AP1 tests 2-3 combo

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what is pseudohyperkalmeia

lysis of rbcs, wbcs or throbocytosis sample. High k+, LAB ERROR

Which blade is curved which is straight

mac is curved miller is straight

what is the reduction % of volume with a class 1 hemorrhage?

less than 15%, which would be a blood loss less than 750 mL

what is poor interincisor distance

less than 3 cm or two fingers (other place says 4cm)

the ASA task force says a transfusion should be administered in patients with what hemoglobin value?

less than 6

what would a critically low hemoglobin be?

less than 6

Thyromental distance bad sign

less than 7 cm or 3 fingers = mandibular hypoplasia >9cm can also be difficult =

what was old guideline for uncuffed ett?

less than 8 is uncuffed, no they just say neonate use uncuffed, kids can use either.

acute pancreatitis and mag

low

chewing tobacco and k+

low

hyper aldosterone and mag

low

hyperparathyroid and mag (when ca++ increases mag goes....)

low

licorice and k+

low

porphyria and mag

low

renal tubular disease and K+

low

too much adrenalcorticosteroids and k+

low

Accroding to art does high or low na+ cause cerebral edema, confusion, coma, agitation

low (book says both)

hyperaldosterone and k+? All other electrolytes and high adrenal steroids?

low (hyper adrenal steroids decrease all electrolytes but na+)

What are 3 risks of albumin (1 electrolyte)

low ca++ infection (human product) allergy reaction (human product)

Why is KCl given and not other forms of k+

low cl- causes kidneys to have a hard time retaining K+

What happens with older patients and third spacing

low protien increased third spacing

what do you worry about with low Hgb vs high

low= o2 carrying capacity high = too much clotting

Burns and K+

lower

where do you want you epidural catheter placed for labor or lower abdominal anesthesia?

L2 or L3 interspace

free water deficit equation

(na/140)-1 x tbw

What is normal number ml in epi wash

0.2ml in 1:1000l

What is Epidural dose of levobupivacaine

0.5%

which medication would you use for a beir block?

0.5% lidocaine

how long do pts lay flat after blood patch

0.5-1 hrs (i think this what to book says)

bicarb epidural

1 cc/10 ml

how much local do you inject when doing a superior laryngeal nerve block

1 ml of 2% lidocaine above the membrane and 2 ml 2% lido after advancing through the membrane

What is the usual dose of platelets?

1 unit per 10 kg of body weight

Normal dose of plts

1 unit/kg (book says one per 10kg)

pencil point needles are associated with less than a ____ % risk of PDPH and a failure rate of approximately ____ %

1% 5%

Chance of PDPH

1%, less with pencil tip than cutting

Treatment for severe mag depletion

1-2 g over 5 min then 1-2g/hour Mag Sulfate

clonidine SAB

15-30mcg

What is a normal hemoglobin for men?

17

What is a MBT pack

2 units 0 neg blood 6 units PRBCS 4 FFP 1 plt

Max hours for LMA

2-3 hours

what flow of 02 can go through fiberopitc port

2-4 L

What is volume needed if epidural catheter is at L2-L3 and you want a T11-T12 block

3 levels x both cephalad and caudad = 1.5 x 6 = 9cc

Arts normal k+ range

3-5 mEq/L

Normal value for serum ca++

8.8-10.5

What is the average blood volume for an infant?

80 ml/kg

What is the average blood volume for a full-term neonate?

85 ml/kg

How many cartilages in larynx and names

9 thyroid, cricoid, epiglottic (single) arytenoid, corniculate, and cuneiform (pairs)

How long after HES administration has RRT been reported

90 days

How long should hospitalized patients who recieved HES be monitored for renal function postop

90 days

the full range of neck flexion and extension varies from ____ to ____ degrees and decreases approximately ____% between ages 16 and 75.

90 to 165 degrees 20%

What is the average blood volume for a premature neonate?

95 ml/kg

critically low hgb and critically high

< 6hgb >18

What is the max dose of hespan/hetastarch/hextend in order to reduce anticoagulation problems

<20cc/kg although art does a lot less than this

Osmolarity level (due to high na+ ) with coma seizures death

>430

Know how fast you can give CaCl

Art said look in the book

ASA difficult airway step 1

Asses likelihood and impact of: difficult ventilation difficult intubation difficulty with pt. cooperation difficult traceostomy

what nerve fibers are not mylenated

C

Pts. considered full stomach (pregnant, DM, emergency, hiatial hernia) can use LMA?

NO!

What are things that make bag mask vent difficult concerning (box 22-2): Seal (3) Age weight oral cavity (2) Lungs History (2)

Seal - beards, altered anatomy, ng tube age= greater than 55 weight = obese oral airway = obstruction or no teeth Lungs - stiff-poor compliance History - sleep apnea or snoring

define the term transfusion trigger

a single threshold for transfusion

What is a colloid?

a solution containing osmotically active substances of high molecular weight that do not easily cross the capillary membrane and therefore draw fluid into the intravascular space and expand circulating volume.

Describe the dura matter?

a thick and tough membrane. Provides the most protection for central cord structures

How much is in a bag of whole blood?

about 500 mL

what are some common colloids?

albumin, dextran, gelatins, and hetastarch which is also known by the great Menardie as Hespan

What coagulation factors does ffp contain

all of them

what is the aggresive but definitive way to treat a PDPH?

an epidural blood patch

psych and low ca++

anxiety depression irritable confused/psychotic/dementia

If RSI do you extubate deep or awake

awake

hypopharynx (laryngopharynx) beginning and end

begins at epiglottis (level of hyoid bone and base of tongue) and ends at opening to glottis (cricoid cartilage). Includes portion above esophagus.

Headache with hypernatremia hyponatremia or both?

both (look at table 20-4 and box 20-1)

when the cartilage disappears what does the bronchi change into?

bronchioles

pulm signs of low ca++

bronchospasm laryngospasm

what locals are often used in a sciatic nerve block?

bupivacaine 0.5%, ropivacaine 0.5%, and lidocaine 1.5%

which local and concentration would you choose for a subarachnoid block for a c-section

bupivicaine 0.75%; it will last longer than 0.5% (will last 1.5 to 2 hours) and longer than lidocaine

what are facial causes of an upper airway obstruction?

burns congenital abnormalities trauma

while doing a test dose in an epidural, if you inject in to a vein and your test dose contains epi, how much should your heart rate and BP raise?

by 20% within 30 seconds

what envelopes the trunks in the brachial plexus?

by a fascial sheath, which is a closed space at the interscalene space, and is also known as the sheath of the brachial plexus

how to the vocal cords compensate in a unilateral injury of the recurrent laryngeal nerve?

by shifting the midline to the uninjured side

What is the treatment for hypocalcemia?

calcium chloride or gluconate PO calcium vitamin D

3 treatments of high mag

calcium, diuretics dialysis Lower non-depolarizing paralyitc dose

according to the ASA difficult algorithm you are in the emergency pathway, meaning you have unsuccessful intubation with inadequate ventilation. what would you do next?

call for help and attempt emergency non invasive airway ventilation

What happens to esophageal sphincter if cuff is over inflated on LMA

can cause it to open

Difference between airway exchange catheter and bougie

can jet ventilate with airway exchange cathrter or bag mask

What can happen with bougie and airway exchange catheter placement if it is too distal

can perforate lower airway or irritate it

What is mapllampati class "0"

can see epiglottis

What are the two last phases of lung development

canalicular phase - weeks 16-26 -- terminal and resp bronchioles Terminal sac phase - weeks 24-36- primitive alveoli

What are some contraindications to cell saver per art (look at table 20-16)

cancer c-section (amniotic fluid) infection including BOWEL SURG

4 main causes of hyper ca++

cancer meds granulomatous disorders (TB leprosy) Nonparathyroid endocrine disorders

What is fixed volume cardiac state?

cannot compensate for BP drop

What is charted in the graphic area of the record (4)

care given drugs/fluids vitals pt response

Most innervated part of the lower airway for sensation

carina

Which direction should needle go into trachea in retrograde intubation vs. needle cricothyrotomy

caudal in cricothyrotomy and cephalad in retrograde intubation

Steroids and fluid status

cause fluid overload and hypernatremia

the ______ of the local anesthetic generally affects the density of the block

concentration

two causes of primary hypoparathyroidism

congenital maternal hyperparathyroidism

When using a nerve stimulator in doing a brachial plexus block what is done with the amplitude as the needle approaches the sheath?

continuously decreased so that the muscle response to the stimulus is maintained

What does ASRA say about coagulopathy and CNB

contraindicated

electrical translocation devices provide a ________ of variable amplitude that is administered through a conducting device

controlled stimulating impulse

When used cricoid pressure should used until

correct placement of ett is confirmed

What is the treatment for hypernatremia?

correct underlying cause replace water deficit dialysis change slow at a rate of 10 to 20 mEq per day

The epidural space is continuous from the base of the ________ to the base of the _________ at the _________ membrane

cranium, sacrum, sacrococcygeal

which cartilage is below the thyroid carilage?

cricoid cartilage

which cartilage of the trachea is the only one that is a complete ring?

cricoid cartilage

What is laryngotracheobronchitis

croup- inflammation of airway below vocal cords

How does hyperinflation of ett cuff cause obstruction

crushes lumen of tube, need to pass stylet or airway exchange catheter.

Do arytenoids sit on cricoid cartilage or thyroid

crycoid. The cricoid is larger in posterior and rises superiorly in the posterior where the thyroid is only an anteriolateral cartilage.

When trauma surgeon says "i just cant seem to get them to stop bleeding", what should you give them

cryo

What causes pdph

csf leak causes vasodilation, pressure on vault, meninges and tentorium traction

What do you need baseline before art line

cuff pressure. Chart this

What should you be careful not to hold onto with magill forcep when advancing ett

cuff, may rupture

How is fastrach (ILMA) different

curved rigid tube guiding handle epiglottic elevating bar guiding ramp in floor of mask

what are the 2 main types of needles used for spinals?

cutting and non cutting or pencil tip

Treatment for n/v with spinal epidural (4)

decadron zofran pressors fluids

In low risk ambulatory surgeries, why are fluid bolus often given

decrease pain, nausea, dizziness, and increases street rediness

loc and high mag

decreased, drowsy (same as high ca++)

What can sepsis and hypomag do to calcium and vit D

decreases vit D and ca++

Repiratory status and high mag (at what level of high mag)

depression or arrest with 10-15

what is usually added to an anesthetic to make it hyperbaric?

dextrose

Drugs for high K+

dextrose and insulin Ca gluconate/CaCl bicarb kayexelate lasix

Arts 5 treatments for high k+

dialysis calcium insulin and glucose diuretics kayexelate

pre-oxigenation in osa and obesity

doesn't last as long and hypoxia more profound

When inserting LMAs should they be in non-dominant or dominant hand

dominant

Does FFP have to be typed and crossmatched

don't have to be but desireable

why would a total spinal happen?

due to cephalad spread of local to pons

The epidural space is a potential space outside the _________ but inside the _________

dural sac, vertebral canal

What does the brachial plexus do at the lateral border of the first rib and posterior of the clavicle?

each of the 3 trunks divides into vental and dorsal divisions

In high risk pts is it better to give fluids early or late in the case

early

What kinds of pts should difficult airway equipment be used on when student is first learning?

easy airway patients

Is proseal or fastrach used more for intubation

fastrach. Proseal and classic aren't designed well for intubating. Fastrach is what almost everyone uses if they have to intubate through it. It is an "intubating LMA"

who is more likely to get a PDPH after a spinal, a female or male?

female

How to confirm placement with double lumen tube?

fiberoptic, look for carina and then blue cuffed tube. If no blue then too deep

When should hespan be discontinued concerning kidneys

first sign of renal injury

What sympathetic/parasym nerves innervate the tracheobronchial tree

first through fifth thoracic ganglia = sympathetic vagus nerve = para

will a hypobaric solution injected into the subarachnoid space sink or float

float

what do extrinsic muscles of the larynx do? 3 main functions

for connections between larynx, hyoid, and neighboring anatomic structures -MAIN FUNCTION is the adjust the position of the trachea during phonation, breathing, and swallowing

Where does vertebral column extend

foramen magnum to tip of coccyx

If you have given the appropriate amount of crystalloid and there appears to still be too low intravascular volume, what does NH say to do

give isotonic colloid not crystalloid (pg 393). However, pg 394 says to give a bolus?

what do you do if you only have o+ and you have to give to a B- patient

give them rhogam unless this is first exposure, then they should be ok

the epiglottis rests above the ___________ where it closes the ___________ during swallowing

glottic opening glottic aperature

what would a critically high hemoglobin be?

greater than 18

what is the reduction % of volume with a class 4 hemorrhage?

greater than 40% which would be a blood loss of greater than 2000 mL

class IV mallampati

hard palate only

What are 4 relative contraindications to surgical cricothyrotomy

hematoma, abcess tumor coagulopathy etc.

What is recombinant factor VIIa used for

hemophilia A, B and other congenital coagulopathies.

Art says paresthesia with high or low k+

high

can you use a cell saver on a Jehovah Witness patient?

if the patient accepts it, then you can

When do we do a caudal block?

in kids with hernia repair, this is very rare because we usually don't do regional on kids

why use paremedian

in older or arthritis where sclerosis is common

When do we use an epidural in cervical vertebrae?

in pain management

what are some complications that can occur with intubation?

in the goose laceration of lips or gums broken teeth dislocate jaw vocal cord injury foreign bodies such as teeth knocked in the airway

where is the epidural space largest (posterior to anterior)?

in the midline of the mid-lumbar region, at 5 to 6 mm

Where is the the supraclavicular portion of the brachial plexus located?

in the posterior triangle of the neck

What is non-reassuring finding for maxillary mandibular protrusion

inability to protrude mandibular incisors

how much does albumin 5% replace?

it replaces plasma loss in a 1 to 1 ratio

What can you give if kid wont hold still or for mentally impaired before CNB

ketamine dart

How can you differentiate normal neuropathy postop after spinal vs cauda equina

lingering bladder dysfunction that lasts 2 days or more

What organs does hespan effect the most

liver and kidneys Often causes needed RRT

6 FFP indications (1 organ, 1 drug, 1 condition, 3 others)

liver disease, coumadin, high PT/INR DIC, clotting factor deficiencies, excess RBC replacement

DM and mag. Pregnancy and Mag

low

calcium and MBT

low ca++ (citrate toxicity)

how is fluid volume deficit calculated?

maintenance (1.5 times wt in kg) times hours NPO

What can be lethal consequence of esphagus perforation

mediastinitis (50% morbidity)

what lies anterior to C1 and is bound superiorly by the base of the skull and inferiorly by the soft palate?

nasopharynx

Does LMA seal the esophageal sphincter

no

Is the provider who cares for pt intraop usually responsible for care post op

no usually a nurse and may be supervised another provider. We make sure they are cared for

If pt has migraine how can you tell if they have SAB PDPH

no way of knowing

would a healthy patient with normal liver and kidney function be likely to develop citrate intoxication after 20 units of banked blood?

no, a normothermic healthy patient can metabolize the amount of citrate present in 20 units of banked blood per hour

Combo CNB good for laboring women

no?

what kind of needle may drag fewer skin contaminants into subdermal tissue

non cutting or pencil point

which kind of spinal needle pierce the dura with a clearly perceptible click or pop

non cutting or pencil point

What kind of tubing needs to be attached to needle cricothyrotomy catheter for jet vent

non-compliant

Where is spinal epid site of action

normally centrally mediated substantia gelatinsosa in dorsal horn

Herbals alone and CNB

not a contraindication

NSAIDS and CNB

not a contraindication

Most common cause of hypernatremia

not enough water intake

According to the AANA what should be documented on the anesthesia record?

patient identification provider information equipment checks minimal monitors techniques medications intake and output procedural data preanesthesia evaluation informed consent

according to the AANA what does the operating room nurse document?

patient positioning restraints safety straps padding grounding pads tourniquets warming blankets other aspects of care

What are the topical doses used for awake intubation of the following (table 22-6): phenylepherine lidocaine cetacaine benzocaine cocaine lidocaine nerve block

phenly- 1% - only used as vasoconstrictor in nasal intubation Lido - 2 or 4% cetacaine? benzo - 20% cocaine - 4% lido - 2%

what is the role of the cricothyroids?

phonation

what is the role of the lateral cricoarytenoids?

phonation

Another name for intravascular volume

plasma

How is LMA classically inserted

pointer finger at back of cuff, posterior portion of cuff on palate, lubricate and slide in along palatopharyngeal curve. Usually fully deflated

Urine production and hyper na+

polyuria or oliguria

high ca++ and renal s/s (urine amount and 3 others)

polyuria polydipsia dehydration prerenal azotemia kidney stones nephrocalcinosis

Other than suctioned blood, what else needs to be calculated as blood loss

pooled blood, towels, drapes, floor etc.

Why age >55 = difficult bmv

poor airway muscle tone

What are rigid and semi rigid fiberoptic scopes used for

poor mouth opening poor neck mobility

proper patient _______ is important to ensure successful catheter placement

positioning

What does CRNA or OR nurse document

positioning, restraints, straps, padding, grounding, tourniquets, warming blankets etc.

What should you check with positioning intraop

pressure points ulnar nerve (mostly from side of bed) arm dropping (radial nerve) arm stretch beyond 90 degrees make sure head is neutral Do ROM Message head Periorbital edema

When would a nasal awake intubation be needed

previous airway difficulty, neck fractures, halo device, small oral opening, mass, critical care

Lateral cricoarytenoid muscles

primary adductors of cords. Attach to lateral criothryoid cartilage and arytenoids

what are LMA's used for?

primary airway device during appropriate surgical procedures valuable tool in managing a difficult airway a conduit for intubation of the trachea

what three thing does the ECF do?

provides a medium for cell nutrients, electrolytes, and waste products

Art's four reasons to use cricoid pressure

reflux rapid sequence full stomach Sometimes to help view

Are pts with fixed volume cardiac state relative or absolute contraindication

relative

3 causes of hyper mag

renal failure (not losses or insufficiency) Mag administration adrenal insufficiency

Normal dose of FFP

reverse coumadin = 5-8 ml/kg all others 10-20 ml/kg

Angle of left vs right mainstem bronchus

right = 25-30 (easier to intubate) Left = 45 (harder to intubate)

what is the function of the cricoarthyroids?

shortening and increasing tension of vocal cords

will JW use albumin

some will some don't, it is human

when using a nerve stimulator for a femoral block what should the milliamps be set at?

start at 1 and have a goal of 0.2 to 0.4

when doing an interscalene block, what are the settings the nerve stimulator should be at?

start at 1 milliamp decreased to 0.5

what is usually added to an anesthetic to make it hypobaric?

sterile water

in a bier block the patient in placed _______ and several layers of a suitable ________ material are wrapped around the arm in preparation for the tourniquet

supine, padding

what are intercostal nerve blocks used for?

supplementing balanced anesthesia techniques to increase the tolerance of the surgical procedure

total body water equation

tbw = kg x 0.6

Who is responsible for insturment and gauze count

tech

what are the landmarks to use in doing a median block at the wrist?

tendon of the flexor palmaris longus, and the flexor carpi radialis

Epi wash works best with which SAB meds

tetra> lido>Bup

once your wire is in placed and clamped in a retrograde intubation what can be done next?

the ETT tube is directed over the wire and passed into the trachea. as the tube enters the larynx tension on the wire is increased

what level will you see cardiac changes in an epidural or spinal?

the T1 to T4 area contains the cardiac accelerator fibers

Which of the single cartilages of the larynx is at the top of the three

the epiglottis

what is a surgical cricothrotomy?

the establishment of an airway by surgically incising through the cricoidthyroid membrane and placing a cuffed tracheostomy tube or an ETT.

where is the ECF found?

the extracellular fluid is the fluid outside of a cell.....also referred to as plasma

which nerve is formed from the contributions of the second, third, and fourth lumbar nerve roots?

the femoral nerve

what is the bromage grip?

the needle is grasped between the thumb and index finger with the patients body acting as a firm support for the needle stabilizing hand and helps prevent advancement or withdrawal fo the needle tip form the subarachnoid space

when placing a spinal, what is the paramedian approach?

the needle is inserted 1 cm or about 1 finger breadth lateral to the caudad aspect of the interspace, then directed toward the spinal canal and angled slightly cephalad then medially about 10 to 15 degrees

what is the cauda equina and location?

the nerve pathways of the spinal cord that continue in a collection of rootlets which extend from L1 to S5

which nerve is frequently injured when patients undergo extensive pelvic surgery?

the obturator nerve

The vestibular ligaments are thickenings of what

the quadrangular ligament that attaches from epiglottis to arytenoids to thyroid cartilage.

in the brachial plexus what happens after the rami pass the lateral border of the scalene muscles?

the reorganize into trunks

in the brachial plexus what do the rami from C 5 and C 6 combine to form?

the superior or upper trunk

what is formed by the space between the epiglottis and the base of the tongue?

the superior vallecula

what are the three main types of epidural needles?

the tuohy and the hustead and the crawford

which epidural needle is the easiest ?

the tuohy because it allows for directional placement of the epidural catheter into the space and the curved blunt tip is less likely to penetrate into the subarachnoid space

although forearm and anticubital fossa i.v.'s have been used for bier blocks, what is the risk of doing so?

there is an increased possibility of a partial or complete failure of the block when the hand or wrist is the surgical target

why is a patient with a long thyromental distance of 9 cm considered a difficult airway?

there is indication for difficulty due to a large hypopharyngeal tongue, caudal larynx, and longer mandibulohyoid distance

how common are permanent nerve injuries?

they are rare, less than 1 per 10,000, which is less than 0.1%

what kind of laryngeal nerve injury could be caused by dissecting aortic arch aneurysms and mitral stenosis

they can place traction on the recurrent laryngeal nerve and cause hoarseness

If functional residual capacity is limited, how does that effect preoxygenation

they cannot tolerate apnea as long (pregnancy, obese, lung disease etc.)

What happens to narcs that are more lipid soluable in CNB additive

they go intravascular and uptake is quicker Quicker onset, shorter duration Higher plasma levels (similar to csf concentratin)

According to the AANA where should notations be documented?

they may be made in dictated or written narrative forms for inclusion in the progress notes in the patients chart

Best poisitioning for CNB

they need to turn back into halloween cat

in the brachial plexus what do the median, ulnar, and musculocutaneous nerves supply?

they predominatly supply the ventral portions of the upper extremity

Why are dermatomes important?

this is how we assess our blocks

how long should a retrograde intubation take?

this procedure is usually not an emergency and can take 5 to 7 minutes

Where is the spinous process of vertebrae more steep

thoracic is most steep, cervical also steeper than lumbar

According to M and M what are the three classes of patient that will get an ETT

those at risk for aspiration Body cavity surgery Head and neck surgery (I would add positioning to this, i.e. prone)

Who is awake fiberoptic intubation preformed on?

those with anticipated difficult airway

What is 25% albumin used for mostly

those with extensive ecf volume

What do you pass wire through for retrograde intubation

through a 18-14 gauge needle or Cook needle in cricothyroid membrane

What fingers should go on cricoid during cricoid pressure

thumb and index finger

Hand position for mask ventilating

thumb and index on mask pinky on angle of madible for jaw thrust other fingers on bony part of chin. Soft tissue pressure may cause obstruction from movement of tongue

what does the recurrent laryngeal nerve provide motor function for?

thyroartenoid lateral cricoartenoid interarytenoid posterier cricoarytenoid

which of the single cartilages is the largest?

thyroid

what are the three single cartilages of the larynx?

thyroid cricoid epiglottis

What are the 4 "times" anesthesia needs to chart

time-out OR start time surgical cut time surgical end time

in a bier block how much is the tourniquet pressure increased to after exsanguination?

to 250 mmHG or 100 mmHg above their systolic blood pressure, then the esmarch bandage can be removed

why does the posterior side of the trachea lack cartilage?

to accommodate the esophagus during the act of swallowing

what is the function of the bronchi?

to provide humidification and warming of inspired air as it passes to the alveoli

true or false? the proseal LMA was designed with a second posterior cuff that when inflated helps to separate the respiratory and GI tracts?

true

true or false? the recurrent laryngeal nerve and the superior laryngeal nerve are two branches of the vagus nerve that innervate the hypopharynx

true

true or false? the thyromental space is an available pliable compartment directly anterior to the larynx, where the tongue can be displaced during direct laryngoscopy to improve direct line of site with the glottic opening

true

true or false? the trachea originates at the inferior border of the cricoid cartilage and extends to the carina

true

true or false? the trachlite can be used in patients with a small oral opening and minimal neck manipulation?

true

true or false? the use of only herbal supplements appear not to increase the risk of spinal hematoma?

true

true or false? unless prohibitively small cutting needles are used, the incidence of PDPH is clearly reduced with the use of non cutting needles

true

true or false? we use the epiglottis when we intubate?

true

true or false? while inside the spinal canal the nerve roots are covered with dura matter?

true

about _______ of total body water is in the ICF

two thirds which is also about 28 liters

Arts 4 treatments for high na+ and how fast you should change na+ levels

tx underlying cause replace water deficit dialysis change at a rate of 10-20 mEq/day unless acute

Type and screen vs type and cross

type is ABO and Rh Blood is screen other significant antibodies Ultimate test is crossmatch where two blood types are mixed in a trial transfusion.

what are the landmarks for an ulnar block at the wrist?

ulnar styloid process, tendon of flexor carpi ulnaris, and ulnar artery (ANT)

Is cuffed or uncuffed tube more likely to cause airway fire?

uncuffed, 02 leaks into airway

what can result in a bilateral injury of the recurrent laryngeal nerve?

unopposed tension and adduction of the vocal cords resulting in stridor, which may deteriorate into severe respiratory distress and possibly death.

Epi SAB

wash 0.1-0.2mg 1:100k

When should you be careful with considering autologous blood transfusion?

when 02 carrying is poor. Open heart is often OK because on pump

When should PT or PTT be treated? What is normal PT/INR

when >1.5 times normal. Normal pt is 11-13. INR is 0.8-1.1

what are indications to use a proseal LMA?

when a classic LMA may not provide sufficiant ventilation or airway protection, and endotracheal intubation would rather be avoided

when should tracheal extubation be performed?

when the patient is in the surgical plane of anesthesia or fully awake to avoid laryngospasm

If OR start time and anesthesia start time are the same, should they be documented at the exact same time

yes

If a patient is symptomatic from blood loss do we replace blood even if allowable blood loss level hasn't been reached yet

yes

Is there increased risk of nerve injury with spinal catheter placement

yes

Should laryngoscope be used to reintubate when AEC is in place?

yes

should pts bring cpap from home

yes

you are called to place an epidural on a 22 year old who takes garlic every day. Can you place it without doing any lab work?

yes

Can pt get 1st dose of coumadin day before surg and get CNB

yes if less than 24 hours and only 1 dose

can a 16 year old pregnant patient have an epidural or spinal without parental consent?

yes, she would be emmancipated

Does cricoid pressure work if it displaces esophagus laterally

yes, the hypopharynx and cricoid cartilage function as one unit. 50% of patients have lateral esophagus and 90% with cricoid pressure. Regardless, it is still effective

when intubaing what does in the goose mean?

you are in the esophagus

What nerve can be blocked for facet pain and where is the nerve

you can block the medial branch nerves that wrap around the facet joints and innervate them. The site of injection is on the lamina of the vertebrae. If effective, this site can also be ablated for deinnervation.

Why is it important to know bronchus anatomy with DL tube placement

you can inflate cuff too deep in right (branches at 2.5 cm) and may occlude upper lobe on accident.

Why should End Tidal be charted and not what is on the dial

you can prove what was given just in case they have recall or something

why doesn't art use bicarb

you have to find preservative free and by the time he gets that all figured out, his block would have been set up anyway

What do you do with follow-up complaints

you need to follow up again or comfort them if not an issue (like recall with mac)

according to the ASA difficult algorithm you have adequate face mask ventilation following a failed intubation. what you be next to try

you would follow the non emergent pathway meaning to have alternative approaches to intubation

who is more likely to get a PDPH after a spinal, the young or the old?

young

should you transfuse your patient if their hemoglobin is between 6 and 10?

your decision should be based on specific clinical factors such as cardiopulmonary reserve, expected blood loss, o2 consumption, and the presence of atherosclerotic disease

fraction of excreted urine equation

(na urine x plasma creatinine) / (Na plasma x creatinine uriine) x 100

Induction sequence per ART (11 steps)

-100% o2 mask with strap -Then bp cuff, pulse ox, and ekg with pulse ox on opposite finger as bp cuff -Then start with fentanyl (100mcg) -Then lido IV (100mg), helps with propofol and ett -Then wait for minute then propofol (200 mg) -***Then try to ventillate until pt. is floppy, make sure you can VENTILATE BEFORE succs or roc -Then roc or succs -***tape eyes -Intubate -Hook up circuit -Look for condensation and auscultate, c02

Four surgical, anesthesia or medical indications for ett (table 22-4): Critical illness, airway shared with surgeon, inneffective oxygenation with mask or supraglottic airway (2), procedure affects ventilation or perfusion, inadequate airway protection from supressed reflex (GCS <10), paralytics, prolonged surgical time, positioning, Controlled c02 management, High aspiration risk, difficult airway

---Surgery: airway shared with surgeon requires pralysis surgery effects vent/perfusion prolonged surgical time (more than 2-3 hours) ---Anesthesia: Aspiration Difficult airway positioning Ineffective 02 with supraglottic airway ---Medical: critical illness airway reflexes down Inneffective sugraglottic airway controlled co2

Differences between classic LMA and proseal

-large deep bowl with no fenestrations (grille) makes intubation easier -larger posterior cuff (2 separate cuffs?) -gastric drainage tube and opening at tip -bite block -anterior pocket for finger during seating

3 Indications for cryo and most common

-low fibrinogen (less than 80-100mg/dL) -von willebrand disease -microvascular bleeding/DIC (Art said Microvascular bleeding is most common)

how much fluid do you need to replace due to the fluid loss from a minimal procedure such as a short superficial procedure?

0 to 2 mL/kg

what is the adjustable amplitude range on a nerve stimulator?

0 to 5 milliamps

What is a good walking epidural

0.0625% bupivicaine with 4mcg/cc fentanyl

when doing an continuous infusion approach to the brachial plexus, how much should the continuous infusion be ran at?

0.125 to .0.25 mL at a rate of 4 to 6 mL/hour

What is bupivicaine concentration for pain control and weak pn control

0.25% for post op pain control and 0.125% for weaker pain control in epidural

in the trachea the cartilaginous rings and plates continue until the bronchi reach ______ to _______ in size

0.6 to 0.8 mm

Most common drug in spinal kit

0.75% bupivicaine

3 purposes of fiberoptic suction port

02 fog removal and 02 supplement, med instillation,suction

What should be done just after extubation

02 with facemask

how many units of platelets will be provided by one bag of whole blood?

1

How many C- shaped cartilage rings in trachea

16-20

what size of the average epidural needle?

17 guage

How long can morphine give pain relief per art in CNB

18-24 hours

When was the ASA difficult airway algorithm made and updated

1991 updated 2003

how many branches does the femoral nerve have?

2

Mandibular protrusion test classes

A- lower incisors protruded beyond upper B- same level C- lower incisors cannot protrude past upper

ASA difficult airway step2

Try to deliver supplemental oxygen throughout process

what is the 3 3 2 rule?

a non scientific way to ensure that upper airway geometry is adequately assessed. it evaluates various airway proportions using finger breadths as a measurement. It is a combination of different geometric dimensions that relate mouth opening and size of mandibular space to the position of the larynx in the neck.

when using a nerve stimulator in a sciatic nerve block what should the setting be set to?

frequency of 2 Hz and an intensity of 1 milliamp until plantar flexion response then it is decreased to less than 0.5 milliamps

How to gauge choice of nasal airway?

from the nare to earlobe

What herb takes more than 24 hours to return to homeostasis?

garlic, ginko, ginsing

7 Indications of difficult facemask ventilation (include sp02 level). What other type of ventilation does this apply to?

gas leak poor chest rise absent breath sounds gastric air poor co2 return decrease o2 lower than 92% with 100% 02 necessity to use oral airway or 2 handed mask ventilation

What happens if positive pressure is too high with LMAs?

gastric inflation

what are some complications that can occur with a bracial plexus block?

hemidiaphragmatic paresis, Horner's syndrome, Recurrent laryngeal nerve involvement, verterbral artery injection, total spinal, nerve injury, LAST, hematoma, infection, pneumothorax

Thirst with hypernatremia hyponatremia or both?

hyper

What can renal insufficiency do to na+

hyper na+

if a solution has a specific gravity greater than 1.0015, what would the baricity of that solution be?

hyperbaric

According to Dr Nag, what are the 2 most likely causes of hypocalcemia?

hyperventilation and massive transfusion of citrated blood

if a solution has a specific gravity less than 0.999, what would the baricity of that solution be?

hypobaric

Addisons and sodium

hypotonic hypovolemic hyponatremia

what are the signs of Horner's Syndrome?

a triad of miosis, partial ptosis, and loss of hemifacial sweating

how far is the bifurcation to the right upper lobe from the carina?

about 2.5 cm

how much local is injected when doing an ankle block?

about 3 to 8 ml injected per nerve

is trachlight more or less succesful than conventional laryngoscopy

about the same

When do you start blocking accessory muscles in spinal?

above t4

Muscle Tone and apgar scoring

absent =0 Some flexion of extremities =1 Active and spont. movements of limbs = 2

what is a hyperbaric solution

it has a specific gravity that is greater than that of CSF. this solution would fall or sink to the lowest anatomic point

what are bronchial and alveolar causes of a lower airway obstruction

acute repiratory distress syndrome (ARDS) aspiration pneumonia asthma bronchospasm COPD pulmonary edema

what is the function of the lateral cricoarytenoids?

adduction of the vocal cords (closes)

Name 6 types of risks with blood transfusion

administration error graft vs host infection trali Trim (transfusion related immune modulation--from leukocytes in transfusion, leads to worse immunity and higher infection and cancer rates) Non-hemolytics (fever, rash chills etc)

BIL injury to vagus nerve problems

affects both superior and recurrent laryngeal nerves (near total paralysis like after giving succs) -Phonation is severely impaired (or Aphonia) -Airway control is ok

the right recurrent laryngeal nerve recurs around the ___________.

brachiocephalic artery

CV signs of low ca++ (2 ekg, bp, drug, other if really bad)

brady hypotension arrest dig insensitivity qt prolonged

CV rhythms with high k+

brady, vf, asystole

how is the nasopharynx connected to the posterior portion of the nasal cavity

by the internal nares

how is exsanguination accomplished in a bier block?

by wrapping an Esmarch bandage at close overlapping intervals tightly around the arm, starting at the finger tips and continuing up to the tourniquet.

What is the surgery art listed that can be done under spinal that effects the highest durmatome

c-section

Nasopharynx lies anterior to ______ vertebrae

c1

What can make aldosterone high

chronic low blood pressure due to chf, liver, or kidney issues or dehydration

The book 5 causes of calcium chelation. Chfaflation

citrate. hyperphosphatemia free fatty acids alkalosis fluoride poisoning

Which mallampati classification has visualization of the soft palate, fauces (archway between oral and pharengeal cavities), and uvula?

class 2

Which mallampati classification has visualization of the soft palate and base of the uvula?

class 3

which mallimpati classification is where the hard palate is only visible?

class 4

what does limiting sedation while using a nerve stimulator help with?

it helps the patient tolerate the procedure, maintain sufficient alertness to respond to the stimulus, and be coopertive

according to the ASA difficult algorithm you have inadequate face mask ventilation following a failed intubation. what you be next to try

consider and attempt an LMA. if the LMA is adequate then follow the non emergent pathway. if the LMA is not adequate follow the emergency pathway

what is Sellick's maneuver?

cricoid pressure

What size of cuff vs. uncuffed in kids

cuffed, use 0.5mm smaller tube (age +16/4 for kids, use 0.5 smaller for cuffed)

What does banked blood storage do to the following: 2,3 dpg, Cell damage (2), energy, pH, clotting (3 other than factors) clotting factors (2), RBC characteristics, electrolytes, inflammation

decreased 2,3 DPG oxidative and free radical release decreased ATP acidosis Increased endothelium adhesion, lower plt viability, microaggregates less V and VIII decreased flexibility and membrane loss proinflammatory products released hemolysis

Main categories that lower K+

decreased intake or absorption Renal GI losses Sweat and burns Alkalosis Insulin B2 agonists

Deep tendon relfexes and high mag

decreases (same as high ca++)

which of the ankle nerves innervates short extensors of the toes and sensory to skin on lateral side of hallux and medial side of second toe

deep peroneal nerve

which of the ankle nerves lies lateral to the anterior tibial artery

deep peroneal nerve

Total fluids needed intraop (potentially)

deficit + maint +evap + blood loss May also add bolus or bowel prep loss

how much will a unit of PRBC's raise an H & H?

it should raise hemoglobin 1 and hematocrit 3

What are the 3 guidelines for HES in open heart surg

discontinue at the first sign of coag problems Monitor coag status Often causes more bleeding with these pts.

how does the trachlite work?

it uses transillumination of the neck to accomplish endotracheal intubation. it has a bright light source that does not require low ambient light for optimum performance

When is surgical cut time done

it varies Some do when you cut, some with local Find out what facility wants You can also write down both times if you disagree with someone

Side effect of SAB opioids

itching

What kind of wire is used for retrograde intubation

j-wire or #2 mersilene suture

Does you have to be sensitized to have ABO reaction or Rh reaction

just Rh, ABO you do not have to be sensitized first.

Paremedian approach and ligaments entered

just flavum

What should you do if a band of innervation is lost in a few dermatomes post op after spinal or epidural

keep them in the hospital and watch them because a hematoma may be building

What should you do with care plans after the case

keep them, they might apply to other cases. Put on computer and you can print them off without having to redo them

what additive has shown to be the most effective in a bier block?

ketorolac 15 to 30 mg helps to provide a degree of post operative analgesia without increasing the risk of bleeding

What population gets caudal epidural

kids

Neuro s/s and high ca++ (walking, loc, reflex, muscle tone/strength)

lethargy and confusion fatigue and weakness ataxia coma hypotonia and deminished reflexes

What filter is on cell saver

leukocyte

With age and obesity what happens with soft palate

more movable and can block the airways during GETA

Is glidescope blade more curved or less than regular mac blade

more, to help you get to anterior airways

Mags main function in the body is to act as a _________

enzymatic cofactor of 300 rxns

Drugs of choice for brady hypotension with spinal accelarator block

ephedrine, if bad then epi and atropine. Also give fluids and position them head down if needed (not going to make them much worse if already brady)

Is caudal anesthesia suppose to be epidural or spinal

epidural

Which is slower to place, an intrathecal or epidural?

epidural

Is backache more common in spinal or epidural

epidural 30-45%

what is contained in the epidural space (5)?

epidural veins, fat, lymphatics, segmental arteries, and nerve roots.

With fixed cardiac diseases like Aortic stenosis should epiD or spinal be placed

epidural, doesn't drop pressure as much

Main structure prevents aspiration

epiglottis

what are the 5 things the internal superior laryngeal nerve provides sensory for?

epiglottis base of tongue supraglottic mucosa thyroepiglottic joint cricothyroid joint

in the Cormack and Lehane Grading system what is seen in a grade 4?

epiglottis cannot be seen; only view is of the soft palate

Where does the larynx begin and end

epiglottis to the cricoid cartilage

What happens if trachlite is put in esophagus vs trachea

esophagus is posterior and there will be a diffuse glow trachea = well defined circumscribed glow, below thyroid prominence

what does the first 3 in the 3 3 2 rule measure?

estimates oral access, or the inter-incisor gap distance

How to confirm good mask seal and preox ventilation (2)

et co2 et 02

Nose innervation other than mucous membranes

ethmoidal and nasalpalatine branches of facial nerve (VII). Also CN I olfactory

true or false. ropivicaine 2% can be used for epidural dosing?

false, it can be used in spinal but not epidural dosing

true or false? the epiglottis exists as a double leaf cartilage?

false, it exists as a single leaf cartilage

true or false? the trachlite is less stimulating than laryngoscopy, but has a higher incidence of a sore throat?

false, it has a lower incidence of a sore throat

true or false? spinal anesthesia often affects pulmonary function?

false, it is rarely affected

true or false? all headaches after a spinal are considered a PDPH?

false, not all headaches after a spinal are PDPH.

true or false? highly protein bound drugs have a shorter duration as compared to the less protein bound drugs

false, the highly protein bound drugs have a longer duration

true or false? the glidescope blade is modified to resemble a miller blade?

false. it is made to resemble a Macintosh blade with a 60 degree anterior bend and 18 mm wide

Mag level that lower extremity and patellar reflex is lost

lower DTR at 4-7 loss of patellar at 7-10

What do nephrotic syndorme and chronic renal failure do to Vit D

lower it

What do phenytoin and primidone (anticonvulsants) do to ca++

lower it

What is retrograde intubation wire retrieved with in oral or nasal airway

magill forceps

What orthopedic procedures would be an indication for cell salvage?

major spine surgery knee replacement hip replacement

Is scoliosis a contraindication for CNB (central neuraxial blockade)?

no, just means that injection will be difficult

Does trachlite require low ambient light

no, not like light wand

Do high risk patients usually get a bolus? How should they be managed

no, they do better with more restrictive fluid amounts. Best to monitor urinie output and titrate fluids to 0.5-1.0ml/kg/hr

safe to give woman of childbearing year 0+ blood when type is unknown

no, unless you give rhogam, may have Rh antibodies, but male is ok if no transfusion has ever been given

Can you store cell saver blood

no, use it right away

What unit should drugs be charted in

not in cc. Always in actual dose, volume varies by concentration

How is fastrach insertion different than normal LMA

not much different, the metal portion will be on chin at beginning of insertion and LMA goes in until resistance is met or metal handle meets the face

what is a quinkie?

not to be confused with an short intimate encounter with a twinkie, it is mostly known as a cutting needle for spinals

Does anesthesia start time include pre-op

not unless you did a block pre-op, but it might have a separate start and end time just for the block

High ca++ and GI (appetite, other related organ, BM, and 2 others)

nv anorexia pud pancreatitis constipation

Where is there c-shaped cartilage vs. o shaped

o is in cricoid cartilage c is in trachea and thyroid cartilage

What is trauma blood usually

o-

How much more accurate is crossmatching than screening

on hundredth of 1% percent (0.01%)

According to ART, Which side should person applying cricoid pressure stand?

on right side so they can and you the ett

Where is microvideo camera on video laryngoscopes

on the blade (middle of blade with glidescope)

in the brachial plexus where does the inferior trunk lie?

on the first rib, superior to the subclavian artery

in the Cormack and Lehane Grading system what is seen in a grade 3?

only the epiglottis can be visualized; no portion of the glottic opening can be seen

in the Cormack and Lehane Grading system what is seen in a grade 2?

only the posterior portion of the glottic opening can be visualized; anterior commissure not seen

Which side/s of the LMA cuff should be lubricated?

only the top side that will go against the palate

Nosopharynx and oral cavity join where?

oropharynx

what part of the pharynx lies at C2 to C3 and is bound superiorly by the soft palate and inferiorly by the epiglottis?

oropharynx

what part of the pharynx opens in the mouth anteriorly through the anterior and posterior tonsillar pillars?

oropharynx

Arts 5 symptoms of high ca++

paralytic ileus thirst (also in book with high na+ low energy low appetite weakness

What are some symptoms of hyperkalemia

parasthesia cardiac dysrhythmias including peaked T's, wide QRS's, Bradycardia, V-fib, asystole

where do sympathetic and parasympathetic innervation of nose arise from

parasympathetic is cn VII sympathetic is superior cervical ganglion

what could be some other causes of hypocalcemia?

parathyroid hormone insufficiency vitamin D insufficiency parathyroid hormone resistance states

The Book's 3 causes for hypocalcemia

parathyroid insufficiency vitamin d defecient Calcium chelation

who is albumin 25% well suited for?

patients with excessive ECF who need intravascular expansion.

Pt with BID SQ heparin, how long until it is ok to place CNB

peak is in 2 hours, must wait longer (probably 4 hrs?). Book says no contraindication with BID or less than 10,000 units/day

What are the three sizes of handles or laryngoscope

peds handle normal handle Stubby

Difference between adult and peds mask

peds mask smaller to reduce dead space

Is ett migration more profound in kids or adults

peds, their airway is shorter and there is less room for it to move.

Is croup more serious in peds or adults

peds. They have a smaller airway that if inflamed can close off

what is the role of the thyroarytenoids?

phonation

what are the three landmarks when doing a popliteal fossa approach to the sciatic nerve block

popliteal crease, the medial border of the femoris biceps muscle laterally, and the tendon of the semitendinous muscle medially

what is the most commonly discussed and managed complication of neuroaxial anesthesia? Back pain PDPHA Nausea and vomiting hypotension

post dural puncture head ache

Are arytenoid cartilages anterior or posterior

posterior

.

posterior and superior

For respiration: Larynx muscles involved, innervation, and main function

posterior cricoarytenoid muscles recurrent laryngeal nerve abduction of vocal cords

What abducts the vocal cords

posterior cricoarytenoid muscles (they are the only abductors)

What muscle opens the rima glottis (opening between vocal folds). This is the only muscle that opens the vocal folds.

posterior cricoarytenoids`

which of the ankle nerves are deep?

posterior tibial and deep peroneal

which of the ankle nerves arises from the 4th and 5th lumbar roots and the 1st, 2nd, and 3rd sacral roots?

posterior tibial nerve

which of the ankle nerves travels as a larger branch of the sciatic nerve and lies on the medial side of the achilles tendon?

posterior tibial nerve

What two things cause lordosis?

pregnancy and obesity

who is more likely to get a PDPH after a spinal, pregnant or non pregnant

pregnant

Calculate estimated blood volume for men women and infants

premies - 95 ml/kg Full term - 85 ml/kg infants 80 ml/kg Men 75 ml/kg women 67 ml/kg

If fraction of excreted urine is less than 1% what does that mean

prerenal (hypotension or hypovolemia) is the cause for high creatinine

true or false? the distance to the epidural space varies with vertebral level and is loosely correlated with patient weight

true

true or false? the fastrach LMA can be used as a conduit for intubation using a fiber-optic bronchoscope and preloaded ETT.

true

Arts resp and cv s/s with high mag (3)

resp depression brady myocardial depression

what is the role of the posterior cricoarytenoids?

respiration

What can be some causes of hypercalcemia?

results when movement of calcium from the bone to the ECF exceeds the ability of the kidney to excrete calcium primary hyperparathyroidism (most common) malignancy (second most common)

When should we tape eyes

right after induction drugs, unless they rsi. We may scratch cornea on intubation because our hands rest their

What connector is needed between face mask and breathing circuit?

right angle

The right recurrent nerve "recurs" around the ____ artery

right subclavian artery

Thyroarytenoid

role: phonation function: shortening and relaxing of vocal cords; adduction innervation: RLN

What can happen to cuff easily with double lumen ETT

rupture on teeth

the sciatic nerve is the continuation of the upper division of the ________ and is the ______ trunk in the body

sacral plexus, largest

What is SPA

salt poor albumin, comes in same 5 and 25% concentrations

What is considered isobaric

same as CSF

What is the c-trach intubation device

same as fastrach ILMA except has a video screen

What are the sizes of proseal LMA

same as regular LMA

what shape should ETT stylet have when using a video laryngoscope?

same curve as video scope blade

which of the ankle blocks is a terminal branch of the femoral nerve and travels down the lateral side of the knee

saphenous

which of the ankle nerves provides sensory innervation to the medial side of the malleolus

saphenous nerve

which of the ankle nerves are superficial?

saphenous, sural, and superficial peroneal

which block is used in conjuction with lumbar plexus, femoral or saphenous nerve block to provide complete anesthesia and postoperative analgesia for lower extremity surgery

sciatic

true or false? the nerves in the brachial plexus combine, divide, recombine and divide again as the pass between the anterior and middle scalene muscles, through the posterior triangle of the neck, and into the axilla?

true

Combitube description

two lumens, if first attempt of lower lumen is in trachea, then just ventilate. Normal position of lower lumen is in esophagues. Lower cuff is inflated in esophagus and upper cuff is inflated in pharynx. Then positive pressure can be done

how long should cricoid pressure be held for?

until correct placement of an endotracheal tube is confirmed through traditional methods

How long can 100% pre-ox keep blood oxygenated after apnea in healthy people

up to 12 min

what is the normal head extension of the atlanto-occipital joint

up to 35 degrees

What is absolute contraindication of jet vent

upper airway total obstruction (cannot exhale and will hyperinflate lungs and cause co2 retention)

what is cricopharyngeous muscle

upper esophageal shincter

What is the general guideline for CNB gauge choice

use the smallest needle you can get away with

What is a short form

used for easy short cases like dental, mac, endo, office

What kind of blade is used in glidescope and what is procedure

uses blade similar to mac use like a mac, insert into vellecula and lift ett can be inserted through the glidescope with rigid stylet in shape of glidescope or off to the side with stylet in right angle just proximal to cuff

What kinds of things can cause transient neuropathy with spinals

using high dose like 5cc of 5% lido or 4cc or 0.75% bupivicaine or using cont. cath

When is end-anethesia time usually

usually 5-10 min after they are in recovery because we are with them until then

what level to transfuse CV patients

usually 8-10 hgb due to poor 02 carrying capacity

When is combitube considered

usually after failure of LMA, bougie, or intubation

What are some symptoms of hypomagnesiumia?

usually asymptomatic weakness A-fib V-fib seizures

Once the ett is placed over the wire and is advanced to the larynx during retrograde intubation, _______ is placed on the wire

tension (to allow easier passage)

What do the intrinsic muscles of the larynx control. 2 main functions

tension of the vocal cords and opening and closing of the glottis

what three drugs are considered highly protein bound?

tetracaine, bupivacaine, and ropivacaine

When removing an LMA, should it be removed when pt. is in stage III or stage I of GETA?

stage I, you want airway reflexes to be intact when you pull an LMA. This can be assessed if they can open their mouth on command

How can you tell if patient is lightly sedated (stage II) vs. awake enough for extubation

stage II will cough and and hold breath with suciton, but no purposeful movment or eye opening like when in plane I

when should hydration be done with CNB and dose?

started 30 min prior and ending when you place. Usually 1 - 1.5 liters

oropharynx beginning and end

starts at end of soft palate posteriorly (bottom surface of soft palate and uvula) and ends at epiglottis (or base of the tongue about the level of the hyoid bone around c4) Anteriorly starts at tonsilar pillars

How can you test for sensory block

stick something sharp in both side of hip (L1-L2) and move cephalad

Pradaxa and CNB

stop 7 days before or normal TT (thrombin time or ECT (ecarin clotting time)

________ and ________ are ominous signs of severe respiratory obstruction and indicate a 50% decrease in circumfrance from normal or a diameter reduced to 4.5 mm or less

stridor and dyspnea

acute bilateral reccurrent laryngeal nerve palsy can do what

stridor and resp distress due to unapposed tension on cricothyroid muscles (unless they are not innervated either by vagus nerve damage)

what does the recurrent laryngeal nerve provide sensory for?

subglottic mucosa

What can extreme head flexion or inappropriate bite block do to airway

submandibular duct obstruction and subsequent massive tongue swelling.

What is the equation for ABL?

subtract the target hematocrit from the starting hematocrit then times that by the EBV the divide it by the starting hematocrit ((EBV x (starting hct-target hct))/starting hct)

What two things should be done prior to extubation

suction and 100% 02

According to ART, what can be done to help pts. passing through stage II after extubation to prevent laryngospasm

suction them out really well.

2 positions patients can be in for fiberoptic intubation

supine or sitting

When is whole blood given in OR

when autologously drained preop and then we give it back once they have lost volume later

When do bronchioles begin

when cartilage ceases

When should you go slow with SAB

when puncturing the dura, once you get csf you can speed up procedure again

what is done with the amplitude on a nerve stimulator as the needle approaches the nerve?

the amplitude is adjusted (usually decreased)

what does the anterior branch of the femoral nerve innervate?

the anterior surface of the thigh and the sartorious muscle

The left recurrent nerve "recurs" around the ______

the aorta

what does the left recurrent laryngeal nerve loop around?

the aorta

Define dermatome

the area of cutaneous sensation supplied by a spinal nerve that is anatomically indentified as it passes through an intervertibral foramen

What artery supplies the cricoid cartilage to thyroid cartilage and membranes in between (most of larynx)

the cricothyroid artery

What is specific gravity?

the density of a substance compared with the density of water

when is the wire removed in a retrograde intubation?

when the ET tube is advanced through the larynx and cannot pass further. once the wire is removed then the tube is advance further into the trachea

what is the Fastrach LMA also known as?

the intubating LMA

why is the amplitude lowered in a nerve stimulator as the needle approaches the nerve?

the lower amplitude decreases the discomfort experienced by the patient while enhancing the ability to accurately identify the neurovascular bundle

in the brachial plexus what does the rami from C 7 continue to form?

the middle trunk

which nerve is primarily a motor nerve that has some mixed sensory fibers to the hip, medial aspect of the femur, and the skin and soft tissue of the lower portion of the thigh?

the obturator nerve

which area are the uvula and the tonsils found?

the oropharynx

Who should always make sure the seal is good with BMV

the primary provider, the assistant can squeeze the bag or help with the seal, but the primary provider should always have at least one hand on mask

Which local anesthetic would you use in a total knee athroplasty under spinal

the procedure will last 45 mins to an hour so tetracaine with epi would be a good choice cause it lasts the longest

traction applied to the right subclavian could cause damage to which laryngeal nerve?

the right recurrent laryngeal nerve

when doing a bier block on the lower extremity what would you set the cuff pressure at when the cuff is on the lower leg?

the same as the arm, 250 mmHg or 100 mmHg above blood pressure

what can occur if ventilation is performed using postitive pressure greater than 20 cm H2O with the classic LMA

the stomach can become inflated

what are the false vocal cords

the vestiblar folds and they can get easily damaged

According to the third recommendation for infusions set forth by the AABB what is the recommendation for hospitalized, hemodynamically stable patients with the acute coronary syndrome?

there is no reccomendation

describe the difference between the hypopharynx and the laryngopharynx.

they are the same thing

how long will a transfusion of platelets raise the platelet count for?

6 to 7 days

At what high level do we always treat high K+

6.0

What is totaly body water %

60%

D02> ____ is associated with survival in high risk pts

600

Look at table 20:16

...

What is high dose lovenox

1.5mg/kg/day

what angle is the hustead needle?

15 degree less pronounced curve

what are the three criteria that defines a massive transfusion?

1. replacement of estimated blood volume within 24 hours 2. greater than or equal to 10 units of PRBC's over 24 hours 3. 50% of blood volume within 3 hours or less

what are the five things to tell a patient to do when assessing their mallampati?

1. sit upright 2. extend the neck 3. open the mouth as much as possible 4. protrude the tongue 5. avoid phonation

what is the specific gravity of CSF?

1.004 to 1.009

What is formula for epidural volume

1.5 cc per level wanted but for each level up you also go one level down

What is the maintainence fluid rate for adults

1.5 ml x kg

how do you use lipid emulsion in the treatment of LAST?

1.5 ml/kg of 20% bolus, then 0.25 ml/kg gtt

how do you determine the rate for your maintenance drip?

1.5 times kg

what are 4 complications related to improper application of cricoid pressure?

1. airway obstruction 2. difficulty in placement of the larygoscope blade 3. impeding glottic visualization 4. difficulty with tracheal intubation

How do you give deficit volume

1/2 preop 1/4 1st hour 1/4 2nd hour

at 25 psi and 1 second inspiration at RR of 20, what is TV and minute volume with jet ventilation

285 ml tidal volume 5.7 L/min

serum osmolality equation

2Na + (Bun/2.8 )+ (glucose/18)

What is the max cc to be used in a spinal

2cc

what is a good witaker size to use on a c-section patient

24 to 25 gauge (use 22 gauge on older patients)

Gas is pushed into the stomach if supraglottic devise pressure is _______cm H20 or higher

25 (except King LT is 30)

when placing a spinal for a vaginal delivery what dose of lidocaine would you use and what is the duration?

25 mg, the duration would be 15 to 25 mins without epi and 40 mins to an hour with epi

what sizes of needles are used the most for spinal blocks?

25 to 27 gauge, 3.5 inches

when placing a spinal for a anorectal surgery what dose of lidocaine would you use and what is the duration?

25 to 50 mg, the duration would be 15 to 30 mins without epi and 45 mins with epi

Demerol epidural

25-100mg

Name some benefits to CNB compared to GETA

Decrease Stress Response **** Dvt Embolus Ileus Improved resp fux compared to GETA

How long do platelet last before transfusion?

7 days culture after 4 days. If in whole blood than only last 2 days. (book says stored for max of 5 days)

According to the AABB how much is recommended to adhere to a restrictive transfusion strategy in hospitalized and/or stable patients?

7 to 8 g/dl

PRBC unit volume

300ml

what is the average blood volume for an adult man?

75 ml/kg

what is the tonicity of D5 half NS?

432, thus making it a hypertonic solution

what is the angle of the left mainstem bronchus?

45 degrees

Those at particular risk of meylinolysis are those that have been hyponatremic for more than ___ hours

48 hours

when placing a spinal for a genital or lower extremity procedure what dose of lidocaine would you use and what is the duration?

75 to 100 mg, the duration would be 45 to 60 mins without epi and 1.25 to 1.5 hours with epi

How many cervical dermatomes?

8 because there are 8 intervertebral foramen

when placing a spinal for a anorectal surgery what dose of hypobaric tetracaine would you use and what is the duration?

6 mg, the duration would be 1 hour without epi and 3 hours with epi

Desirable mag level in preganany induced htn

4.2-8.4

Normal level for mag in PIH pts

4.2-8.4

Normal ionized ca++

4.5 - 5.4 mmol/dL or 1.1-1.4 mmol/L

how much total local do you inject in an axillary block?

40 mL in increments of 5 mL

Osmolarity level (due to high na+ ) with cramps hyperreflexes twtiches and spasms

400-430

Neck circumference greater than _____ = tough intubation

43 cm

4 causes of croup

Post intubation edema around glottic and subglottic structures Multiple intubation attempts Too large of ett Excessive neck head an neck movement

what is the ratio that PRBC's should be administered?

a ratio of 1 mL for every 2 mL of blood loss

where do you look while placing an ETT with a glidescope?

at the LCD screen

When is post op follow up evaluation usually made

at the end of the day or the next morning

Is retrograde intubation wire removed at skin or in mouth

at the skin

what cervical joint allows most mobility

atlanto-occipital

Two major advantages of deep or awake extubation

Deep- no CV stim, and decreased coughing and straining Awake - Airway reflexes return (decreased aspiration) and airway maintainence

Disadvantages of deep vs awake extubation

Deep- poor airway reflexes, increased aspiration risk, airway obstruction Awake - Increased CV stim, increased cough and strain

What is arytenoepiglottic muscle

attaches from arytenoid to epiglottis and closes the epiglottis over the glottis (recurrent laryngeal nerve)

how to test for sympathetic block

cold temp

Why is ICP an absolute contraindication with CNB

CSF may keep them from herniating. or may increase ICP

What other drugs can increase duration in SAB and Epidural (other than epi or opioids)

Clonadine 75mg in epidural, 15-30 in spinal Neo 5-10mcg for spinal No decadron

what grading scale offers an objective assessment of the gottic opening during laryngoscopy using direct line of site?

Cormack and Lehane Grading system

What is anesthesia start time

Depends a little on provider Should be the time that you start anesthetic and stay with patient. This may start in the ER with a trauma

What is autologous transfusion

Donate well in advance of surgery and give day of surg

Allowable blood loss (ABL) equation

EBV x (starting hct - target hct)/ starting hct

True or false? Nausea and vomiting are not important factors to include in your post-op care plan?

False

Decadron SAB

N/A

What is best fluid for neuro cases according to ART

NS

what blood type is the universal donor?

O blood

Most significant contraindication to CNB

Pt refusal

What labs should be drawn for patients getting HES

Renal function Liver function coags

Why use quinkie?

Some older people who have tough ligaments also Elderly are not very at risk for PDPH

what does AABB stand for?

it is the American Association of Blood Banks it is also how a stuttering person starts singing the ABC's

how deep is the thoracic region of the epidural space?

it may be 3 to 5 mm deep and is narrower (lateral width).

When do we use just mask ventillation and no LMA or tube with volitile agent GETA

Very short GETA cases, especially with kids, like ear tubes (BMT) and tonsils etc. Also in code or in ER/Trauma

Why is spina bifida an absolute contraindication

open neural cord more infection and it won't work well. Also more risk of neural damage

Pradaxa and CNB and catheter

Wait 7 days for block (or check ect or TT). 24 hours post needle or 6 hours post catheter removal, whichever is later

Where do you document a follow visit?

a progress note is good, but some forms have a spot to document it

What cardiac procedures would be an indication for cell salvage?

Valve replacement redo bypass grafting

What are methylperabins?

They are addatives in locals that people may be allergic to BUT THEY AREN"T IN SPINAL AND EPIDURAL LOCALS

What are cookgas ILA and Air-Q

They are intubating LMAs. Air-q is disposable. Both have stylet for ett stabilization during LMA removal

How far past vocal cords should ett be placed. What is depth should place ett in cm?

Until proximal end of cuff is 1-2 cm past the cords. This will place the distal end of tube between carina and cords. Cuff size x 3

What is the synopsis of the article about intraop fluid restriction in major elective GI surgery

Use colloids to maintain UOP > .5ml/kg/hr Only use crystalloids for maintanence use colloids for volume to volume replacement No need to replace third space loss/diruesis Avoid deep general anesthesia Eliminate preload

What is 4-2-1 rule

Used for peds in fluid maintainence first 10kg = 4ml/kg 10-20kg = 2ml/kg after that 1 ml/kg

Arts 5 symtpoms for low mag

Usually asymptomatic weakness, a. fib vf seizures

When are follow up visits required

Usually the next day. Done on All cases JACHO requires this May not always get them.

What is OR time vs. anesthesia start time

Usually the same but not if anesthesia time started outside the OR or if before surgeon gets there or something.

Is a history of a difficult airway significant

VERY STRONG predictor of difficult airway

Can you do any SAB case with Epi-D instead?

Yes, realizing the anesthesia won't be as dense or last as long with epidural

Do we give 20-30 mg/kg bolus for most cases? Over how long

Yes, with ambulatory patients, no with high-risk pts. Usually over 30 min.

What should you do if all answers to "airway approach algorithm" are yes or some are no?

Yes= proceed with induction and paralysis No= abandon management and consider MAC or regional OR follow difficult airway algorithm/guideline

how do you know how many ml's to place in a spinal

a 5 foot person would get 1 cc, every inch above 5 feet gets an extra 0.1 cc in order to get a T8 block

how high of a block do you want for a c-section?

a T6 block

what is in the middle of the blade of a glidescope?

a camera and features an anti fog system

what is a Eldor needle?

a combined spinal epidural needle with two channels, one for the spinal needle and the other for the epidural catheter

what is mandibular hypoplasia?

a condition that does not allow the tongue to fit into the thyromental space

Who usually applies cricoid pressure, assistant or provider

assistant

vitamin A toxicity and electrolytes

causes high ca++

What does nagelhout say about large volumes of NS

causes hyperchloremic acidosis

What is ramping for

elevate the shoulders, neck, and head to improve ability to BMV. Increases FRC

What might need to be considered if pt is hoarse post op

emergent reintubation due to airway muscle or nerve damage and airway obstruciton

bronchiole purpose

humidity and warming

Four signs of right mainstem bronchus intubation

increased peak pressure asymmetric chest expansion unilateral breaths sounds hypoxemia

For sphincteric function of larynx: muscles involved, innervation, and main function

interarytenoid muscle- closing of posterior commissure of glottis Arytnoepiglottics muscle - closing of laryngeal vestibule

What causes N/V with CNB

ischemia in vomit center of medulla and gut

are hernia or bunion repair minimal moderate or severe evap loss

minimal

Do osa pts usually only need one or two practitioners for airway

often two especially for ventilation

Where is preanesthesia evaluation form often printed

on back of anesthesia record

alkalosis and k+

lower

anterior subglottic mucosa

SLN-external sensory

Base of tongue

SLN-internal sensory

Epiglottis

SLN-internal sensory

cricothyroid joint

SLN-internal sensory

supraglottic mucosa

SLN-internal sensory

thyroepiglotic joint

SLN-internal sensory

b2 agonists and k+

lower

insulin and k+

lower

Low mag treatment

replace 2-4 grams

Read the document on Canvas called "documenting the standard of care: The anesthesia record"

...

Table 20-6

...

Duramorph SAB

.25-.3mg

What is charted q 5 min

HR and BP (maybe rr although he did not say this)

what is the dermatome that coorlates with the nipple area?

T4 or T5

where do you want your epidural catheter placed for thoracic surgery?

T4 to T5

Is compressing the ETT pilot balloon a reliable indicator of cuff pressure?

no

What antibodies does Rh negative patient have

"D" antibodies ONLY IF SENSITIZED

With an unanticipated difficult airway, your first intubation attempt is ususally ________ look and the second is preformed under _______________.

"awareness" best possible conditions

What are the two mechanisms of laryngospasm

"glottis shutter closure"- intrinsic laryngeal muscles cause cord adduction causing partial obstruction "ball valve closure" extrinsic laryngeal muscles cause contraction of the false cords and supraglottic soft tissues- cause complete airway obstruction

Which version of Hetastarch has least coagulopathy issues

(HES) hydroxyethy starch aka VOLUVEN

What is normal value for plts? When should plts be transfused

100-400 Usually when less than 50 but not when more than 100 (microvascular bleeding)

how many ml's down is a patinet who had a bowel prep?

1000 ml

Three methods of nasal lido topical application

-5ml viscous in each nare -4ml 4% lido and 1ml of 1% phenyl to nebulizer (takes 20 min but is effective for subglottic structures -Atomizer - denser block, bigger droplets, same dose of lido/neo

Cell saver should be considered if expected blood loss will be > _____ml

1000ml

Name 6 advantages of airway exchange catheter concerning: ventilation (2), Abilities of lumen (4), insertion safety, depth confirmation, ett replacement.

-BMV adaptor or leur lock jet vent**** -can remove ett but still have access to airway -Lumen allows for: suction, ventilation/oxygenation, meds, ***co2 monitor** -blunt tip with perforated sides reduces airway trauma -radiopaque depth markers -Sufficient length and rigidity for ett replacement

No regional if plts less than

100K , 50k if you do serial labs

What is volume of Lap radiolucide stripes sponge if saturated

100ml

What is the tonicity of 3% NS?

1026, thus making it a hypertonic solution

What is volume of saturated raytec sponge

10ml

What 4 things can be done to decrease nose bleeds in nasal intubation or nasal airway insertion according to art (not just meds)

-Meds -cocaine, phyenylepherine, lido epi -nasal trumpet and slowly increase size until you can get ett down lumen -Soften them with warm water -lubricate

What is in the upper aiway

-Nagelhout says starts at cricoid cartilage and goes up (including the larynx)

next few flashcards will be from table 22-1

.

Hyponatremia causes, look at box 20-1

...

Look at anesthesia record and memorize where things go

...

Memorize table 20-4

...

how to place bougie. How far do you insert it?

-advanced behind where you think epiglottis is -advance into glottis and feel it bounce on tracheal ring -Advance until 25 cm mark is at the lip -place ett over bougie

Tongue general sensation

-anterior two thirds is by mandibular brand of tirgeminal (v3) aka lingual nerve -posterior third is by glossopharyngeal (CN IX)

Four anesthesia/surgical ett indications. (table 22-4)

-high aspiration risk (blood in airway or GI problems) -Predicted difficult airway -Position other than supine -Ineffective oxygenation with supralaryngeal airway

Four medical indications for ett (table 22-4)

-inadequate airway reflex (like glascow scale less than 10) -Inneffective oxygenation with supralaryngeal device -critical illness -control of co2 (like cranial surgery or copd)

ETT placement with fastrach

-inflate ett and lma cuffs to check integrity -lubricate ett and pass into central lumen -lubricate LMA and insert ***remove ett adaptor and set aside for later*** -pass ett to 15 cm where epiglottic elevating bar will push it up -use fastrach handle to lift anterior and advance ett -inflate cuff and replace ett adaptor -attempt to ventilate and confirm via etco2 and bil breath sounds -can leave fastrach LMA in if needed or remove . -IF removing LMA, remove ett adaptor and set aside -deflate ett balloon and LMA balloon -place fastrach stylet on end of ett and provide counter traction caudally as LMA is removed - once ett is visualized, hold ett and remove stylet and LMA -reconfirm correct ett placement

Two ways to directly use local on vocal cords (and dose)

-nasal or oral ett is placed close to trachea, then pt breaths in lido and coughs it onto back side of vocal cords (5ml 2%) -Same thing with video or fiberoptic scope and visualize cords

What are the six FDA reccomendations for HES products (setting, organ dysfunction, RRT, stop at first sign of (2), surgery case type)

-no use in ICU, sepsis or critically ill -no use with renal dysfunction -stop with first sign of renal injury -RRT needed up to 90 days after. Monitor renal fx for 90 days -no use in open heart. Causes coagulopathy -Discontinue at first sign of coagulopathy

What 4 things might make supraglottic airway placement or ventilation difficult (box 22-2)

-restricted mouth opening -obstruction in upper airway -distorted airway = effects seal -stuff lungs

Should you try to convice pt to get regional anesthesia

no

What are 3 risks of cricoid pressure not associated with intubation visualization

-rupture of esophagus during vomiting -decreases upper/lower esophageal sphincter tone -laryngeal discomfort can can cause vomiting

Divisions of vagus nerve in airway

-superior laryngeal branch (exterior and internal) -recurrent laryngeal nerve

where will you insert your needle when doing a femoral nerve block?

1 cm lateral to the femoral artery and 1 cm inferior to the inguinal ligament

PRBC raises Hbg and Hct how much

1 hgb and 2-3 hct

what is the maximum cuff or touraquet time for a bier block?

1 hour is most discomfort produced by the tourniquet, but a dual tourniquet system and preoperative or intraoperative administration of small doses of opiods may extend this time to 2 hours

Fluid replacement for bowel prep

1 liter low. Add that amount to deficit

when doing an interscalene block how much of a test dose should you give?

1 mL

what are some common locals to use in an ankle block?

1% lidocaine, 1% mepivavcaine, 0.25 to 0.5% bupivacaine, or 0.2 to 0.5% ropivacaine

Three main indications for supraglottic devices

1- rescue ventillation 2-alternative to ett in select patients in elective surgery 3-conduit for intubation

American association of blood banks 4 recommendations for transfusion hgb thresholds

1- restrict transfuion to 7-8 hgb for hospitalized pts 2- hospitalized cv disease pts transfuse at 8hgb or less 3- No reccomendation for hospitalized stable pts with acs 4- decision to transfuse should be influenced by hgb level and symptoms (can give blood earlier just have rational)

4 basic elements to difficult airway cart + 2 suggested extras

1- standard larynngoscopy 2- intubation by alternative means 3- tube position control 4- equipment for anesthetizing airway * also video or fiberoptic are often available*

3 Steps for using macintosh. What ligament is pulled?

1- tip in vellecula 2- tension on hyoepiglottic ligament by lifting force 3- this causes indirect elevation of epiglottis

One unit whole blood provides ___ units of plts. What are apharesis plts

1. Apharesis is where plts are taken from pt and remaining blood is returned to patient. One unit of apharesis plts = 6 whole blood plts.

Allowable blood loss for female who weighs 100 kg and has starting Hct of 30

1166ml

Age less than ____ years old you would do needle vs surgical cricothyrotomy

12

what is the hemoglobin range for children?

12 to 14.5

when placing a spinal for a hernia or pelvic procedure what dose of bupivacaine would you use and what is the duration?

12 to 15 mg, the duration would be 1.5 hours without epi and 2 hours with epi

What is a normal hemoglobin for women?

12.3 to 15.5

What are the normal values for sodium?

135 to 147 mEq/L

Arts normal sodium value

135-147

Studies show prbcs can be stored how long before they start to deteriorate

14 days

when placing a spinal for a back or spine surgery what dose of bupivacaine would you use and what is the duration?

15 to 20 mg, the duration would be 1 to 1.5 hours without epi and 1.5 to 2 hours with epi

what is the reduction % of volume with a class 2 hemorrhage?

15 to 30%, which would be a blood loss of 750 to 1500 mL

what are the 4 distinguishing features of the fastrach LMA?

1. anatomacally curved rigid airway tube 2. integrated guiding handle 3. epiglottic elevating bar 4. guiding ramp built into the floor of the mask aperture

according to the ASA difficult algorithm what are your three things to consider when your initial attempt to intubate is unsuccessful?

1. calling for help 2. returning to spontaneous ventilation 3. awakening the patient

according to the ASA difficult algorithm when failing at a noninvasive awake intubation what are your three options?

1. cancel the case 2. consider feasibility of other options 3. invasive airway access

Fent SAB

10-25 mcg

Sufent epidural

10-60mcg

what are 4 indications of a surgical cricothyrotomy?

1. failed airway 2. tramatic injury of maxillofacial, cervical spine, head or neck structures making intubation through the head or nose difficult 3. immediate relief of an upper airway obstruction 4. the need for a definitive airway for neck or facial surgery assuming intubation is not possible

according to the ASA difficult algorithm you had a successful ventilation after your emergency noninvasive airway attempt, what are your next 3 options?

1. invasive airway 2. consider feasibility of other options 3. awaken the patient

what are 5 thing unique to the proseal LMA?

1. larger deeper bowel with no grille 2. posterior extension of the mask cuff 3. gastric drainage tube running parallel to the airway tube and existing at the mask tip 4. silicone bite block 5. anterior pocket for seating an introducer or finger during insertion

what are 6 ways to tell if an airway would be difficult?

1. look externally 2. evaluate with 3 3 2 rule 3. mallampati score 4. obstruction of upper airway 5. obesity with big neck and redundant soft tissue 6. neck mobility

What is the first thing to apply to the patient when they arrive in the OR

100% 02 before any monitors or anything else. get them preoxygenating

Four treatments of laryngospasm (o2, pressure, drug, and last resort)

100% 02 positive pressure vent 10-20cmh20 Lidocaine IV, 1-1.5mg/kg If none of the above work: succs 0.2-0.5 mg/kg or 4-5mg/kg IM

how small is the cervical epidural space?

1.5 to 2 mm, thus leaving very little room for error

what medication is good to use for your test dose in an epidural?

1.5% lidoacaine with 1:200,000 epi solution. This provides45 mg of lido with 15 mcg of epi in a 3 mL dose

What are the normal values for magnesium?

1.8 to 3.0 mg/dL

Normal mag levels

1.8-3.0

Normal range for Mag

1.8-3.0mg/dl

Cell washing devices can provide a volume equivalent to _____ units of blood per hour for transfusion in cases of massive blood loss.

10

How high should head be in sniffing postition

10 cm

when placing a spinal for a cesarean delivery what dose of bupivacaine would you use and what is the duration?

10 mg, the duration would be 1 to 1.25 hours without epi and 1.5 to 2 hours with epi

how much local is injected when doing a sciatic nerve block?

10 ml in 5 ml increments although the slides say 15 to 20 ml

when placing a spinal for a hernia or pelvic procedure what dose of tetracaine would you use and what is the duration?

10 to 12 mg, the duration would be 1.5 hours without epi and 2 to 3 hours with epi

when placing a spinal for a back or spine surgery what dose of tetracaine would you use and what is the duration?

10 to 15 mg, the duration would be 1 to 1.5 hours without epi and 2 to 2.5 hours with epi

how long is the trachea in adults?

10 to 20 cm

Max cell saver rate

10 units/ hr

How long is trachea in adults

10-20cm

How often to monitor neuro status in CNB pts who are anticoagulated

2 hrs

When using a nerve stimulator in doing a brachial plexus block what is the milliamps set at after the needle has been introduced into the subcutaneous tissues?

2 milliamps

how much fluid do you need to replace due to the fluid loss from a moderate procedure such as an uncomplicated intra-abdominal or orthopedic procedure?

2 to 4 mL/kg

according to the "Smart" airway stratigies, what is considered a failed intubation and what should be done

3 attempts or unable to maintain >90% sat Call for help and go to failed airway algorithm

how much test dose should you inject into the epidural space?

3 mL of a rapid acting low toxic local with or without epi.

What is onset time of 2% lido for SAB

3-5 min

gas flow and time for 100% preoxygenation? How long does preoxygenation last in apnea most of the time?

3-5 min 5L 5-8 minutes of apnea

FFP use is discouraged if INR is less than ______ unless actively bleeding

2.0

what is the distance from the skin to the lumbar epidural space using a midline approach?

2.5 cm to 8 cm, with an average of 5 cm

When does right bronchus bifurcate

2.5 cm. Bifurcates to upper lobe

duramorph epidural

2.5-5 mg

How much resistance to breathing in nose

2/3 of total

Max positive pressure with LMA vs proseal

20 cm h20 with LMA 30 with proseal

what is the max dose of Hespan?

20 mL/kg

can trachlight be used in cannot intubate cannot ventilate?

no

Normal K+ levels

3.0-5.0 (art) book says 3.5-5.0

What are the normal values for potassium?

3.5 to 5.0 mEq/L

An ett cuff pressure above ____ mmHg can cause trachea damage

30 (suprglottic pressure above 25 causes gastric inflation)

How obese before difficult bmv

30 bmi (art said above 26)

what is the angle of the tuohy needle?

30 degrees, thus being the most pronounced curve

what is the reduction % of volume with a class 3 hemorrhage?

30 to 40 %, which would be a blood loss of 1500 to 2000 mL

What is the tonicity of NS?

308, thus making it an isotonic solution

How many L/min flow during preoxygenation? And what position should the apl valve be in during preoxygenation

5-10l/min apl open

Phenyl SAB

5-10mcg

Sufent SAB

5-10mcg

significant mortality is associated with hemoglobin values less than _______ g/dl?

5

urinary retention is common after neuraxial anesthesia with an incidence of _____ and ______%

5 and 70%

When does left bronchus bifurcate

5 cm and bifucates to left superior and inferior lobe bronchi

when placing a spinal for a vaginal delivery what dose of tetracaine would you use and what is the duration?

5 mg, the duration would be 1 to 1.5 hours without epi, and 2.5 to 3 hours with epi

how much will one unit of platelets raises the platelet count

5 to 10

how much should be injected when doing a radial block at the wrist?

5 to 7 ml under the brachioradialis muscle

what is the tonicity of D5 NS?

586, thus making it a hypertonic solution

What syringe and how much fluid for LOR with epidural

5cc syringe with 2cc water or air or both

Epi epidurals

5mcg/mL 1:200k (so in 3ml you get 15mcg)

What is concentration of 1:200k epi

5mcg/ml

the archetypal brachial plexus is formed by the rami from the ____ to the ____ cervical nerves and the ____ thoracic nerve

5th, 8th, 1st

One donor can donate ___ units of plts at once

6

When K+ gets higher then ____ then attempt to lower it

6

one bag of platelets from a donor is equivalent to approximately how many platelet concentrates?

6

Trali is defined as ALI within _______ hours of transfusion

6 hours

when placing a spinal for a anorectal surgery what dose of hyperbaric tetracaine would you use and what is the duration?

6 mg, the duration would be 1 to 1.5 hours without epi and 3 hours with epi

when placing a spinal for a genital or lower extremity procedure what dose of tetracaine would you use and what is the duration?

6 to 10 mg, the duration would be 1.5 hours without epi and 2 to 3 hours with epi

what is the average blood volume for an adult woman?

67 ml/kg

How effective is caffine in PDPH

70%

clonidine epidural

75 mcg bolus

What blood type is a person with type A B blood compatible with?

A B, A, B, & O

where do you insert the needle for an unlar nerve block?

A finger is placed in the ulnar sulcus, extending approximately 1 cm proximal to the condyle. The insertion point for the needle is between the medial condyle of the humerous and the olecranon process of the ulna

what blood type is the universal recipient?

AB

Chronic bilateral recurrent laryngeal nerve palsy can do what

Airway control problems less frequent due to atrophy of other muscles etc May have aphonia though

recurrent laryngeal nerve innervates what?

Airway sensation below vocal cords- intrinsic muscles of trachea except cricothyroid (art said supraglotic mucosa?)

What are some relative contraindications for a spinal or epidural?

Allergy. fixed volume cardiac states. hypovolemia. shock. neurologic disease or disorders. patients who don't understand. history of H/A or B/A. prior bad experience with SAB/regional

Where can an epidural be injected vs a spinal

An epidural may be given at a cervical, thoracic, or lumbar site, while a spinal must be injected below L2 to avoid piercing the spinal cord.

What times are important to document?

Anesthesia start procedure start procedure end antibiotic time any blank on the form that needs a time

what are pharyngeal and laryngeal causes of an upper airway obstruction?

Angoedema foreign bodies epiglottis hematomas hemorrage laryngospasm laryngotracheobronchitis aka croup subglottis stenosis tumors or lesions

What blood type is a person with type B blood compatible with?

B & O

What does BURP accronym stand for?

Backwards, upwards, right, pressure This moves larngyeal structures into view because we try to look on right side and move tongue to left.

What is considered hypobaric

Baricity less than 0.9999

Gold standard for ruling out cervical spine fractures

CT

Four treatments for low calcium

CaCl CaGluconate Po Ca++ Vit D

What is the difference between CaCl and calcium gluconate

CaCl is more irritating Ca Glu= less tissue damage if extravisation CaCl is more water soluable and has better bioavailability, works faster

where do you want you epidural catheter placed for chronic pain treatment or surgeries of the arms, shoulders, or upper chest?

C7 to T1

If you have dermatome involvement of the pinky finger, what does that mean with dermatome block level?

C8, your block is too high!

What is CNB combo technique

Combo - Find space after you have a loss of resistance, you get into epidural space with epidural needle and then advance a smaller needle into spinal space. Then you pull smaller needle back and then thread catheter into epidural space. This allows you to do a spinal for quick profound relief. Then you thread catheter and can give future doses in epidural space.

How to measure size of oral airway

Corner of mouth to ear lobe. It needs to go just past the tongue

After intubation what is likely to be going on if sp02 dips vs. co2?

Sp02 is usually and obstruction, lung disease, or bronchial intubation CO2 drop is usually disconnected circuit or perfusion problem like pulmonary embolism

What is the average Hgb for men and women and kids

Men = 13-17.5 Hgb Women 12.5-15.5 Hgb Kids 12-14.5

What happens if pt. bites on flexible LMA

Metal rings will get perminantly smashed

Name the following dermatome landmarks Inferior scapula zyphoid umbillicus pelvis

T4-t5 - is mid nipple Inferior scapula T6-7 T6- zyphoic T10 is umbillicus T12 - is pelvis

what is the dermatome level of the xyphoid

T6

where do you want you epidural catheter placed for upper abdominal surgery?

T8 to T10

Never withdraw a epidural catheter through

THE EPIDURAL NEEDLE!!!!

What is the treatment for hyponatremia?

Correct underlying cause infusing 3% saline at a rate of 1 to 2 mL/kg/hour sodium administration should not raise sodium levels no more than 10 to 1 mmol.L in 24 hours fluid restriction diuresis I V conivaptan oral treatment with tolvaptan

Phenyl epidural

N/A

demerol SAB

N/A

4 common hypertonic fluids

D5 1/2 NS D5LR D5NS NS 3%

How does difficult airway society differ from ASA

DAS suggests that you use LMA immediately following failed intubation and then revert to face mask if LMA fails

Difference between direct laryngoscopy and direct tracheal intubation

DL = laryngoscope to get direct line of sight DTI = process of placing ett in trachea these are usually done together

What is the intraop fluid most commonly used

NS

Is it easier to learn on Mac blade or miller

for most people mac is easier

Match the followinig as Elevators or Depressors of larynx (muscles): . Digastric thyrohyoid omohyoid stylohyoid stylophryngeus sternohyoid sternothyroid mylohyoid geniohyoid

Depressors: Omohyoid, sternohyoid, sternothyroid

ASA difficutl airway step 4

Develop primary and alternative strategies A. awake intubation B. intubation after GETA

what are the 'four dementions of difficulty' with airway management'

Difficulty to : -bag mask vent -direct laryngoscopy with tracheal intubation -supraglottic airway ventilation -invasive airway placement

What are some causes of laryngospasm

During stage II: airway manipulation stimuli from blood or fluids, mucous in pharynx stimulation of larynx

what is circ nurse responsible for regarding names

Names of everyone including reps

What do the branches of superior laryngeal nerve innervate

EXTERNAL (motor) laryngeal nerve - motor cricothyroid muscle. Sensory Anterior supraglotic mucosa . INTERNAL (sensory) laryngeal nerve- Pure sensory. Epiglottis to vocal cords (hypopharynx above vocal cords including the base of the tongue) - Also all of the cartilage joints

What should you do during preoxygenation if they are claustraphobic

Need to give them more sedatives without making them obtunded. Ask them if they can hold the mask on them.

What size of ett should be used if you have to reintubate someone with an airway exchange cath? Why?

Ett internal lumen should be very close to external diameter of AEC Reduces the chance of airway trauma

true or false? it is standard to pull back on the epidural catheter through the needle?

FAAAAAAAAALLLSSE!!!!! Never attempt to withdraw the catheter through the needle! this may cause shearing of the catheter and embed particles in the patients back

What is in cryoprecipitate (6 factors)

Factor, I, VIII, von willebrand, fibrinogen, fibronectin, XIII (book just says VWB, VIII, and firbrinogen)

True or false? the spinal cord levels correspond with the vertebral levels

False

true or false? antibiotic redosing is important on your preop plan?

False, it is important on the post op plan

true or false? debilitated, mentally impaired, and intubated patients are at a higher risk for developing hyponatremia

False, they are at risk for hypernatremia

True or false? upper airway obstuctions are not an emergency?

False, they should be concidered an emerency and managed with extreme care because of the potential to become total airway obstructions.

True or false? very rapid infusion of blood can increase the level of ionized calcium?

False. It can reduse the level of ionized calcium which is referred as citrate intoxification

True or false? the spinal cord is a rectangular structure?

False. it is a cylindrical structure

What is a murphy eye?

Fenestration at end of ett to allow more options for ventilation if one hole is plugged

What lab is needed before autologous infusion

H and H

How would you position pt right after SAB for pt getting a C-section vs. someone having foot surgery?

Foot surgery sit them up so lower spinal C-section, lay them down until you get the level desired for c-section (T6 or so)

Other than CNB what else should you get consent for at same time

GETA

hemolytic reactions may be obscured by ________ during surgery

GETA

What are some symptoms of hypokalemia?

GI impairment Neuromuscular impairment renal impairment CV impairment respiratory muscle weakness dysrhythmias

What can be some causes of hypokalemia?

GI loss Renal loss poor intake increased losses from skin Redistribution from ECF to ICF promoted by beta-adernergic stimulation, insulin, and alkalosis

Art says what 4 organs effected with low k+

GI, neruomuscular, renal, and cv impairment

How long for the following to wear off: Garlic Ginko Ginsing

Garlic: 7 days Ginko: 36 hours Ginsing: 24 hours

What needs to be considered for preop careplan?

Get weight, anxiety level, pain, set up the equipment you will use for case.

What is ARTs favorite type of oral airway and why

Guedel. This has a central lumen that you can ventilate through

According to the AABB restrictive triggers may be _________ in patients with signs and symptoms of low blood volume or other risk factors such as in patients experiencing __________ or ________

Harmful acute myocardial infarction unstable angina

What is HELLP syndrome. Is it contraindicated for epidurals and spinals

Hemolysis Elevated Liver enzymes Low Platelet count With PIH get HTN to liver that causes liver damage. NO SPINALS or epidurals!

How many pts will get Hep b, HIV or hep c with transfusion

Hep B= 1: 31-205K HIV = 1:1.5 million Hep c= 1: 2-3 million

heparin and k+? Dig relationship with K+ and Ca++? Adrenal steroids relationship with K+ and Mag+?

Heparin= higher K+; High K+ or Ca++ = dig toxicity; Inverse for adrenal steroids and K+ and Mag+ levels

What is dermatome for the following Thumb anterior forearm (2) Anterior thigh (3) Posterior thigh Clavicles Lateral arm(2) Medial Arm (2) calf (2) Dorsal hand (3) Palmar hand (3) Thumb Other fingers (2) Nipples umbilicus Inguinal groin (3) lateral lower leg (2) Medial lower leg (2) lateral foot top of foot (3) medial foot sole of foot perineum (3) Pollux Other toes(2)

Here is a great dermatome link: http://bedahunmuh.files.wordpress.com/2010/05/dermatomes.jpg

Why would you want to extubate deep rather than light?

High abd, brain, cvp, iop, and blood pressures. May dehisce or bleed. Also in reactive airways where fighting the tube may cause laryngospasm However risks have to be weighed in difficult airway/ aspiration risk

What is conservative PDPH treatment (5)

Horizontal position Caffine Iv 500; po 300mg Theophylline TIme Oral pain meds

What are the insertion angles for hustead crawford and tuohy needles ***test question****

Husted - 15 degree angle on tip - Insertion angle 15-30 Tuohy - 30 degree angle on tip (15 -30 degree insertion angle) Crawford - Straight tip (Straight edge, insertion angle (little more risky, can cut on accident) - 30-45 degree insertion angle

Nerve in nasal mucosa for smell

I (olfactory)

C and L grades

I= full view of the glottic opening II= only the posterior portion of the glottic opening. Anterior commisure not seen III= only epiglottis is visualized. No glottic opening IV = no epiglottis, only a view of the soft palate

Bougie is best suited for what cormack and lehane grades

II or III, best if you can see part of epiglottis at least.

With coumadin you can remove a CNB catheter when

INR <1.5

What is the treatment for hypomagnesiumia?

IV replacement severe hypomagnesemia can be treated with 1-2 g over 5 minutes followed by administration of 1-2 g/hour

If pt. has been on maintenance gtt before surg while npo do they have deficit?

If amount is equal to operative maintainence then they don't have a deficit

What does acidemia do to ionized ca++ and why?

Increases it. Decreases protein bound fraction of ca++.

What are 4 subglottic airway techniques

Needle cricothyrotomy with jet vent Retrograde intubation Surgical/percutaneous cricothyrotomy Tracheotomy- not done in emergency and not done by anesthesia

Arts 4 s/s of high na+

Intracranial hemmorage seizures decreased reflexes (book says hyper reflexes) agitation

What is 3-3-2 rule

Intubation evalutaion: Numbers in this order Three fingers interincisor Three thyromental two between hyoid bone and thyroid notch (chin-neck juction)

What covers conus elacticus and what is it?

It is the lateral portion of cricothyroid ligament. The thyroid cartilage covers it. It thickens and forms vocal cords superiorly

pharynx beginning and end

Just superior to glottic opening at cricoid cartilage and opening to esophagus inferiorly, to base of skull superiorly

Should dentures be removed before BMV? OGT and shave?

Keep dentures May need to remove beard or ogt

Difference between king LT and combitube

King LT only has one ventilation port. king LTS-D is disposable and allows for a OG tube. Can give positive pressure up to 30cmh20

What is nitrous documented as

L/min

What pressure should ett cuff be inflated to?

Less than 25cm H20.Usually 20-25. This will require varying volumes of air. Not to be confused with max LMA pressure of 20 (except proseal which may be 30)

What is the difference between Bupivicaine, levobupivicaine and Ropivicaine

Levobupivicaine is just the S-enantiomer of bupivicaine (the active 50% of bupivicaine) Ropivicaine is a similar structure to Bupivicaine but not the same

What are the only two hypobaric locals

Lido and Tetra, no Bupivicaine

When are longer acting narcs used?

Longer cases or post op

What do certain antibiotics do to k+ and mag

Lower it, in fact most drugs in the book that change electrolyte concentration tend to lower them

My favorite anatomy description of airway is found where

M and M chp 19

Calculate fluid deficit

Maintainence rate x hours npo

What is adult size of laryngoscope blades? Peds?

Miller 2 Mac 3 for most adults (up to miller 4 Mac 5) Miller 1 Mac 2 for most peds There is a miller 0 and mac 1 for neonates

If running epidural low dose and they are on coumadin, what should you do (3)

Minimal epidural meds Assess sensory and motor daily Hold coumadin if PT >3.0

How often should you rub head and do ROM

Minimum Q 2 hours Don't interfere with surgery

What determines when you should give autologous blood back to them

Monitor H and H and give back when it gets low

What is in PRBCs

Mostly RBC and a little of other blood cell types and platelets and plasma

Arts 2 signs of low ca++

Muscle spasm/cramps Twitching/tingline in fingers mouth

When to transfuse the patient according to ASA taskforce

Never hgb>10 Usually <6 hgb except those with 02 carrying problems

If difficult intubation, will an LMA likely be difficult too?

No, and will open up time to use other means of intubation.

Preoxygenate in rapid sequence?

No, but maybe in modified RSI might still preoxygenate in emergency even though considered full-stomach if benefits outweigh risks

With ankylosing spondylitis or RA, do you attempt to put head in sniffing position?

No, it may injure pt. Do not manipulate neck with cervical spine pathology

Will JW use PRBCs?

No, some will say yes if they are going to die.

Can you just give DDAVP to pt who has von wlllebrand and is needing a spinal?

No, you could give FFP though. DDAVP only works if you have 1/2 genes of von willebrand. If you have some but not enough factor then DDAVP will help you release more.

When is care handed off to PACU nurse? After extubation?

Not necissarily, leave when PACU nurse is comfortable. Ok to still be intubated and in pain with NV etc. You do your best to address issues and give orders etc. Also nice to give meds for pain, NV, and BP etc. so they don't have to

What blood type is a person with type O blood compatible with?

O

What is transforamenal epidural

Often do a transforamenal epidural right where nerve root comes out (go in from the side instead of the median part) and they inject steroid just proximal to the nerve root that exits the lateral intervertebral foramen [these are often for disk herniations- that causes smashed nerve roots] lasts 6-12 months.

Where is post anesthesia follow-up note often made

On a portion of the preanesthesia evaluation there is a box for post anesthesia note. Progress note can also be used.

Where are preop notes charted

On back of anesthesia form or dictation

What is suppose to be in post op evaluation (follow-up)

One place says: Recovery from anesthesia, evaluation, treatment,and follow-up of possible anesthesia-related complications. ANOTHER PLACE SAYS: 1. Time and date of visit 2. Complications, if any 3. General status a. Systems reviewed should reflect care given 4. Signature

Atrixia and CNB

Only do single needle pass and no catheter

Morgan and Mikhail questions from here on: If a patient has throbocytopenia or coagulation issues, should they get oral or nasal airway?

Oral

What are the two parts that are documented on in postanesthesia care

PACU, often done by nurse Post op evaluation/follow-up done by anesthesia provider

What is the most commonly discussed and managed complication of CNB

PDPH

What is the treatment for hypokalemia?

PO and I V replacement Rates of I V replacement have a maximum rate of 10 to 20 mEq/hour with cardiac monitoring

What blood product is the component of choice for improving oxygen carrying capacity?

PRBC's

Other than waiting with heparin before CNB what also must be done

PTT (this is really what guides you)

what is the basic information that is needed to be charted according to the AANA article

Patient identification, provider information, intake and output, equipment checks, , monitors, techniques, medications, and procedural data are all part of the basic data that is necessary for every anesthesia record. A record of any parameters monitored during the anesthetic should also be part of the basic data.

What should the following procedures dermatome block level be? per art Perianal Total hip Abdominal - C Section

Perianal - L1-L2 Total hip -T10 Abdominal - T4-T6 C Section t4-t6

What pts are Ca++ pushes used for

Poor cardiac function, in signs of pending arrest like flat p wave and wide qrs.

5 Main causes of low mag

Renal diseases and losses GI losses and poor absobtion Endocrine pregnancy Drugs

What structure extends from the base of the skull to the level of the cricoid cartlage

Pharynx (According to the Nag)

What structure extends from the posterior turbinates/base of the tongue to the opening of the glottis?

Pharynx (according to Menardies notes)

PDPH s/s

Photophobia, diplopia, pain in forehead toward occuput, pain in shoulders, worse than migraine

what are the three meninges of the spinal cord from innermost to outtermost?

Pia matter Arachnoid matter Dura matter

Flow sequence for BMV difficulty management (6 steps)

Position pt one hand vent reposition to sniffing place oral airway two hand vent consider supraglottic device or awaken patient or invasive if needed

Who needs to be signed onto the anesthesia record (3)

Provider Information 1. Primary anesthetist 2. Secondary anesthetist, if any 3. Relief provider, times of relief, credentials

If you are having a hard time ventilating, your first reaction is to do what (but shouldn't do this)?

Push reservoir bag harder. But this isn't fixing the problem and may cause gastric distention.

How often to chart vitals and comfort after spinal

Q2-5min for 15 min

EKG with k+ > 8.5

QRS is sine wave, v fib and arrest

What SAB needle poses biggest PDPH risk and how should it be inserted

Quinke of any size. To reduce PDPH it should be inserted with bevel parallel to the menineal fibers that run cephalad to caudad.

What is in a bag of whole blood?

RBC's Plasma WBC's Platelets

What is in a bag of PRBC's?

RBC's WBC's some plasma

Thyroarytenoid

RLN motor

interarytneoid (adductors)

RLN motor

lateral cricoarytenoid

RLN motor

posterior cricoarytenoid (adductor)

RLN motor

Trachea

RLN sensory

subglottic mucosa

RLN sensory

dissecting aortic arch and mitral stenosis cause strain of what nerve

RLN causes hoarseness

Does acute injury to the RLN or the superior laryngeal nerve cause respiratory distress and stridor

RLN, becuase then tension and adduction are unapposed

Main indications (2) for cricoid pressure

RSI for full stomach

what does the SHORT accronym stand for

Reasons why cricothyrotomy/tracheotomy is difficult surgery hematoma obesity radiation tumors

why pts get sleepy with CNB

Reticular activating system is depressed

5 Indications for FFP

Reversal of warfarin Correction of known coagulopathy Microvascular bleeding with long prothrombin time (PT) PTT>1.5 x normal Dilutional coagulopathy

if a persons blood is Rh negative what are they compatible with?

Rh negative

if a persons blood is Rh positive what are they compatible with?

Rh positive and Rh negative

What can be some causes of hyponatremia?

SIADH water intoxification hyperglycemia mannitol excess glycerol therapy diuretics Vomiting/diarrhea third spacing sweating ketonuria renal failure hypothyroidism drugs porphyria pain stress positive pressure ventilation CHF nephrotic syndrome cirrhosis

cricothyroid (adductor tension)

SLN-external motor

With pt supine where are the two low points in the vertebrae and where are the peak and trough of lumbar and thoracic vertebrae

Saccrum and Thorax o Apex of the lumbar curve is L3-L4 o Trough of thoracic curve is T4

What can be some causes of hyperkalemia?

Shift of potasium from ICF to ECF resulting from lysis of cells, acidemia, beta blockers increased intake impaired renal excretion

S/S of PDPH

Spinal headache - post dural puncture headache Photophobia like a migraine, N/V

If person develops spinal hematoma how ill it manifest?

Slowly, usually venous, over days and weeks will build pressure and cause nerve damage

what is the dermatome level of the umbilicus?

T10

Superior laryngeal nerve block steps

Supraglottic block 1-find greater cornu of hyoid (round structure below angle of mandible 2-walk needle off the caudal edge of cornu and it will bounce of membrane, 3-aspirate and inject 1ml of 2% lido 4-advance 2-3 mm through membrane and inject 2ml of local 5- repeat on other side

What do you report to pacu nurse

Surg diagnosis and procedure medication history allergies Procedure Medical history problems during anesthesia meds and fluids given preop and intra labs baseline VS and labs gtt rates orders like ekg, cxr Med orders vent settings especially meds toward end and reversal

Two most common causes of transfusion reaction death

TRALI and hemolytic rxns

What is duration of action of most common meds for SAB with and without epi

Tetra = 1.0-1.5hrs; 2-3 hours with epi Marc = 1.0-1.5 ; 1.5-2.0 w epi Lido is 15-60 min; 1.0-1.5 hours

Memorize table 44-6 in text. Pg. 1093

This is about epidural opioids

Describe the difference between the vestibular and vocal folds and the vestibular and vocal ligaments

The vocal ligament is a superior thickening of cricothyroid ligament. the Vestibular ligament is an inferior thickening of the quadrangular ligament. The vestibular ligament is actually superior to vocal ligament, not attached to it. The "folds" are folds of mucosa that cover the ligaments. The mucosa extends from epiglottis and the first fold is over the superior vestibular ligament and then it folds again over the vocal ligament inferiorly (vocal fold)

what happens to opioids that are water soluable in CNB additives

They are not absorbed and stay in space. Slower onset, longer duration

What are surgeon preference cards

They are often for surgeon insturment preference We can make them for anesthesia

What is unique about c6-c8

They are only on the posterior body and so they innervate the posterior arm as well

What do cricothyroid muscles do

They cause larynx and thyroid cartilage to move anterior and downward (away from cricoid cartilage) which causes tightening of vocal folds (higher pitch)

What are rae ett?

They curve sharply once they exit mouth or nose to get ett out of the way.

What is unique about C5 and T1

They lie next to each other on anterior chest and arms but are separated posteriorly by c6-c8

why are cleft palate patients hard to intubate

They often have a hole in their palate

What vascular procedures would be an indication for cell salvage?

Thoracoabdominal aortic aneurysm repair AAA repair

What is a transfusion trigger

Threshold where blood products should be given. Used to be rigidly based on labs, not it is not rigid based on clinical data

What do transverse and oblique arytenoid muscles do

Transverse are parallel between arytenoids. They bring arytenoids together and adducts the cords? The oblique runs cris-cross between arytenoids and also adducts cords. They might also continue to form aryepiglottic muscle.

what do leukocyte filters reduce the risk of

Trim and non-hemolytic

True or false? Documenting your follow up visit is required by JACHO?

True

True or false? in the epidural space compartments, occupied mostly by fat but also nerves and fibrous tissue, repeat at each segment in a metameric fashon

True

What is the most important part of blood compatibility

Type (abo and rh) Antibodies are less important thus cross match isn't nearly as important at the abo RH

What needs to be on intraop care plan

Warmth BS reasons for selection, dose, and redosing for all drugs

Do we have to document tornequet, warming blanket, restraints, straps etc. times

We can, but if someone else is timing it we don't have to

ASA difficult airway step 3

Weigh merits and feasibility of basic choices : -Awake intubation vs. attemps after GETA induction -Non-invaseive intubation vs. invasive intubation -Preservation of spont. vent vs. ablation of spont vent.

Upon insertion of an ett into a fastrach, at what point does ett push the epiglottic elevating bar up?

When ett is inserted 15 cm (look at markings on ett). There should be dark line on ett at 15 cm.

what is a glideScope?

a video laryngoscope that provides a laryngoscopic view equal to or better than that of direct laryngoscopy without manipulation of the head into sniffing position

when using a trachlite what happens as the light source enters the trachea?

a well-defined circumscribed glow is noticed below the thyroid promenance and can be readily seen on the anterior neck. oh and menardie says to turn off the lights to see the light better

what is the function of the posterior crioarytenoids?

abduction of the vocal cords (opens)

(Gag Reflex) When posterior wall of pharynx is touched, impulses are carred _________(afferently/efferently) by the ___ nerve to the ____ where they synapse with nuclei of the _____ nerve and the ______ portion of the _______ nerve. The efferent response returns through the ______ nerve resulting in a gag reflex as the muscles of the ________ elevate and _____

afferently, glossopharyngeal medulla, vagus cranial, spinal acessory vagus, pharynx constrict

When is type and cross no longer valid

after 2 units of trauma blood. May become predominant type

At what point are colloids often used rather than more crystalloids to expand volume

after 3rd liter

When are pts retransfused after normovolemic hemodilution

after bleeding has stopped

What are some symptoms of hypernatremia

agitation hyper-reflexia ICH seizures thirst weakness cerebral edema muscle twitching hypovolemia polyuria or oliguria renal insuffeciancy

how should you treat a total spinal?

airway and ventilation, CV support, trendelenburg, fluids, Epi, ephedrine

according to the ASA difficult algorithm what are your two choices with an awake intubation?

airway approched by noninvasive intubation or invasive intubation

What primarily is responsible for osmotic pressure intravascularly

albumin

What are the intrinsic muscles of the larynx innervated by? What is the exception

all by the motor portion recurrent laryngeal nerve except cricothyroid muscles which is external (motor) branch of superior laryngeal nerve

What are the purpose for check boxes on an anesthesia care plan?

although they help with speed, they help quality.

what can be used as an alternative to an Esmarch bandage while doing a bier block?

an air-inflated splint

what are trachea causes of a lower airway obstruction

angioedema aspirated foreign bodies hematoma hemorrage tuomors or lesions

Thrombin inhibitors (2 names) and CNB

angiomax and iprivask No Data, don't do it

Where is mandibular hyoid distance (MHD) measured

angle of mandible to the hyoid bone (usually via xray)

is the epiglottis anterior or posterior to the vocal cords?

anterior

what does the external superior laryngeal nerve provide sensory for?

anterior subglottic mucosa

What is unique about glidescope camera

anti fog heating element located on middle of the blade

4 indications for fiberoptic scope

anticipated difficult airway cervical spine immobilization*** anatomic abnormalities failed to intubate but can ventilate

What is the risk of too much colloid (not albumin so much)

anticoagulation (maybe renal damage)

Is blood type named according to antigen or antibody

antigen because that is what is on the cell. Thus the cell type. The antibodies are not made by RBCs obviously and thus the blood type of RBC does not come from antibody type

What are five classes of meds often considered for awake intubations

antisialagogue opioid benzo IV sedative drugs to lower aspiration risk

what should tell the patient to report during a bier block?

any symptoms of LAST

Where does oral airway move tongue

away from soft palate and posterior pharyngeal wall

the brachial plexus is a large network of nerves that extend from the neck through the _______ and innervate the ________

axilla, upper extreamity

what does BURP stand for?

backwards upwards right pressure

What are two ways to irrigate

bag with a trigger Sponge

When airway has inflammatory partial obstruction what should you do when intubating

be very careful, may cause total obstruction, especially with fiberoptic

why is the sniffing position important?

because it helps to improve laryngoscopic views by promoting displacement if the tongue by better aligning the oral, pharyngeal, and laryngeal axes

although a single tourniquet can be used on a bier block, why is a dual tourniquet recommended?

because it provides a means to extend the length of the block after the initial onset of tourniquet pain

why would high block may impair ventilatory function?

because of intraabdominal or intercostal muscle paralysis

why does epi prolong the duration of spinal anesthesia?

because of vasoconstriction, thereby delaying normal uptake of local anesthetics

According to art where is the laryngopharynx

between hyoid and glottis

Which ion is important in coagulation

ca++

which ion is mainly a secondary messanger in cells

ca++

Autologous transfusion indications (2 type of case and 3 pt specific)

cabg/high blood loss cases high antibodies rare blood type Those w hx of multiple transfusions

What is the treatment for hypermagnesiumia?

calcium (in urgent situations as an antagonist) diuretics dialysis reduce nondepolarizing paralytic dose discontinue administration of mag

the second recommendation from the AABB states to adhere to a restrictive strategy in hospitalized patients with preexisting ____________ disease and consider transfusion for patients with symptoms or a hemoglobin level of ______ g/dl or less

cardiovascular 8

what causes a post dural puncture headache?

caused by a leak of CSF that out-paces production. the medulla and brainstem drop into the foramen magnum, stretch the meningies and pull on the tentorium

What does extracellular compartement serve as a medium for

cell nutrients, electrolytes, waste products

What additives will prolong bupivacaine?

clonadine or decadron (but no decadron in CNB)

what is the function of the interarytenoid?

closing of posterior commissure of the glottis

Arts 4 neuro s/s with high mag

cns depression sedation hyporeflexia weak

according ot the "smart" airway stratigies, what are two primary airway verifications

co2, bilateral breath sounds

What should you monitor in MBT

coags and hemostasis maybe ca++

Whats in FFP?

coagulation factors

Only LA that vasoconstrics

cocaine

What was the original med for spinals

cocaine

What are the five criteria for apgar and what is normal score

color heart rate respirations Reflex/irritability response Muscle tone Normal = 8-10 moderate distress 4-7 Needs resucitation = 0-3

supraglottic tubes. Name several

combitube, king laryngeal tube, rusch easy tube, and LaryVent. all are placed blindly and can be positioned into esophagus

If a patient with an ett has been repositioned, what must be done?

confirm ett correct placement again to rule out ett migration

What are some symptoms of hyponatremia?

confusion seizures coma agitation cerebral edema nausea/vomiting cramps weakness headache

What opioids is there no spinal dose for

demerol

What happens if serum sodium is too rapidly corrected?

demylenation and seizure, coma, spasticity

What is the most common airway malpractice claim

dental trauma

What are some symptoms of hypermagnesiumia

depression of PNS and CNS sedation hyporeflexia weakness respiratory depression bradycardia myocardial depression

What is the treatment for hyperkalemia?

dialysis calcium insulin and glucose (Menardie says this is typical) diuretics (Menardie says this is slow) kayexelate (be sure this is done right before taking the patient to the PACU) sodium bicarbanate

Three treatment for high ca++

dialysis iv fluids diuretics

According to M and M a lumbar epidural can be used for any procedure below the

diaphram

What is defined as difficult airway (3)

difficulty with mask ventiation, laryngoscopy, or intubation

According to Dr Nag, in a massive blood transfusion accompanied by crystalloids and colloids will not provide coagulation factors. what can this lead to?

dilutional coagulopathy dilutional thrombocytopenia

According to Menardie what are some other risks of massive blood transfusion

dilutional coagulopathy volume overload metabolic alkalosis (late) hyperkalemia hypothermia

What are risks of MBT concerning: coagulopathy (2) volume status pH (2) Electrolytes Temp

dilutional coagulopathy and citrate coagulopathy volume overload metabolic alkalosis (late) acidosis (early) Hyperkalemia Hypothermia

risks of cell saver use (2)

dilutional coagulopathy and throbocytopenia Monitor clotting levels and plts w point of care

What is LMA supreme

disposable proseal LMA

Five things that make invasive airway difficult (box 22-2)

distortion of neck anatomy obesity or short neck trauma impediments/devices around neck Surgery causing limited access

if the first blood patch does not work what would you do?

do another blood patch

what should you do if a blood patch does not cure a PDPH?

do another one, duh!!!

What is the rule for placing a spinal in a patient on thrombolytics

do not place even after 24 hours

What questions should you ask CNB patients about bleeding risk

easy bruising or bleeding in gums or cuts? Any drugs that cause anticoagulation

when doing a retrograde intubation what 2 options do you have to insert via cricothyrotomy?

either a J wire or a number 2 Mersilene suture

Where should you grab ETT when using magill forceps in nasal intubation

either below or above cuff

Should generic or trade name be documented

either but be consistent

What is charted Q15 min

ekg, SP02, fi02, monitors like biz, gases

what patients would be good to use a paramedian approach?

elderly and arthritic

according to the ASA difficult algorithm you had an unsuccessful ventilation after your emergency noninvasive airway attempt, what is next option?

emergency invasive airway access

What does gut release due to ischemia

emetogenic substances like seratonin

Hoarseness or airway obstruction noted immediately in the post-op period is found; what should be evaluated?

evaluation for possible emergent reintubation or tracheotomy

What needs to be documented preop according to AANA article (5)

evaluation of pt review of systems and records personal communications physical assessment Informed consent obtained

NH says the bougie or exchange catheter is better

exchange catheter

where does the spinal cord begin and end?

extends from the medulla oblongota through the spinal foramen to the level of the L2 vertebra

Tongue sense of taste

facial nerve (vII anterior two thirds glossopharyngeal nerve (IX) posterior 1/3

Indications for surgical cricothyrotomy

failed airway trauma to neck face or airway immediate relief of obstruction need for definitive airway for neck or facial surgery if intubation is not possible

what is failed intubation

failure to place ett tube after several laryngoscopic attemps (Nagelhout p. 437)

True or false? The vertebral foramen is palpable on skinny people

false

True or false? you should be sure to document any threats a patient makes to you, or document anything that blames others?

false

true or false? a nerve stimulator can be used for enhancing any technique except for an ultrasound guided nerve block

false

true or false? the thyroid cartilage wraps completely around posteriorly the larynx

false

true or false? the use of NSAIDS is a contraindication to spinal and epidural anesthesia

false

where do you inject your needle while doing a traditional approach to block the brachial plexus?

firmly press your fingers into the interscalene groove and insert the needle in between fingers slightly in a caudal direction

What care plan is required to be done each day

first case of the day and biggest case of the day

What happens with nasal membranes with general anesthesia

general depresses sns which causes vasodilation in nasal passages and cause more BLEEDING and ENGORGEMENT with blood.

What should "plan B" be with CNB

general, have the stuff ready

What Neurosurgery procedures would be an indication for cell salvage?

giant baislar aneurysm

How does Dr Nag say to give calcium gluconate for treatment of hypocalcemia?

give 10 mL of 10% over 10 minutes, followed by an infusion of 0.3 to 2 mg/kg/hour of elemental calcium

Arts normal dose of plts

give 6 pack and then follow up labs

the ASA task force says a transfusion is unnecessary in patients with what hemoglobin value?

greater than or equal to 10

What is the pts sensation as a needle passes the ligamentum flavum

gritty, especially with epidural

What is eschmann stylet

gum elastic bougie

Lab to check before autolougous donation

h and h

How long do h2 blockers, gastroprokinetic agent, or sodium citrate need to be given before induction to reduce aspiration

h2 blocker is 45-60 min (ranitidine etc.) antacids is 10-20 min gastroprokinetic agent is 20-30 min (reglan)

how long should a patient be in the supine position after having an epidural blood patch in treatment for a PDPH?

half an hour to an hour

burns and crush injuries and K+

has it listed as both for burns. However, I would imagine early in burn it is high and later k+ is low. Crush is high

hct of cell saver blood

hct 55

What is sniffing position

head elevated on bed, with extension. aligns oral and trachial planes

Lithium and ca++

high

Peaked narrow T wave with high or low k+

high

adrenal insufficiency and ca++

high

TB can cause what with ca++

high ca++

Tb and electrolytes

high ca++

acromegaly and electrolytes

high ca++

being immobile and electrolytes

high ca++

berylliosis and electrolytes

high ca++

estrogens and electrolytes

high ca++

histoplasmosis and electrolytes

high ca++

hyperthyroid and electrolytes

high ca++

leprosy and electrolytes

high ca++

milk-alkali syndrome and electrolytes

high ca++

Thiazides and ca++

high.

What can be some causes of hypermagnesiumia?

iatrogenesis treatment of preeclampsia treatment of preterm labor treatment of ischemic heart disease treatment of cardiac dysrhythmias renal failure adrenal insufficiency

what are the landmarks for a sciatic nerve block?

identify the greater trochanter, posterior illiac spine, and sacral hiatus

how much local do you inject when doing an ulnar nerve block at the elbow?

if parasthesia is elicited withdraw 1 mm and inject 2 to 3 ml. If parasthesia is not elicited 3 to 5 ml

What is the storage lesion

if prbcs are stored longer than 14 days, then you have changes in blood bank blood

Where is intercristus line

iliac crest L3-L4 (tuffiers line)

What can be some causes of hypernatremia?

impaired water intake

What can be some causes of hypomagnesiumia?

increased renal or GI loss poor intake alcoholism

How does "ramping" help obsese patient's during mask ventilation

increases functional residual capacity

when doing an interscalene block how much local do you inject if there are no symptoms of toxicity?

incremental injection of 3 to 5 ml, each follwed by aspiration, for a total of 30 to 35 ml (according to nagelhout, but the slides say 15-25ml)

Always make sure suction is on and ready before ______

induction (before any indcution drugs given) because you need to suction before larygoscopy

What is the size of ETT you should use for infant, peds, adults (How deep should cuff be for adults)

infant 3.5 mm - child (Age + 16/4) Female adult 7.0-7.5 --- 24 cm (art said 21-23) deep Male - 7.5-9.0 --- 24-25 cm deep

TRALI pathogenesis

inflammation and allergic rxn cause leaking wbc in alveoli, cause lung injury and edema

the lateral cutaneous nerve passes inder the lateral border of the ________ and provides the sensory innervation to the lateral aspect of the _____.

inguinal ligament, thigh

how much do you inject when doing a glossopharyngeal block?

inject 1 to 2 ml 2% lidocaine

which of the laryngeal nerves is only sensory?

internal superior laryngeal nerve

what are the 3 main nerves innervating the larynx?

internal superior laryngeal nerve external superior laryngeal nerve recurrent laryngeal nerve

the intercostal nerves emerge from the ________ and follows the rib in the costal groove which is located on the __________ aspect of the rib

intervertebral foramen, anterioinferior

If fraction of excreted urine is > 2% what does that mean

intrinisic renal disorder is responsible for high creatinine

the _______ of the larynx control the tension of the vocal cords as well as the opening and closing of the glottis

intrinsic muscles

What is ILMA

intubating LMA or Fastrach LMA

unilateral recurrent laryngeal nerve damage does what

ipsilateral paralysis of vocal cord (hoarseness and poor quality)

What is the filum terminale

is a delicate strand of fibrous tissue, about 20 cm in length, proceeding downward from the apex of the conus medullaris.It is one of the modifications of pia mater. It gives longitudinal support to the spinal cord

what does the second 3 in the 3 3 2 rule measure?

it assesses the mandibular length from the tip of the mentum to the mandible-neck junction and gauges the ability of the tongue to displace within the submadibular space during laryngoscopy

when would a PDPH occur after a spinal?

it can occur within several hours to the first or second post op day

What kind of needle is used in needle cricothyrotomy

large bore needle or angiocath (venous or arterial) (14-18 gauge is for retrograde)

What is stubby used for

large chest, the handle gets in the way. Usually obese people

Why is lumbar CNB less risk than thoracic

larger epidural space spinal cord is not there so less risk of spinal cord damage although risk of cauda equina still exists

What are the three axis

laryngeal and pharyngeal and oral

What is cormack and lehane grading system

laryngoscopic difficulty

what are some respiratory complications during extubation?

laryngospasm airway obstruction aspiration sore throat soft tissue obstruction ventilatory depression laryngeal edema vocal cord malfunction cyanosis breath holding coughing hypercarbia hypoxemia

what structure begins with the epiglottis and extends to the thyroid cartilage?

larynx

Where does superior thyroid artery travel

lateral to the crycothryoid membrane

If you are mask ventilating with apl valve open, but the resivoir bag keeps going flat, what is probably happening?

leaky mask seal

What are the strengths of Lido, Rop and Bup for surgical block in Epidural

lido is 1-2% Rop is 0.5-0.75% Bup is 0.5

what is lido lollipop and how to use

lido ointment on tongue blade, place it on back of the tongue for 1-2 min

which would be a good choice for a 10 min prone procedure lidocaine 0.5% with epi lidocaine 2% hypobaric lidocaine 5% hyperbaric bupivicaine with epi

lidocaine 5% hypobaric

what locals are considered less protein bound

lidocaine, and mepivacaine

Where is the the infraclavicular portion of the brachial plexus located?

lies in the axilla

What are the three channels in a fiberoptic scope

light source fiberoptic lens fiberopitic Aspiration channel

what is the only way to correct error in charting

line out

What type of liver procedures would be an indication for cell salvage?

liver transplant

What two drug classes are good for reducing coughing and straining on extubation

locals opioids

what landmarks do you use when doing a superior laryngeal nerve block?

locate greater cornu of hyoid bone, beneath angle of mandible

what landmarks do you use when doing a translaryngeal/transtracheal block?

locate the cricothyroid membrane, superior to cricoid and inferior to thyroid

TPN and mag

low

What is a MBT (3 definitions)

massive blood transfusion -Replace estimated blood volume in 24 hours -10 or more units of prbcs in 24 hours -or 50% of blood volume in 3 hours or less

What is max jet vent inspiratory pressure and what is normal?

max is 50 normal is <25

Teeth most at risk during intubation

maxillary incisors

What complication happens if pt is trying to breath with an obstruction (like oral airway not working)

may get negative pressure pulm edema

What happens to co2 with leak

may not look as high

what does the 2 in the 3 3 2 rule measure?

measures the mandibulohyoid distance from the mandible-neck junction to the tip of the thyroid notch and assess the position of the larynx in relation to the base of the tongue

Arytenoid dislocation can be casued by

mechanical force of ett against it or forceful intubation

What direction should a nasal ett be inserted

medial and perpendicular to nare along floor of nose

in the brachial plexus what are the branches of the lateral and medial cords?

median, ulnar, and musculocutaneous nerves

what is the glidescope made of?

medical grade plastic

What is the difference between technique of using mac blade vs. miller

miller pulls the epiglottis back gently Mac pulls the anterior tongue back in vellecula and indirectly lifts the epiglottis

is chole, acl min, mod or sever evap loss

moderate

in the Cormack and Lehane Grading system what is seen in a grade 1?

most or full view of the glottic opening

What part of care plan is positioning

mostly intraop

If you put retraction on chest, what airway nerve do you worry about

mostly right recurrent laryngeal nerve because it goes around the subclavian

Position for thyromental distance

mouth closed and head extended

What causes high antibodies for blood transfusion rxn

multiple transfusions hx

What are some symptoms of hypocalcemia?

muscle cramps and spasms twitching or tingling especially in fingers or mouth tetany muscle weakness seizures bradycardia and hypotension broncho and laryngeal spasms

corrected sodium equation

na+ 0.016 x (glucose - 100)

Is oral et tube or nasal tube better tolerated for longer cases

nasal

what can be done during jet vent to improve exhalation

nasal or oral airway. You can also push on the chest slightly

What is the superior portion of the pharynx?

nasopharynx

What part of pharynx are adenoids

nasopharynx

what part of the pharynx is the adenoids found in?

nasopharynx

Post op care plan concerns

pain nv extubation/ventillation cxr NMBD paralytic abx Post op destination like ICU, or fast track BS

What should be documented on follow-up visits

pain vs NV When block was wearing off Recovery Recall "how was anesthesia" Satisfaction

What symptoms does spinal transient neuropathy cause

pain and paresthesia in butt and legs

intercostal nerve block can provide analgesia for post operative _________ when epidural analgesia is not desired or possible

pain control

Apgar color scoring

pale/blue= 0 pink body blue extremities =1 Pink everything =2

non-reassuring finding of normal jaw closure

overbite

Is suction or oxygen usually used through fiberoptic port

oxygen, suction is difficult because lumen is small

EKG with k+ 7.5 -8.0

p wave flat, wide qrs, nodal and escape vent rhythms

should you transfuse PRBC's for a patient with a class 3 hemorrhage?

probably nessesary

if intubation and ventilation have failed should a fiberoptic be used

probably not, it is too time consuming. Good for fail to intubate but can ventilate

Is LMA ok for those with reactive airway

probably, less irritating than ETT.

Should ideal or adjusted body weight be used for fluid calculations

probably. Most people do one or the other but no actual weight in obese

what are some indications of spinals or epidurals?

procedures of the lower extremities, perineum, and abdomen. acute and chronic pain management obstetric procedures, Labor analgesia

EKG changes when k is 6.0-7.5

prolonged PR, peaked t, short qt

what are the four functions of the larynx

protection of lower airway from aspiration -patency between hypopharynx and trachea -protective gag and cough reflexes -phonation

What 2 things should be done if endobronchial intubation is discovered

pull back ett and hyperinflate to expand atalectasis.

What should be done with kids loose tooth

pull it out before intubation. Tell fam tooth-fairy came

in a patient who has been laboring for 4 hours where the epidural seems to only be working on one side what would be a good option?

pull the catheter back a cm and re-position the patient. If it doesn't start to work place a second epidural

What if you lay down pt after spinal and you still don't get the level of block you want

put their head down (hyperbaric solution)

What is ett made of and why is this important

pvc, flammable especially with 02

What are the check boxes and grids for

quality management not speed of charting. Helps to prompt as well

What are the three names of SAB needles and the one that is cutting

quinkie is cutting sprotte and whitacre are pencil-point

in the brachial plexus what are the branches of the posterior cord?

radial and axillary nerves

What Urology procedures would be an indication for cell salvage?

radical retropubic prostatectomy Cystectomy Nephrectomy

Other than sniffing what can be done to align airway axes

raise the head of the bed in addition to applying the blankets under the head

ASA taskforce summary of transfusion guidelines (different than american association of blood banks)

rarely transfuse for hgb>10 Usually administered when hgb <6 hgb 6-10 is based on clinical factors such as cardiopulmonary function/02 levels

When using a nerve stimulator in doing a brachial plexus block what is done with the amplitude as the needle enters the sheath?

reduced to 0.5 milliamps

What does vagus nerve innervate in airway (sensation, motor, autonomic NS)

sensation below epiglottis. Parasympathetic of bronchiotracheal tree. Also intrinsic muscles of larynx.

What should be documented intraop (3)

sequence of care given, drugs/fluids, responses (vitals)

is colon resection, and aorta repair min mod or severe evap loss

severe

Main difference between complex and short forms

short has more room for wasted drugs and remarks Long form has more room for graphic vitals charting

what is the function of the thyroarytenoids?

shortening and adduction of vocal cords Art said these relax the vocal cords

What are volatile agents documented units

should be End Tidal % Some people do what is on the dial

What is black line on LMA tube for

should be near the lips if placed correctly. Same with bite block

What is McGrath video scope

similar to glidescope but portable. uses one AA battery and has 1.7 inch screen. Macintosh like disposible blade, with similar anterior angle to glidescope

What is airtraq and how is it used

similar to glidescope but uses prism. Doesn't have to have monitor. Has similar mac blade. Cheap and disposible. Antifog LED if on for 30 seconds

what risks are there in using a trachlite in a patient with an upper airway anomaly?

since it is inserted blindly there is a greater risk of injury or failure in these patients

how do you prevent a complication of nerve injury in a sciatic nerve block?

slow needle advancement, do not inject with parasthesia

how do you advance the needle of a nerve stimulator

slowly

3 types of difficult airways that trachlight is good for

small oral opening minimal neck manipulation Anterior ariway

pt. position if initial attempt at LMA placement is not successful

sniffing

In brain what is most osmotically important substance unlike the rest of the body

sodium (albumin in the rest of the body)

the nasopharynx is separated from the oropharynx by the ________.

soft palate

What is not in PRBCs

some of the clotting factors like 5 and 8

will JW use cell saver

some will some won't offer to give in continuous circuit instead of going to bag

Why is assistant often needed to insert nasal airway

someone to help advance the tube while you use laryngoscope and Magill forcept. Then once at cords, tell assistant to advance the tube through the cords.

What are variations in vertebrae anatomy

sometimes +/- 1 thoracic or lumbar vertebrae

according to the AANA where should the preanesthesia eval be documented?

sometimes it appears on a special part of the anesthesia record, usually on the back, or sometimes a separate form is used.

when placing a spinal what is a Taylor approach?

this takes advantage of the L5 interspace (the largest). 1 cm medial and 1 cm caudad to the posterior superior iliac spine point is where a needle is inserted and angled medially and cephalad at a 55 degree angle toward the 5th lumbar interspace

what are the indications for doing an intercostal block?

thoracic or upper abdominal surgeries, rib fractures, breast surgery, pain relief form herpes zoster and cancer

Who should be extubated fully awake (2)

those with risk of aspiratioin Difficult airways

What are some things to document on personal notes?

threats emotional outbursts stuff that was wrong in a case

the anterior and lateral larynx is formed by the _________.

thyroid cartilage

Does thyroid have posterior portion? Cricoid?

thyroid doesn't, cricoid does

Anteriorly, the thyroid cartilage fuses and forms the ________

thyroid notch

What test is indicitive of "anterior larynx"

thyromental distance

what are the 5 nerves of the ankle that get blocked?

tibial nerve, sural nerve, superficial nerve, deep peroneal nerve, and saphenous

what is the fastrach LMA used for?

to be used in the cannot intubate and cannot ventilate scenario as well as in situations where difficult intubation is anticipated it also allows for reasonable control of the airway through the intubation process

why do you do a test dose prior to injecting large amounts of medication into the epidural space?

to determine whether the catheter or needle has inadvertantly entered the subarachnoid spaced or possibly threaded into a vein

Arts 2 treatments for low na+ and dose

treat underlying cause 3% saline at a rate of 1-2ml/kg/hr Once stable slower to raise sodium not more than 10-15mmol/L in 24 hours

what are the landmarks to use in a TAP block?

triangle of petit is an anatomical space between the posterior attachment of the EO and anterior attachment of the latissimus dorsi muscle to the iliac crest

What 3 nerves need to be blocked in airway block

trigeminal - nasal septum and lateral wall and anterior tongue glossopharyngeal - posterior third or tongue, soft palate, oropharynx vagus- hypopharynx, larynx, trachea

What 2 nerves can be damaged by prolonged face mask use

trigeminal and facial nerves (not glossopharyngeal...)

True or false? Cell salvage should be considered in all cases where significant blood loss, greater than 1000 mL, is expected or possible?

true

True or false? monitoring coagulation factors and maintaining homeostasis is importing with a massive blood transfusion?

true

True or false? plans of sending the patient to the PACU or ICU after surgery should be part of the post op care plan?

true

True or false? platelet transfusions are indicated for a patient with a micro-vascular bleeding, continued bleeding or they have a platelet dysfunction and their count is between 50 and 100 K?

true

True or false? the ASA difficult algorithm provides guidelines for dealing with difficult facemask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation?

true

What does crna document intraop

vitals positioning meds Times Names of anesthesia providers

IF INR <2 should you use ffp or vitamin K if not bleeding?

vitamin K.

the ________ of the local anesthetic affects the spread form the needle, or catheter, to the epidural space

volume

What is the treatment for hypercalcemia?

volume expansion with NS loop diuretic to enhance calcium excretion dialysis biphosphonates, mithramycin, calcitonin, glucocorticoids, and phosphate salts also have been used in treatment

in an epidural what is dose described as?

volume multiplied by concentration

What types of patients is cryoprecipitate for

von Willebrand disease DIC probable or documented deficits in fobrinogen

REOPro and CNB

wait 1-2 days

LMWH QD (or low dose) and CNB and cath

wait 10-12 hours then do procedure or pull cath also wait 2 hrs before first dose after pulling cath

ticlopidine (Ticlid) and CNB

wait 14 days

LMWH and restarting after removal of CNB catheter

wait 2 hours after pulling

LMWH (BID or high dose) and CNB

wait 24 hours since last dose

plavix and CNB

wait 7 days

what are the 2 pencil point needles used in spinals

whitacre and sprotte

QRS with high k+

wide

Why don't we give bolus an hour before spinal epidural

will be third spaced and won't help with hypotension

What happens if you give hypobaric LA to thoracic spinal pt who is prone?

will float to cervical

CV and hypermag

with 5-10 level you can get hypotension brady, 15-20 arrest

When are false vocal cords damaged

with difficult intubation, may push hard on those vestibular folds.

how should you grip your epidural needle while applying a syringe and/or passing the catheter into the epidural space?

with the bromage grip

how should you hold your spinal needle when attaching a syringe to it?

with the bromage grip

How to fix tachyphylaxis with LA

withdraw catheter and place at different level

Are airway exchange catheters tolerated well by patients usually?

yes

Does dextran cause coagulopathy like the hetastarch/hespans

yes

Does intraop charting need to have a grid

yes

should you transfuse PRBC's for a patient with a class 4 hemorrhage?

yes it would be necessary

can you place spinal catheters

yes, but hast to be labelled REALLY WELL so that epidural dose isn't given intrathecally

Has ASA difficult airway algorithm decreased airway events

yes, even though there is no evidence to back it up

If patient has difficult time being facemask ventilated will an LMA work usually?

yes, highly sucessful

can a trachlite be used in a difficult airway?

yes, it can be used in both anticipated and the unanticipated difficult airway when laryngoscopy has failed

what can be done for awake intubation if regional block cannot be done

you can use local or use several adjunct meds in smaller doses to not cause respiratory compromise in already compromised patients

How do you calculate posterior bleeding

you can't, you don't see that blood

What is the maximum depth an airway exchange catheter can be placed

25-26 cm

How long do afrin and phenylepherine need to work in nasal airway before intubation

2-3 min

what is the tonicity of D5W?

253, thus making it a hypotonic solution

Does 5% or 25% albumin replace plasma at 1:1 ratio

5%

What are the two different concentrations of albumin?

5% and 25%

what are the two albumin [ ]

5% and 25% 5% is in 250ml 25% is in 50 ml

What percent dextrose in hyperbaric

5-10% (somewhere else says 5-8%)

1 unit of plts raises value and for how long

5-10k for 6-7 days. 6 pack from whole blood raises it 30-60k (or one apharesis unit).

LMA size for weight

1-less than 5 kg---2-4 ml cuff 1.5 = 5-10kg 2= 10-20 kg up to 10ml 2.5 = 20-30---up to 15 ml 3= 30-50 ---up to 20ml 4=50-70 --- up to 30ml 5=70-100---up to 30ml ART just does LMA 3= 40-50kg; 4 = 50-60kg; 5= 60+ (size of tube x10 +10)

what are the four endpoints in the ASA difficult airway algorithm

1-intubate awake or asleep 2-adequate or inadequate facemask ventilation or LMA 3-Approach intubation with special means 4-Emergency airway

fluid amount for epidural per ART instead of Nagelhout

1-1.5 liters for spinals and epidural over 30 min Start it when you start procedure

How quick should na+ be corrected in hypo na+ patients and dose

1-2 meq/hour 3% saline 1-2 ml/kg/hr then slowed to 10-15mmol/L in 24 hours

Which pharyngeal arches form the airway

1-4 and 6 (from arch 1 in anterior mouth to 6 in lower airway)

Four general guidelines for ASA difficult airway

1-Plan ahead and be prepared for difficult intubation 2-if you are suspicious of airway trouble, intubate awake 3-If you can still ventillate but are in trouble, wake pt. up 4-When making intubating choices, do what you do best. DAWB

Name the 7 "global criteria" for extubation

1-acceptable hemodynamics 2-normothermia 3-Able to maintain patent airway (cough, Gag and LOC) 4-Adequate muscle strength (TOF ratio >0.9 or 5 second head lift, or strong hand grip 5-Aceeptable metabolic function (electrolytes, acid-base balance) 6-Hematologic indicators (hemoglobin and oxygen delivery balance) 7-adequate anelgesia for optimal respiratory effort . HeNoStrongMain, Heme Anal is Met

3 indications of difficulty with invasive airway placement

1-bleeding 2-inability to find the right structures 3-puncture of trachea instead of crycothyroid membrane

Sequence for placing surgical cricothyrotomy over trocar

1-check tube cuff for air leaks 2- palpation of membrane and stabilization between first two fingers 3-insertion of trocar through CT membrane in caudal direction 4- aspiration of air and advancement into trachea 5-removal of trocar and inflation of tube cuff 6- securing the tube with a tracheotomy tie and confirming ventilation

3 treatments for croup and 4 for laryngospasm

1-humidified supplemental oxygen 2-racemic epi (0.5ml of 2.25% in 2.5 ml NS) 3-Dexamethasone 0.1-0.5 mg/kg Laryngospasm: 1-100 % 02 2- positive pressure 10-15cmh20 3- lidocaine 1.0-1.5 mg/kg 4- if all else fails 0.2-0.5 mg/kg succs

Where are the two points that LMA is used in ASA difficult airway

1-in anesthetized pt whose trachea cannot be intubated but pt can be ventilated with facemask 2- in cannot intubate cannot ventilate with facemask

Transtracheal block steps

1-locate cricothyroid membrane 2-use 22-24 gauge angio cath with 5ml 2% lido 3- needle is placed midline and advanced caudal 4-when air bubbles are aspirated, advance catheter and withdraw needle 5-Have pt. inspire, inject local, this will cause pt to cough and local to get on vocal cords

Four main methods to maintain airway patency

1-mask vent 2-supraglottic airway 3-tube below vocal cords 4- invasive

sequence for placing sugical cricothyrotomy via seldinger technique

1-place head in neutral position 2- insert dilator into airway catheter 3-palpate CT mem and insert introducer needle caudal 4-insert guidewire through catheter until 2 inches beyond catheter 5-incise neck with single scalpel insertion along guide wire 6-Thread catheter/dilator over the guide wire and advance ("pops") 7- advance catheter off dilator and assess for ventilation 8- secure and ventilate

2 steps for miller blade

1-place tip posterior to epiglottis and 2- apply gentle force to directly lift the epiglottis

What are indications of difficult supraglottic ventilation (3)

1-same as with face mask vent, but also leak pressure less than 10-15cmH20 2-poor expired tidal volume 3-multiple failed attempt by multiple peole

6 respiratory criteria for extubation (vital capacity, insp force, spo2, pa02, pco2, rr to tv ratio):

1-vital capacity > 15ml/kg 2-inspiratory force > 20cm H20 3-sp02>90 4-Pa02>60mmHg 5-Paco2 <50mmHg 6-RR to TV ratio less than 100 breaths/min/liter

the philosophy of the ASA difficult algorithm is based on what 4 things?

1. plan ahead and be prepared for failed attempts 2. if you suspect airway trouble intubate awake 3. if you get into trouble and can still ventilate, wake up the patient 4. when making intubation choices do what you do best

What are 2 common hypotonic fluids

1/2NS D5W

when placing a spinal for a hernia or pelvic procedure what dose of lidocaine would you use and what is the duration?

100 mg, the duration would be 45 to 60 mins without epi and 1.25 to 1.5 hours with epi

what is the normal value of platelets?

100 to 150 K

CaCl , calcium gluconante, and bicarb dose for high K+

10ml of 10% over 10 min CaCl 10ml of 10% over 3-5 min for gluconate (elsewhere in the book it says over 10 min followed by a gtt of 0.3-2 mg/kg/hr) Bicarb: 50-100 meq over 10-20 min.

What are the two sizes of airway exchange catheters for adults

11 and 14 french

What should peak pressure be kept at to reduce gastric inflation with supraglotic airways and facemasks?

15-20 cm H20 (art said max was 20) inflation often occurs at 25cmh20 (can increase this in King LT to 30)

What is onset time for marcaine 0.75% SAB

5-8 min

What is LA mixed in to make it hyperbaric

5-8% dextrose

What is the tonicity of half NS?

154 thus making it a hypotonic solution

What is max dose for spinal of marcaine usually

15mg or 2cc

how big is a typical standard epidural needle?

16 to 18 gauge and 3 inches long

how many C shaped cartilage rings are in the trachea?

16 to 20

what is epi wash

1:1000K epi. Draw it up and just inject it into garbage

what should expiration ratio be for jet vent to reduce barotrauma? What else can be done?

1:2 or 1:3 also need a in-line pressure regulator

what is the concentration of epi used in epidurals

1:200,000

How much bicarb to speed up LA onset

1cc bicarb per 10ml

Art's paremedian approach

1cm lateral and 1cm caudad 10-15 degree angle

After CNB, (not cath) no IV heparin for ____hr and can pull catheter after___hrs

1hr, 2-4 (verified in book)

Dilaudid epidural

1mg

Decadron Epidural

1mg/10cc (but art says you don't do this)

For each ____ ml of blood loss ___ml of prbcs is transfused

1ml because the hct is higher in prbcs

how much local is injected in an ulnar block at the wrist?

2 to 4 ml, then another 2 ml is injected as the needle is withdrawn from the deep fascia. 3 to 5 ml in a half ring to block the dorsal branch

how much local is injected in a median block at the wrist?

2 to 5 ml in the carpal tunnel, and another 2 to 3 ml after the needle in withdrawn from the fascia of the carpal tunnel

Whats in a MBT pack?

2 units O negative blood PRBC's times 6 FFP times 4 platelets times 1

Mepivicaine and lidocaine concentration in epidural

2% lido 1-2% mepivicaine

Airway management guidelines for number failed laryngoscipic intubations and allowed time before you try and do something different.

2-4 attempts and between 5-10 minutes of total procedure time

When pulling cath on someone with IV Hep how long should you wait to pull it and then restart heparin?

2-4 hour after D/C and then restart 1 hour after

What is a very high dose marcaine spinal

2-4ml of 0.75%

What is onset time for epidural meds

2-chloroprocaine = 10-15 Lido = 10-15 Mep = 15 Bup = 15-20 Rop = 15-20 Levo = 15-20

when doing an interscalene block how much local would you inject while doing an ultrasound approach?

20 mL after injecting 1 to 2 mL to verify placement

How long does antisiologue take to work?

20 min, may not be useful for most awake intubations

at the conclusion of a bier block the cuff may be deflated for as long as _____ minutes after injection of the local

20 minutes

how much local is injected when doing a TAP block?

20 ml

when using an ultrasound for a femoral nerve block how much local should be injected?

20 ml

What is the correct amount of cricoid pressure

20 newton (2kg) while awake 40 newton (4kg) when asleep (30-44 newtons needed for good occlusion)

when doing a femoral block what volume of local anesthetic should you give?

20 to 30 ml, but 30 ml will have best results in blocking the obturator

10 to 20 mL/kg of FFP is the guideline for administration (unless you are reversing warfarin), how much should it increase coagulation levels?

20 to 30%

Max blood person w normal kidneys, liver, and normothermic, can have per hour without citrate toxicity

20 units prbcs

What is the dose you should give for a bolus per nagelhout

20-30 ml/kg But art gives different amount for epidurals/spinals

How much does FFP increase coagulation levels

20-30%

How much does pt/inr and PTT increase with1 unit FFP

20-30%

According to ART max peak pressure with LMA

20cmH20

How does tetracaine come in spinal kit

20mg powder, usually you mix that into 2cc to get a 1% tetracaine or 4cc to get 0.5%

What is the max dose of hespan

20ml/kg or 1500 ml Art usually only goes 500 rarely 1000

Common sab needle gauge in elderly and young

22 in elderly and 25 in young

what is the range of sizes for spinal needles?

22 to 29 gauge 3.5 to 5 inches

When extension is reduced to ______ degrees visualization becomes difficult

23

how many intervertebral disks

24

how many vertebral movable joints

24

What is the tonicity of LR?

273, thus making it an isotonic solution

rough number of liters fluid intracellular

28 L

while threading the epidural catheter into the epidural space to a depth of ____ to ____ cm it is important to warn the patient that a "_________" sensation my be felt in their legs

3 to 5 cm, funny bone

how much local do you inject when doing an intercostal block?

3 to 5 ml at each desired level

How long do alveoli continue to develop after birth

3 years

Epidural chlroprocaine epidural concentration

3%

What sizes does fastrach (ILMA) come in

3,4,5

What is the onset time for 0.5-1.0% tetracaine in spinal

3-5min

What is normal test dose drug and concentration and volume for epidural

3-5ml 1.5% lido with 1:200K epi even when doing bupivicaine

How thick is legamentum flavum at L2-L3?

3-5mm (5-6mm per nagelhout; 10mm/cm)

How long do colloids last in intravascular space

3-6 hours

The spine has how many vertebrae?

33

How many vertebrae and breakdown

33 Cervical -7 thoracic-12 lumbar-5 sacrum-5 coccyx-4

how much local do you inject in a popliteal block?

35 to 40 ml

when doing a bier block on the lower extremity what would you set the cuff pressure at when the cuff is on the thigh?

350 to 400 mmHg so it can occlude the femoral artery, but it increases the occurance and intensity of tourniquet pain

Osmolarity level (due to high na+ ) with confusion restlessness agitation and HA

350-375

what is the tonicity of D5 1/4 NS?

355, thus making it an isotonic solution

Osmolarity level (due to high na+ ) with ataxia, tremors, weakness

375-400

What is the ratio of crystalloid to blood when giving blood

3:1

When are 3rd spaced fluids mobilized to intravascular space

3rd day. Careful with renal and cv disease

When does pregnancy cause problem with bmv

3rd trimester

If heparin longer than _____ days then need to check _____

4 plts (for HIT)

If hematoma is suspected, how long should you wait before asking for surgery?

4 hours

how do you calculate a maintenance drip for a pediatric patient that is 10 kg or less

4 ml/kg/hour

how much fluid do you need to replace due to the fluid loss from a severe procedure such as a prolonged highly invasive procedure?

4 to 8 mL/kg

"fast track" preox

4 vital capacity breaths in 30 seconds

What is the better formula for Peds? Can it be used for adults

4-2-1 rule (1st 10 kg =4ml/kg, 10-20 = 2ml/kg, >20kg = 1ml/kg) yes, it can be used for adults

How long does coumadin take to wear off

4-5 days

What is the safe dose of lidocaine

4-5 mg/kg or 7 if using epi

When is autologous donation done? How much time needed between donations

4-5 weeks before surg need 72 hours between donations

what is normal dose of FFP for coumadin reversal and all other purposes

5-8ml/kg 10-20ml/kg for all other purposes

when placing a spinal for a vaginal delivery what dose of bupivacaine would you use and what is the duration?

5 to 7 mg, the duration would be 1 hour without epi and 1.5 hours with epi

for the reversal of warfarin, FFP is usually administered in doses of ____ to ____ mL/kg

5 to 8

platelet transfusions are usually indicated when platelet count is less than______?

50 K

what med do you give in a bier block and how much?

50 ml of 0.5% lidocaine into the i.v. catheter

when placing a spinal for a cesarean delivery what dose of lidocaine would you use and what is the duration?

50 to 75 mg, the duration would be 30 to 45 mins without epi and 1 to 1.25 hours with epi

increasing the dose of hyperbaric bupivacaine from 10 mg to 15 mg prolongs duration of sensory block by ____ % and increases the maximum sensory level achieved

50%

What are the sizes of oral airways? Normal guedel for adult

50, 60, 70 , 80 , 90, 100. Not sure what the units are here.... art didn't say 80-100 guedel for an adult

Fent epidural

50-100mcg

dilaudid SAB

50-100mcg

What is the correct dose of epi for anaphylaxis?

50-100mcg IV push

How many ml in 1 unit whole blood

500

Minimum blood needed to run cell saver

500 small bowl 1000 if they use big bowl

Dose of dextrose and insulin with high K+

50ml D50 and 10 units of regular insulin then recheck glucose in an hour

what is the tonicity of D5 LR?

525, thus making it a hypertonic solution

when placing a spinal for a anorectal surgery what dose of bupivacaine would you use and what is the duration?

8 mg, the duration would be 1 hour without epi and 1.5 to 2 hours with epi

when placing a spinal for a cesarean delivery what dose of tetracaine would you use and what is the duration?

8 mg, the duration would be 1 to 1.5 hours without epi, and 2.5 to 3 hours with epi

when placing a spinal for a genital or lower extremity procedure what dose of bupivacaine would you use and what is the duration?

8 to 12 mg, the duration would be 1.5 hours without epi and 2 hours with epi

How long to decompress hematoma before nothing can be done

8 hours

What are the normal values for calcium?

8.8 to 10.4 mg/dL

calculate allowable blood loss for 80kg male

80 kg x 70ml / hct 39 (starting hct) = 143 ml. This means that each 143 is 1 hct Starting 39 hct how much blood can be lost to get to 25 hct 143 x 14 hct = 2002 ml (can loose 2000 ml of blood)

What blood type is a person with type A blood compatible with?

A & O

what nerve fibers are the heaviest and responsible for motor function

A Alpha

What is duration of epidural meds with and without epi

Chlor = 45-60/ 1-1.5 Lido = 1.5 -2hrs / 2-3 hrs mep = 1.5-3 hrs / 3-3.5 hrs Bup = 2.5-4 / 3+ hours Rop = 2-3 hours/ 150 min + Levo = Sam as bup

what is 02 flow documented as

L/min

where does conus medularis terminate

L1-L2

The umbilical area is directly anterior to the _____ vertebrae but recieves cutaneous innervations from ______

L3, T7 to T11

Where is tuffier's line

L4 although this is not always accurate Line drawn between two superior iliac crests

3 adjunct devises that are good for extubation in difficult airway that allow for reintubation

LMA (replace quickly after extubation) Extubate over a : fiberscope exchange cath

What are six things to include on the post anesthesia care eval when taking your patient to the PACU?

LOC Airway Pain Nausea/Vomiting Vitals Temperature

What needs to be charted in PACU? Which one does Jacho require?

LOC Airway/02 Pain NV VS Temp (Big one for JACHO- hypotherm)

What are 3 common Isotonic fluids

LR NS D5 1/4 Ns (maybe hypotonic)

What fluid not to give with ca++

LR has phos that may cause lower ca++

In non-cerebral hemorrhage what fluid does NH say to use

LR instead of NS due to acidosis

Synopsis of LR in acidosis article

LR was not superior to NS in DKA acidosis concerning normalization of pH

Per ART, what do we worry about post extubation

Laryngosapsm airway obstruction negative pressure edema cord malfuction external compression aspriation sore throat vent depression laryngeal edema Other is HTC Hec

What are the 5 rosenblatt questions in the "airway approach algorithm"

NISAA is acronym is use to remember these 1- is irway management Necessary 2- will directy laryngoscopy and Intubation be straightforward 3-can Supralayngeal ventilation be used 4- Has Aspriation risk been minimized 5-can patient tolerate Apneic period?

true or false? all of the laryngeal nerves take off from the vagus nerve?

true

Arts signs of intravascular injection

Numbness/ tingling in mouth, ringing in ears, fast heart rate is sign of intravascular

When are mature alveoli present in fetus

week 36

Too much heparin is absolute contraindication to CNB how much is this?

TID or > 10,000 units/day

What is especially important to chart in airway for future reference of airway difficulty

The laryngeal view grade. Will help future anesthesia providers judge how difficult airway will be.

What happens on repeat c-sections with uterine cut time

The time from uterus cut time to delivery is often longer and puts baby more at risk

Density of block for CNB (both) is equal to?

Total Dose! Concentration to a lesser degree. Art got this mixed up when he taught it

what is a supraglottic device?

a device that sits above or surrounds the glottis

what would a non reassuring finding be when doing a thyromental distance examination?

a finding of less than 3 ordinary finger breadths

what are some factors that can cause laryngospasm?

a number of factors can cause it such as airway manipulation, noxious stimuli in pharynx, or stimulation of the larynx with inadequate anesthetic depth

what is cell saver blood mixed with

heparinized saline that is eventually spun out

how much smaller should the epidural catheter be than the needle?

about 2 gauges smaller

What is the tonicity of the human body?

about 285, give or take

how long do colloids last in the intravascualr space?

about 3 to 6 hours

how big is a bag of PRBC's?

about 300 mL

how long is the left mainstem bronchus before it bifurcates into the left superior and inferior lobe bronchi?

about 5 cm

which vertebrae does the larynx coincide with?

about C3 or C4 to C6

is PDPH more common in epidural or spinal

about the same

Apgar Irritability/reflexs scoring and respirations scoring

absent =0 grimace or noticeable facial movements =1 Cough, sneezes or pulls away=2 absent =0 weak, irregular, gasping =1 strong, lusty cry = 2

Apgar HR scoring

absent =0 less than 100= 1 >100 = 2

what are oropharyngeal causes of an upper airway obstruction?

absesses such as peri-tonsillar Ludwigs angina sleep apnea tongue

why does trachea only have c shaped cartilage and not o shaped

accomidates swallowing

What are 4 risks of cricoid pressure when it comes to intubation difficulty

airway obstruction difficult laryngoscope placement impede glottic visualization difficulty with intubation

What are the colloids that cause anticoagulation

hespan, hetastarch 6%/hextend and dextrans

how is crioid pressure done?

an assistant places their thumb and index finger in the cricoid cartilage to compress the underlying esophagus against the cervical vertebrae

what has a blunted bevel and a gentle curve of 15 to 30 degrees at the tip?

an epidural needle

cryoprecipitate gtt rate? Filter? How quickly must it be used after thaw?

as fast as possible at least 200ml/hr, with filter within 6 hours of thawing

Normal neck flexion-extension range in degrees

anywhere from 90 to 165 degrees

what is the angle of bifurcation of the right mainstem bronchus

approximatly 25 to 30 degrees

what are the 3 paired cartilages of the larynx?

arytenoid corniculate cuniform

when is laryngospasm believed to occur?

as a result of sensory stimulation of the internal branch of the superior laryngeal nerve and afferent responces from both the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve

nasopharynx beginning and end

begins at posterior nasal cavity (chonche) extends through posterior soft palate (uvuala is in oropharynx)

Larynx begins and ends at what cervical level

begins between 3-4 and ends at 6th (cricothyroid muscle)

Where does trachea begin and end

below cricoid cartilage ends at carina

Drugs for SAB itching

benadryl 25-50mg Nubain 5-10mg

Which locals cause methemoglobinemia

benzocaine and procaine

What is considered hyperbaric

baricity > 1.0015

what are the 3 ventral and dorsal divisions of the brachial plexus clinically important?

because the ventral divisions generally supply the ventral (flexor) portion of the upper extremity and the dorsal divisions generally supply the dorsal (extensor) portions.

Early signs that preceed toxicity and first signs of toxicity of LA

before = lightheaded, tinnitus, circumoral numbness and tingling After = visual disturbance, muscle twitch, convusions

how much pressure should be applied in cricoid pressure?

between 30 and 44 newtons. it is recommended that 20 newtons be applied prior to loss of consciousness and that the pressure should be increased to 40 newtons after loss of conscoisness

Where dose blood pool commonly in c-section

between legs, need to wait until after case to count this loss

where is the superior vallecula

between the epiglottis and the base of the tongue

where is the sciatic nerve located

between the greater trochanter and ischial tuberosity. gluteal area sciatic nerve is 10 cm from midline, aka, the buttcrack

where is the inferior vallecula

between the inferior edge of the epiglottis and the true vocal cords

What is glottic opening

between vocal folds

name three drugs for use in aspiration risk reduction in awake intubation

bicitra metoclopramide H2 blocker

What to always use with fiberoptic to prevent damage

bite block

what color or pen should be used

black or blue sometimes facility specifies

Indications for MBT (3)

bleeding (hgb), symptomatic or certain diseases

How is trachlight inserted

blindly, so if there is airway anomaly then it may be difficult

Uvula purpose

block food from going from oral cavity into oropharynx (according to nagelhout... I think he might have meant nasopharynx)

Three consents obtained

blood procedure anesthesia

what is the definitive treatment for a post dural puncture head ache?

blood patch; it is 95% effective

What should your intra op care plan for a diabetic include?

blood sugar checks

Is the blue or clear cuff the bronchial cuff in double lumen ETT

blue = bronchial

Weakness with hypernatremia hyponatremia or both?

both

coma with hypernatremia hyponatremia or both?

both

cramps with hypernatremia hyponatremia or both?

both

irritability/agitation with hypernatremia hyponatremia or both?

both

cerebral edema with hypernatremia hyponatremia or both?

both (art says hypo)

confusion/disorientation with hypernatremia hyponatremia or both? What are the two unique symptoms of hyponatremia only? Hyper (5)?

both. Hyponatremia = n/v and anorexia. Hyper = Thirst, ICH, Twtich, hypovolemia and oliguria/polyuria, hyperreflexia

blood supply to larynx

branches of thyroid arteries

at the lateral border of the pectoralis minor muscle, the brachial plexus cords divide into 2 __________ that reorganize to form the _____________ of the upper extremity

branches, peripheral nerves

how is the thyroid cartilage connected to the hyoid bone?

by the thyrohypoid fascia and muscles of the larynx

what is done with the distal end of the wire once it is in place when performing a retrograde intubation?

it is secured with a clamp at the neck

oropharynx is anterior to _______ vertebrae

c2-c3

Larynx extends from c___ to c__

c3,4 to c6

Where does phrenic nerve originate from (cervical levels)

c3-c5

cricoid cartilage is at _______vertebrae

c5-c6

Which mallampati classification has visualization of the entire oropharynx including the soft palate, uvula, fauces (archway between oral and pharengeal cavities), and tonsillar pillars?

class 1

trace arterial blood supply to cricothyroid artery

cricothyroid artery, superior laryngeal artery, superior thyroid artery, external carotid

vocal ligaments are a thickening of what

cricothyroid ligament (which extends up to aretynoids and attaches to thyroid cartilage)

what does the external superior laryngeal nerve provide motor function for?

cricothyroid to do adductor tension

What kinds of things do you document in journal

emotional outbursts threats Anything that goes wrong with the case. Put names in your journal

Does anesthesia have to chart names of all present in OR

no, just the anesthesia providers involved

Do you use loss of resistance with spinal

no, look for csf

sodium deficit equation

deficit = na goal - na plasma x tbw (water)

When indications for cricothyrotomy are present the decision to place it should not be ___________

delayed

What is D02 and what is factored into it

delivered oxygen to tissues: -CI -sp02 -hgb

True or false? the use of FFP is encouraged if the INR is less than 2.0 in the absence of bleeding, and the use of vitamin K is discouraged if the patient is on warfarin?

false, FFP would be discouraged and Vitamin K would be encouraged

true or false? in daily clinical use, an LMA should not be used in place of bag mask ventilation during general anesthesia?

false, is can be used in place of bag mask ventilation

true or false? unilateral injury to the recurrent laryngeal nerve can compromise respiratory status?

false, it does not compromise respiratory status

True or false? injury to the superior laryngeal nerve will cause respiratory distress?

false, it does not usually cause respiratory distress.

true or false. a quinkie needle is often referred to as a pencil point?

false, it is a cutting needle

true or false? the anterior portion of the cricoid cartilage forms the posterior border of the larynx?

false, it is formed by the posterior border of the cricoid cartilage

true or false? the carnia has low innervation, thus making it unsensitive to sensory stimulation

false, it is richly innervated making it sensitive to sensory stimulation

True or false? in a PDPH vasoconstriction is caused by high CSF pressure

false, it vasodilation is caused by low CSF pressure

true or false? all of the approaches to the brachial plexus seem to use 30 to 35 mL of local?

false, only the interscalene, subclavian, inersternocleidomastoid and continuous catheter approaches do.

how do you do a test dose in a spinal?

you don't do a test dose in a spinal, but you can do an epi wash

true or false? visulization of the vocal cords is not possible with use of a fastrach LMA?

false, they can be seen with the aid of either a videoscope or fiberscope

true or false? epidural needles should be placed in a caudad direction

false, they should be placed cephalad

true or false? extension of less than 23 degrees of the atlanto-occipital joint means that visualization would be easy?

false, visualization would be difficult

true or false? it is standard to use an epi wash in an epidural?

false, washes are only used in spinals

True or false? the eipdural space is an air filled space physical space

false, you create a space when you inject

true or false? Cormack and Lehane grade 1 would be an easier intubation, grades 2 and 3 are difficult, and grade 4 requires a tracheotomy?

false. grades 1 and 2 are generally associated with an easier intubation, where 3 and 4 correspond with higher degrees of intubation difficulty

true or false? epidural catheter should be advanced at least 6 cm but no more than 10 cm

false. is should be only 3 to 5 cm

true or false? the use of cell salvage in combination with a leukocyte depletion filter is deemed unsafe?

false. it appears to be safe

true or false? the epidural space is a uniform column surrounding an equally uniform and tapering spinal cord?

false. it is a series of lateral, posterior, and anterior compartments existing among the vertebral body, lamina, and pedicles

true or false? when doing a bier block an 18 to 20 gauge i.v. is placed in a distal vein?

false. it is usually a small bore i.v. such as a 23 to 25 gauge and is preferred in the dorsum of the hand

true or false? the motor component of the recurrent laryngeal nerve provides motor function to all of the muscles of the larynx except for the thyroarytenoid?

false. it provides motor function to all except the cricothyroid muscle

True or false? after giving a test dose when doing an interscalene block a more pronounced twitch will be observed in the quality of the motor twitch; this indicates the needle is probably within the bracheal plexus sheath

false. you will see a fade, thus indicating the needle is probably within the bracheal plexus sheath

why is the arm raised after application of a tourniquet in a bier block?

for exsanguination

what is the purpose of cricoid pressure?

for posterior displacement of the cricoid cartilage against the cervical vertebrae with the patient in a 20 degree head up position to prevent regurgitation and possible aspiration of stomach contents during the induction of general anesthesia

how is the thyromental distance measured?

from the thyroid notch to the lower border of the mentum (at the chin) when the patients head is extended and mouth is closed

What dose palatine nerve innervate

from trigeminal nerve and sphendopalatine nerve. innervates superior and inferior surfaces of the hard and soft palate

pehochormocytoma and electrolytes

high ca++

sarcoidosis and electrolytes

high ca++

Is hypovolemia more associated with low or high na+

high na+

hallucinations with hypernatremia hyponatremia or both?

high na+

muscle twitch with hypernatremia hyponatremia or both?

high na+

Lower airway obstruction s/s

high peak pressure low tv imparied ventilation

What two things are needed for jet vent

high pressure source and a pressure regulator

Acute and chronic renal failure and K+

higher

Rhabdo and k+

higher

ace and k+

higher

addison's disease and K+

higher

cyclosporin and k+

higher

dig toxicity and K+

higher

exercise and K+

higher

nsaids and k+

higher

why do restrictive lung disease cause poor bmv

higher pressure required for ventilation needed and tighter seal needed

what is the hallmark sign of an upper airway obstruction in the unanesthetized patient?

hoarse or muffled voice, difficulty swallowing secretions, stridor and dyspnea

4 Hallmark signs of upper airway obsturction

hoarse or muffled voice, difficulty swallowing, stridor, dyspnea

what does unilateral injury to the recurrent laryngeal nerve result in?

hoarseness

bilateral denervation of of superior laryngeal nerve does what

hoarseness or tiring but airway is not jeopardized

unilateral injury to vagus nerve problems?

hoarsenss airway is protected

abciximab, eptifibatide, and tirofiban and restarting after procedures

hold 4-6 weeks

what is considered to be conservative management of a PDPH?

horizontal position, adequate hydration, oral analgesics, 500 mg I.V. caffeine benzoate, 300 mg oral caffeine or theophylline

Per ART 5 things we worry about during extubation

htn tachy cough breath hold Difficult extubation cyanosis HTC Hec

posteriorly, the thyroid carilage rises toward the _________ at the base of the tongue as the posterior _________

hyoid bone cornu

intracranial bleeding with hypernatremia hyponatremia or both?

hyper

What electrolyte disorder with any cancer of the bone or parathyroid cancer

hyper ca++

With what electrolyte imbalance should you reduce your non-depolarizeing paralytic dose

hypermag

hyper ca++ and CV s/s (BP, ekg x 4, dig)

hypertension sinus brady or av block short qt or bbb (heart is similar to high K+) vent dysrhythmias more dig toxicity

anorexia with hypernatremia hyponatremia or both?

hypo (high ca++ also according to art)

N/V with hypernatremia hyponatremia or both? What two electrolytes cause thirst? Low appetite?

hypo na+ = NV; Thirst = hypernatremia and hyper ca++, Low appetite = hyper ca++ and hyponatremia

the internal branch of the superior laryngeal nerve provides sensory input to the _________ above the vocal folds (cords).

hypopharynx

what part of the pharynx lies posterior to the larynx and is bound by the superior border of the epiglottis and the inferior border of the cricoid cartilage at the C5 to C6 level

hypopharynx

Where is epiglottis located in pharynx

hypopharynx or laryngopharynx

2 indications for 3% NS Per ART

hypovolemic resuscitation hyponatremia

Three major consequences of laryngospasm

hypoxia negative pressure pulm edema Cardiac arrythmias

what can happen if traction is applied to either the aorta or the brachiocephalic artery during thoracic surgery?

injury can occur to the recurrent laryngeal nerve thus causing hoarseness or stridor.

How to block lingual nerve

innervates anterior 2 thirds -have them anesthetize with topical on tongue first -protrude tongue -displace to one side and make gutter" -Where gutter meets the base of platoglossal arch 23-25 gauge needle is inserted 0.25-0.5 cm and is aspirated. -If air, then too deep, blood then move medial (carotid) -inject 1-2 ml lido

what does the posterior branch of the femoral nerve innervate?

innervation to the quadriceps muscles, knee joint, and its medial ligament and the origin of the saphenous nerve

While doing an axillary approach what should you tell the patient to do prior to injecting your local?

instruct them to immediately inform you if symptoms of last occur, such as, dizziness, tinnitus, metallic taste in mouth, circumorul numbness or tingling, visual disturbances, or muscle twitching

Laryngospasm is believed to be due to stimulation of the ______ nerve and afferent responses from _______nerves

internal branch of superior laryngeal nerve external branch of superior laryngeal nerve and recurrent laryngeal nerve

describe the fat in the epidural space?

it is physiologically fluid, acting as a pad and lubricant for the movement of neural structures within the canal

what do you know about a malplaced tongue that does not fit into the thyromental space?

it can obstruct the direct line of site with the glottic opening during laryngoscopy

what happens to the sciatic nerve as it is in the lower third of the thigh?

it divides into the internal and external popliteal nerves

what happens to the brachial plexus after the axilla?

it ends in the 4 terminal branches that supply the upper extreamity

where does the oropharynx lie?

it extends between the soft palate and the base of the tongue. The posterior portions connects directly with the nasopharynx

how effective is caffeine in treating PDPH?

it has been shown to eliminate headache in up to 70% of patients, but this effect may be transient

What does thyroarytenoid muscle do? How many parts to the muscles is there?

it has two parts. Vocalis attaches the thyroid to the arytenoids and causes loose vocal folds and lower pitch. Runs along lateral site of vocal ligament. The thyroepiglottic muscle attaches to epiglottis and closes it.

when doing a femoral nerve block what does the acronym NAVY mean?

it helps with the landmarks from lateral to medial, nerve, artery, vein, yin yang!!

What is cell salvage?

it involves the aspiration of blood shed into the surgical field into a specialized apparatus that concentrates the RBC's and washes the shed blood to remove debris, after which the RBC's are re-infused.

describe the posterior epidural space

it is a series of fat-filled tripodial pads, shaped like a three-sided sand dune

what angle is the crawford needle?

it is a straight tip

describe the arachnoid matter of the spinal cord

it is a thin spiderweb-like covering. this subarachnoid space is filled with CSF which help to protect the spinal cord from shock injuries

what is the intravascular portion of the ECF?

it is also referred to as plasma

how effective is an epidural blood patch in treating PDPH?

it is associated with a greater than 90% cure rate.

when would you use a taylor approach for a spinal?

it is best used for pelvic and perineal surgeries

where is the thyromental space?

it is bordered laterally by the neck, superiorly by the mentum, and inferiorly by the hyoid bone, which is semi fixed

do you need to worry about ABO combatibility with FFP?

it is desirable

Is vit K useful for coumadin or not effective

it is effective

when doing a retrograde intubation and your wire is visualized in the poserior pharynx, what is done with it next?

it is either advanced through the mouth or nose, often with magill forceps

what happens after you insert your wire or line via crcothyrotomy in a retrograde intubation?

it is passed cephalad into the oropharynx, this is done through a 14 to 18 gauge I V catheter or cook needle

where is the nerve located in the costal groove?

it is the most inferior of the neurovascular bundle

what is the interstitial compartment of the ECF?

it is the overflow reservior for the intravascular compartment

describe the pia matter

it is thin and is in direct contact with the outer surface of the spinal cord.

when would retrograde intubation be used?

it is used in a situation when intubation has failed but ventilation is possible

When is cell salvage, aka cell saver, used?

it may be used in surgical cases in which significant blood loss is likely, as well as in cases of unexpected massive blood loss.

what could happen if cricoid pressure is maintained during active vomiting?

it may result in a rupture of the esophagus

where does the sciatic nerve go?

it passes out the pelvis through the great sacrossciatic foramen, below the piriform muscle, then it descends between the major trochanter and the tuberosity of the ishium to the lower third of the thigh

what is the trans arterial technique for doing an axillary block?

it uses the intentional penetration of the axillary artery and aspiration of blood as the end point for determining that the needle is within the sheath

where will you see the femoral nerve on an ultrasound?

it will be a triangular hyperechoic structure lateral to the femoral artery

what is a hypobaric solution?

it would be less dense than CSF, and it would rise or float to the highest anatomic position

what do high airway pressures usually mean after intubation

kinked tube, low compliance, high resistance to flow

Why is surgical cricothyrotomy not suggested in kids younger than 12

larynx is small and pliable (makes procedure difficult)

when doing an interscalene block, what are the 5 landmarks to be aware of?

larynx. sternocleidomastoid. external jugular vein. cricoid cartilage, interscalene groove

what are the principal adductors of vocal cords

lateral cricoarytenoid muscles

For phonation: muscles involved, innervation, and main function

lateral cricoarytenoid muscles - adduct cords lateral thyroarytenoids- shortening and adduction of cords Medial cricoarytenoids-shortening of vocal cords Cricothyroids- shortening accoring to NH (actually lengthens) and increase cord tension INNERVATION - is all RLN except cricothyroids are external laryngeal nerve

purposes of airway exchange catheters

leave in during difficult airway extubation exhange of ett use it similar to bougie for placement

How can you test motor block

leg lift

will a patient with a high BMI take more or less of anesthetic in an epidural

less

3 advantages of tachlight vs. conventional laryngoscopy (one of them is type of difficult airway it is good for)

less affected by anterior larynx less stimulating less sore throat

The incidence rate of persistent parenthesia is:

less than 0.1%

what is commonly used to assess mouth opening, size of tongue, size of oral pharynx, and assessment of posterior oropharyngeal structures?

mallampati classification

what can cause glottis closing via epiglottis with LMA placement (2)?

malposition or overinflation

unilateral denervation of cycothyroid muscle does what

minimal effects, very subtle (exterior branch of superior laryngeal nerve)

Amount of evap loss in surgery type

minimal invasive surgery 2ml/kg/hr moderate 2-4 ml/kg/hr Severe 4-8 ml/kg/hr

What is meant by awake intubatioin

misnomer. Usually have both sedation and local and may be very drowsy, but able to cooperate and ventilate on their own

What happens during pre ox if not tight mask fit

mix nitrogen into it

what are extrapulmonary causes of a lower airway obstruction

morbid obesity=BMI greater than 30 pregnancy trauma

When is a surgical cricothyrotomy used?

most airway alogrithms and strategies recommend this procedure as a means of providing ventilation for patients who cannot be intubated or ventilated with a facemask or supraglottic device

what part of the pharynx will the auditory (eustachian) tubes be found in?

nasopharynx

where are opening to eustachian tubes and adenoids? Nasopharynx or oropharynx?

nasopharynx

what is the main reason people get nausea with a CNB?

nausea immediately after initiation of CNB is often considered a sign of significant hypotension

Name the causes of secondary hypoparathyroidismd (2 damage, 2 electrolyte, 2 illness, 3 drugs, other)

neck surg. carcinoma High or low mag sepsis pancreatitis burns Drugs (chemo, etoh, cimetidine)

in a spinal what is a strait midline approach?

needle is inserted directly midline between the spinous process and toward the umbilicus perpendicularly to all planes or at the lumbar level with a slight cephalad angle

what are some possible causes to permanent nerve injury with CNB

needle trauma to the nerves, hematoma, abscess, undiagnosed neurological disease

How far should you put in epidural catheter

needs to be 3-5cm deep. However, you may put it in deeper and the withdraw it once the needle is out of the back

Are most patients subject to low levels of ca++ from blood transfusions and citrate

no, not unless hypothermic and liver or kidneys disease. Can process 20 units/hour without low ca++.

Will you treat everyone only when they get to <6 Hgb

no, not with heart or lung disease or other 02 carrying problem, you may treat them when hgb <8

Do medial branch nerves have motor function

no, pureley sensory

With severe asthma do we always intubate?

no, we try not to if we don't have to because they have reactive airway on extubation

Thrombolytics and CNB

never

How to care for fiberoptic scope

never bend tight or kink, drop or banged protect in case

What gasses are good to use on kids other than sevo

nitrous, halothane if available

Are 'Short" items absolute contraindications for cricothyrotomy or tracheotomy?

no

Can HES be used with patients with liver disease

no

LMWH + antiplt and CNB?

no CNB

How is glidescope larygoscopy different than traditional

no direct view, must use video inserted midline rather then sweeping from right to left Must use stylet shaped the same way as 60 degree blade (most angled than normal blade)

should you transfuse PRBC's for a patient with a class 1 hemorrhage?

no it would not be necessary if there was no preexisting anemia. Their hemoglobin would be greater than or equal to 10

when placing a spinal how many ml's should you first inject for a test dose?

no more than 2 ml to avoid transient neuropathy

Epi wash with epidural?

no only with spinal

Does any supraglottic device have the same aspiration protection as and ETT

no, although some have some protection

is fastrach harder to insert than regular LMA

no, easy to adapt

Do you document things that didn't happen during your care

no, if someone aspirated after you are not with them, you don't have to chart that

Should HES be used for critically ill pts

no, including sepsis

Can you give blood patch through catheter?

no, infection risk and small catheter could get clogged plus tip of catheter is in wrong place.

Is retrograde intubation used in emergencies? How long does it take

no, it usually takes 5-7 minutes

do you need test dose with spinal?

no, just give half and wait a few min and then give the rest

when do you turn on the nerve stimulator?

not until the needle enters the skin

__________ may occur in the upper or lower airway and can severely limit the effectiveness of BMV.

obstruction

What is a six pack of plts

obtained from one donation of apharesis plts or six whole blood donations

What is trousseaus sign

occlude blood flow to arm for 3 min and your hand and finders will flex due to hyper reflexia from hypocalcemia

How should late entries be documented

often with a progress note with rough times and state it is a late entry

Spinal and epidural needle approach for scoliosis?

on the outside of the C curved spine, The vertebrae or more open here

Where should you put pulse ox if they are using retractors on chest

on the right arm. That will tell you if they have occluded subclavian artery and recurrent laryngeal nerve damage. Unlikely that you will be able to tell on the left because left is aorta. Unilateral = hoarseness

When cartilage in airway ceases

once bronchi reach 0.6-0.8 cm in size

when placing an epidural what is the hanging drop technique?

once the needle is in the interspinous ligament the hub is filled with NS. As the needle is advanced into the epidural space the drop of NS is drawn into the needle by the negative pressure

when placing an epidural what is the loss of resistance technique?

once the needle is in the interspinous ligament the stylet is removed and a syringe is placed containing 2 to 3 ml of NS or air and advanced while applying slight pressure on the syringe.once the needle is in the epidural space an immediate loss of resistance occurs

What are the two types of lights in laryngoscopes

one has fiberoptic, and one has electric connection with bulb in the blade

what is an armored ETT

one that risists being kinked but will remain permenantly kinked if pt bites too hard

about _______ of total body water is in the ECF

one third

Why would you place needle cricothyrotomy over surgical

only if anatomy is less favorable with surgical or kids

How many planes can fiberoptic scope move

only one, but you can change that plane by rotating scope

Do we chart padding of body

only upper body, but make sure someone is charting what we don't

When are late entries ok

only with vitals or in a code. Vitals aren't late because you always are looking at them

Innervation of nose mucous membranes

ophthalmic division (v1) of trigeminal nerve anteriorly (anterior ethmoidal nerve) maxillary division (v2) posteriorly (sphenopalatine nerve) SEE M & M pg. 310-311 for nerves, muscles, cartilages

What is one of the first things you should consider if bag mask vent is difficult

oral airway

Oral airway or nasal better in head trauma

oral if possible. Nasal can go to cranial vault

What length of ett should you use for oral and nasal

oral is tube size x 3. Nasal you add 2-3cm to oral.

___________ innervation in the tracha is derived from branches of the vagus nerve.

parasymphathetic

class II mallampati

part of uvula soft palate tonsil pillars

How does exhalation occur with jet vent

passively through upper airway

what are absolute contraindications for spinal or epidural?

patient refusal uncorrected coagulopathy infection at the site of the block unable to obtain informed consent increased ICP

When discussing respiratory status on your post-op care plan what are some criteria to consider?

post op ventilation and proper reversal

What part of care plan are blood gas found in

potentially all three

Is whole blood or PRBCs safer

prbc, less wbc and antibodies that cause rxns

What part of care plan are BS checks

pre, intra, and postop

What is acute normovolemic hemodilution

removal of whole blood right be fore case and then give crystalloid to dilute blood so when blood is lost it is dilute. Then after bleeding stops, you give whole blood back with higher HCT to increase amount of RBCs

During laryngoscopy sweep the tongue from

right to left

Soft palate location and purpose

rises during swallowing to prevent food in nose. posterior 1/2 to 1/3 or palate

lateral cricoarytenoids

role: phonation function: close glottis, adduct vocal cords innervation: RLN

cricothyroid

role: phonation function: elongates and increased tension of cords innervation: ELN

posterior cricoarytenoids

role: respiration function: abduct vocal cords, open glottis innervation: RLN

Internal arytenoids

role: sphincteric function function: closing of posterior commissure of glottis innervation: RLN

Other than tongue what else dose glossopharyngeal nerve innervate in the airway

roof of pharynx, tonsils, under surface of soft palate

Alternative ways to insert LMA

rotate 180 degrees, or partially/fully inflate.

If resistance is felt while inserting and ett over any catheter what can be done?

rotate about 90 degrees back and forth with gentle pressure

What are the 3 neuro/reflex/nerve signs of low ca++

seizures hyperreflex paresthesia

what is the role of the interarytenoid?

sphinicteric function

Is introducer used with epidural or spinal

spinal because the needle is small gague

where are the 2 regions that the spinal cord enlarges?

spinal segments of C4 to T1 and L2 to S3

How does test dose of spinal differ from epidural

spinal you are not worried about a huge dose going intrathecal or vascular. You can inject half of your dose, wait 3-5 min and then inject the other half

Just like normal extubated patients those with airway exchange catheters can still .....(3 items)

spontaneously breath clear secretions phonate

CNB (both) volume increases what

spread of the block

true or false? 100 mcg of fentanyl can be injected as a test dose in an epidural?

true

which of the ankle nerves becomes superficial in the middle two thirds of the lower leg and remains subcutaneous as branches

superficial peroneal nerve

which of the ankle nerves provides innervation in the dorsum (top) of the foot?

superficial peroneal nerve

superior and inferior boarders of hypophargynx according to nagelhout

superior is epiglottis inferior is cricoid cartilage and upper esophageal sphincter is at lower edge

Treatment for TRALI

supportive

trace blood supply to the supraglottic region of larynx and infraglottic region of larynx (nagelhout version of blood flow)

supra- external carotid, superior thyroid artery, superior laryngeal artery Infra - external carotid, inferior thyroid artery, inferior laryngeal artery

The inter incisor gap is especially useful for what ventilation devices

supraglottic airways like LMA

which of the ankle nerves are formed from the union of a branch of the tibial and common peroneal

sural

which of the ankle nerves provides sensory innervation to the lateral posterior portion of the sole of the foot, and portion of achilles tendon above the ankle

sural nerve

Should blood sugar management be included on the post op care plan for a patient with the sugar diabetes?

sure

What are some generally accepted contraindications to cell salvage?

surgery involving woulds contaminated by bacteria sepsis bowel contents amniotic fluid malignant cells

Is needle or surgical cricothyrotomy preferred

surgical, more secure and better ventilation

the tracheobronchial trees receive ________ innervation from the first through the fifth thoracic ganglia.

sympathetic

How much above and below a sensory block will sympathetic and motor block be

sympathetic 2-4 levels above motor is 2 below

What is chvostek's sign

tap masseter muscle and get facial twitch from hyperexcitibility due to low ca++. Chomp-stick

when placing a spinal you feel a click or a pop....what should you do next?

that means you have passed though the dura, so you should remove the stylet and wait several seconds for CSF to return through the small gauge needle

what would you consider about the ease of intubation when you measure a patients thyromental distance less than 6 cm?

that would be the same as less than 3 finger breadths so they would be considered to have a higher incidence of a difficult intubation

what is included in the infraclavicular portion of the brachial plexus?

the 3 cords and their terminal branches

What happens to the brachial plexus as its divisions enters the axilla?

the 3 posterior combine to form the posterior cord, the anterior divisions of the superior and middle trunks combine to form the lateral cord, and the anterior division of the inferior trunk continues to become the medial cord

what is included in the supraclavicular portion of the brachial plexus?

the 5 primary ventral rami and the 3 nerve trunks and their 6 divisions

how would you calculate a maintenance drip for a pediatric patient that is 10 to 20 kg

the first 10 kg gets a calculation of 4 ml/kg/hour, then any wieght over that initial 10 kg gets calculated at 2 mL/kg/hour. for example: a 20 kg child would have 40 mL/hour plus 20 mL/hour equaling 60 mL/hour

how would you calculate a maintenance drip for a pediactic patient that is over 20 kg?

the first 10 kg gets a calculation of 4 ml/kg/hour, thenext 10 kg gets calculated at 2 mL/kg/hour. the rest that is over 20 kg gets 1 mL/kg/hour for example: a 25 kg child would have 40 mL/hour plus 20 mL/hour plus 5 mL/kg.hour equaling 65 mL/kg/hour

what is formed by the space between the inferior edge of the epiglottis and the true vocal cords?

the inferior vallecula

Where is the ICF found?

the intracellular fluid is found inside the plasma membrane....this is where chemical reactions take place.

what is a laryngospasm?

the involuntary protective reflex and contraction of the laryngeal musculature

when doing a 3 3 2 measurement if the 2 is more than 2 finger breadths what does that mean?

the larynx may be positioned too far down the neck and could be difficult to visualize

when doing a 3 3 2 measurement if the 2 is less than 2 finger breadths what does that mean?

the larynx may be tucked under the base of the tongue, which would be indicitive of an anterior larynx

what nerve of the lumbar plexus is formed from the second and third lumbar nerves and is the first to leave the compartment?

the lateral femorl cutaneous

How long can you manipulate the level of block with positioning after SAB

the length of drug onset so usually 3-8 min (somewhere said maybe up to 60min)

what protects the posterior epidural space

the ligamenta flava, the lamina, and the spinous processes

The vertebrae with the widest space is:

the lumbar vertebrae

What does 7.0 ett mean? What are lines on outside?

the lumen in mm cm on outside

true or false? The higher the site of injection the higher the the level of sensory block, but this is limited by the anatomy of the spinal cord

true

when doing an airway block how much direct local is put on the cords?

the patient takes a deep breath while instilling 5 ml of 2% lido

when doing a test dose with lidocaine in an epidural how will you know if you are intravascular?

the patient will have tinnitus, a metallic taste in their mouth, circumoral numbness, or a rushing sound in the ears which will only last for less than 5 minutes

in the brachial plexus what do the radial and axillary nerves supply?

the predominatly supply the dorsal portions of the upper extremity

besides having a larger epidural space, what is another important factor to stay midline with an approaching anesthetic needle?

the presence of the epidural veins.

what are the landmarks to use when doing a radial block at the wrist?

the radial styloid process and the radial flexor muscle

in the brachial plexus what combines to form the inferior or lower trunk

the rami from C 8 and T 1

traction on aorta or brachiocephalic artery during thoracic surgery can cause damage to what nerve

the recurent laryngeal nerve (RLN) which can cause malfunction of the cricothyroid muscle and hoarseness

what does the laryingopharynx include?

the region of the pharynx lying between the hyoid bone and the glottis

what is baricity?

the resting position of two fluids with differing specific gravities when the fluids are mixed in a single container, such as CSF and an anesthetic agent in the subarachnoid space.

what landmarks used in an intercostal nerve block?

the rib is palpated posterior to the midaxillary line. the lateral border of the sacrospinal muscle which lies about 7 to 10 cm from the midline

what can occur if ventilation is performed using postitive pressure greater than 30 cm H2O with the proseal LMA

the stomach can become inflated

What part of fiberoptic scope is most likely to cause infection

the suction port. It can be hard to clean between uses.

what needs to be documented on the post anesthesia care evaluation when taking an intubated patient to the PACU?

the type of tube and vent

If you give large volumes of fluids, what should always be addressed

the underlying cause

true or false? Unilateral or bilateral vocal cord paralysis can most often be attributed to nerve or mechanical injury and may manifest as partial or complete airway obstruction?

true

what if a patient demonstrates substantial or complete immobility of the atlanto-occipital joint?

then significant laryngoscopic compromise should be anticipated

true or false? a CSE is a viable option for a person having a total knee at 7:30 in the morning?

true

true or false? a nerve stimulator should have a digital readout of the amplitude?

true

true or false? all epidural solutions should be injected at 3 to 5 cc increments every 3 mins and titrated to desired anesthetic level?

true

why does the epidural needle have a blunt bevel and a gentle curve?

to pass through the skin and ligamentum flavum and abut against the dura

clinically what is the posterior segment of the cricoid cartilage used for?

to push against the esophagus during cricoid pressure

With unilateral RLN injury the vocal cords shift______

to the uninjured side

oropharynx anterior boarder to oral cavity?

tonsilar pillars

what are some common causes of laryngotracheal edema (4)

too large of cuff High cuff pressure double lumen tube traumatic suctioning

dig and ca++

too much ca++ = dig toxic Too little ca++ = dig resistant

Which ion potentiates action of Non-depolarizing NMBDs

too much mag

the duration of a spinal anesthetic is based primarily on anesthetic choice and ________.

total dose

Difference between total spinal and high spinal

total is coma high is brady and dyspnea

What does nagelhout say the lower airway is?

trachea to alveoli (below cricoid cartilage)

what does the fourth recommendation set forth by the AABB state?

transfusion decisions should be influenced by symptoms as well as hemoglobin concentration

What is TRALI

transfusion reaction acute lung injury Lungs swell, edema, microvascular hemmorage etc

What is TNS

transient neurologic symptoms symptoms

True or false? there has been a recorded Jehovah Witnesses who survived with hemoglobin as low as 1.8?

true

True or false? when calculating fluid deficit and fluid replacement you should take bowel prep and evaporative loss into consideration?

true

true or false every incremental dose in an axillary block should be considered a test dose?

true

true or false? cricoid pressure is a mainstay of anesthetic practice, particularly during rapid sequence induction of general anesthesia in patients at high risk for gastric aspiration?

true

true or false? intercostal nerve blocks can provide analgesia during or after chest tube placement insertion to limit the patients discomfort

true

true or false? plasma proteins, such as albumin, maintain osmotic pressure to maintain volume?

true

true or false? proper atlanto-occipital mobility is required for an adequate sniffing position?

true

true or false? supraglottic airways, such as an LMA, were first introduced as a substitute for face mask ventilation as as an alternative to difficult tracheal intubation?

true

true or false? surgery, neck trauma, or neoplasms can cause injury or damage to the recurrent laryngeal nerve and the superior laryngeal nerve

true

true or false? the IVF and the ISF are parts of the ECF?

true

true or false? the cricoid has a posterior segment?

true

how much does 25% albumin expand intravascular volume?

up to 5 times the volume infused.

How far can neck move with full extension to full flexion in cm?

up to 6 cm (average of 3.8 cm)

How long can an airway exchange catheter stay in?

up to 72 hours

ULBT classes

upper lip bite test I is prtrude lower incisors past upper and bite above the vermilion boarder II-can move the lower incisors in line with the upper and can bite lip below vermilion boarder III- Lower incisors cannot move in line with upper and cannot bite upper lip

should you transfuse PRBC's for a patient with a class 2 hemorrhage?

usually not necessary, unless preexisting anemia and/or cardiopulmonary disease

What is bicitra?

usually used preop to lower stomach acid (sodium citrate). Usually oral

What 3 extra times are charted with c-section

uterine cut time. Baby is at risk once uterus is cut Birth time Apgar times (1 and 5 min)

If you have loss of sensation up to t10 and have a lot of hypotension, you probably just have _______, if you get brady and your sensation is T8-T6 then it is probably due to ____ _____ with ______ block

vasodilation high spinal sympathetic

Can "short form" be used for longer cases?

yes, just number them. One page has enough for 3.5 hours of info. Complex has enough room for 5 hours

How does high spinal effect respirations

ventilatory function (how deep they breathe) intercostal and abdominal muscle paralysis around T4? There is no phrenic nerve problem this high, just accessory.

what are the 5 parts that the brachial plexus is composed of?

ventral rami, trunks, divisions, cords, and their branches

what instructions are given to a patient when using a nerve stimulator?

verbally identify discomfort, and do not move during the advancement of the needle

Aggrastat and Integrilin (eptifibatide, and tirofiban) and CNB

wait 8 hours (allows normal plt function)

4 ways to reduce fiberoptic scope fogging

warm on pt. lip antifog liquid warm in warm saline Blow 02 through suction lumen

Cost of running cell saver

washing and infusing is $700

What is tracheomalaicia? What problem can it cause with anesthesia?

weak tracheal cartilage that can cause collapse of trachea. Bad for extubation

What are some symptoms of hypercalcemia?

weakness low energy low appetite nausea/vomiting increased thirst/dehydration paralytic ileus/constipation

2 reflex, 3 muscle signs of low ca++

weakness spasm tetany chvostek's and trousseaus sign hyperreflex

when is a primitive blood gas barrier developed in fetus

week 26

because of the tripodal, dunelike shape of the epidural space, when can an anesthesia provider expect it to narrow considerably?

when approaching laterally to the midline, and in more caudad areas of the space

When is LMA used in OB patients

when intubation has failed and face mask ventilation is difficult

When are platelet replacements indicated for levels between 50k-100k instead of <50k

when microvascular bleeding at risk for plt dysfunction continued bleeding

what is an isobaric solution?

when the baricity equals 1

When do you still need more reversal when you have 4/4 train of four twitches

when they have poor breathing

what is the cornus medullaris?

where the spinal cord tapers after the L2 area


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