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The OSCE in anaesthesia - book > OSCE 2 > Flashcards

OSCE 2 Flashcards

(39 cards)

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1
Q

2.1 Humphrey ADE
pg 81

i Componenets

ii what pressure does relief valve open at

iii advantage

A

Inspiratory + expiratory tubing

Humphrey block

  • apl valve
  • indicator
  • reservoir bag

Lever - spont / cv

vent port / saftey pressure relief valve
(opens at 60)

Adv
1 Effic Sv + CV
2 Single system adult / children
3 Choice - semi closed w/out soda lime or circle w canister
4 Easy scavenge
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2
Q

2.1
iv
What are the changes with lever position

v
Explain how it functions as each

A

mapleson A when lever up - SV
FGF 50-60

lever down - mapleson E CV
70ml kg min

Level up - A
resevoir bag -> inspiratory limb

Expire - thru expire limb to APL- scavenge connected
end expiration - mix alveolar and dead space thru apl
inspiratory - gas breathed inspiratory limb + resevor bag

Lever down
reservoir bag isolated inspiratory limb 
\+
APL valve isolated from expiratory limb
acts as a t piece - 
insp limb gas delivery tube to patient end of T piece and expiratory limb acts as a reservoir limb of t piece

attach reservoir bag and apl converted to D
exp limb reservoir of t piece can be connected to ventilator

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3
Q

2.2
ECG basics

standardisation

Normal recording speed

RBBB

LBBB

RAD

LAD

A

5mm = 1mv

Normal recording speed 25mm/sec

RBBB
QRS >120ms -
rSR’ / rsR’ V1
Wide Term S in lead 1 and V6

LBBB
QRs >120
upright QRS I + V6
Predom neg qrs in V1

RAD
neg I
Pos III

LAD
III neg

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4
Q

2.2 PM Insertion indications

A

1 Sinus node -
sick sinus syndrome
recurrent stoke adams
SN dyfxn

2 CHB
Symp 2nd hb
symp bifasic
trifascic hb

3 Chronic AF

4 Persistent / symp 2nd or 3rd hblock w. MI

5 Atribeicent pacing in mod to severe hf

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5
Q

2.3 Data interpretation

Aspirin

A

Act charcoal + lavage may be useful for 24hr

Acidic drugs - elim alkaline urine
achieve 1.26 soium bic
increase elim - plasma level 3.6>

HDial - considered >5.1 / lower w/ fetaures
aspirin 90% prot bound - OD >25% removed by HD

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6
Q

2.4 Cushing reflex
features

what happens

whats the response to the initial defence mechanism

A

HTN
Bradycardia
Increased intracranial HTN

Ischaemia of hypothalamus -
activates SNS
increase Contractility , HR, VCON

Increase bp maint CPP

Raised BP increased baroreceptor d.c
= inhibition of vasomotor centre
increase PS d/c
= bradycardia

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7
Q

2.4 Diabetes insipidus in Ischaemia

A

High urine output
low urine osmolality 50-200
high serum osmolality
norma to elevated serum sodium

U out >90ml kg day ~4ml kg hour
spec gravity < 1.101

Trauma surgery pit / hyptohal
Rx DDAVP

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8
Q

2.5 Stellate ganglion block

anatomy pic page 95

where is stellate ganglion

describe techniqu 5 points

A

Anatomy page 95

C7-T1
Vertebral + subclavian close

  1. Informed consent
  2. Drugs / equipment check
  3. Aseptic technique
  4. supine + neck extended
    5 Between trachea + carotid sheath
    @ cricoid
  5. chassaignacs tubercle of c6
  6. neg aspiration + inject LA
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9
Q

2.5 b

Indicatios for stellate ganglion block

A

1 Pain syndrome
CRPS 1+2
Refractory angina
phatnom limb pain

2 Vascular insufficiency
Raynauds
frostbite
oblit vascular disease

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10
Q

2.5 c
Features of successful block

Fetaures horners

A

Horners
Increase temp ipsi UL

Ptosis
miosis
anhydrosis
enopthalmos
loss ciliospinal reflex
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11
Q

2.5 d

Name 4 complications of stellate ganglion block

A

Needle in wrong place
1 vascular injury
haematoma trauma to carotid

2 Neural injury - vagus / brachail plexu

3 Pulmonary injury - PTX haemotx

4 Oesophageal perf

Spread LA

1 IV inject

2 Epidural block

BP injury

Infection

Soft tissue / neuraxial

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12
Q

2.6 Communication of brain stem testing

a marking scheme for osce station

A

1 Introduce self

2 Confirm talking to right person

3 asks what understand so far

4 explains breathing machine on life support

5 explains scan findings

6 Neurosurgical r/v + opinion

7 Explains procedures of bs test

8 respeated again

9 signifcance of brains stem testing / breathing machine off

10 organ donation

11 reassure explain

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13
Q

2.6 b

Principles of communication

A
  1. Introduce + explain role and purpose
  2. Establish understanding + knowledge of person

3 Honest + Provide correct info and facts

  1. Explain in simple language
  2. Actively listen
  3. Respond to verbal and non verbal
  4. Summarise and clarify - provide opportunity clarification
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14
Q

2.6
Brain stem testing
3 preconditions

A
  1. Apnoea + MV
  2. Establish cause coma = reversible injury
  3. Exclude reversible causes

Brian stops working not send mentions to unconcoius fxn + cant recieve info back
= No chance of recovery and by law has passed away

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15
Q

2.7
Tech skill
a LP -> spinal anaesthesia

Surface landmarks - spine

Describe procedure

A

C7 - Most prominent Spinous process

T7 - Inferior scapula tip

L3-4 - ASIS TUFFIERS LINE

Locate - asis / iliac crest sitting / lateral
not higher LP / spinal

Procedure

  1. Consent, resus, equipment
  2. IV access establish
  3. Monitoring ecg spo2 nibp
  4. strelity
    5 back prep -> antiseptic soln + sterile draping
  5. LA infiltration
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16
Q

2.7 Needles for spinal
a
types

gauge

procedure

what if its bloody?

Study These Flashcards
A

Quincke - cutting

Sprote / Whitacre - pencil point

<24g generally

Introducer inserted into space
Spianl introduced - LOR when Dura pierced
Free CSF flow

if bloody -wait CSF clear - then inject
bloody - resite

17
Q

2.7 Spinal

1 How much LA for each segment to be blocked

2 What affect spread of LA

  1. Contraindications to Spinal
  2. Blood supply to spinal cord
Study These Flashcards
A
  1. 0.2ml

In avg 70kg man
1-1.5ml 0.5% bupivacaine = saddle block
2-2.5 T10
2.5-3ml - T4-T6

2 Baricity
patient position

3 
Patient refusal
System / Local infection
Abnormal clotting
Raised ICP

1 anterior
@ magnum: join vertebral
join radiular - 1 arteria radicularis magna - / artery adamkiewicz (aorta low thoracic / lumbar)
damage = ant spinal artery syndrome

2 posterior spinal artery
Post inferior cerebellar artery
-supplement spinal branch vertebral, deep cervical intercostal

18
Q

2.8 Cardiac exam

Study These Flashcards
A

IPPA

Radiofemoral delay - coarct

19
Q

2.9 Wrights respirometer

1
what measure

2 How does it work

3 Uni or bidirectional flow

4 Advantages?

5 disadvantages

Study These Flashcards
A

TV + MV

direct gast hru oblique slot in small cylinder

enclosing vane - made to rotate
spindle mounted connected pointer - moves over a dial indicating amt gas passed

Unidirectional flow
dont register gases flow back thru device reverse direction inpinges on bottom edge vane = not rotate

small
portable tv measurer
Not require electrical supply

5 -
Min flow 2L/min
over read at high and under at low
water condensation can cause it to stick
no diplay of measured volume - no elec output
20
Q

2.9 Wrights respirometer

b

whats the resistance to flow#

2 other devices measuring flow

Principle behind pneumotachograph

Study These Flashcards
A

Low

2 cmH2O @100l min

Pneumotachograph
Rotameter

Constant orifice
variable pressure flow meter

Gas flow thru fixed resitsance = drop pressure

differential pressure transucer senses pressure gradient accross restance
change pressure proprtional flow

advantages -
high accuracy
display reading

21
Q

2.10 BLS Pregnants mother

Study These Flashcards
A
  1. Seen is safe
  2. Check signs of life?
    feel pulse and open airway
  3. Call cardiac arrest, trolley, senior help
    obstetrician + paediatrician
  4. Insert wedge under right side / manual displacement
    - relieve aortocaval compression
  5. Chest compression 30:2
  6. BMV/ Intubate
  7. Arrest trolley arrives - get pads on
8. Hs 
hypoxia
hypovolaemia
hypothermia
hyper/po kalaemia
T
tension ptx
toxin
tamponade
thrombembolism
22
Q

2.10 b
Pads are on
see a bradycaria - hr 38
how manage?

Rx

Rf for asystole

Study These Flashcards
A 
Adverse signs
rate <40
bp <90
Heart faiulre
vent arrythymia

Rx
Iv Atropine 500ug

max dose 3mg atropine
in 500ug doses

RF asys

  1. Recent asystole
  2. Mobitz 2
  3. CHB w/ broad QRS vent pause >3s
23
Q

2.10 c
challenges resus preg

causes of maternal death

Challenges in preg anaes

Study These Flashcards
A
  1. CO. Blood vol / oxyge consumption increase
  2. Consider baby
  3. Gravid uterus - compression iliac / abdo vessels
Causes mat death:
Thromboembolism
hypertensive disorder preg
haemorrhage
amniotic fluid embolism
  1. Increase risk aspiration
    tracheal intubation more diff - changes anatomy

ectopic preg
abruption
rupture - massive haemorrhage

immed resus fail - consider emergency section
better change survival if 5m of arrest

24
Q

2.11 Anatomy
a
i Vagus nerve diagr pg 115

ii Origin of vagus

iii how many nuclei

iv
what foramen does it leave

v
what other structures leave with it

Study These Flashcards
A 
1 Vagus
2 SupLN
3 IntLN
4 ExtLN
5.RecLN

Medulla oblongata

  1. Dorsal nucleus
  2. Nucleus ambiguus
  3. Nucleus tractus solitarius

Jugular foramen

  • Accessory N
  • Glossopharyngeal
  • IJV
25
2.11 Anatomy Vagus nerve b i What are the relations of the vagus nerve ii course Right vagus iii course left vagus iv other branches of vagus
Neck - passes in carotid sheath between IJV + Internal carotid artery beyond border thyroid cartilage - between IJV and common carotid ii R passes subclavian between innominate vein descends side trachea to back root of lung - spread pulonary plexus L Thorax between l carotid and subclav - behind l innominate - crosses left side archa aorta descend beind root of left lung - posterior pulm plexus iv Jug foramen - meningeal + auricular Neck pharyngeal Thorax - inferior cardiac post bronchial abdomen gastric coeliac hepatic
26
2.12 Lap chole hx taking previous awareness
Types awareness Explicit awareness - >recalls event - rare 1/1000 - no cardiac surgery GA Risk - cardiac csection trauma emergency Implicit awarenss brain retains abilitiy take information into subconscious part brain - no spont recollection - conscious recall - unpleasant dram ``` RF awareness Impaired CVS status anticipated difficult airway hx awareness heavy alcohol intake bzd opiod chronic use asa 4/5 ```
27
2.13 Failed intubation
DAS algorithm PDF
28
2.14 PNS i function ii 2 factors determine energy requirement propagate impulse iii Why supramax stim iv where ulnar v where neg and pos
Monitor depth of NM fxn Induction - assess depth maintenance - titrate repeat does recovery - assess adequacy reversal Stimulus strength mA Duration of stimulus m/s Ensure all motor fibres of nerve stimulated ~60mA - acheive most (increase above pointless - not produce stronger response Distal - 1cm proximal to flexion crease wrist 2-3cm prox to distal one Negative - distally - on nerve Positive proximally
29
2.14 PNS What muscle contraction - observe when ulnar stim Methods of assessing whats a dbs whats a ptc whats mech of ptc whats signif ptc
Adductor pollicis brevis Visual Tactile EMG Accelomyography Two bursts of 50hz tetanic stimulation sep 750ms Single twitch stim following tetanic stim - count response Increase mobilisation of ach subseq single twitch release supernormal ach ptc<5 profound block >15 = 2 TOFs twitch's
30
2.15 Defibrillator safe use of defib
1. checks leads - position + monitor on patient 2. confirms rhythm 3. applies pads correctly a - right upper sternum below clavivle b - 5th IC left any axillary line 4. charge safe energy level - 150-360 biphasic 5. Visual sweep before shocking - stand clear 6. Remove oxygen 7. Deliver shock while looking at monitor 8. Resume CPR
31
2.15 Defib a what would do if patient has PM what about symbols
Place electrode 12-15cm from PM unit If has pacemaker - current travel along wire - causing burn where tip contact w/ myocardium AP placement BF - body floating defib proof CF - cardiac floating - defib prrof if equip does not demonstrate them they should be removed from patient before defibbing
32
2.16 CXR - reporting a CXR
Date / Patient Projection Penetration rotation adequate A- Airway - mid/dev Patent B - Bones Defects clavicles ribs sternum scapulae / vertebrae C - Cardiac silhouette / shape/ CT ratui D Diaphragm r diaph high left costophrenic margins air E - Effusion empty space F - fields - infiltrates, interstitial markings, masses, air bronchograms, increase vascularity, discrete / gen shadow G - Gastric bubble H - Hilar region left high right shadowing I - inspiration 6 rib anteriorly 10 post
33
2.17 Hx of VV patient -
ICU admission nut allergy seizures
34
2.18 Communication - sux apneoa Points to hit in comms w/ a parent of a kid i+v
1 Introduce self 2 Confirm talking right person 3. Explain reason for admission icu 4 avoid jargon 5. reassure sedated, pain free and will wake up 6. Sux correct drug and why 7. recognisnsed complication 8. why not able to breathe 9. blood tests 10. anaes safe in future 11. write gp 12. family undergo blood tests 12. sympathetic
35
2.18 b | Sux apneoa
Normal cholinesterase - 4-6min Prolonged block- acquired / genetic factors Clear FH difficult identify Delay cause recovery excluded - NM TOF - Reduced all 4 twtich no fade to teatnus no PTC Delay test if blood transfusion given (8/52) Blood taken - dibucaine no plasma cholinesterase Normal pl chol 1000-3500u/L Dibuc no - % inhib of pl cholin by amide LA dibuc Normal ~80 60 heterozygous block up to 20m <20 homozygous block 4-8 h Most acq - drug induced MTX Neostigmine Organophosphates
36
2.19 ACF anatomy Diagr 1 ii Diagram 2 nerve supply sensoryh iii How block LCN of forearm iv What movements by stimulating median nerve at axilla
diagram page 143 Page 144 LCN - Continuation Musculocutaneous N Innervates skin lateral aspec forearm Block Subcut infiltration LA / inject LA between brachioradial + biceps iv Flexion wrist abduction thumb
37
V How block median N @ elbow vi How block ulnar nerve at elbow vii How find Radial N in acf how block viii response if radial nerve stim at elbow
v medial to brachial artery - elbow crease vi Ulnar groove - medial epi - posterior consent equip drugs elbow flexed, arm abducted, supine 3-4ml LA inject 2-3 prox to epicondyle vii Radial N - deep between biceps tendon and brachioradiais 2cm above crease line between 2 structures viii Wrist and finger extension
38
2.20 Tech skill - LOOK AT THIS IN BOOK AGAIN i ankle block for hallux valgus removal ii other nerves for complete ankle block iii which is not a branch of sciatic iv structures page 149 v terminal branches of tibial
1. Superficial peroneal 2. Deep peroneal 3. Saphenous 4. Tibial 5. Sural iv Saph not branch sciatic v tib divides medial and lateral plantar nerves
39
2.20 b tech skills ankle block vi how block tibial nerve @ ankle how block deep peroneal N Where local to block sural
vi Tibial block inject LA behind medial malleolus anterior to tibial artery pulsation vii deep peroneal: Lies medial dorsalis pedis a block inject LA medial side of artery between A + EX hall long 1st metatarsal Subcut infiltration of LA behind lateral malleolus subcut infiltration 5-10cm above medial malleolus along course of long saphenous V

The OSCE in anaesthesia - book (5 decks)

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