Flashcards in Toronto Notes Gems Deck (66)
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1
6 As of General Anesthesia
Anesthesia
Anxiolysis
Amnesia
Areflexia (muscle relaxation not always required)
Autonomic Stability
Analgesia
2
Discuss β-blockers (b1 vs. b2) & its cautions
• b1 receptors are located primarily in the heart and kidneys
• b2 receptors are located in the lungs
• Non-selective b-blockers block b1 and b2 receptors. Caution is required with non-selective b-blockers, particularly in patients with respiratory conditions
where b2 blockade can result in
airway reactivity
3
Pre-Anesthetic Checklist
SAMMM
- Suction: connected and working
- Airways: laryngoscope and blades, ETT, syringe, stylet, oral and nasal airways, tape, bag and mask
- Machine: connected, pressures okay, all meters functioning, vaporizers full
- Monitors: available, connected and working
- Medications: IV fluids and kit ready, emergency medicines in correct location and accessible
4
Suspect Difficult Bag-Mask Ventilation with:
BONES
Beard
Obesity/Obstetrics
No teeth
Elderly
Sleep apnea
5
Differential Diagnosis of Poor Bilateral Breath Sounds after Intubation
DOPE
Displaced ETT
Obstruction
Pneumothorax
Esophageal intubation
6
Causes of Intraoperative Shock
SHOCKED
Sepsis or Spinal shock
Hypovolemic/Hemorrhagic
Obstructive
Cardiogenic
anaphylactiK
Extra/other
Drugs
7
Discuss Opioid Equivalency for morphine, codeine, oxycodone & hydromorphone
• 10 mg morphine
• 100 mg codeine
• 5 mg oxycodone
• 2 mg hydromorphone
8
Use NSAIDs with Caution in Patients with:
• Asthma
• Coagulopathy
• GI ulcers
• Renal insufficiency
• Pregnancy, 3rd trimester
9
Common Side Effects of Opioids
• Nausea and vomiting
• Constipation
• Sedation
• Pruritus
• Abdominal pain
• Urinary retention
• Respiratory depression
When prescribing opioids, consider:
• Breakthrough dose
• Anti-emetics
• Laxative
10
Classic Presentation of Dural Puncture Headache
• Onset 6 h-3 d after dural puncture
• Postural component (worse sitting)
• Occipital or frontal localization
• ± tinnitus, diplopia
11
Differential of ST Segment Changes
ST Elevation “I HELP A PAL”
- Ischemia with reciprocal changes
- Hypothermia (Osborne waves)
- Early repolarization (normal variant; need old ECGs)
- LBBB
- Post-MI
- Acute STEMI
- Prinzmetal’s (Vasospastic) angina
- Acute pericarditis (diffuse changes)
- Left/right ventricular aneurysm
ST Depression “WAR SHIP”
- WPW syndrome
- Acute NSTEMI
- RBBB/LBBB
- STEMI with reciprocal changes
- Hypertrophy (LVH or RVH) with strain
- Ischemia
- Post-MI
12
Important Contraindications to
Exercise Testing
• Acute MI, aortic dissection,
pericarditis, myocarditis, PE
• Severe AS, arterial HTN
• Inability to exercise adequately
13
Treatment of NSTEMI/Immediate Treatment of Acute MI
BEMOAN
β-blocker
Enoxaparin
Morphine
O2
ASA
Nitrates
14
Complications of MI
CRASH PAD
Cardiac Rupture
Arrhythmia
Shock
Hypertension/Heart failure
Pericarditis/Pulmonary emboli
Aneurysm
DVT
15
Use Ejection Fraction to Grade LV
Dysfunction
• Grade I (EF >60%) (Normal)
• Grade II (EF = 40-59%)
• Grade III (EF = 21-39%)
• Grade IV (EF ≤20%)
16
Five Most Common Causes of CHF
• CAD (60-70%)
• HTN
• Idiopathic (often dilated
cardiomyopathy)
• Valvular (e.g. AS, AR and MR)
• Alcohol (dilated cardiomyopathy)
17
Precipitants (c.f. exacerbations) of Heart Failure
HEART FAILED
- Hypertension (common)
- Endocarditis/environment (e.g. heat wave)
- Anemia
- Rheumatic heart disease and other valvular disease
- Thyrotoxicosis
- Failure to take meds (very common)
- Arrhythmia (common)
- Infection/Ischemia/Infarction (common)
- Lung problems (PE, pneumonia, COPD)
- Endocrine (pheochromocytoma,
hyperaldosteronism)
- Dietary indiscretions (common)
18
Features of Heart Failure on CXR
HERB-B
Heart enlargement (cardiothoracic ratio >0.50)
Pleural Effusion
Re-distribution (alveolar edema)
Kerley B lines
Bronchiolar-alveolar cuffing
19
Discuss the regime with beta blocker use in acute on chronic HF patients
Patients on β-blocker therapy who have acute decompensated heart
failure should continue β-blockers
where possible (provided they are
not in cardiogenic shock or in severe pulmonary edema)
20
Chronic Treatment of CHF
• ACE inhibitors*
• β-blockers*
• ± Aldosterone antagonists* (if severe CHF) e.g. spironolactone
• Diuretic
• ± Inotrope
• ± Antiarrythmic
• ± Anticoagulant
*Mortality benefit
21
(4) types of Cardiomyopathy
HARD
- Hypertrophic cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy
- Restrictive cardiomyopathy
- Dilated cardiomyopathy
22
(3) Major Risks Factors for DCM
Alcohol, cocaine, family history
23
Acute Pericarditis Triad
• Chest Pain
• Friction Rub
• ECG Changes
24
Ewart’s Sign
Bronchial breathing and dullness to percussion at the lower angle of the left scapula in pericardial effusion due to effusion compressing left lower lobe of lung.
25
Classic Quartet of Tamponade
• Hypotension
• Increased JVP
• Tachycardia
• Pulsus paradoxus
26
Beck’s Triad in cardiac tamponade
• Hypotension
• Increased JVP
• Muffled heart sounds
27
DDx Pulsus Paradoxus
• Constrictive pericarditis (rarely)
• Severe obstructive pulmonary disease (e.g. asthma)
• Tension pneumothorax
• PE
• Cardiogenic shock
• Cardiac tamponade
28
Symptoms of Acute Limb Ischemia
6 Ps – all may not be present
- Pain: absent in 20% of cases
- Pallor: within a few hours becomes mottled cyanosis
- Paresthesia: light touch lost first then sensory modalities
- Paralysis/Power loss: most important, heralds impending gangrene
- Polar/Poikilothermia (cold)
- Pulselessness: not reliable
29
Classic Triad of Ruptured AAA
• Pain
• Hypotension
• Pulsatile abdominal mass
30
