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3. Oral Boards > Lange Flash Cards > Flashcards

Lange Flash Cards

1
Q

Achondroplasia considerations

A

Neuro: kyphosis, scoliosis, spinal stenosis, foramen magnum stenosis - difficult/unpredictable spread of local for neuraxial, pain/ataxia/incontinence/apnea due to spinal cord compression. Consider head/neck CT/MRI to assess craniocervical junction, spine imaging for neuraxial.
Cardiac: N/A
Pulm: OSA, potential difficult airway due to limited neck extension, large tongue, large mandible, atlanto-axial instability. Consider sleep study. Have difficult airway equipment, consider AFOI.
GI: N/A
FEN/K: N/A
Heme/ID: N/A
Endo: N/A

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2
Q

Acromegaly considerations

A

Neuro: often GH secreting pituitary adenoma, may have HA, visual field defects, elevated ICP. Kyphoscoliosis.
CV: heart failure, arrhythmias, CAD. EKG/echo.
Pulm: OSA, potential difficult intubation - facial changes, large tongue, pharyngeal mucosa hypertrophy, prognathism (prominent jaw), small glottis opening. Consider AFOI, have difficult airway equipment.
GI: N/A but may be on octreotide
FEN/K: renal failure, check hyponatremia, hypokalemia
Heme/ID: N/A
Endo: hypopituitarism, replacement with hydrocortisone and thyroxine. Check TSH. Hyperglycemia. May be on steroids.

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3
Q

Acute porphyria considerations

A

Enzymatic defect in heme synthesis —> overproduction heme precursors and intermittent attacks (abdominal pain, vomiting, fever, mental status changes, seizures in AIP, blistering skin lesions in variegate porphyria).

Tx: hydration, glucose, Hematin

Triggers: barbiturates, ergots, Etomidate, ropivacaine, Metoclopramide, steroids, hydralazine, dehydration/fasting, stress, infection.

Neuro: autonomic and peripheral neuropathy, bulbar involvement, hypothalamic dysfunction, AMS, seizures, coma. Often have neurologic deficits.
CV: Autonomic instability
Pulm: Aspiration risk (bulbar weakness)
GI: abdominal pain
FEN/K: avoid dehydration (trigger). Red/purple urine. May have HypoNa, hypoK, hypoCa. Check urine porphyrin and porphyrigen precursors.
Heme/ID: infection (trigger). Carbohydrate load to suppress porphyrin synthesis.
Endo: carb load (above)

If PPH: NO ergotamine!

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4
Q

Acute porphyria crisis management

A
  • remove trigger/end surgery
  • IV hydration with dextrose (D10)
  • hemetin (inhibits ALA synthetase)
  • antiemetics for N/V (no reglan!)
  • opioids for pain
  • beta blockers for HTN/tachycardia
  • if seizure, give midazolam NOT phenytoin
  • monitor electrolytes
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5
Q

Acute porphyrias: unsafe or unproven drugs

A

Barbiturates
Ergots
Metoclopramide
Steroids
Etomidate
Ropivacaine (lido, bupi ok)
Hydralazine
Nifedipine
Phenoxybenzamine
Pentazocine

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6
Q

Adrenal insufficiency considerations

A

Addisonian crisis: back, leg, abdominal pain, vomiting, diarrhea, dehydration, hypotension, LOC, hypoglycemia, hyperkalemia.

Neuro: AMS/LOC if Addisonian crisis
CV: vasopressors, fluid if Addisonian crisis, hypovolemic
Pulm: RSI if vomiting
GI: abdominal pain, N/V/D if Addisonian crisis
Fen/K: hyperK, hypoNa. Prerenal dailure.
Heme/ID: N/A
Endo: consider consult, stress dose hydrocortisone 100mg (continue q6h for Addisonian crisis). AI may be primary (autoimmune, infections like TB) or secondary (chronic steroids, tumor, radiation, surgery, drugs like ketoconazole)

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7
Q

Adrencorticol excess considerations (Cushing syndrome)

A

Neuro: potential elevated ICP, eval for sx pituitary tumor (HA, bitemporal hemianopsia, DI). Psychosis, depression, somnolence.
CV: HTN, LVH, asymmetric septal hypertrophy, CHF. Increased sensitivity to catecholamines.
Pulm: OSA, cor pulmonale
GI: N/A
Fen/K: hypoK, DI (if pituitary tumor)
Heme/ID: erythrocytosis, impaired wound healing, infection
Endo: hyperglycemia, consider endo consult

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8
Q

Alcoholism considerations

A

Prevent withdrawal (benzos), nutrition supplementation, thiamine. Consider RSI if ascites 2/2 cirrhosis, full stomach/intoxicated. Monitor for periop withdrawal.

Neuro: peripheral neuropathy, Wernicke-Korsakoff syndrome (ocular signs, ataxia, confusion). Decreased MAC acute intoxication, increased MAC chronic.
CV: cardiomyopathy, arrhythmias, tachycardia/HTN in acute intoxication
Pulm: PNA, abscesses
GI: GERD, gastritis, varicose, liver disease, pancreatitis
Fen/K: N/A
Heme/ID: pancytopenia, coagulopathy
Endo: N/A

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9
Q

Amyotrophic lateral sclerosis (ALS) considerations

A

Neuro: bulbar palsy, altered response to neuromuscular blockers (NDMB prolonged duration—reduce dose, monitor TOF, hyperK with sux). Hyperreflexia, atrophy, orthostatic hypotension, rearing tachycardia. Neuraxial safe but avoid high block.
CV: autonomic dysfunction
Pulm: risk for post op mechanical ventilation, aspiration risk 2/2 bulbar palsy, avoid worsening respiratory depression.
GI: aspiration risk, full stomach. Aspiration ppx.
Fen/K: N/A
Heme/ID: increases risk PNA
Endo: N/A

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10
Q

Ankylosing spondylitis considerations

A

“Bamboo spine.” If neuraxial, caution for high block (smaller epidural space). Morning stiffness improves with exercise.

Neuro: spine fracture/collapse, nerve root/cord compression, cauda equina, if C-spine involved may be difficult intubation and impossible tracheostomy. Consider preop airway imaging and AFOI.
CV: AR, MR, conduction defects
Pulm: restrictive defects, limited chest expansion, may need chest PT.
GI: Co-morbid with ulcerative colitis/Crohn’s
Fen/K: N/A
Heme/ID: N/A
Endo: N/A

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11
Q

Anterior mediastinal mass considerations

A

If airway or vascular compression, options are: awake patient if possible, reposition, rigid bronch with ventilation distal to lesion, sternotomy and elevate mass off vessels

Eval flow-volume loop (intra-thoracic obstruction), CT or imaging for airway compression, echo, CXR, EKG

Neuro: N/A
CV: risk of cardiac collapse with induction. May need to place micropuncture for ECMO/CPB prior to induction (or go on electively). SVC syndrome.
Pulm: risk airway obstruction (in peds, if tracheobronchial compression >50% cannot do GETA). Consider AFOI. If asleep, maintain spontaneous ventilation with slow titrated induction. Have rigid bronch available (and someone who can do it). Check mask ventilation prior to muscle relaxant. Caution postop airway obstruction.
GI: N/A
Fen/K: N/A
Heme/ID: often due to Hodgkin’s lymphoma or NHL
Endo: N/A

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12
Q

Aortic dissection considerations

A

Neuro: stroke, circulatory arrest, consider EEG, SSEP, MEP, TCD, NIRS, CSF drain (stroke more of a concern Type A, spinal cord ischemia more of a concern Type B)
CV: tamponade, AR, MI, h/o HTN. Goal SBP <115, impulse control
Pulm: hemothorax
GI: mesenteric ischemia
Fen/K: renal malperfusion/failure
Heme/ID: hemorrhagic shock
Endo: avoid hyperglycemia

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13
Q

ASD/VSD considerations

A

Eisenmenger syndrome: increased PVR leading to R->L shunt (cyanotic, clubbing). Large VSD = delayed growth, FTT.

Neuro: IV induction agents slower onset. Can have paradoxical emboli causing stroke.
CV: Split S2. Decreased SVR: decreases L-> R shunt. May be on digoxin, diuretics, afterload reduction. ASD=RAD, RVH, RBBB. VSD = LVH, LAH. Echo, lytes.
Pulm: Maintain oxygenation, although 100% FiO2 decreases PVR -> worsens L->R shunt.
GI: N/A
Fen/K: N/A
Heme/ID: IE ppx for first 6 months after repair.
Endo: N/A

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14
Q

Asthma considerations

A

Airway instrumentation can cause parasympathetic reflex bronchoconstriction. GETA carries risk of bronchospasm. Avoid meds causing histamine release (atracurium, mivacurium)

Neuro: N/A
CV: cor pulmonale (RV failure); HTN from chronic steroids
Pulm: air trapping, hyperinflation, increased WOB, V/Q mismatch. PFTs to assess severity/reversibility, ABG severity. Peak flow meter 15=20% reduction = exacerbation. PFTs: reduced FEV1, reduced FEV1/FVC, increased RV/FRC. Avoid triggering stimuli, treat B2 agonists, corticosteroids, chest physio, abx if PNA. Deep extubate if safe.
GI: N/A
Fen/K: hypoK, hyperglycemia, hypoMg with high-dose beta2 agonists.
Heme/ID:
Endo: hyperglycemia if chronic steroids

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15
Q

Burn patient considerations

A

BSA rule of 9th: head 9%, arms 9% each, legs 18% each, chest 18%, back 18% (head 18% for children). Count 2nd and 3rd degree.

Parkland formula: 4cc LR/kg/% BSA (half first 8 hrs, second half over 16 hrs)

Neuro: ACh receptor proliferation–avoid sux after 24 hrs, may be resistant NDMRs.
CV: Hypovolemic/distributive shock. Decrease CO, decreased response to catecholamines, increased SVR first 24-48 hrs. Then increased CO, decreased SVR after 48 hrs.
Pulm: Secure airway early (edema). Inhalation injury, risk airway obstruction. Eval for facial burns/edema, stridor, respiratory distress. ABG, carboxyhemoglobin–consider hyperbaric therapy.
GI: GI ppx.
Fen/K: Metabolic acidosis. Maintain UOP >0.5=1cc/kg/hr
Heme/ID: Avoid infection–strict aseptic technique. Risk sig blood loss.
Endo: N/A

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16
Q

Carcinoid considerations

A

Tumor releases serotonin, histamine, substance P, prostaglandins, kallikrien, etc. FLUSHING, HYPOTENSION, HYPERGLYCEMIA, BRONCHOSPASM.

Dx: urinary 5-HIA and serum chromogranin A.

Triggers: stress, anxiety, exercise, foods high in serotonin, histamine-releasing meds, catecholamines.

Carcinoid crisis: due to tumor manipulation = bronchoconstriction, hypotension, hyperglycemia. Tx octreotide 50-100mg q5-10min.

Neuro: Avoid anxiety
CV: right-sided valve regurg/stenosis, RV failure, hemodynamic instability, SVT. Serotonin can cause hypotension. Eval EKG, echo. Conflict: catecholamines can worsen mediator release.
Pulm: bronchoconstriction
GI: GI tumor, liver dysfxn, risk bowel obstruction. Eval LFTs.
Fen/K: N/A
Heme/ID: N/A
Endo: a/w multiple endocrine neoplasia. Octreotide can cause hyperglycemia.

17
Q

Cardiac contusion considerations

A

Usually involves RV, often in setting of emergency trauma. Heart failure, arrhythmias.

Dx: exam for chest trauma, contusion; EKG, echo, troponin, CXR.

18
Q

Cardiac tamponade considerations

A

May be acute (shock) or chronic. Equilibrium of pericardial and diastolic pressures = impaired ventricular filling. May have cardiovascular collapse with induction anesthesia (decreased sympathetic tone, decreased venous return from PPV). If hemodynamically significant, drain prior to GETA.

Beck triad: elevated JVP, hypotension, distant heart sounds.

Signs:
- Pulsus paradoxus: inspiratory fall in SBP >10
- Electrical alternans on EKG
- Kussmaul sign: JVP distends w/ inspiration

Neuro: N/A
CV: Fixed stroke volume, CO is rate dependent. Pre-induction invasive monitors/lines. In arrest, CPR may be ineffective. Avoid hypovolemia, bradycardia, decreased SVR. Maintain inotropy.
Pulm: Caution with PPV–decreases preload further! Maintain spontaneous ventilation if able.
GI: N/A
Fen/K: N/A
Heme/ID: Have blood available
Endo: N/A

19
Q

Cerebral aneurysm considerations

A

Vasospasm tx: nimodipine
Triple H: HTN, hypervolemia, hemodilution
Conflict: need to secure airway in AMS but avoid BP swings (minimize transmural pressure )

Neuro: Emergency if SAH. Increased ICP (HA, LOC). Maintain CPP >60, normocapnia, mild hypothermia (32-34 C), avoid hyperglycemia.
CV: HTN = risk rebleed, HoTN = impaired CPP. Keep SBP <160, MAP >85.
Pulm: Protect airway, risk neurogenic pulm edema
GI:
Fen/K: SIADH, CSWS (hypoNa)
Heme/ID:
Endo: Avoid hyperglycemia

20
Q

COPD considerations

A

Neuro: N/A, consider epidural/regional techniques but caution ISC in COPD. Avoid/minimized narcotics.
CV: pulmonary HTN, cor pulmonale (JVD, pedal edema). CAD in smokers.
Pulm: V/Q mismatch, hypoxia/hypercarbia. Eval if able to speak full sentences, pursed lips, home O2/CPAP, severity, therapy, exacerbating factors. Pre-op chest physiotherapy, abx if infection, inhaled beta agonists and anticholinergics. I:E >1:2 (air trapping)
GI: N/A
Fen/K: N/A
Heme/ID: carboxyhemoglobinemia (smoking)
Endo: N/A

21
Q

Chronic renal failure considerations

A

Assess comorbidities: CAD, HTN, DM, PVD
Optimize: dialyze up to 24 hrs before
Nephrotoxic drugs: NSAIDs, aminoglycosides
Renally excreted drugs: morphine, meperidine, pancuronium - altered pharmacokinetics

Neuro: uremic encephalopathy, autonomic/peripheral neuropathy. Avoid or reduce midazolam (reduced protein binding = increased plasma free levels, decreased elimination)
CV: autonomic dysfunction–> orthostasis, Cr >2 risk factor for MACE. EKG for hyperK, ischemia.
Pulm: if peritoneal dialysis, consider draining to optimize respiratory function
GI: hypoalbuminemia, gastroparesis if DM
Fen/K: volume overload, electrolytes (hyperK, hyperMg, hypoCa)
Heme/ID: platelet dysfunction, anemia, coagulopathy
Endo: N/A

22
Q

CAD considerations

A

Noninvasive stress testing only if will change management. Therapy options: medical, percutaneous, surgical. Cardioprotection: statins, beta blockers, alpha-2 agonists, antiplatelet agents. Greatest risk for MI is POD 1-3.

Volatile anesthetic may protect against ischemia-reperfusion injury.

23
Q

Cystic Fibrosis considerations

A

Mutation in CF transmembrane regulator protein found on exocrine glands.

Neuro:
CV:
Pulm: obstructive disease, decreased mucociliary clearance = inflammation, chronic infection, hypoxia/hypercarbia.
GI: retention of pancreatic digestive enzymes leading to auto digestion, fibrosis, pancreatitis, malabsorption.
Fen/K:

24
Q

Diabetes considerations

A

Neuro: cerebrovascular disease, peripheral neuropathy, autonomic neuropathy, retinopathy
CV: autonomic neuropathy/orthostatic hypotension, increased risk CAD
Pulm: stiff joints due to glycosylation–may have limited C-spine ROM
GI: gastroparesis/aspiration risk
Renal: nephropathy
Heme/ID: wound infection
Endo: hyper/hypoglycemia, DM1 risk for DKA (dehydration, acidosis, vomiting, fatigue, confusion, unconsciousness), DM2 risk for HHS (hyperosmolar hyperglycemia syndrome)

Sx hypoglycemia: weakness, fatigue, confusion, seizures, sweating, tachycardia

25
Q

Down Syndrome (T21) considerations

A

Key: keep in mind risk for difficult airway and C-spine instability, post-op pulm issues (OSA).

Neuro: possible developmental delay
CV: endocardial cushion defects, TOF, pulm HTN. Accelerated CAD.
Pulm: atlantoaxial instability, tonsillar/adenoid hypertrophy, macroglossia, subglottic stenosis, pulm HTN, OSA (risk difficult airway). Eval: C-spine X-ray (recommended all patients between 3-5 yrs age), repeat if previously abnormal; changes in gait, motor function, bowel/bladder function. If Hx/PE suggest cord compression: cancel elective, if emergent use C-spine precautions. Keep neck neutral. Often need smaller ETT than predicted age to avoid postintubation croupt.
GI: higher incidence GERD, TEF, duodenal atresia, celiac disease.
Renal: N/A
Heme/ID: leukemia, polycythemia.
Endo: hypothyroidism

26
Q

Duschenne Muscular Dystrophy

A

Most common childhood muscular dystrophy. Caused by lack of dystrophin, affects skeletal, cardiac and smooth muscle. Can have anesthesia-induced rhabdomyolysis that is NOT MH (not at increased risk MH). Still use trigger-free anesthetic to avoid inhalational agents and succinylcholine (no inhalational induction). TIVA preferred.

Neuro: sensitive to NDMRs. Regional anesthesia OK. Hypotonia, pseudohypertrophy calf muscles, scoliosis.
CV: cardiomyopathy, arrhythmias. Consider EKG/echo.
Pulm: most common cause of death is respiratory failure. Pharyngeal muscle weakness, risk aspiration, have NPPV ready for high-risk patients post-op. Chest PT prn.
GI: dysphagia, gastroparesis (smooth muscle dysfunction)
Renal: hyperkalemia with succinylcholine
Heme/ID: N/A
Endo: may be on chronic corticoid therapy (slows disease progression)

  • Caution with benzos (respiratory insufficiency)
  • Use peripheral neuromonitor if NDMB (up to 4x prolongation of block)
  • Prep similar to MH case (machine flush, no volatiles/succinylcholine)
  • Monitor for signs hyperkalemia/rhabdo (hyperkalemia without hypermetabolism)
27
Q

Epiglottitis and Croup considerations

A

Goal: maintain spontaneous ventilation. Inhalational induction -> intubation; have surgical backup for emergency trach. Be prepared difficult airway including rigid bronch, have small ETT sizes available.

Neuro: N/A
CV: N/A
Pulm: upper airway obstruction. Epiglottitis- drooling, dysphagia, sudden stridor. Croup - gradual stridor, minimal dysphagia, no drooling, often improves w/ nebulized epi, dexamethasone consider heliox.
GI: N/A
Renal: N/A
Heme/ID: Epiglottitis -H. influenzae, Group A strep, staph; broad-spectum abx. Croup - parainfluenza.
Endo: N/A

Ddx: foreign body aspiration, tracheitis, tonsillitis, retropharyngeal abscess, vascular rings, allergic reaction, diphtheria.

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