Principles of Anesthesia Quiz #2 Flashcards
1
Q
What is a primary survey for a trauma patient?
A
Takes 2-5 minutes ABCDE sequence of trauma -Airway -Breathing -Circulation -Disability -Exposure
2
Q
What is a secondary survey to a trauma patient?
A
Begins only when ABCs are stabilized
Examine from head to toe and obtain studies
3
Q
What is a tertiary survey for a trauma patient?
A
To avoid missed injuries
Identifies all injuries
Typically within 24 hours
Awake patient more able to commnicate
4
Q
What is always the top priority of assessing a patient?
A
Establishing/maintaining a patent airway.
5
Q
All patients with a severe trauma or head injury should be assumed that they have a what?
A
Unstable cervical spine fracture
6
Q
Unconscious patient with major trauma is always at increased risk for ___ and must be ___ ASAP
A
aspiration
intubated
7
Q
What does MILS stand for?
A
Manual in-line stabilization
8
Q
If patient arrives with ETT in place, you must verify and document correct ___
A
position Neck extension or lateral rotation -moves ETT away from carina Neck flexion -moves ETT toward carina
9
Q
List five criteria that increase the risk for potential instability of C-spine
A
Neck pain Severe distracting pain Any neurological signs and symptoms Intoxication Loss of consciousness
10
Q
What are three assessment skills?
A
Look, listen, feel approach
11
Q
What are three signs of adequate circulation? Inadequate circulation?
A
Adequate
-HR, Pulse amplitude, blood pressure, signs of peripheral perfusion
Inadequate
-Tachycardia, weak/unable to palpate peripheral pulses, hypotension, pale cool cyanotic extremities
12
Q
What is the most common cause of shock in trauma patients?
A
Hypovolemia
-tachycardia, poor cap refill, decreased blood pressure, hypotension, tachypnea, delirium
13
Q
What is not an accurate indicator of acute blood loss?
A
Hct, Hgb
-Dilutional hematocrit
14
Q
In a patient with hypotension related to hypovolemic shock, how should you treat it?
A
IVF and blood products, not pressors.
15
Q
Getting a Type and cross takes ___, a type and screen ___, uncrossed O-negative PRBC ___.
A
45-60 min
5-10 min
Immediately
16
Q
What is the crystalloid of choice?
A
LR
NS leads to hyperchloremic acidosis
17
Q
When using colloids, what is the best option?
A
Albumin over hespan or dextran
Remember to warm all fluids, cold fluids can exacerbate v-fib
18
Q
When assessing disability, what does AVPU stand for in a rapid neurological assessment?
A
Awake
Verbal response
Painful response
Unresponsive
19
Q
List things included in a secondary survey
A
Glasgow coma scale
CT for pneumothorax
Pericardiocentesis for pericardial tamponade
Check extremities for fractures
Foley and NGT placed
CXR obtained in all patients with major trauma
20
Q
Tertiary survey is usually done within ___ hours of initial injuries.
A
24
21
Q
What are four common induction agents for a trauma related patient?
A
Ketamine (1-2 mg/kg)
Etomidate (0.2-0.3 mg/kg)
Propofol (dose greatly decreased)
Pentothal
22
Q
What are treatments for heard trauma patients?
A
Fluid restriction, unless hypovolemic Diuretics Bariturates Deliberate hypocapnia -Hyperventilate
23
Q
What are things to avoid in head traumas?
A
Anesthetic agents that increase ICP Hyperglycemia Hypertension Hypotension Trendelenburg position Pre-medications Anticholinergics
24
Q
What is cushing’s triad?
A
Hypertension (widening pulse pressure)
Bradycardia
Respiratory depression
25
What are signs of increasing ICP?
Early warnings: Change in LOC, irritability, mild confusion, pupillary change, decrease in Glasgow Coma Score
Late signs: Difficult to arouse, coma, posturing, fixed pupils, ECG changes, Cushing's response.
26
Treatments for increased ICP?
```
Diuretics - Mannitol 0.5 g/kg
Steroids - Decadron 1 mg/kg
Barbiturates
Deliberate hypocapnia (PaCO2 28-32)
Mild hypothermia
Intraventricular drain (IVD)
```
27
How do you calculate CPP?
CPP = MAP - (CVP or ICP)
| keep > 60 mmHg
28
What high thoracic injuries will eliminate sympathetic innervation of the heart/vessels?
T1-T4
29
Spinal shock, acute injury higher than ___ will lead to severely impaired CNS function
T6
30
What is the triad of spinal shock?
Hypotension
Bradycardia
Hypothermia
31
Sux is safe to use during the first ___ hours following spinal injury
24-48
32
Autonomic hyperreflexia occurs when injury happens where?
Above T5 (85%)
33
What are symptoms of autonomic hyperreflexia?
Severe hypertension
Bradycardia
Cardiac dysrhythmias
34
What do you avoid with autonomic hyperreflexia?
Avoid anectine
35
What do you avoid with pneumothorax?
N2O
36
What do you do to turn a pneumo into an open pneumo?
14g into 2nd intercostal space at midclavicular line
37
Where are most bronchial ruptures located with a hemothorax?
2.5 cm of the carina
38
What is Beck's triad and what does it identify?
Neck vein distention, hypotension, muffled heart tones.
Cardiac tamponade
39
What is common with cardiac tamponade?
Pulsus paradoxus - 10 mmHg decrease in BP during spontaneous respiration.
Best induction agent - ketamine
40
List meds you would give for patients with delayed gastric emptying
```
Tagamet - decreases H+
Antacid - neutralize existing acid
Reglan - decreases gastric emptying time
-10 mg po > 1 hours before induction
-10 mg iv over 1-2 min
```
41
What is the most important factor to consider with gastric emptying time?
The between last po intake and time of trauma
42
What is a common assessment to guesstimate the area of burn on a patient?
Rule of 9s
43
What are the different depths and gradings of burns?
```
1st degree
-Epithelium only
2nd degree
-Extend into dermis; most painful
3rd degree
-Destroy entire skin thickness and nerve endings
4th degree
-Destroys muscle, tendon, ligament, and bone
```
44
What direction does carbon monoxide inhalation shift the oxyhemoglobin curve?
Left
45
What are interventions to treat carbon monoxide inhalation?
Administration of 100% O2 will shorten the half-life of COhb from 4 hours in room air to < 1 hour
46
What is the Parkland formula for fluid replacement in burn patients?
Crystalloid 2-4 ml/%BSA burned/kg over 24 hours
Typically use the high end of the range
4ml/%BSA burned/kg in 24 hours
47
Where does fluid shift in a burn patient?
From intravascular to interstitial space
48
What are key considerations when caring for a burn patient?
Increased metabolism
- increased O2 consumption and CO2 production
Hyperkalemia from tissue destruction
Heat loss is serious problem
49
What do you not want to use on burn patients in the first 24 hours?
Anectine
Need higher than normal doses of NDMR due to altered protein binding and increased number of extrajunctional Ach receptors
50
What are common problems in trauma?
```
Hypotension
Hypovolemia
Desaturation
Hypertension
Tachy/Bradyarrhythmias
Sudden Cardiac Arrest
```
51
Where does blood shunt when using vasopressin?
Above the nipple line
52
What are the communicating blood supplies to the liver?
Portal vein
-75% of blood volume to liver is partially deoxygentated venous blood.
-low pressure, 6-10 mmHg
Hepatic artery
-from celiac trunk from abdominal aorta. 25% of blood volume to liver.
25% of CO - 800-1200 ml/min
53
What does the portal triad consist of?
Portal vein
Hepatic artery
Bile duct
Located at the corner of each hepatic lobule
54
Describe the 3 zones of the hepatic acinus
Zone 1 - Cells lie between portal triads, 1st to receive everything in the blood.
Zone 2 - Cells have intermediate characteristics between Zone 2 and 3.
Zone 3 - Cells are closer to central vein, last to receive incoming blood. (most susceptible to injury)
55
What are Kupffer cells?
Part of the monocyte-macrophage system, act as phagocytes to remove colonic bacteria, endotoxins, cellular debris, viruses and particulate matter from entering the bloodsream from the portal circulation.
56
Hepatic blood flow, ___% comes from hepatic artery, ___% comes from portal vein.
30
70
57
Hepatic artery blood flow is dependent on ___ and some degree of ___
metabolic demand
| autoregulation
58
List perioperative causes of decreased hepatic blood flow
```
Mechanical ventilation
Hypercarbia
PEEP
Hypotension
Hemorrhage
Hypoxemia
```
59
Hepatic arterial buffer response, what does it do?
Dilates hepatic artery to increase blood flow and compensate 25-60% for decreases in portal vein blood flow.
60
How is oxygen supplied to the liver?
Oxygen requirements for the liver are met 50% by the hepatic artery and 50% by the portal vein. Oxygen supply to the liver is 50:50
61
What drugs worsen hepatic dysfunction?
Acetaminophen, isoniazid, methyldopa, phenytoin, indomethacin
62
Describe the 2 types of hepatorenal syndrome
Type 1 - Serum creatinine doubles to >2.5 mg/dl in less than 2 weeks, poor outcome
Type 2 - Stable/slower course of progressive renal failure
63
What do liver tests identify?
Liver function tests do not measure hepatic function, they represent a release of damaged or dead hepatocyte intracellular contents into the systemic circulation at one point in time only
64
What measures actual liver function?
Albumin
Prothrombin time
Pseudocholinesterase concentrations
65
What is normal hepatic volume?
450 ml (~10% of total blood volume)
66
What is the most prevalent protein in the bloodstream?
Albumin
67
Describe serum bilirubin and what normal ranges are
Reflects the balance between production and biliary excretion, normal is <1.5 mg/dL. If bilirubin exceeds 3 mg/dL, jaundice is usually obvious.
68
Describe serum aminotransferases
Measures enzymes that are released into the circulation as a result of hepatocellular injury or death
AST, SGOT, ALT
69
Describe serum albumin
Normal range 3.5-5.5 g/dL, half-life is 2-3 weeks, so this test may be normal with acute liver issues, and albumin levels of less than 2.5g/dL are generally indicative of chronic liver disease, acute stress, severe malnutrition.
70
Which enzyme best assesses hepatocellular damage?
ALT (alanine transaminase) or SGPT (serum glutamic-pyruvic transaminase)
ALT most specific marker
71
What about the GST?
Glutathione S-transferase, detects drug-induced hepatocellular damage. GST best option for liver function tests unless 5 NT is available.
72
What about 5-NT?
5 nucleotidase, choose this test as gold standard for liver function against all other tests.
73
What volatile agent affects portal blood flow the most? Least?
Halothane the most
| Isoflurane the least
74
List things that can result in drug-induced hepatitis
```
Direct dose-dependent drug toxicity
Alcoholic hepatitis (most common)
25+ g or more of Acetaminophen
Oral contraceptives
Mushrooms
Halothane
```
75
What are three major complications to cirrhosis?
Variceal hemorrhage from portal hypertension
Itractable fluid retention (ascites) and hepatorenal syndrome
Hepatic encephalopathy or coma
76
What NMDA do you want to use with cirrhosis patients?
Nimbex
77
What are the four major sites of portal vein hypertension?
Gastroesophageal
Hemorrhoidal
Periumbilical
Retroperitoneal
78
How is a MAC changed for a chronic alcoholic?
MAC is probably increased in a sober chronic alcoholic, and the acutely intoxicated nonalcoholic patient probably has a decreased MAC
79
What is the most common disorder in alcoholics?
Megaloblastic anemia
80
Ascites is secondary to ___
Portal vein hypertension
81
What is the diuretic of choice to treat ascites?
Spironolactone
82
If you draw off more than 5L of fluid on an ascites patient, what do you need to do?
Give 5-10 g/L of albumin
83
___ is the most important predictor or short-term survival after liver resection.
Intraoperative blood loss
84
Explain the Pringle maneuver
Minimizes EBL intraop, places clamp or tourniquet to occlude hepatic venous and arterial inflow during parenchymal transection, intermittent or continuous
85
Target ___ is the most important monitor during hepatic resection
CVP
86
What is fulminant hepatic failure?
Liver failure with encephalopathy
87
What is it called when there is a problem with the production of heme?
Porphyria
88
Acute intermittent porphyria produces the most serious symptoms and is caused by ___
Drug administration
89
___ stimulate increases and possibly overproduction in porphyrins
Barbiturates
90
What drugs do you avoid with porphyria patients?
```
KEPT MAN
Ketorlac
Etomidate
Pentzocine
Thiopental
Methohexital
Nifedipine
```
(Give IV glucose)
91
What are the 6 P's of acute intermittent porphyria?
```
Porphobilinogen deaminase deficiency
Pain in abdomen
Pscyhological symtpoms
Peripheral neuropathy
Pee abnormality
Precipitated by drugs
```
92
What is Budd-Chiari syndrome?
Blockage in one or more veins that carry blood from the liver back to the heart
93
What is a TIPS procedure and when do you do it?
Transjugular intrahepatic portosystemic shunt
For portal hypertension in ESLD
94
What are the three stages of liver transplantation?
Preanhepatic
Anhepatic
Neohepatic
95
What does a decrease in CO and an increase in SVR indicate in a new liver transplantation?
Graft is functioning correctly, if you are still giving large amounts of FFP and not using CaCl, indicates the new liver is able to metabolize the citrate preservative and base deficit normalizes.
96
A chronic alcoholic patient is bleeding and awaiting surgery, what treatments might be implemented to control the bleeding?
Platelet transfusion
Vitamin K
FFP
Cryoprecipitate (for low fibrinogen levels)
97
What do you treat delirium tremens with?
Long acting benzodiazepine (Librium)
98
When do you discontinue herbal medications before surgery?
1-2 weeks before
| ```
Saw Palmetto
Ginkgo biloba
Ginger
Garlic
Feverfew
all promote bleeding
```
99
How much cardiac output do the kidneys receive?
1,200 ml of blood per min. Most perfused organ. 20-25% of CO, 1.25L/min
100
What part of the kidney is most vulnerable to ischemia?
The inner stripe of the outer medulla
The medulla extracts 80% of the delivered oxygen it receives
101
Blood is delivered to the glomerulus via the ___ and exits the glomerulus via the ___
afferent arteriole
| efferent arteriole
102
The ___ are the blood vessels supplying the loops of Henle
vasa recta
103
What's the difference between glomerular filtration, tubular reabsorption, and tubular secretion?
Glomerular - Filters blood. High hydrostatic pressure.
Tub/reabsorption - Transport out of renal tubule back to body.
Tub/secretion - back into lumen, out to urine
104
What do the proximal tubule, loop of Henle, and distal tubule do?
Proximal - reabsorbs the bulk of filtered fluid
Henle - Establishes and maintains an osmotic gradient
Distal tubule - Adjusts urine pH, osmolality, and ionic composition
105
Calculate renal blood flow
RBF = (MAP-VP) x VR
VP - venous pressure
VR - Vascular resistance
106
What happens if a MAP drops below 60 mmHg?
Glomerular filtration ceases
107
What is the most common cause of renal failure?
Prolonged renal hypoperfusion, causing depression of RBF, GFR, urinary flow, and excretion of electrolytes
108
What is the most accurate method available to measure overall renal function?
Creatinine clearance
Normal 100-200
ESRD <10
109
What happens to H2 blockers and Reglan if given to patients with renal failure?
Will accumulate, no excretion
110
What volatile agent don't you use with ESRD?
Sevo
111
What are some potentially nephrotoxic agents to avoid?
NSAIDs
Aminoglycosides
Radiographic dye
112
List loop diuretics
Furosemide (Lasix)
Bumetanide (Bumex)
Ethacrynic acid (Edecrin)
Torsemide (Demadex)
113
List thiazide diuretics
```
Work on distal tubule
Chlorothiazide (Diuril)
Hydrochlorothiazide (Esidrix, HydroDIURIL)
Chlorthalidone (Hygroton)
Metolazone (Zaroxolyn)
```
114
List potassium sparing diuretics
Spironolactone (Aldactone)
Triamterene (Dyrenium)
Amiloride (Midamor)
115
Name a carbonic anhydrase inhibitor
Acetazolamide (Diamox)
116
What is the best test to determine pre renal failure from renal failure?
Fractional excretion of filtered sodium (FEna), 90% specific and sensitive.
117
List GFR values for normal, decreased renal reserve, renal insufficiency, and uremia
Normal - 125 ml/min
Decreased renal reserve - 50-80 ml/min
Renal insufficiency - 12-50 ml/min
Uremia - <12 ml/min
118
List four common electrolyte disturbances in chronic renal failure
Hyperkalemia
Hypocalcemia
Hypermagnesemia
Hyperphosphatemia
119
List 6 interventions for treating hyperkalemia
```
Give Ca++
Administer HCO3-
Hyperventilate
Give insulin-glucose
Administer a B2-adrenergic
Give Kayexalate
Dialyze patient
```
120
During a TURP, ___ ml of resecting fluid can be absorbed in each minute of resecting time, with the amount absorbed r/t size and congestion of gland, MD experience, and number of venous sinuses opened.
10-30
121
List signs of bladder perforation during a TURP
Abdominal pain, abdominal distention, skin cold/cooler over abdomen, pain, referred shoulder pain, hiccup, SOB, tachycardia, hypotension or hypertension, diaphoresis, vomiting
