OSCE 1 Flashcards

Question

1.8 b Indication for CTB in head injury x7 RFactors to warrant further look x 3

Answer 1

1 GCS < 13 on initial assessment · 2 GCS < 15 at 2 hours after injury on assessment in the emergency department · 3 Suspected open or depressed skull fracture · 4 Any sign of basal skull fracture · 5 Post-traumatic seizure · 6 Focal neurological deficit · 7 More than one episode of vomiting since the head injury risk factors 1. Age > 65 years · 2. A history of bleeding or clotting disorder · Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from height of > than 1 metre or 5 stairs) · 3.More than 30 minutes’ retrograde amnesia of events immediately before the head injury On assessment can the patient actively rotate the neck to 45 degrees to the left and right? if Y - no need for further

Answer 2

1. Persisting coma GCS 8< after initial resus 2. Confusion >h 3 Deterioration in LOC after admin 4 Progressive FND

Answer 3

4-12 Prox lumen - open 25cm tip in RA measure cvp 1.5ml Draw traces as inserted and wedges thru diagram page 35 scaler of 40mmhg, RA 0-4, RV 25 -2 PA Resembles trace CVP in RA Thermistor situated? 4cm prox tip 1 assessment of volume status CVP unreliable 2 Sampling mixed venous blood calc shunt fraction 3 Measure CO using thermodilution 4 Derivation of CV indices such PVR DO2 and uptake Arrhythmia on insert knotting in rv balloon rupture Pulmonary infarction Measured CVP PAP PCWP CO SVO2 Derived CI SV SVI SVR SVRI PVR PVRI

Answer 4

PAFC swan and ganz in 970 7 or 7.5G and 110cm long Balloon tip capacity 1.5ml Before insert - traducer and zero - wave up down appear monitor - ensure corrected to correct advamced 20cm before inflate baloon RA - CVP mon rv systol 25

Answer 5

5 rescue breaths Compressions 15:2 Doses Adren 10mcg kg .1ml/kg of 1:10000 IO dose 10ug Amiodarone 5mg / kg Atropine 20mcg / kg Dose DCCV 4 J Kg Weight 2x age + 4 Fluids 20ml kg IO after 3 attempts

Answer 6

Hypoxia hypovolaemia hypo / hyper kalaemia hyothermia Tension PTX Tamponade Toxins Thromboembolism

Answer 7

1. Checks vitals + calls critical incident 2. call 4 help 3. 100% O2 4. Check ETT 5. Auscultate 6. Ask for adrenaline 7. Check drip give floods 8. look cutaneous signs 9. Admin Anaphylaxis adjuncts 10. Reassess vitals + repeat adren prn

Answer 8

1 Tachycardia 2 Hypotension 3 Severe bronchospasm 4 Low sats - im gas exchange & reduced peripheral perfusion 5 low etco2 reduced pumonary perfusion 6 Unresponsiveness to ephedrine metaraminol

Answer 9

❶ Call for help. Note the time. Stop or do not start non-essential surgery. ❷ Call for cardiac arrest trolley, anaphylaxis treatment pack and investigation pack. ❸ Remove all potential causative agents and maintain anaesthesia. • Important culprits: antibiotics, neuromuscular blocking agents, patent blue. • Consider chlorhexidine as cause (impregnated catheters, lubricants, cleansing agents). • Consider i.v. colloids as a possible cause. • Change to inhalational anaesthetic agent (if not already). ❹ Give 100% oxygen and ensure adequate ventilation: • Maintain the airway and, if necessary, secure it with tracheal tube. ❺ Elevate patient’s legs if there is hypotension. ❻ If systolic blood pressure < 50 mmHg or cardiac arrest, start CPR immediately. ❼ Give drugs to treat hypotension (Box A): • Hypotension may be resistant and may require prolonged treatment. • Give adrenaline bolus and repeat as necessary. • Consider starting an adrenaline infusion after three boluses. • If hypotension resistant, give alternate vasopressor (e.g. metaraminol, noradrenaline infusion +/- vasopressin) • Give glucagon in ß-blocked patient unresponsive to adrenaline. ❽ Give rapid i.v. crystalloid: 20 ml.kg-1 initial bolus, repeated until hypotension resolved. ❾ Give hydrocortisone as part of resuscitation (Box B). ❿ If bronchospasm is persistent, consider → 3-4 ⓫ Take 5-10 ml clotted blood sample for serum tryptase as soon as patient is stable. • Plan for repeat sample at 1-2 hours and >24 hours. ⓬ Give chlorphenamine when feasible (Box B). ⓭ Plan transfer of the patient to an appropriate critical care area. Note tasks in Box D. ⓮ Prevent re-administration of possible trigger agents (allergy band, annotate notes/drug chart)

Answer 10

Box A: DRUGS TO TREAT HYPOTENSION IF CARDIAC ARREST → 2-1 • Adult adrenaline: i.v. 50 μg (= 0.5 ml of 1:10 000) i.m. 0.5 mg (= 0.5 ml of 1:1000) if i.v. not possible • Paediatric adrenaline: i.v. 1.0 μg.kg-1 (0.1 ml.kg-1 of 1:100 000) [1:100 000 solution made by diluting 1 ml of 1:10 000 up to 10 ml] • If no i.v. access, intraosseous adrenaline dose same as i.v. • Suggested adrenaline infusion regimes (adult): 5 mg in 500 mL dextrose = 1:100 000, titrate to effect 3 mg in 50 mL saline. Start at 3 ml.h-1 (= 3 μg.min-1), titrate to maximum 40 ml.h-1 (= 40 μg.min-1) * Glucagon (adult): 1 mg, repeat as necessary * Vasopressin (adult): 2 units, repeat necessary (consider infusion)

Answer 11

``` Box B: OTHER DRUGS • Hydrocortisone i.v. doses: • Adult: 200 mg • Child 6-12 years: 100 mg • Child 6 months-6 years: 50 mg • Child <6 months: 25 mg • Chlorphenamine i.v. doses: • Adult: 10 mg • Child 6-12 years: 5 mg • Child 6 months-6 years: 2.5 mg • Child <6 months: 250 μg.kg ```

Answer 12

Box D: DON’T FORGET • Repeat testing for serum tryptase at 1-2 hours and >24 hours. Store at 4 degrees • Liaise with hospital laboratory about analysis of samples. * Liaise with department anaphylaxis lead regarding referral to a specialist allergy or immunology centre to identify the causative agent * Inform the patient, surgeon and general practitioner. Report Inform patient

Answer 13

Anaphylactic - acute hypersensitivity rxn - previously sensiteised to antigen Immune med Ige mast cell med His + LK released mast cell Not relate to dose type 1 or immed hypersensitivity Anaphylactoid - no prior exposure, can occur on 1st exposure, not IgE med, less severe (can be fatal) related to dose of agent Similar symptoms = sim causative agents rel from mast cell difficult different clinc

Answer 14

1st exposure no symp ige atnibod develop over 14 days attached to mast cell mast cell may have 500000 IgE attach membrane second and subseq exposure - severe reaction combines with cell bound IgE mast cell release contents severeal mediator rel - symp can produce his alone symptoms vary mild to severe depending amt histamine rel anaphylaxis - without protection - old theory 1st exposure used body protection / defences against toxic agent body without defences for subsequent exposures.

Answer 15

Main stream Cuvette Co2 sesnor - between ett and system No need sampling vapour condense on sensor - can result fals high sense heated 39C heavier and cumbersome Adv No delay, no loss in gass no mixing sample w/ inspired

Answer 16

Side stream Sensor located main unit gas aspirated - small pump via sampling tube at rate of 50-150ml min gas also contain anaes - should be scavenged / return system Factors affecting response time 1 Response time depend on transit + rise time 2 Transit time depends on length of sample tube 3 rise time depends on optimum flow and size of chamber - very low flow and large chamber increase rise time

Answer 17

1 Inspiratory baseline - should be at 0 as elevated means rebreathing 2 Expiratory upslope shallow - obstruction 3 Plateau representing mixing of alveolar gas if sloped not flat - uneven mixing - COPD 4 Inspiration Fall to 0 downstroke

Answer 18

Capnometry measure of Co2 conc during resp cycle Capnography graphic representation CO2 conc - waveform plot as EtCO2 vs time CO2 plot y Time - X

Answer 19

Capnography uses IR absorption Co2 gases molecules 2/= diff atoms absorb rad in IR spec Co2 strong absorption at 4.26 Spec scope page 58 Amt IR absorb proport to CO2 conc Electrical output photodetector present partial pressure Co2 in sample chamber

Answer 20

Sudden decrease in etco2 to near 0 = airway disconnection totally obstructed airway or vent malfunction Sudden decrease to low level reduced CO or leak Exponential drop due to reduced pulmonary perfusion - low CO / PE Gradual decrease hypervent / hypothermia gradual increase - hypervent or increase body temp

Answer 21

1 High freq A/C cut or coag tissue during surgery cutting - sine wave coag - damped or pulse sine wave 2 High frequency current (min fx on cardiac and skel muscle) localised high density current (current per unit area) High at forceps at low at earth plates depending equipment - accetpable level leakage determ 3 0.5- 1Mhz 4 Large plate reduce current density 5 Current flow thru patient and earther thru any metal - attach patient 6 Fire and explosion pacemaker dysfxn 7 monopolar needs neutral plate bipolar forceps travels one limb and leaves other other bipolar - lower power

Answer 22

1 Outer case is earthed 2 Isolating capacitor - high impedance to low frequency current 3 Floating circuit active electrode and neutral electrodes are isolated from earth connection 'earth free circuit' 1 Good connection to neutral plate to patient 2 not activating diathermy until active electrode contact with tissues 3 Regular servicing

Answer 23

CF - leakage current <10amperes BF Higher protection vs shcok than provided w/ B LIKE cf - FLOATING RESPECT TO EARTH B type = non cardiac grounded applied parts come into contact with patient C type = heart f floating - isolating CF is for cardiac application - higher degree protection vs shock than BF

Answer 24

Normal cardiothoracic ratio

Answer 25

1 introduce 2 Discuss in presence of witness 3 confirms facts listens to hix find out what does recollect 4 apology 5 advise precaution measure taken 6 unstable - stabilised careful drug - possible during that had awareness 7 any pain during it 8 rare, complcation with trauma patients 9 interview senior consultant 10 Follow up 11 Psychological support 12 Ressures future ga safe 13 advise documented and write gp 14 want to know anything more 15 polite rapport

Answer 26

Explicit memory - concsiou awarenss w/ recall +/- pain implicit - perception during anaes w/out recall or concious awareness poss confused ketamine high obs and trauma tiva human error judgement or faults

Answer 27

See patient early ward nurse / reposible apology not guilt - helps patient get facts right find out what recall explanation and conduct and safety special interest boss reassure

Answer 28

page 72 1-8

Answer 29

i V A N above down ii 1 posterior 2 anterior iii ``` Thoracic surgery breast upper abdo procedures - chole rib # IC drain ``` iv NV bundle between internal IC + Inner IC muscle ``` v PTX intravasc injection Bleeding nerve damage LAST ``` vi Mixed spinal

Answer 30

t1-t12 Spinal nerves emerging intervertebral foramina divide into anterior post div post - sens and motor to parvert region connect symp chain anterolat to vert body and comm thru rami communicantes ``` ant division ic space - ICN runs costal groove inner surf inf border of body rib = protection ``` T1 - UL T2 Intercostbrachail T3-6 thorax t7 down - abdominal wall t11 t12 - subcostal Block - no viscera cover D/T vascularity - high propensity for LAST Higher peak plasma vs other blocks

Answer 31

1 Olfactory - smell 2 Optic ``` Pocket acuity chart - seperately visual fields Diam pupils Direct + Consensual Accom reflex ``` ``` 3 4 6 Oculomotor Trochlear Abducens Ex ox muscle SO4 LR6 3 - levetor palpebrae - eye elevator - PS fibre w/ 3rd - a/w disrupt ps activit - pupil dilate ``` 5 trigeminal - mastication + sensory innervation feel masseter bulk - clench teeth ``` sense Opthalmic max mandib pin prick fine touch cold + warm ``` corneal reflex V + VII Cotton bud touching cornea - observe reflex blinking 7 Facial look creases raise eyebrows, shut eyes tight, show teeth bloow air out lesion peripheral - entire half face central - upper half spare - dual innervation ``` 8 Vestbicoc hearing and balance - hearing tested bilat connect precise diagnosis difficult whisper webber rinne audiogram ``` ``` 9 + 10 Glossopharyngeal + Vagus Test together hoarseness swall dific aa look palate - uvula reamains midline soft palate rises symett unilat - uvula drawn to normal side gag sens ix motor x - stim back throat ``` 11 Accessory trapezius + SCM wwasting muscle shrug shoulder and turn head 12 hypogloassoal tongue muscle - ask prtude - wasting fasic deviation unilat lesion - towards affect side

OSCE 1 Flashcards

(56 cards)