Oral Board

Question 1

PFTs- which would you order and why?

Answer 1

FEV1, FVC, MEFR (max epiratory flow rate), MMEF (max mid expiratory flow 25-75%. FEV1/FVC - restrictive vs obstr dz, MEFR helps identify large airway obstr assoc with asthma and MMEF give an effort independent eval of small airways

Question 2

Tachycardia- causes

Answer 2

primary or secondary
primary- svt, vent arrythm
second- hypoxemia, hypercapnia, decr perfusion (anemia, low C.O.), pain (somatic, visceral, sympathetic), hypovolemia (absolute [volume] or relative [obstructive shock]), extraneous work related variables

Question 3

Will you proceed with lung surgery for patient with lung disease?

Answer 3

The worst case scenario for the case is catastrophic bleeding requiring total pneumonectomy. If this occurs I would need to refer to a split lung test to evaluate if the patient will become ventillator dependent afterwards.

Question 4

Go through the difficult airway algorithm…

Answer 4

Step 1: global assessment which includes identifiying difficulty (ventillation, DL, cooperation, trach), locating material and staff resources
Step 2: assess for feasibility of avoiding intubation; topicalized sedated vs. intubation under GA; need for preserving spont vent
Important points for GA with ablate spont breathing-
—confirm preoxygenation- use cpap
—always use short acting drugs if need to abort or at least confirm ability to mask ventilate
—always find multiple ways to deliver O2
—use techniques most comfortable
If cannot intubate/ventillate:
1) call for help
2) non invasive emergency vent adjuncts- lma, jet vent, rigid bronch, combitube
3) perc / surgical airway

Question 5

Go over NALS

Answer 5

No intervention needed- crying, good color, good tone, spontaneous breathing, HR >100bpm. Focus on temperature reg.
If non-vigorous baby- place pulse ox
While waiting for signal-> stimulate baby, observe airway, lay supine, neutral head position, suction if see secretions
Evaluate for meconium staining (may require ETT suctioning)
If Remains non vigorous->PPV (titate FiO2 to sat and HR)
IF HR 60-100bpm revealutate after 30 seconds and continue PPV
IF HR chest compressions
Intubate if chest compressions, cant mask vent
compression rate 90 per minute
breath rate 30 per minute
Epi late addition, 100-300 mcg/kg 0.1-0.3 mL/kg of 1:100,000
give volume
no naloxone, no bicarb

Question 6

What are the considerations prior to intubating (crossing the line)

Answer 6

ABCD
Airway- evaluate the specific source of dificulty
Belly- full stomach precautions
Conduit- types of equipment, monitors
Drugs/delivery- what drugs are available and IV access

Question 7

What are the procedure risk stratification descriptions:

Answer 7

Emergent- <6 hours needed- no work up avail
Urgent- 6-24hrs limited work up avail
Time sensitive- 1-6 weeks for delay
Elective-

Question 8

What are considerations of HOCM?

Answer 8

C.O. impaired with decreased SVR (arterial vasodilators), reduction in preload. This may may increase the degree of dynamic obstruction. Inotropic agents like Epi are usually not used in these patients because of increased LV outflow gradient.

Question 9

Describe peripartum cardiomyopathy

Answer 9

It is typically a dilated CM that occurs in the last timester or atleast 6 months post, must consider volume status

Question 10

Concerns for cardiac implantable device

Answer 10

Need to know underlying rhythm and indications, ICD versus ppm, when last interrogated, action if magnet, location of surgery, ability to use bipolar cautery

Question 11

What are risk factors that factor into a risk assessment cardiac score?

Answer 11

Cr >2, insulin dependent DM, HF, h/o CVA, CAD

Must evaluate functional METS >4-> (flight of stairs, brisk walk)

Question 12

When to do a cath? When to do a stress test?

Answer 12

Cath- active ACS or post stress
Stress- risk factors and/or <4 MET activity
Helps determine if need particularization or initiation of beta blockade in higher risk

Question 13

How many days should you wait for elective surgery after balloon angio? BMS? DES?

Answer 13

14 days- baloom, 30 days- BMS, 365 days- DES
Elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosi

Question 14

What are the features of the CVP waves?

Answer 14

a-atrial contraction 
c-ventricular contraction
V- venous return
x- decent from downward displacement of ventricle during systole
y- passive ventricular filling

Question 15

What is a normal CVP? PAP? PCWP?

Answer 15

CVP 0-8, PAP 15-30/6-12, PCWP= 5-15

Question 16

How to calculate SVR (nml value)? PVR (nml value)?

Answer 16

SVR = 80 x(MAP - CVP) / CO (1200-1500 dyne-sec/cmsqr)

PVR = 80x (PAP - PCWP)/CO (100-300)

Question 17

What is the orientation of the brachial plexus branches when performing an axillary block?

Answer 17

musculocutaneos- corocbrachealis musc
median- superficial/lateral to ax artery
radial- deep to ax artery
ulnar medial to ax artert

Question 18

what nerves need to be blocked to prevent tourniquet pain?

Answer 18

intrercostalbrachial (T2) and medial brachial cutaneous (C8,T1) field block at the humerus head

Question 19

Discuss management of total spinal

Answer 19

early recognition is key- brady, hypotenstion, resp distress, anxiety.
Reverse T
Atropine/ephedrine to treat brady
IVF bolus, phenylephrine to treat hypotension
mask ventillation for oxygenation
supportive verbalization to talk patient through temporary block

Question 20

Discuss ASRA guidlines for UFH, LMWH, warfarin, Plavix, new anticoagulants

Answer 20

UFH- 2 hr weight, no evidence of increased risk
LMWH- ppx dose or single daily- 12h, therapeutic dose or twice daily is 24h,warfarin 4-5 days and inr <1.5 (inr may be nml but other factors may still be abn), plavix 7 days based on labeling

Question 21

What is the management of LAST

Answer 21

Call for help
airway- ventilate
seizure suppression- use benzos avoid prop if cv collapse
Call for ECMO available
ACLS
Intralipid

Question 22

What are the hallmarks of MH and treatment?

Answer 22

Hypermetabolic state- hyperthermia, hypercarbia despite nml to hight tv, musc rigidity, metabolic acidosis, incr lactate, incr CK, myoglobinuria, rhabdo

Stop volatile agents, call for help, hyperventillate, initiate TIVA, high flows and either mask vent with ambubag or get filter, establish large bore IV and give dantrolene, treat hyperK, MHAUS recomends na-bicarb for acidosis

Question 23

What are the causes of non amion gap acidosis

Answer 23

Hardup 
Hyperalimentation
Acetizolimide
Rta 
Diarrhea
Uterosigmoid fistula
Pancreatic fistula

Question 24

How to prepare for and detect sitting crani?

Answer 24

Ga, Aline, central line with subclavian or ac access- use multi orifice catheter positioned in ra detected by iv ecg showing biphasic p wave
Avoid nitrous
Precordial Doppler - right of sternum between 3rd and 6th rib

Question 25

How to treat air embolism

Answer 25

Notify surgeon, high flow 100% fio2, aspirate central line, volume , pressors (epi), b/l ij pressure to identify source via back bleeding, head down position