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Year 6 - MBBS COPY > PACES: I&I > Flashcards

PACES: I&I Flashcards

1
Q

How do you structure your answer for any instrument?

A

What? Why? Size? How? CIs? Comps?

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2
Q

Instrument

A

What: Oropharyngeal Airway Why: provide a non-def airway for pt w impaired level of consciousness at risk of upper airway collapse or if the manual manoeuvres are unsuccessful Sized: distance b/w maxillary incisors to angle of mandible How: in adults inserted upside down and rotated within the oral cavity + in children inserted the correct way up CIs: a conscious person w intact gag reflex + foreign body obstrcing airway Comps: damage to teeth, palate, oropharynx + improper sizing can lead to bleeding

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3
Q

Nasopharyngeal Airway

A

What: Nasopharyngeal Airway Why: provide a non-def airway for pts who are semi conscious and unable to tolerate a guedel or have a clenched jaw Sized: diameter of the pts little finger How: by using a rotational action up to the flared end which prevents it becoming irretrievable CIs: base of skull # and facial trauma/surg Comps: damage to nasopharynx, intracranial placement, laryngospasm, vomiting

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4
Q

What are the signs of a base of skull #? (4)

A

Racoon eyes w tarsal plate sparing, postauricular ecchymosis, haemotympanum, CSF otorrhoea

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5
Q

Image

A

What: iGel - buccal cavity stabiliser, epiglottic rest, gastric channel Why: a supraglottic airway used as a step prior to intubation esp for short elective procedures <4hrs, cardiac arrests, prehosp airway mx Sized: according to the pts weight How: use K-Y jelly, insert w the number facing towards you when behind the pt who is in the ‘sniffing the morning air’ position, glide downwards and backwards along the hard palate until the tip is in the oesophageal opening, taped down CIs: non fasted, trismus, >40cm H2O ventilation pressure Comps: leak + aspiration

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6
Q

LMA vs iGel

A

Ultimately that would be the anaesthetists decision: The LMA-Protector provides a better airway seal The iGel is faster to insert, a/w less mucosal injury, allows for easier gastric tube insertion

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7
Q

Endotracheal Tube

A

What: Endotracheal Tube Why: def airway thus preventing aspiration used commonly in trauma cases, long surg w general anaesthetics and pts w GCS <8 Sized: age, sex, height - position checked by looking for symmetrical rising of chest on ventilation, bilateral breath sounds, no gurgling over epigastrium How: inserted into trachea via oropharynx using a laryngoscope and Eschmann Tracheal Tube Introducer by anaesthetist, tape to secure tube in airway, inflate balloon w air below vocal cords to maintain position and protect from aspiration CIs: Mallampati score of >=3 + sev airway obstrc where a cricothyrotomy might instead be indicated Comps: inappropriate placing, injury to larynx esp vocal cords, pneumothorax, atelectasis, infection, sore throat, tracheal stenosis

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8
Q

Uncuffed ET

A

Used in children <8yo as the smallest diameter of the airway is the cricoid ring However may have to place again if the sizing is wrong, doesn’t allow for as high ventilation pressures or protect against aspiration as well

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9
Q

Tracheostomy

A

What: Temporary Tracheostomy Why: def airway thus preventing aspiration used acutely in maxillofacial surgery or electively in ITU pts for more efficient ventilation w dec dead space Sized: How: via transverse incision made 1cm above sternal notch CIs: Comps: injury to oesophagus or recurrent laryngeal nerve, haemorrhage, pneumothorax, sore throat, tracheal stenosis

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10
Q

ET Tube vs Tracheostomy

A

Tbc

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11
Q

Laryngoscope

A

What: Laryngoscope - if blades are curved it’s McKintosh va straight it’s Miller Why: aids intubation + dx of vocal problems and stricture Comps: soft tissue injury, pharynx/larynx scarring, ulceration, abscess

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12
Q

What are the two definitive airways?

A

Endotracheal Tube + Tracheostomy

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13
Q

What is a key principle of administering oxygen via venturi or high flow nasals?

A

You can give an exact FiO2 as air flow > PIFR

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14
Q

What are examples of variable devices ie the FiO2 is dependent on PIFR? (3)

A

Nasal Cannula, Hudson Mask, NRB

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15
Q

What is the avg peak insp flow rate in a healthy individual?

A

20L/min

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16
Q

How do you measure PIFR?

A

Spirometry

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17
Q

Venturi

A

What: Venturi - uses Bernouli principle to mix oxygen w room air Why: deliver b/w 2-15L/min at a fixed FiO2 Comps

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18
Q

What are the different types of venturi valves?

A

Blue: 2-4L/min = 24% O2 White: 4-6L/min = 28% O2 Yellow: 8-10L/min = 35% O2 Red: 10-12L/min = 40% O2 Green: 12-15L/min = 60% O2

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19
Q

High-Flow Nasals

A

Humidified and well tolerated V high flow can be achieved

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20
Q

Nasal Cannula

A

What: Nasal Cannula Why: Comps: nasal sores + epistaxis therefore encourage use of water based creams

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21
Q

NRB

A

What: Non-Rebreather Mask - ensure the bag in full before placing Why: deliver up to 15L/min and ~85% FiO2 Comps:

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22
Q

Self-Inflatable Bag-Valve-Mask

A

What: Self-Inflatable Bag-Valve-Mask Why: Comps: barotrauma from lung inflation + aspiration/vomiting from gastric insufflation

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23
Q

NIV

A

CIs: drowsiness + pneumothorax

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24
Q

Devers Retractor

A

This is a Devers retractor. I have used it in open abdominal surgery to allow the surgeon to operate.

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25
Self-Retaining Retractor
This is a self-retaining retractor. I have seen this used to hold wounds open during an appendicectomy and hernia repairs.
26
Forceps
These are the two common types of forceps: toothed for skin + nontoothed for inside the peritoneal cavity
27
Scalpels
These are the two common types of scalpels: disposable and non-disposable
28
Feeding NG Tube
What: Feeding NGT - fine bore w radio-opaque guide wire Why: long term enteral nutrition for pts post op, ITU, unsafe swallow Sized: tip of nose round ear to epigastrium How: consent pt, place aqua gel on tip, go along the floor of the nasal passage, ask pt to keep swallowing as you advance, confirm correct placement CIs: base of skull # and facial trauma/surg Comps: NGT+feeding ie nasal trauma, misplacement, blockage, refeeding syndrome, electrolyte imbalance, feed intolerance
29
Ryles Tube
What: Ryle’s Tube - wide bore w metal tip, clear, stiff Why: part of the drip and suck tx for bowel obstrc to decompress + insert drugs or contrast into the GIT Comps: the larger diameter inc risk of nasal trauma + misplacement and blockage
30
How do you ensure the NGT is in the correct place?
Document: the pH aspirate is \<5.5, bubbling upon epigastrium auscultation following air insertion, on CXR bisects the carina and tip sits below the diaphragm in the gastric bubble
31
Drains: Open vs Closed
Open - fluid collect in stoma or guaze - inc risk of infection Closed - tubes into bag or bottle - dec risk of infection
32
Drains: Active vs Passive
Active - maintained under suction - eg redivac following mastectomy, neck dissection, joint replacement Passive - drains by pressure differentials, overflow, gravity - eg stoma, NGT, robinsons, foleys
33
Describe bubbling and swinging wrt chest drains?
Bubbles - air is being expelled during expiration Swinging - the fluid going up and down the tube during insp/exp Swinging w/o bubbles shows all the air from the pneumothorax is out
34
If the drain doesn’t stop bubbling what does this suggest? And what should you do?
There’s a fistula -\> requires specialist intervention
35
TED Stockings
What: TED Stockings Why: mechanical VTE prophylaxis usually used in conjunction w pharmacological eg LMWH to prevent DVTs CIs: pts w arterial disease
36
Hickman
What Why: the dacron cuff prevents back tracking of infection and forms a bond w surrounding tissue to prevent line migration Sized How CIs Comps
37
Tesio vs Hickman
Tesio - doesn’t have a dacron cuff, buried deeper, used for haemodialysis therefore double lumen Hickman - dacron cuff, tunnelled s/c, used for long term parental nutrition/abx/chemo therefore single lumen
38
Long Term Central Venous Line
The remnant of the line is tunnelled s/c which dec incidence of infection Indicated for longterm parenteral nutrition, longterm IV abx or chemo
39
Two-Way Catheter
What: Two-Way Urinary Catheter - Male v Female Why: therapeutic ie retention and immobile pts + diagnostic ie measure UO and collect sterile sample Sized: inc Charrière inc circumference usually 12-14Ch for adults How: consent pt, clean w saline and anaesthetise w instillagel, use ANTT, wait until urine starts to drain, inflate the ballon w 10ml of water, attach bag, ensure foreskin repositioned, document CIs: consider suprapubic access if urethral injury, high riding prostate, pelvic fracture, scrotal haematoma Comps:
40
Three-Way Catheter
What: Three-Way Irrigation Catheter Why: allows for bladder irrigation in pts w haematuria at risk of clot formation Comps:
41
Foley vs Long-Term Urinary Catheter
Foley: \<28d + latex Long-Term: \<3m + silicone
42
Catheter Bag
T
43
Leg Bag
T
44
Urometer Drainage Bag
T
45
Approach to Chest Radiograph
Pt+Image Details, RIPE, Most Obv Abnormality, A-F, Ddx
46
What does RIPE stand for?
Rotation Inspiration Penetration Exposure
47
How do you work through A-F of a CXR?
A: Trachea B: Hila C: Mediastinum D: Diaphragm E: 🔼 Bones + Lines F: 🔽 Fields + Pleura
48
Trachea Deviation
Ipsilateral: collapse, fibrosis, surgery Contralateral: tension pneumothorax + pleural effusion
49
Approach to Abdominal Radiograph
Pt+Image Details, RPE, Most Obv Abnormality 1. Bowel Gas Pattern 2. Extraluminal Gas 3. Soft Tissues 4. Calcification 5. Masses 6. Bones
50
Bowel: Small vs Large
Small: valvulae conniventes vs Large: haustral folds The 3-6-9 Rule: small, large, caecum PLUS appendix \<6mm
51
Approach to CT Head
Midline Shift + Symmetry
52
Approach to MSK Radiograph
Pt+Image Details, Most Obv Abnormality, JOAST, Ddx
53
What does JOAST stand for?
Joint Outline Attitude Soft Tissues Texture
54
Bleed: Acute v Chronic
Tbc
55
Insert Image
Extradural Haematoma: lentiform ie lens shaped + biconvex ~ Day Lucid Interval
56
Insert Image
Subdural Haematoma: crescentic ie moon shaped + concave ~ Wk Lucid Interval
57
Insert Image
Subarachnoid Haemorrhage: the star sign ie presence of blood within the basal cisterns and sulci
58
Insert Image
Weber A
59
Insert Image
Weber B
60
Insert Image
Weber C
61
Insert Image
SH1
62
Insert Image
SH2
63
Insert Image
SH3
64
Insert Image
SH4
65
Insert Image
SH5
66
Insert Image
Ant Shoulder Dislocation
67
Insert Image
Post Shoulder Dislocation
68
Insert Image
Colles’ #
69
Insert Image
Alzheimer’s Disease
70
Insert Image
Smith’s #
71
Rigler’s Triad
SBO Pneumobilia Ectopic Calcified GS
72
CT vs MRI
CT - more detailed bony structures, white bone, black water unless contrast MRI - more detailed soft tissues, T1 black water, T2 white water
73
PCT vs Tube
Tbc
74
What layers do you pass through during an epidural?
Skin S/c Fat Supraspinous Interspinous Ligamentum Flavum
75
What is the composition of the crystalloids?
0.9% Sodium Chloride: 154 Na, 154 Cl, 300 OsmolaLity Hartmann’s: 131 Na, 112 Cl, 5 K, 4 Ca, 29 HCO3, 281 OsmolaLity 5% Dextrose: 50g Dextrose + 278 OsmolaLity
76
Where outlines the mediastinum on a chest radiograph?
Right atrium, ascending aorta, SVC, aortic arch, main pulmonary artery, left ventricle
77
Where does one tend to aspirate and why?
Right lower lobe as the right bronchus is more vertically oriented
78
What does the majority of the hila consist of?
The lower lobe pulmonary arteries
79
Where do you first see a pleural effusion?
Obscured CP angles
80
What places opacification in the right middle lobe?
Up to the horizontal fissure and loss of right heart border
81
What is the radiological sign of consolidation?
Air Bronchograms Plus inc density and no volume loss
82
Ddx for Consolidation
Pus - Pneumonia Fluid - Oedema/Haemorrhage Cancer - Adenocarcinoma
83
Bronchopneumonia vs Pulm Oedema
If there’s NOT bilateral perihilar appearance, blunting of the CP angles, enlarged upper lobe veins think bronchopneumonia \> oedema
84
Bronchopneumonia vs Multifocal Adenocarcinoma
If there’s NO raised WCC and the pt is systemically well think cancer or bleed \> pneumonia
85
What are the signs of COVID pneumonitis?
Patchy peripheral areas of ground glass opacification and consolidation w a mid/lower zone predominance
86
What are the signs of emphysema?
Inc anterior ribs + flattened diaphragm
87
What are the sinister underlying causes of lobar collapse?
Central obstructing cancer + FB aspiration
88
What is the sail sign indicative of?
Left Lower Lobe Collapse
89
Left Lower Lobe Collapse
Mediastinal shift towards ie volume loss in hemithorax, ‘sail sign’ triangular opacity behind heart, obscured diaphragm, unable to visualise the descending thoracic aorta, depression of left hilum
90
Left Upper Lobe Collapse
Mediastinal shift towards ie volume loss in hemithorax, veil-like opacity in upper zone, obscured heart border, still able to visualise the descending thoracic aorta, elevation of left hilum
91
Collapse vs Surgery
You’d expect to see clips following surgery and the main bronchus would be cut near the carina
92
What is the usual cause of an entire lung collapse?
Cancer obstructing the main bronchus
93
Ddx for White Hemithorax
Lung Collapse Pleural Effusion
94
What does lobulated pleural thickening suggest?
Malignant Mesothelioma
95
What does pulmonary TB look like on CXR?
Typically affects the upper lobes giving mixture of consolidation, nodular shadowing and cavitation
96
Which cancers cause miliary metastases?
Thyroid + Renal
97
Miliary TB vs Metastases
The pt will be septic if it’s TB
98
Where do inhalational and haematogenous disease tend to occur?
Inhalational - Upper Zones Haematogenous - Lower Zones
99
Pulmonary Nodule vs Mass
\> 3cm
100
What is characteristic of lung cancer on CXR?
Solitary mass w spiculated edge
101
Ddx for Dark Hemithorax
Pneumothorax
102
What are the causes of pneumomediastinum? (3)
Spontaneous A/W Pneumothorax Oesophageal Rupture
103
What should you be worried about if the pt is SOB and they have a normal CXR?
PE
104
What is pathognomonic for pulm oedema?
Septal ie Kerley B Lines
105
Where does the oblique fissure run in a lateral view?
Ant CP angle to T4
106
What are causes of non-cardiogenic pulm oedema?
Altered Permeability \> Inc Osmotic Pressure Neurogenic, ARDS, TRALI, RAS, heroin induced, near drowning, high altitude
107
Which part of the colon is fixed/variable?
Fixed ascending/descending/rectum as they’re retroperitoneal Variable transverse/sigmoid as they have mesentery
108
What causes the bowel to dilate? (3)
Distal mechanical obstruction, ischaemia, sick bowel
109
What is the Rigler sign?
A sign of pneumoperitoneum when gas outlines both sides of the bowel wall
110
What are the two types of caecal volvulus?
1. Axial Torsion 2. Caecal Bascule +/- Small Bowel Obstruction
111
What is the sign of a sigmoid volvulus?
Coffee bean sign: distended loop of colon arising from the pelvis
113
How can you tell if an AXR is adequate in terms of both penetration and coverage?
You can see the vertebrae, edges of the pelvis and down to the greater trochanters
114
What is the 10 day rule for women of child bearing age?
Imaging of abdomen/pelvis using ionising radiation should be restricted to the first 10 days following onset of menstruation
115
What causes cavitary lung lesions?
Infectious: strep, klebsiella, mycobacterium, aspergillosis, parasites Non-Infectious: cancer, GPA, congenital
116
What do you need if the CXR does not show a rib fracture or splenic injury but there’s clinical suspicion?
CT
117
Self Catheter
Tbc
118
CVC vs PICC
Length + Lumen
119
MRI: T1 vs T2
We commonly use T1 to visualise anatomy and T2 to visualise disease: look at the water which will be black in T1 and white in T2
120
What is Chilaiditi's sign?
An incidental finding where gas containing bowel is positioned between the right diaphragm and the liver which is often misdiagnosed as pneumoperitoneum
121
What sign is pathognomonic of SBO?
The presence of a ladder pattern on an erect film showing fluid air levels within each loop of bowel
122
What does a diaphragmatic hernia look like on a CXR?
The diaphragmatic border is lost and the hemidiaphragm is elevated with a fluid level in the gastric buddle and absence of lung markings
123
Mx of SBO
'Drip and Suck' Gain IV access to take bloods inc vbg for lactate and immediate electrolytes then start IV fluids and place a catheter to monitor fluid balance Place a NG tube to decompress the distended stomach, give analgesia and antiemetics, keep NBM and discuss w surg team, CT AP to determine level of obstrc and cause, monitor obs closely

Year 6 - MBBS COPY (35 decks)

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