the three order neurons?
58
Where is pain modulated?
Either inhibited or augmented in the substantia gelatonosa in the dorsal horn (Rexed Lamina II + III)
Inhibited through GABA and glycine. Descending pain pathway releases NE, 5HT, endorphins
Augmented by central sensitization and wind up
59
Where do you feel pain?
Cerebral cortex and limbic system
60
MOA of opioids?
G protein receptor
Reduces intracellular cAMP
61
Which opioids release histamine?
Morphine
Meperidine
Codeine
62
Rank opioids
Most potent
1. Sufentanil
2. Fent + remi
3. Alfentanil
4. Dilauded
5. Morphine
6. Meperidine
63
Opioid chart
64
Which opioids produce an active metabolite? Concerns?
Morphine and meperidine
Morphine - Produces m3g and m6g
m6g causes respiratory depression with impaired renal function
Meperidine causes seizures
65
Combining meperidine with an MAOI may cause what?
Serotonin syndrome
S&S - hyperthermia, mental status changes, hyperreflexia, seizures
66
Which opioid has the fastest onset of action? Why?
pKa of 6.5 so 90% is unionized
Low Vd and high protein binding to alpha-1
67
Which opioid has the largest Vd? The smallest?
Largest - fentanyl
Smallest - remi because it is metabolized so fast
68
Which opioid can cause QT prolongation and torsades?
Methadone
69
Benefits to an opioid partial agonist? (agonist-antagonist)?
-Produce analgesia without respiratory depression
-Ceiling effect
-Low dependence
-Can cause acute withdrawal
-Can cause dysphoric
-Reduces efficacy
70
What is the best quantitative test for neuromuscular function?
Tongue blade against force
71
Which induction drugs have an active metabolite?
Versed
Ketamine
72
Vapor pressures of our gases?
Sevo - 157
Iso - 238
Des - 669
N2O - 38,770
73
What are the byproducts of each gas?
Iso and Des create carbon monoxide
Sevo - compound A
74
Blood gas solubilities?
Des - .42
N20 - .46
Sevo - .65
Iso - 1.45
75
FA/Fi curve
rank
N20
Iso
Des
Sevo
Halothane
76
Does a high or low cardiac output increase FA/Fi?
A low cardiac output decrease gas uptake which increases the onset of action
Low CO - means fall asleep faster
High CO - means it will take longer to fall asleep
77
What are the 4 vessel rich groups and how much CO do they receive?
78
What is the rule of 2's for hepatic metabolism for gases?
DISH
Nitrous - .002
Des - .02
Iso - .2
Sevo - 2
Halothane - 20
79
What is the minimum FGF for sevo? What is a MAC hour?
1L/min up to two MAC hours
2L/min after two MAC hours
80
1 MAC hour equals;
1% sevo?
2% sevo?
4% sevo?
1% sevo x 2 hours
2% sevo x 1hours
4% sevo x 30 minutes
81
Which gas will be most affected by a R-L shunt? What about L - R?
Des because it has a low solubility
(bypasses the lungs, no way for it to enter the body)
A L to R shunt has no impact on time
82
How many more times soluble is N20 when compared to blood? Why does this matter?
34x more soluble
This is why it accumulates in closed spaces
83
Timeframe for intraocular gas bubble and nitrous.
Avoid N20 15 minutes before placing bubble
Silicone - 0 days
Air - 5 days
SF6 - 6 days
Perfluropropane - 30 days
84
Which factors do not affect MAC?
Potassium levels
Magnesium levels
Thyroid function
Gender
HTN
CO2 between 15-95
85
Where does nitrous work in the brain?
1. NMDA
2. Potassium 2P channels
86
Where do gases produce unconsciousness?
Cerebral Cortex
Thalamus
RAS
87
Where do gases produce amnesia?
Amygdala
Hippocampus
88
Where do gases produce autonomic modulation?
Pons
Medulla
89
Which gas produces coronary steal? What is it?
Iso
Sclerotic vessels can't dilate while normal ones can which diverts blood away from the areas that need O2
90
How does Nitrous affect the SNS?
It is an SNS stimulant and increases MAP
91
How do the gases affect CMRO2?
Gases - uncouples
Nitrous - Couples - increases both blood flow and CMRO2
92
How do gases effect evoked potentials?
Increases latency (waves spread out)
Decreased amplitude (shorter height)
Avoid nitrous as well
93
Rank the sensitivity to gases
SSEP and MEP
Brainstem
Visual
Most sensitive
1. Visual
2. SSEP+MEP
3. Brainstem
94
What increases PVR?
Hypoxia
Low FiO2
Hypercarbia
Acidosis
PEEP
High airway pressure
Polycythemia
SNS stimulation
Surgical stress
Vasoconstrictors
95
What is the treatment for anticholinergic syndrome?
Physostigmine
96
LMA sizes and ET
97
LMA sizes
98
With locals, pKa is correlated to?
Onset of action
99
With locals, duration of action is correlated to?
Protein binding
100
With locals, potency is correlated to?
Lipid solubility
101
Fentanyl duration of infusion
102
Which drugs inhibit pseudocholinesterase?
Neostigmine
Echothiopate
Esmolol
Birth control
Esmolol
Cyclophosphamide
103
CVC distances
104
cvp
105
The line isolation monitor does
alarms when an electrical fault occurs
106
Early signs of MH in a spontaneously breathing patient?
1. Tachypnea
2. Tachycardia
3. Warm soda lime
4. Masseter spasm
5. Dysrhythmias
107
Which steroid is pure mineralocorticoid?
Aldosterone
108
Which steroids are pure glucocorticoids?
Dexamethasone
Betamethasone
109
Which steroids promote both mineral and glucocorticoids?
Prednisone
110
Vapor pressures of each gas?
Sevo - 157
Iso - 238
Des- 669
Nitrous - 38770
111
Oil:Gas of each gas
Nitrous - 1.4
Des - 19
Sevo - 47
Iso - 91
112
Which anesthetic gas has the lowest boiling point?
Des
113
A. Nitrous
B. Des
C. Sevo
D. Iso
114
Which factor influences anesthetic uptake the least?
FGF
115
Induction is prolonged
***** This is different with IV induction meds. The higher the CO the faster the induction
116
Draw CVP waveform
117
Mechanical event of a Wave on CVP and its electrical event?
wave - Right atrial contraction
electrical event - Just after p wave (atrial depolarization
118
Mechanical event of C Wave on CVP and its electrical event?
wave - RV contraction and the tricuspid valve bulges into RA
electrical event - Just after QRS (ventricular depolarization
119
Mechanical event of x descent and its electrical event?
wave - RA relaxation
electrical event - ST segment
120
Mechanical event of V Wave on CVP and its electrical event?
wave - Passive RA filling
electrical event - Just after T wave (ventricular repolarization)
121
Mechanical event of y descent on CVP and its electrical event?
wave - RA empties through tricuspid valve
electrical event - After the T wave
122
Factors that increase and decrease CVP value?
123
What conditions cause loss of a wave on CVP?
Afib
V pacing
124
What causes an increased a wave on CVP?
Anything that causes a high resistance (think RV dysfunction)
-Tricuspid stenosis
-Diastolic dysfunction
-MI
-Chronic lung disease leading to RV hypertrophy
-AV dissociation
-Junctional rhythm
-PVC
125
What causes an increased v wave on CVP?
Anything that increases volume and pressure in the RA
-Tricuspid regurg
-Acute increase in intravascular volume
-RV papillary ischemia
126
Pulmonary artery waveform
127
Phases of cardiac action potential
128
Leads graph
129
Which leads monitor the RCA and inferior side of heart?
II, III, aVF
130
Which leads monitor the Circumflex and lateral side of the heart
I, aVL, V5, V6
131
Which leads monitor the septum and LAD? What about the anterior side and LAD?
All monitor the LAD
V1, V2 - septum
V3, V4 - anterior
132
Which heart block has a longer, longer, longer p wave then dropped?
133
Antiarrhythmic chart
134
Class 1 Antiarrhythmics?
Na Channel blockers
Work on depressing phase 0 and phase 3
135
Class 1A Antiarrhythmics? How do they work?
Na channel blockers
-Quinidine, Procainamide
Moderate depression of phase 0
136
Class 1B Antiarrhythmics? How do they work?
Na channel blockers
-Lidocaine, phenytoin
Weak depression of phase 0
137
Class 1C Antiarrhythmics? How do they work?
Na channel blockers
-Flecainide
Strong depression of phase 0
138
Class II antiarrhythmics? How do they work?
Beta Blockers
Slows phase 4
139
Class III antiarrhythmics? How do they work?
K channel blockers
Amiodarone, Bretyium
Prolongs phase 3
140
Class IV antiarrhythmics? How do they work?
Ca channel blockers
Verapamil, Diltiazem
Slows conduction through AV node
141
Which drug and drug class is used in cerebral vasospasm ?
Nimodipine - CCB
142
What are the "cutting" needles for a spinal
Quincke and Pitkin
Greene needle is a rounded bevel
143
Within what timeframe does a spinal hematoma need to be resolved in?
Within 8 hours
144
Which conditions need prophylactic antibiotics?
-Cardiac transplant with valve
-Dental procedures
-Repaired congenital defects
-Unrepaired cyanotic heart defect
-Prosthetic valve
-Previous endocarditis
145
Which conditions DO NOT need prophylactic antibiotics?
-Unrepaired cardiac valve disease
-Coronary stenting
-CABG
-GI or GU procedures
-Mitral valve prolapse
