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Nashville Review 2024 > Nashville Medicine and Complications > Flashcards

Nashville Medicine and Complications Flashcards

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1
Q

What is ASA 1?

A

Class I – normal healthy patient (non-smoker; no or minimal alcohol use)

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2
Q

Examples: Current
smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well controlled DM/HTN, mild lung disease)

What ASA is this?

A

ASA 2

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3
Q

Poorly controlled DM or HTN, COPD, morbid obesity BMI >40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderately reduced EF, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, of CAD/stents.)

What ASA is this?

A

ASA 3

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4
Q

(Examples: recent (<3 mos.) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of EF, sepsis, DIC, ARD, or ESRD not undergoing regular dialysis)

What ASA is this?

A

ASA 4

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5
Q

Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple system organ dysfunction.

What ASA is this?

A

ASA

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6
Q

Class VI ASA give an example:

A

A declared brain-dead patient whose organs are being removed for donor purposes.

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7
Q

Describe the Mallampati classifications:

A

*Class 1: visualization of the soft palate, fauces, uvula, anterior and posterior pillars

*Class 2: visualization of soft palate, fauces and uvula

*Class 3: visualization of soft palate and base of uvula

*Class 4: soft palate is not visible at all

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8
Q

How do you choose the ET tube size for a pediatric patient?

A

Estimate by size of little finger OR

Diameter: (age + 16)/4 i.e 4y.o. = size 5 *Length: (age/2) = 12 i.e. 4y.o. = 14 cm

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9
Q

How much tidal volume should you be giving a pediatric patient?

A

tidal volume 10-15cc/kg

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10
Q

Cardiac output in children needs to be twice as high as adults due to what reason?

A

increased metabolic rate and oxygen consumption

Major determinant is Heart rate

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10
Q

What is a laryngospasm?

A

Protective reflex to prevent foreign matter from entering the larynx, trachea, or lungs.

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11
Q

How do you treat a laryngospasm?

A

100% Oxygen

Suction all blood and foreign/pack surgical site to prevent further bleeding into the hypopharynx

Depress patient’s chest and listen for a rush of air to indicate patency

If obstruction persists, break spasm with positive pressure via 100% O2 and full-face mask with good seal (appropriately sized for child vs. adult patient.)

If obstruction persists - Succinylcholine

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12
Q

How much succinylcholine do you give for a laryngospasm?

A

Adults 0.1-0.2mg/kg IV for adults (small dose 10-20mg IV for partial obstruction). Pediatric dose 0.25-0.50mg/kg IV

In a complete spasm where smaller dose fails to break spasm, use 20-40mg IV

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13
Q

What are the complications of using succinylcholine?

A

Myalgias

Malignant hyperthermia

Hyperkalemic cardiac arrest (in susceptible patients with myopathies)

Masseter muscle spasm in pediatric patients (potential indicator of MH)

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14
Q

What is a brochospasm?

A

Constriction of the walls of the bronchioles often caused by mast cell degranulation that can occur in response to allergic triggers or physical stimuli (secretions or ETT). Airway diameter decreases due to mucosa thickening and increased production of thick, viscous mucous.

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15
Q

How do you treat a laryngospasm?

A

Inhaled beta agonist via
inhaler of nebulizer Oxygen

Epinpehine

Intubation if deteriotion

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16
Q

What is the dosage of epinephrine require to treat bronchospasm?

A

1:1000 0.3 to 0.5 mg SC/IM

10-20mcg of 1:10,000 solution to response of anapylaxis

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17
Q

What are the NPO guidelines?

A

Clear liquids: 2 hours
Light solids: 6 hours
Fatty Solids: 8 hours

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18
Q

Treatment in emerging aspiration patient:

A

Encourage coughing to clear airway

Put chair in Trendelenburg (head down 15 degrees) with patient onto right side

Suction airway – remove any foreign material

100% oxygen

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19
Q

During aspiration event if patient fails to improve and develops signs of severe dyspnea, cyanosis, tachycardia, and hypotension what do you do?

A

Activate EMS

Clear airway again

Intubate and manage bronchospasm with beta agonist

Small volume tracheobronchial lavage

No antibiotics and no steroids

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20
Q

Post emergent management of a recovered patient after aspiration includes:

A

Observe at least 2 hours in office

Discharge criteria
SpO2 > 94% on room air

No wheezing, shortness of breath and minimal cough

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21
Q

Describe the normal capnography wave:

A
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22
Q

What is asthma?

A

A chronic inflammatory disorder of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and cough particularly at night or in early morning. These symptoms are usually associated with widespread but variable airflow limitation that is at least partially reversible either spontaneously or with treatment.

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23
Q

Whats the classic triad of asthma symptoms?

A

Wheeze (high-pitched upon expiration)

Cough – may be dry of productive (mucoid or pale yellow sputum)

Shortness of breath or difficulty breathing

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24
Describe intermittent asthma:
Symptoms 2 or fewer days per week No interference of normal activity FEV1 between exacerbations are normal range
25
Describe mild persistant asthma:
Symptoms more than 2x weekly Minor interference with Mormal activity FEV1 within normal range
26
Describe moderate persistant asthma?
Daily symptoms and need for short acting beta agonist Some limitation of normal activity FEV1 60-80% of predicted
27
Describe severe persistant asthma?
Symptoms throughout the day Extreme limitation of normal activity Nocturnal wakening nightly FEV1<60% of predicted
28
What are the main drugs used to treat asthma?
Short –acting beta-2-selective adrenergic agonist Low dose inhaled glucocorticoid Alternatives – Leukotiene receptor agonists, theophylline, and cromoglycates
29
What's the Most common sign of an acute coronary syndrome (70-80% of affected patients)?
Angina visceral ache, sharp dermatome, and impending doom
30
What is cardiomyopathy?
Heart muscle becomes enlarged, thick or rigid. May become replaced with scar tissue. Dilated; hypertrophic; restrictive; arrhythmogenic; right ventricular
31
What is a STEMI?
transmural infarction of the myocardium, thus the entire thickness of the myocardium undergoes necrosis, resulting in ST elevation
32
What is an NSTEMI?
non-occlusive thrombus of a coronary artery, or an occlusive thrombus in a minor artery. No ST elevation or Q waves
33
Management of patients with known frequent angina attacks:
Prophylactic Nitroglycerin 0.4mg SL prior to stressful procedure 100% O2 Anxiolytics – IV sedation to control stress response Psychological support – stress reduction
34
Patient is having an angina event in the chair what do you do? He's had previous heart attacks...
Terminate procedure Administer O2 @ 4L via mask or nasal canula Monitor vitals Sublingual nitro if SBP >90mmHg CP >5 minutes -> administer second dose of nitro IV morphine 1-3mg increments at 5 minute intervals ASA 160-325mg -> chew If patient unresponsive to 3 doses of nitro in 10 minutes, assume AMI and activate EMS
35
What leads will have elevation in an inferior MI?
S-T segment elevations in leads II, III, and aVF (acute inferior)
36
What do q waves represent?
Q waves represent scarred heart tissue from prior MI
37
What is anaphylaxis?
Massive release of chemical mediators Progressive cardiovascular collapse due to increased capillary permeability refractory to treatment, smooth muscle spasm, and acute pulmonary edema.
38
How do you manage a Mild reactions – urticarial, mild angioedema?
50mg Diphenhydramine IV, IM or PO (Stop offending agent)
39
How do you manage a severe allergic reaction with IV epi:
Epinephrine IV 1:10,000 (1mg in 10mL Adults: titrate 0.2mg (2mL) to 0.5mg (5ml) to affect every 2-5 minutes Children: 0.01mg/kg Support circulation with IV fluids – Adult = rapid infusion of 1L lactated Ringer’s
40
If IV is unable in an emergency during an allergic reaction what do you give?
Adults: 0.3 to 0.5mg of a 1:1,000 concentration repeated in 10-20 minute intervals Children: 0.01 mg/kg repeated in 10-20 minute intervals
41
What is the dosage for epi during via ETT tube?
Administered at twice the IV dose
42
In an emergency allergic reaction, what other medications should you give beside epi?
Antihistamine administration – Diphenhydramine 50g (adults); 25mg (child 6-12) Corticosteroids – slow action, but important in regaining homeostasis Dexamethasone 4-12mg IV/IM given slowly
43
Besides succinylcholine whats an alternative you give?
Alternative non-depolarizing NMBA Dose 1.0 - 1.2mg/kg IV Longer duration of action - be prepared for prolonged airway management
44
What are the clinical signs of malignant hyperthermia?
Increasing ETCO2 Trunk or total body rigidity Masseter spasm or trismus Tachycardia/tachypnea Mixed respiratory and metabolic acidosis Increased temperature (may be late sign) Myoglobinuria
45
What is the treatment for malignant hyperthermia?
Dantrolene 2.5mg/kg IV; repeat every 5-10 minutes until fall in HR, normal rhythm decline in muscle tone Stop all triggering agents Hyperventilate Place ET tube Malignant Hyperthermia Association of the United States (MHAUS) hotline (1-800-MH-HYPER)
46
How do you mix dantrolene?
Mix 20mg dantrolene, 3g of mannitol and 60mL of sterile water Administer 1-3 mg/kg bolus rapidly up to 10mg/kg until signs are controlled
47
What is malignant hyperthermia?
Hypermetabolic crisis due to an inherited muscle disorder that can result in elevated levels of Ca+ in the myoplasm of muscle cells resulting in activation of muscle contraction. In MH crisis, the muscular contraction is sustained and heat, lactic acid, and carbon dioxide are produced.
48
What are the risk factors for malignant hyperthermia?
Personal or family history of MH Personal or family history of muscle of neuromuscular disorders (Duchene’s or Becker’s) History of dark of cola-colored urine following previous anesthesia of exercise
49
What are some triggering agents for MH?
Succinylcholine (don’t be surprised if laryngospasm case leads to MH) Volatile anesthetic inhalation agents
50
List some agents that are safe for MH history familial MH history patients:
Local anesthetics Benzodiazepines Opioids Barbituates Propofol Ketamine Nitrous oxide Etomadate
51
How often should you administer dantrolene after MH?
Continue dantrolene administration 1mg/kg every 4-6 hours. ICU observation for 24hours because MH may recur.
52
What is DKA?
Hyperglycemia (>500), anion gap metabolic acidosis, and ketonemia
53
What is DKA?
IV fluids 0.9% NS (1L over 30 minutes) Replace K – measure K+ and replace 10-20 meq/hour IV IV regular insulin (15 units ) then sliding scale Correct pH with bicarb if <7
54
How do you treat hypoglycemia (glucose <50)?
dextrose IV 50% (D50) 1mL/kg IV up to 50mL OR D5W 10mL/kg IV up to 500mL OR Glucagon 0.025 0.1 mg/kg IV/IM/SC up to 1 mg
55
What is Hypertensive Urgency? What should you do?
When BP >220/120 and no signs or symptoms This triggers immediate physician referral
56
What is hypertensive urgency?
When BP >220/120 and Myocardial ischemia Neurological dysfunction Significant bradycardia Pulmonary edema Visual disturbances
57
How does esmolol work?
A cardioselective B1 receptor blocker with rapid onset and short duration of action Good choice if tachycardia present Good in asthmatics (no B-2 blockage) 10-30 mg IV q5minutes
58
How does labetolol work?
An alpha- and ß-adrenergic blocker, given as an intravenous bolus or infusion. 5-20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min.
59
How does hydralazine work?
An arteriolar dilator, given as an intravenous bolus. Initial dose: 5-10 mg given every 20 to 30 minutes; maximum dose: 20 mg. Good for pregnant women or if bradycardia present
60
What is considered hypotension?
A reduction of arterial blood pressure of 15-20% from baseline Bradycardia (early) or tachycardia (late) Decreased cardiac output and tissue perfusion
61
Describe the treatment of hypotension:
0.01 mg/kg of atropine (up to 0.5mg if bradycardia) 5-10mg of ephedrine q5 minutes 0.1mg phenylephrine q 5 minutes – if tachycardia
62
What is Von Willibrand Disease?
Factor VIII deficiency and von Willebrand factor deficiency VWF serves to stabilize platelet adhesion and is produced by endothelial cells and monocytes
63
How do you treat mild vWF and Hemophilia A?
DDAVP→ ↑ release vWF (req >5% active factor VIII to release stores) Desmopressin (synth analog of ADH)→ ↑ stored vWF & VIII from endothelial cells max effect: 15-20 min/ 1⁄2 life 6 hrs (↓ effect w/ ↑ doses b/c limited vWf stored)
64
How do you treat severe vWF disease?
ryoprecipitate (VIII, XII, vWF + fibrinogen) Severe: Factor VIII conc (often does not help w/ VWD alone → + cryo)
65
What medication should you add for vWF and Hemophilia A patients post op?
Amicar (inhibits fibrinolysis), 6g PO qid Note: can give pre-op: 5g IV 30 min before (= loading dose) for hemophilia, bleeding, rebleeds (intracranial aneurysms), GI bleeds
66
How do you treat hemophilia B?
Mild-Moderate: FFP(factors II, VII, IX, X) Severe: IV Proplex (contains concentrate factors II, VII, IX, X)
67
What is sickle cell anemia?
Autosomal recessive disorder of change in chemical composition of HgB with valine substitution for glutamic acid
68
How is sickle cell disease diagnosed?
Diagnosis is by Hgb electrophoresis
69
How is sickle cell anemia treated?
Folic acid – improves RBC turnover Hydroxyurea – Mainstay to decrease crisis frequency by increasing fetal Hgb Early treatment of HTN – mild increases in BP show significant increase of stroke Transfusion therapy – decrease percent of HbS
70
How can you preoperatively treat patient
Adequate o2 Hydration Avoid hypothermia Minimize blood loss
71
What are the 4 type of seizures?
Convulsive – muscle contractions Myoclonic – contract and relax continuously Tonic-clonic (grand mal) – LOC, fall to ground, and jerking movements Absence – brief LOC with minimal activity
72
How do you define epilepsy?
Epilepsy – syndrome of 2 or more unprovoked seizures in a lifetime
73
What is the treatment for status epilepticus?
Control airway O2 Activate EMS Diazepam 10mg over 2 minutes every 10 minutes or (more common in office setting) Midazolam 2mg IV then 1mg/min IV (0.05mg/kg, or 0.025mg/kg in children Glucose check Glucose and thiamine prn Monitors and possible respiratory support in postictal period
74
What are some drugs in the office that can induce seizures?
Methohexital (Brevital) Ketamine (Ketalar) Enflurane.sevoflurane Flumazenil
75
What are OMFS considerations when it comes to Multiple Sclerosis?
Stress reduction – studies show relapses are more common after stressful events Temperature management – relapse may be stimulated by overheating Patients often with history of large steroid doses over prior 6 months necessitating stress-dose steroids Patients with a history of interferon use should prompt an investigation to rule out thrombocytopenia, neutropenia, or anemia Post op pain
76
What is myesthenia gravis?
An autoimmune disorder characterized by weakness and fatigability of skeletal muscles caused by autoantibodies directed against acetylcholine receptors of the neuromuscular junction.
77
What are OMFS considerations when it comes to myesthenia gravis?
Respiratory muscle weakness is a major concern. Can be quantified with PFT’s Avoid non-depolarizing muscle relaxants
78
What is serotonin syndrome?
Occurs when SSRIs are used in combination with agents that increase serotonin concentrations (MAOIs, tramadol, fentanyl, ondansetron and St. John’s Wort) Symptoms include: confusion, agitation/restlessness, fever, diaphoresis, diarrhea, ataxia, hyperreflexia, myoclonus
79
How do you treat serotonin syndrome?
lorazepam 1-2mg slow IV push q30minutes until improvement or extreme sedation Cyproheptadine 4mg PO q4hours Methylsergide 2-6mg PO to block serotonin Propranolol 1-3mg slow IV push
80
When can you treat a coccaine abuser?
No treatment within 24 hours of last use
81
What are your concerns when treating a coccaine addict?
Increased risk of cardiac dysrhythmias Local anesthetics with AND without vasoconstrictors have additive dysrhythmic effects Careful use of epinephrine and bupivacaine due to dysrhythmia potential Avoid ketamine
82
What are the OMFS considerations when it comes to marajuana users?
Few anesthetic considerations THC potentiates the respiratory depressive effects of opioids in acute intoxication
83
When treating a duschene patient what do you need to avoid?
No depolarizing muscle blockers (→ hyperkalemia) Can use non-depolarizing steroidal muscle relaxants ↑ incidence of MH (may be triggered by NDNM blockers, volatile anesthetics) AVOID volatile anesthetics
84
What are the main OMFS considerations for marfans patients?
Consider antibiotic prophylaxis to prevent endocarditis – this is somewhat controversial as it is not specifically recommended in the special cases category of the current AHA guidlines Aortic root problems
85
What are the two medications not to use in pregnant patients?
NSAIDS Nitrous
86
What is pre-eclampsia?
multisystem disoder of unknown etiology Development of new onset HTN (SBP >140 or DBP >90) and proteinuria after first 20 weeks of pregnancy; in absence of proteinuria, concomitant significant end-organ dysfunction
87
What is the treatment of pre-eclampsia?
Treatment: delivery of fetus if there are severe features; bedrest and monitoring until 37 weeks gestation or until status of mother/fetus deteriorates, necessitating delivery
88
What is HELLP syndrome?
Hemolysis; Elevated Liver transaminase levels; Low Platelet counts (<100,000)
89
Whats the treatment of HELLP syndrome?
Treatment: delivery of fetus regardless of gestational age
90
What is Eclampsia?
Seizures or coma in setting of preeclampsia in absence of other pathologic brain conditions
91
What is the treatment for a DVT?
Subcutaneous low molecular weight heparin Enoxaparin 1mg/kg q12h, then titrated to anti-Xa level of 0.6 - 1.0 IU/mL IV unfractionated heparin (IV UFH) Preferred in patients with high risk of bleeding

Nashville Review 2024 (3 decks)

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