Medical Viva 2 Flashcards
(20 cards)
Cerebral palsy (CP) description
Wide spectrum of disease that includes
Movement disorder (spasticity, dyskinesia, ataxia)
Developmental delay.
Visual/speech/hearing impairment
Epilepsy
Associated with multisystem disease -
* Airway - dysphagia, reflux, poor dentition
* Resp - chronic lung disease/recurrent aspiration pneumonitis/kyphoscoliosis/restrictive lung disease/pulmonary hypertension
* Neuropathic bladder
* Contractures
* Osteoporosis
A clinical description of development - not a diagnosis of disease
Caused by brain injury antenatal (80%), perinatal (10%) and postnatal (10%) up to 2 years.
It is non-progressive but lifelong.
Cerebral palsy (CP) severity scale
Gross Motor Functional Capacity system
1 - can walk and climb stairs without limitation
2 - can walk independently but needs railing for stairs
3 - can walk with device
4 - can walk short distances at home with device but wheel chair dependent outside.
5 - fully wheel chair dependent. No antigravity movement in head and trunk.
Myasthenia gravis severity
MG Foundation of America
1 - eyes only
2- mild (a axial >bulbar) (b bulbar >axial)
3 - mod
4 -severe
5 - crisis req intubation
Myasthenia gravis - post op ventilation
Leventhal criteria
1. VC <2.9L
2. Duration >6 years
3. Pyridostigmine dose >750mg daily
4. Co-existing chronic resp disease
5. Major cavity surgery (thoracic, abdominal, pelvic)
Myasthenia gravis - neuromuscular blockade
Increase sensitivity to NDNMB
Resistant to Sux - 2.6x
Myasthenia gravis - weakness in recovery
Weakness in recovery
Cholinergic crisis (worsens with edrophonium, treat with intubation and atropine and withhold cholinerestarse inhibitors)
Myasthenia crisis (improved with edrophonium)
Myasthenia gravis - 20/30/40 rule
Intubate if
Forced vital capacity (FVC) < 20 mL/kg,
Negative inspiratory pressure (NIP) < 30 cm H2O,
Positive expiratory pressure (PEP) < 40 cm H2O
Acromegaly - considerations
Too much GH - can be suppressed with octreotide
Airway - large tongue, jaw, epiglottus = difficult BMV/intubation
subglottic stenosis = smaller ETT
^OSA - sensitive to opioids/sedatives, multimodal analgesia, extubate awake - NIV contrainidcated post transphenoidal surgery
Cardio - LVH, diastolic heart failure, arrhythmia, poor ulnar collateral circulation, radial art line may be contraindicated
Disability - headache, visual disturbances
E - carpel tunnel syndrome, bony prominences - difficult positioning
Endocrine - ^diabetes, MEN1 - parathyroid, pancreatic tumours
Acute porphyria - triggers, prevention, treatment
Non pharm - pain, infection, stress, dehydration, fasting
Pharm - barbiturates, diazepam, phenytoin, dexamethsaone, ketamine, ergometrine
Minimise fasting, carbohydrate load
Attacks = neuro - agitation, seizures, headache, hallucinations, coma
Resp failure, labile BP, tachyarrhythmias, abdo pain/vomiting, red/purple urine and AKI
Treatment is hematin (inhibits ALA synthase), plasmapheresis, carbohydrate loading, supportive
QTc - normal male, female, prolonged at risk of TdP
Treatment of TdP
male 440 female 460
>500ms = risk of TdP
Defib
MgSO4 2g
Lignocaine 1.5mg/kg
QT prolonging drugs
Antiemetics - ondansetron, droperidol, cyclizine
Volatiles - sevoflurane
Methadone
Amiodarone/Sotalol
Macrolide antibiotics - erythromycin/azithromycin
Antidepressants/Antipsychotics
Thiopentone, suxamethonium, ketamine
Quadriplegia
Avoid sux and autonomic dysreflexia - no inhibitory descending pathway
Neuraxial - spascity turns to flaccid paralysis and reflexes go away
Cause - trauma/tumour
Fixation - neck extension
Complete vs partial spinal cord injury = higher risk
Resp compromise - loss of intercostal/diaphragm - spirometry/PFT/noctural BiPAP
Cardio - postural hypotension, volume deplete/anaemia, loss of cardioaccelerator fibres
GI - delayed gastric emptying
Chronic pain
Chronic immobility - bed sores, UTI/SPC, PEG feeds
Seizure in Pregnancy
Obstetric - eclampsia
Anaesthetic - LAST/High block
Neuro - Epilepsy, ↑ICP, Cerebral venous sinus thrombosis, SAH
Metabolic - Hyponatremia/Hypoglycemia
Drug withdrawal - ETOH/benzos
Pseudoseizure
Brugada
STE in V1-V3 with RBBB or iRBBB
Type 1 - coved type
Type 2 - saddleback
S3 Heart Sound vs S4 Heart Sound
S3 - early diastole - volume overload (MR, TR, AR, dilated cardiomyopathy. normal in athletes, pregnancy, children)
S4 - late diastole - pressure overload (AS, HCM, Hypertension)
Multiple Sclerosis
Avoid Sux = ↑K
A Aspiration risk = bulbar dysfunction Consider prophylaxis. Need for RSI
B Resp weakness/failure = central hypoventilation Maximise function.
Multimodal analgesia (maximise non opioid options + LA infiltration/Regional/Neuraxial, minimise opioids)
C Autonomic dysfunction (orthostatic hypotension) Consider artline
D Avoid NMB where possible. Full NMB reversal with TOFR>0.9.
E Neuraxial in Pregnancy Consent Pregnancy = ↓immune function = ↓MS symptoms
Post partum = ↑ immunity = ↑relapse of symptoms regardless of anaesthetic technique
Triggers for disease Avoid intra-operative hyperthermia. Use temp probe
Medications Immunosuppressive meds Consider need for stress dose steroids. Low threshold for prophylactic antibiotics.
Baclofen for muscle spasticity ↑sensitivity to NMB
AF anticoagulation
CHADS
CHADSVASC
Males 2+ Females 3+ anticoagulate
HASBLED
Hypertension
Abnormal Liver (1) or Renal function (1)
Stroke
Bleeding
Labile INR
Elderly >65yo
Drugs (antiplatelet/NSAIDs) (1) (ETOH) (1)
3+ is high risk
Ehlers Danlos - considerations
Fragile skin and hypermobile joints
AAI/C-spine/TMJ, dental, tracheal instability
Pneumothorax
MVP/MR/AR, dilated CM
Resistant to LA/regional
Neuraxial - kyphoscoliosis
Anecdotally more bleeding despite normal traditional coags - TXA/DDAVP/rFVIIa
Vascular subtype with vessel/organ fragility and spontaneous rupture + mortality
Cf Marfans - NOT TALL. NO AORTIC issues
Cushings Syndrome
- excess plasma cortisol
-iatrogenic steroids, pituitary adenoma (Cushing’s disease), adrenal tumour - sleep apnoea
- hypertension, LVH, volume overload,
- HIGH: sodium, bicarbonate, glucose
- LOW: potasium, calcium
Metabolic alkalosis
Psychosis
Exam - moon face, buffalo hump, proximal muscle wasting, abdominal striae, thin skin, easy bruising, poor wound healing, osteoporosis, hirsutism, amenorrhea
Investigations
Urine and serum Cortisol
Plasma ACTH
Dexamethasone suppression test
MRI/PET -pituitary/adrenals
Sleep study
ECG, TTE
Correct BSL, electrolytes, fluid overload - spironolactone
Stress steroids
