Toronto Notes Gems Flashcards
1
Q
6 As of General Anesthesia
A
Anesthesia Anxiolysis Amnesia Areflexia (muscle relaxation not always required) Autonomic Stability Analgesia
2
Q
Discuss β-blockers (b1 vs. b2) & its cautions
A
• 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
Q
Pre-Anesthetic Checklist
A
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
Q
Suspect Difficult Bag-Mask Ventilation with:
A
BONES
Beard Obesity/Obstetrics No teeth Elderly Sleep apnea
5
Q
Differential Diagnosis of Poor Bilateral Breath Sounds after Intubation
A
DOPE
Displaced ETT
Obstruction
Pneumothorax
Esophageal intubation
6
Q
Causes of Intraoperative Shock
A
SHOCKED
Sepsis or Spinal shock Hypovolemic/Hemorrhagic Obstructive Cardiogenic anaphylactiK Extra/other Drugs
7
Q
Discuss Opioid Equivalency for morphine, codeine, oxycodone & hydromorphone
A
- 10 mg morphine
- 100 mg codeine
- 5 mg oxycodone
- 2 mg hydromorphone
8
Q
Use NSAIDs with Caution in Patients with:
A
- Asthma
- Coagulopathy
- GI ulcers
- Renal insufficiency
- Pregnancy, 3rd trimester
9
Q
Common Side Effects of Opioids
A
- Nausea and vomiting
- Constipation
- Sedation
- Pruritus
- Abdominal pain
- Urinary retention
- Respiratory depression
When prescribing opioids, consider:
• Breakthrough dose
• Anti-emetics
• Laxative
10
Q
Classic Presentation of Dural Puncture Headache
A
- Onset 6 h-3 d after dural puncture
- Postural component (worse sitting)
- Occipital or frontal localization
- ± tinnitus, diplopia
11
Q
Differential of ST Segment Changes
A
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
Q
Important Contraindications to
Exercise Testing
A
• Acute MI, aortic dissection,
pericarditis, myocarditis, PE
• Severe AS, arterial HTN
• Inability to exercise adequately
13
Q
Treatment of NSTEMI/Immediate Treatment of Acute MI
A
BEMOAN
β-blocker Enoxaparin Morphine O2 ASA Nitrates
14
Q
Complications of MI
A
CRASH PAD
Cardiac Rupture Arrhythmia Shock Hypertension/Heart failure Pericarditis/Pulmonary emboli Aneurysm DVT
15
Q
Use Ejection Fraction to Grade LV
Dysfunction
A
- Grade I (EF >60%) (Normal)
- Grade II (EF = 40-59%)
- Grade III (EF = 21-39%)
- Grade IV (EF ≤20%)
16
Q
Five Most Common Causes of CHF
A
• CAD (60-70%) • HTN • Idiopathic (often dilated cardiomyopathy) • Valvular (e.g. AS, AR and MR) • Alcohol (dilated cardiomyopathy)
17
Q
Precipitants (c.f. exacerbations) of Heart Failure
A
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
Q
Features of Heart Failure on CXR
A
HERB-B
Heart enlargement (cardiothoracic ratio >0.50) Pleural Effusion Re-distribution (alveolar edema) Kerley B lines Bronchiolar-alveolar cuffing
19
Q
Discuss the regime with beta blocker use in acute on chronic HF patients
A
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
Q
Chronic Treatment of CHF
A
- ACE inhibitors*
- β-blockers*
- ± Aldosterone antagonists* (if severe CHF) e.g. spironolactone
- Diuretic
- ± Inotrope
- ± Antiarrythmic
- ± Anticoagulant
*Mortality benefit
21
Q
(4) types of Cardiomyopathy
A
HARD
- Hypertrophic cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy
- Restrictive cardiomyopathy
- Dilated cardiomyopathy
22
Q
(3) Major Risks Factors for DCM
A
Alcohol, cocaine, family history
23
Q
Acute Pericarditis Triad
A
- Chest Pain
- Friction Rub
- ECG Changes
24
Q
Ewart’s Sign
A
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
Trousseau’s disease/sign
Migratory superficial thrombophlebitis is often a sign of underlying malignancy
31
Antiarrythmic Drug Classification
Some Block Potassium Channels
I – Sodium channel blocker
II – β-Blocker
III – Potassium channel blocker
IV – CCB
32
The Cockcroft-Gault Equation (estimate creatinine clearance (CrCl) in adults 20 yr of age and older)
• For males CrCl (mL/min) =
[(140 – age in yr) x Weight (kg)] x 1.2 / serum Cr (μmol/L)
* For females, multiply above equation x 0.85
* Only applies when renal function is at steady state
33
How many half lives does it need to reach steady state with repeated dosing or to eliminate a drug once dosing is stopped?
For most drugs it takes 5 half-lives
34
Keloids vs. Hypertrophic Scars
```
• Keloids: extend beyond margins
of original injury with claw-like
extensions
• Hypertrophic scars: confined to
original margins of injury
```
35
DDx of Hyperpigmented Macules
```
• Purpura (e.g. solar, ASA, anticoagulants,
steroids, hemosiderin
stain)
• Post-inflammatory
• Melasma
• Melanoma
• Fixed drug eruption
```
36
ABCDE of Melanoma
```
Asymmetry
Borders (irregular)
Colour (variegated)
Diameter (>6 mm)
Evolution (over time)
```
37
Triggers for Atopic Dermatitis
```
• Irritants (detergents, solvents,
clothing, water hardness)
• Contact allergens
• Environmental aeroallergens (dust mites)
• Inappropriate bathing habits (long hot showers)
• Sweating
• Microbes (S. aureus)
• Stress
```
38
PSORIASIS: Presentation and
| Pathophysiology
- Pink papules/Plaques/Pinpoint bleeding (Auspitz sign)/Physical injury (Koebner phenomenon)
- Silver scale/Sharp margins
- Onycholysis/Oil spots
- Rete Ridges with Regular elongation
- Itching
- Arthritis/Abscess (Munro)/Autoimmune
- Stratum corneum with nuclei
- Immunologic
- Stratum granulosum absent
39
PSORIASIS: Triggers
• Physical trauma (Koebner phenomenon)
• Infections (acute streptococcal
infection precipitates guttate psoriasis)
• Stress (can be a major factor in flares)
• Drugs (systemic glucocorticoids, oral lithium, antimalarial drugs, interferon)
• Alcohol ingestion
40
Drug Hypersensitivity Syndrome Triad
* Fever
* Exanthematous Eruption
* Internal Organ Involvement
41
Risk Factors for Melanoma
no SPF is a SIN
- Sun exposure
- Pigment traits (blue eyes, fair/red hair, pale complexion)
- Freckling
- Skin reaction to sunlight (increased incidence of sunburn)
- Immunosuppressive states (e.g. renal transplantation)
- Nevi (dysplastic nevi; increased number of benign melanocytic nevi)
42
Initial Management of Any Patient in Shock
* ABCs
* IV fluids
* Oxygen
* Monitor (HR, BP, urine, mentation, O2 saturation)
* Control hemorrhage
43
NG Tube Contraindications
* Significant mid-face trauma
| * Basal skull fracture
44
Unilateral, Dilated, Non-reactive
| Pupil, think:
* Focal mass lesion
* Epidural hematoma
* Subdural hematoma
45
Signs of Increased Intracranial
| Pressure (ICP)
* Deteriorating LOC (hallmark)
* Deteriorating respiratory pattern
* Cushing reflex (high BP, low heart rate, irregular respirations)
* Lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis)
* Seizures
* Papilledema (occurs late)
* Nausea/vomiting and headache
46
Signs of Basal Skull Fracture
* Battle’s sign (bruised mastoid process)
* Hemotympanum
* Raccoon eyes (periorbital bruising)
* CSF Rhinorrhea/Otorrhea
47
Treatment of Increased ICP
* Elevate head of bed
* Mannitol
* Hyperventilate
* Paralyzing/sedating agents
48
Seatbelt Injuries may Cause:
* Retroperitoneal duodenal trauma
* Intraperitoneal bowel transection
* Mesenteric injury
* L-spine injury
49
Reasons for Emergent Orthopedic Consultation
* Compartment syndrome
* Irreducible dislocation
* Circulatory compromise
* Open fracture
* Injury requiring surgical repair
50
Vascular injury/compartment syndrome is suggested by “The 6 Ps”:
- Pulse discrepancies
- Pallor
- Paresthesia/hypoesthesia
- Paralysis
- Pain (especially when refractory to usual analgesics)
- Polar (cold)
51
Acute Treatment of Contusions
RICE
Rest
Ice
Compression
Elevation
52
Where NOT to use local anesthetic with epinephrine:
Ears, Nose, Fingers, Toes and Penis
53
Gynecological Causes of Pelvic Pain:
* Ovarian cyst
* Dysmenorrhea
* Mittelshmerz
* Endometriosis
* Ovarian torsion
* Uterine fibroids/neoplasm
* Adnexal neoplasm
* PID + cervicitis
54
Signs of PE on CXR
Westermark’s sign: abrupt tapering of a vessel on chest film.
Hampton’s hump: a wedge-shaped infiltrate that abuts the pleura.
55
Causes of Syncope by System
HEAD, HEART, VeSSELS
Hypoxia/Hypoglycemia
Epilepsy
Anxiety
Dysfunctional brainstem
```
Heart attack
Embolism (PE)
Aortic obstruction
Rhythm disturbance
Tachycardia
```
```
Vasovagal
Situational
Subclavian steal!!
ENT (glossopharyngeal neuralgia)
Low systemic vascular resistance
Sensitive carotid sinus
```
56
Treatment of Asthma
ASTHMA
```
Adrenergics (β-agonists)
STeroids
Hydration
Mask (O2)
Antibiotics (if concurrent bacterial
pneumonia)
```
57
If patient has Wolff-Parkinson-White and is in AFib use [...]. Avoid [...] agents as this can increase conduction through bypass tract leading to cardiac arrest
use amiodarone or procainamide.
Avoid AV nodal blocking agents (adenosine, digoxin, diltiazem, verapamil, betablockers)
58
Causes of CHF Exacerbation (c.f. precipitants)
FAILURE
```
Forgot medication
Arrhythmia (Dysrhythmia)/Anemia
Ischemia/Infarction/Infection
Lifestyle (e.g. too much salt)
Upregulation of cardiac output
(pregnancy, hyperthyroidism)
Renal failure
Embolism (pulmonary)
```
59
Acute Treatment of CHF
LMNOP
```
Lasix (furosemide)
Morphine
Nitroglycerine
Oxygen
Position (sit upright), Pressure (BiPAP)
```
60
Risk Factors for VTE
THROMBOSIS
```
Trauma, travel
Hypercoagulable, HRT
Recreational drugs (IVDU)
Old (age >60)
Malignancy
Birth control pill
Obesity, obstetrics
Surgery, smoking
Immobilization
Sickness (CHF, MI, nephrotic syndrome, vasculitis)
```
61
Precipitating Factors in DKA
The 5 Is
```
Infection
Ischemia
Infarction
Intoxication
Insulin missed
```
62
4 Criteria for DKA Dx
* Hyperglycemia
* Metabolic acidosis
* Hyperketonemia
* Ketonuria
63
```
HELLP Syndrome (seen only in
preeclampsia/eclampsia)
```
Hemolytic anemia
Elevated Liver enzymes
Low Platelet count
64
Causes of Acute Ataxia
UNABLE TO STAND
- Underlying weakness (mimic ataxia)
- Nutritional neuropathy (vitamin B12 deficiency)
- Arteritis/vasculitis
- Basilar migraine
- Labyrinthitis/vestibular neuronitis
- Encephalitis/infection
- Trauma (post-concussive)
- Other (rare genetic or metabolic disease)
- Stroke (ischemia or hemorrhage)
- Toxins (drugs, toluene, mercury)
- Alcohol
- Neoplasm/paraneoplastic syndrome
- Demyelination (Miller Fisher, Guillain Barré, MS)
65
(3) main types of Kidney Stones
* 80% Calcium
* 10% Struvite
* 10% Uric acid
66
High Risk Criteria for Infection of wounds
```
Wound Factors
• Puncture wounds
• Crush injuries
• Wounds >12 h old
• Hand or foot wounds
• Wounds near joints
```
Patient Factors
• Immunocompromised
• Age >50 yr
• Prosthetic joints or valves
