Board Review 2007 Karl Wagner MD June 14, 2007
Things to read… Hall Faust Morgan and Mikhail Bible Jensen’s Do questions
Adult pt had GA with ETT. He is now waking at the end. RR 29, VC 12 cc/kg, MIF -15. Do you extubate? no
Criteria for extubation Mechanics -- RR 15cc/kg (adult), >10cc/kg (child), MIF greater than -20 Oxygenation – PaO2 70mmHg on 40% fiO2, A-a grad <350 with fiO2 100 Ventilation – PaCO2 <55, Vd/Vt <0.6 Also afebrile, no pressors, stable vitals, awake and alert
What is the O2 consumption for an adult? Neonate?
3 cc/kg and 6 cc/kg respectively
Is this a normal gas? Newborn umbilical vein 7.35/40/30
ABG’s They will just show you a gas and ask what you should do. Nothing, intubate, give bicarb, leave room. Uvein as before, Uart 7.28/50/20 (remember the weird fetal circ), 60 mins 7.35/30/60, 24 hrs 7.35/30/70, Adult and child 7.4/40/100.
How much blood does Vera have? Neonate 0-30 days -- 85cc/kg Infant 1-12 months – 80 cc/kg Child 1-12 years – 75 cc/kg Adult 70 cc/kg
How do you calculate the dose of bicarb?
They will tell you the patients base deficit (deviation of bicarb from 24) is x and ask you to choose the appropriate dose of bicarb. Kg x be x 0.2 Note: if infant use 0.4
How fast does CO2 climb in one of Woodring’s patients?
6 the first min and 3 every min after. They will just give you the PaCO2 and ask how long the patient has been apneic (don’t forget they start at 40!)
Can you name the six things I listed on the next slide that decrease FRC?
Pregnancy Ascites Neonate GA Obesity Supine position PANGOS
What increases dead space?
Age, anticholinergics Bronchodilators Upright position Hypotension, hypothermia, hypovolemia Smoking Pulmonary disease such as PE or decreased perfusion
ACLS SO Factors that increase closing capacity Age Chronic Bronchitis LV fail Smoking Surgery Obesity
Effects of Hypercarbia (A RIPE) (not breathing enough) Acidosis, arrythmia Right shift O2-Hb curve Intracerebral steel PA pressure increase Epi-norepi release
Hypocarbia (AVCO) (breathing too much) Apnea, alkalosis, airway constriciton v/q mismatch Decrease CO, CBF, Coronary BF, Ca2+ O2-Hb curve to left
Calculate this… I dare you SVR
(MAP-CVP)/CO*80
Local anesthetics quick Where are they metabolized? Or do they just go away quietly?
Esters (procaine, tetracaine, chloroprocaine) – plasma cholinesterase Amides (those with the extra “i”) – liver microsomal enzymes
Calculate this and you will become popular with the ladies… O2 content in blood
Which is more important? Bound or disolved? Go to next slide for answer and nirvana
Give these patients Hb (1.38*Hb*Sat)+(0.003*PaO2)
Trick blood question What is most common virus passed along?
CMV but no one cares because everyone on planet has this already.
How much CO2 can an absorber hold? Bara and Soda
26L CO2 per 100g of stuff
What is the only antiemetic you can give a parki?
Ondansetron – do you remember the receptor it binds?
If a patient is taking an oral alpha 2 agonist (name drug now) do you ever stop it pre op? Why or why not?
Clonidine, and no. It causes rebound hypertension
This can not be learned, only tatooed before exam time. Which blood products need (or don’t need) to be cross matched before giving them to our patients?
Platelets only if refractory to random platelets FFP not crossed Cryoppt not crossed PRBC crossed
Which drugs do not cross the placenta? He is going nowhere soon.
Heparin Insulin Glycopyrollate Nondepolarizors Succhinylcholine
Why does meperidine cause tachycardia?
The molecule is shaped like atropine. The question will list a bunch of drugs, probably narcs and ask which causes tachycardia.
What do you do when Trang goes “who knew that was flamable” while he is using his “laser” in the airway and smoke starts pouring out?
Please remove tube quickly Don’t forget to stop fresh gas flow
What are effects of retrobulbar block?
ptosis Akinesia of globe Anesthesia of globe Blindness
After Stevens lets you do a retrobulbar and the patients starts to seize, where did you inject?
Artery
A guy gets a retrobulbar block and like five minutes later you are reading your wall street journal and the patient brady’s down to asystole. Note: They can go right to asystole they don’t really need the brady part. What just happened?
Occular cardiac reflex, probably from retrobulbar hematoma
What happens when we let the medical student do the retrobulbar block and the patient gets all apneic but no cardiac or seizure symptoms?
That stuff is floating in the CSF and they have brainstem anesthesia aka high spinal
You will have to calculate the fluid balance for someone. Either child or adult. Remember the 4,2,1 rule. They will just say a patient had this procedure and had this fluid was it adequate?
Pt takes dig and needs emergent operation. Potassium is 3.0. Is that ok?
Give KCl and go to OR. Dig tox comes from: Hypokalemia (hey how fast can you give this stuff?) Hypothyroid Hypomagnesemia Hypercalcemia Renal failure (#1 answer Bob)
Classic Old guy s/p chole or colectomy or something. He is having ischemic ST segment changes and is shivering in PACU. BP 220/120 HR 120. What are you going to do first?
Control HR and BP. Fix other stuff second.
10 y/o male with DMD comes to PSE for his upcoming whatever. What test does he need?
ECHO, these guys die from heart failure. They have cardiomyopathies and atrophy of cardiac muscle. The second important system is pulm. They can not cough because they are too weak. They also die from pnuemonia.
At least one airway question. How can I block it so I can do my awake fiberoptic without all that messy lidocaine nebulization?
Glossophyngeal Superior laryngeal Recurrent laryngeal Secret nose nerve for Dr. Gordon and our friends at the ABA.
Hey doc, got a minute? Ask me about the circle system and the circuits that I for sure will have to identify at my exam.
Blocks are like 15 questions or so. Those have to be free points for you. They are going to ask some thing weird that you will loose valuable points on so get these correct. Come to part Dos next week.