Anaesthesia UK : UBP Question 1. Question 1 (Short Form)A 5’7’’, 1.
Home Interior Design – All About Luxury and Elegant Home Design In The World. Slovoed Multilingual Dictionaries. The most advanced dictionary technology from the developers of the world’s leading reference applications. More. Shivering. Shivering and shaking bother about 40 percent of patients after an anesthetic, according to 'Miller's Anesthesia, 7th edition.' Intuitively. Schrier Manual of Nephorology Diagnosis and Therapy Sauers Manual of Skin Disease Samuels Manual of Neurological Therapeutics 6th ed Safani, Chan.
Travelling like tramps around the World for less than $25 a day. This Website Is Intended To Provide Medical Ebooks For Free Download By Doctors & Medical Students.
He is somnolent, uncooperative, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. On examination, he has a swollen right leg, ecchymosis into the periorbital tissue, hemotympanum, multiple facial fractures, and multiple loose teeth. There is an 1. 8g IV in his left arm with D5. LR hanging. Vital Signs: P = 1.
R = 2. 4, BP = 1. O2 sat = 9. 6% on non- rebreathing mask, T = 3. C Pre- operative Management. What is the Glasgow Coma Scale? The patient opens his eyes to pain. What is his score? What are your treatment goals in this patient?
Partners in global health have made tremendous progress in the last decade in the fight against HIV, tuberculosis and malaria. By working together and.
Would you intubate this patient? The patient is becoming more combative. How will you intubate him? Are you comfortable using Succinylcholine?
The neck radiographs show no apparent injury. Is this patient’s C- spine clear? What are the criteria to clear a C- spine? You are having difficulty placing the endotracheal tube with direct laryngoscopy, and the resident suggests a blind nasal technique. How would you respond?
Ok, the patient is intubated. What do you make of his initial vital signs? Does this patient require fluid resuscitation? Are you ok with the D5. LR that is currently hanging?
Any concerns with LR? Would you lower the blood pressure? What is the equation for cerebral perfusion pressure?
Isn’t there autoregulation of blood flow to the brain? What is the range for normal cerebral autoregulation? What is normal CPP? What is ideal in a patient with traumatic head injury? Pre- operative Management. What is the Glasgow Coma Scale? UBP Answer: A scoring system based on eye opening, best motor response, and best verbal response that has a strong correlation with severity of head injury and patient outcome.
A score of 8 or less which persists for 6 hours is considered severe injury and is associated with a mortality rate of approximately 3. A score of 9- 1. 2 suggests moderate injury and a score of 1. The patient opens his eyes to pain. What is his score? UBP Answer: Given that he opens his eyes with painful stimuli (2), withdraws from pain (4), and is exhibiting inappropriate speech (3), his score would be a 9, suggesting moderate brain injury. Glasgow Coma Scale: Patient Response. Score. Eye Opening.
Spontaneous. 4To Speech. To Pain. 2None. 1Verbal Response. Oriented. 5Confused Speech. Inappropriate Speech. Incomprehensible Sounds. None. 1Best Motor Response. Obeys Commands. 6Localizes Pain.
Withdraws to Pain. Decorticate Flexion. Decerebrate Extension. No Response. 13) What are your treatment goals in this patient?
UBP Answer: My initial goals are to assess and secure his airway and then achieve hemodynamic stabilization. Additionally, I would treat and avoid contributory factors to secondary neurologic injury such as hypoxia, hypercarbia, hypotension, and anemia. Finally, a full body assessment for injuries would be performed if not done simultaneously. Would you intubate this patient? UBP Answer: Given the potential difficulty of managing his airway due to his super morbid obesity, facial injuries, C- collar, and signs consistent with basilar skull fracture, I would be very concerned that further deterioration of his mental status could place me in the position of managing his airway emergently (i.
Moreover, this patient with a significant head injury may not tolerate the hypercapnia- induced increases in cerebral blood flow, and subsequent increase in ICP, associated with hypoventilation or apnea. Therefore, I would proceed with intubation, despite the presence of spontaneous ventilation, to reduce the risk of aspiration, hypoventilation, apnea, and to forego the necessity of managing his difficult airway under more emergent conditions. The patient is becoming more combative. How will you intubate him? UBP Answer: My primary goal is to safely secure the potentially difficult airway of this uncooperative and super morbidly obese patient who has facial injuries, a C- collar in place, and signs consistent with a basilar skull fracture (which would eliminate nasal intubation as an acceptable alternative). However, while intubating him I would attempt to avoid: (1) factors that may contribute to increased intracranial pressure, such as hypoxia, hypercarbia, and sympathetic stimulation; (2) hypotension, which may lead to inadequate end- organ perfusion (cerebral perfusion is particularly at risk if his intracranial pressure is elevated); (3) cervical spine injury; and (4) aspiration of either gastric contents or damaged teeth. Therefore, since an awake fiberoptic intubation would not likely prove successful (uncooperative, facial/airway trauma), I would (1) ensure the availability of difficult airway equipment; (2) have the surgeon at bedside and ready to perform a tracheostomy, if necessary; (3) place the patient in 3.
ETT placement. 6) Assuming you are concerned about elevated intracranial pressures, is it advisable to utilize ketamine for induction? UBP Answer: Ketamine- induced increases in sympathetic tone, cerebral blood flow (may increase 5. CMRO2 (total CMRO2 is not increased because increases in some areas of the brain are balanced by decreases in other areas) are undesirable in this patient with potentially elevated ICP. However, my overriding goal when inducing this patient with a potentially difficult airway is to maintain spontaneous respirations throughout induction and intubation. Therefore, given the minimal effects of carefully titrated ketamine on ventilatory drive, I would administer this drug for induction, recognizing that the potential detrimental effects on ICP are small in comparison to those associated with hypoxia, hypercarbia, and loss of the airway. Shouldn’t you use succinylcholine for ETT placement? UBP Answer: While succinylcholine would be desirable in optimizing intubating conditions and reducing the risk of aspiration, I would not utilize it in this case due to concerns for difficult airway management and potentially elevated ICP.
My primary reason for avoiding succinylcholine is the risk of inducing apnea in this patient with potentially elevated ICP (hypoxia and/or hypercarbia lead to increased ICP) and several risk factors for difficult airway management (i. C- collar). Moreover, the transient increase in ICP associated with succinylcholine (possibly secondary to fasciculations) would be undesirable in this patient with apparent head trauma (although this succinylcholine- induced increase in ICP tends to be transient and small in comparison to that which would result from hypoxia or hypercarbia). The neck radiographs show no apparent injury. Is this patient’s C- spine clear? UBP Answer: It is impossible to clear this patient’s C- spine given his mental status, which makes it impossible to rule out pain upon palpation of the cervical spine. Radiographs should include anterior/posterior, odontoid, and lateral neck views showing C1 through T1.
Despite all of these radiographs showing no injury, 7% of fractures are still missed and ligamentous injury is not ruled out. What are the criteria to clear a C- spine? UBP Answer: The criteria include: 1) no cervical pain or tenderness, 2) no paresthesias or neurologic deficits, 3) normal mental status, 4) no distracting pain, and 5) > 4 years of age.
If the above criteria are not met then a negative lateral c- spine showing C1 through T1; an open mouth odontoid view; and thoracolumbar, anterior/posterior, and lateral plain films should be obtained. You are having difficulty placing the endotracheal tube with direct laryngoscopy, and the resident suggests a blind nasal technique. How would you respond? UBP Answer: Given the presence of periorbital ecchymosis and hemotympanum, it would be inappropriate to perform a blind nasal intubation as these findings suggest a possible basilar skull fracture.
With this type of fracture, there is a risk of advancing the ETT into the brain when attempting a blind nasal intubation. Ok, the patient is intubated. What do you make of his initial vital signs? UBP Answer: A hyperdynamic circulatory response is not unusual following head injury and may result from a surge in epinephrine.
Additionally, pain, hypoxia, hypercarbia, hypovolemia, and/or anemia could be responsible for his tachycardia and hypertension. In either case, I would attempt to optimize the patient by controlling his pain, replacing fluid losses with blood products or crystalloid as necessary, and ensuring adequate ventilation. Given my concerns about potentially elevated ICP and decreased cerebral perfusion pressure, I would probably avoid treating his tachycardia and hypertension with a ß- blocker or vasodilator.
If treatment of this kind was deemed necessary, I would use a short acting agent like esmolol. This patient is also mildly hypothermic which may be beneficial in so far as it reduces CMRO2. Does this patient require fluid resuscitation? UBP Answer: Possibly. I would perform a thorough exam with special attention to urine output (if a Foley catheter is in place), mucous membranes, cap refill, and blood loss, recognizing that there could be hidden blood loss in the abdominal compartment or secondary to the right femur fracture. My goals in fluid resuscitation are to maintain cerebral perfusion pressure by restoring circulating blood volume and avoiding hypotension. At the same time, I want to reduce the risk of cerebral edema by maintaining serum osmolality and avoiding significant reductions in colloid oncotic pressure.
Are you ok with the D5. LR that is currently hanging? Any concerns with LR? UBP Answer: I do have a problem with the D5. LR since hyperglycemia may augment ischemic brain injury. For this reason, glucose containing solutions are usually avoided in patients with brain injury. Theoretically, the small amount of free water in lactated Ringer’s solution (1.
L of free water per liter) could result in increased brain edema as compared to an isotonic solution such as normal saline. Would you lower the patient’s blood pressure if it increased to 2.