Anesthesia and EM Exam

The 5 goals of general anesthesia

hypnosis, amnesia, analgesia, akinesia, autonomic and sensory block

3 GA induction things to do before patient arrival

machine check, prep for airway management, prep of routinely administered drugs

2 GA induction things to do after patient arrival (before induction)

Connect standard ASA monitors, establish IV access

2 GA induction things to do immediately before induction

optimize patient positioning, preoxygenation using 100% oxygen

3 types of medications necessary for IV anesthetic induction

sedative (hypnotic agent), adjuvant agents, neuromuscular blocking agent (NMBA)

Perform mask ventilation until patient is adequately ___

anesthetized/relaxed

Propofol, etomidate, and ketamine are ___

sedatives

Short acting opioids, midazolam, and lidocaine are ___

adjuvant agents

Propofol’s mechanism is ___

increasing activity at inhibitory GABA synapses

Propofol induction doses have the CNS effect of producing ___

unconsciousness

Low propofol doses have the CNS effect of producing ___

conscious sedation

Propofol (has/does not have) analgesic properties

does not have

Propofol is a cardiovascular ___, it produces dose-dependent ___ in arterial BP and cardiac output

depressant, decrease

The respiratory system effects of propofol include a dose dependent decrease in ___ and ___. Ventilatory response to ___ is dimished

RR, tidal volume, hypercarbia

Induction dose of propofol is ___ IV

2-2.5 mg/kg

Sedation dose of propofol is ___ infusion

25-75 mcg/kg/min (titrate to desired effect)

Maintenance of GA propofol dose is ___

100-150 mcg/kg/min

Reduce propofol doses in ___, sick, and ___ patients

hypovolemic, elderly

An adverse effect of propofol is ___ irritation that may cause ___ during IV administartion

venous, pain

Pain from propofol may be reduced by administering ___ prior or adding ___

opioids, lidocaine

Etomidate’s mechanism of action is ___

augmenting inhibitory tone of GABA in CNS

Etomidate induction (does/does not) produce unconsciousness

does

Etomidate (does/does not have) analgesic properties

does not have

Etomidate causes (significant/minimal) changes in HR, BP, and CO

minimal

___ is frequently used for induction of GA in hemodynamically compromised patients or cardiac or neuro cases where maintenance of stable hemodynamics is essential

Etomidate

The respiratory effects of etomidate are a dose dependent decrease in ___

RR and TV

___ causes myoclonus, nausea/vomiting, venous irritation, and adrenal suppression

etomidate

Ketamine’s mechanism is ___

NMDA antagonism

___ produces a dissociative state accompanied by amnesia and analgesia

Ketamine

Ketamine (does/does not) have analgesic properties

does

Ketamine (decreases/increases) cerebral blood flow, metabolic rate, and ICP

increases

Ketamine (decreases/increases) HR and blood pressure by release of endogenous ___

increases, catecholamines

Ketamine causes very mild ___ of RR and TV

depression

Ventilatory response to hypercarbia under ketamine is (minimally/significantly) affected

minimally

Laryngeal protective reflexes are maintained longer under ___ than with other IV anesthetics. It alleviates bronchospasm

ketamine

Ketamine’s induction dose is ___ IV and ___ IM

1-2 mg/kg, 5-10 mg/kg

Ketamine’s sedation dose is ___

0.2 mg/kg (titrate to desired effect)

___ causes increased oral secretions, hallucinations, agitation, increased muscle tone, increased ICP, horizontal nystagmus, and increased IOP. Anesthetic depth is difficult to assess

Ketamine

Fentanyl dose is ___ IV

25-100 mcg (0.5-1 mcg/kg)

Lidocaine dose for suppression of airway reflexes is ___

0.5-1.5 mg/kg

Lidocaine dose to reduce pain on injection of other agents

20-30 mg

Reduce or avoid lidocaine in patients with ___

hemodynamic instability

Midazolam dose

1-2 mg (administered in 1 mg increments)

Reduce or avoid midazolam in patients with ___

hemodynamic instability

Lidocaine increases ventricular rate in patients with ___

atrial fibrillation (avoid in WPW or high-grade heart block patients)

___ provide optimum intubating conditions and facilitate surgical exposure/improve surgical conditions

muscle relaxants

A (depolarizing/nondepolarizing/either) muscle relaxant can be used for intubation

either

A (depolarizing/nondepolarizing/either) muscle relaxant can be used for intraoperative relaxation

nondepolarizing

Succinylcholine is a ___ muscle relaxant

depolarizing

Rocuronium and vecuronium are ___ muscle relaxants

nondepolarizing

Rapid Sequence Intubation is a technique used to minimize chance of ___ in patients who are high risk

pulmonary aspiration

In RSI, medications are given in rapid succession to achieve induction and relaxation so airway can be secured with ___ to minimize amount of time patient is at risk of aspiration from the time of induction when airway protective reflexes are lsot until airway is secured

cuffed ETT

History to assess difficult mask ventilation includes obesity, OSA, ___, and prior difficulty

snoring

Exam to assess difficult mask ventilation includes neck ___, facial ___, tongue ___, mouth opening, and presence/lack of teeth

circumference, hair, size

Prior difficult intubation, ___ surgery, head/neck ___or radiation are features that could cause difficult intubation

C-spine, cancer

Mallampati ___ or ___ could cause difficult intubation

3, 4

Large or loose ___ could cause difficult intubation

incisors

Short ___ distance could cause difficult intubation

thyromental

Limited ___ mobility could cause difficult intubation

neck

Inability to protrude ___ could cause difficult intubation

mandible

___ intubation is the safest approach

Awake

Awake intubation requires patient cooperation and some ___

time

For awake intubation you need to ___ airway and additional equipment

topicalize

If noninvasive awake intubation fails, your options are ___ case, consider feasibility of other options, and ___ airway access

cancel, invasive

If initial intubation attempt under general anesthesia is unsuccessful, consider ___, returning to ___ ventilation, and ___ the patient

calling for help, spontaneous, awakening

If intubation under general anesthesia is consistently difficult, attempt ___

face mask ventilation

If face mask ventilation is not adequate after failed intubation attempt, consider/attempt a ___

supraglottic airway (SGA)

If face mask ventilation is inadequate and supraglottic airway is unsuccessful, you go down the ___ pathway

emergency

The laryngeal mask airway (air Q, I-gel, etc.) is an example of a ___

supraglottic airway (SGA)

Nonemergency intubation failure pathway options include ___ introducer, ___ laryngoscopy, bronchoscopy, and intubation through ___

bougie/tracheal, video, SGA

If the nonemergency and emergency intubation pathways fail, the next step is emergency ___ airway access or waking the patient up

invasive

___ in 1727 was the first to measure arterial blood pressure

Reverend Stephen Hales

The mercury sphygmamanometer was developed in ___ by Scipione Riva-Rocci

1896

Current anesthesia related mortality is 1/___ cases

200,000-300,000

Anesthesia preop information needed includes ___ as opposed to chief complaint

case information

Obtain a (complete/focused) history and physical exam for anesthesia preop eval

focused

True or false: labs and cardiac workup studies are always needed for anesthesia preop eval

false

Surgical history with prior ___ history is a necessary part of preop focused history

anesthetic

If patient has no prior surgeries, ask about ___ of ___

family history, anesthetic complications

___ (METS), allergies, medications, NPO status and aspiration risk are important aspects of preop history

functional capacity

Functional capacity is measured in METs, the ___

metabolic equivalent

1 MET = consumption of ___

3.5 mL O2/min/kg of body weight

METs is a measure of the activity a patient can do that correlates with ___ reserve

cardiopulmonary

Patients who can tolerate ___ METs+ of activity do not need further cardiac workup

4

Risk of ___ during surgery is similar to 4 METs

ischemia

The activities that correlate with 4 METs are ___ and ___

raking leaves, gardening

___ meds and ___ meds are key ones that may need to be held prior to anesthesia

hypertension, diabetes

___ and ___ are important medication classes to ask about preop

blood thinners, pain meds/opioids

Preop physical exam includes vitals, airway exam, and at minimum ___ and ___ exams

cardiac, pulmonary

A healthy ASA _ patient having elective routine surgery does not need labs

1

Imaging is (never/rarely/always) indicated preop

rarely

Cardiac workup that includes ___, ___, and ___ is necessary in select patients

EKG, Echo, stress test

The ASA score that applies to a normal healthy patient is ___

1

The ASA score that applies to a patient with mild systemic disease is ___

II

The ASA score that applies to a patient with severe systemic disease is ___

III

The ASA score that applies to a patient with severe systemic disease that is a constant threat to life is ___

IV

The ASA score that applies to a moribund patient who is not expected to survive without the operation is ___

V

The ASA score that applies to a declared brain-dead patient whose organs are being removed for donor purposes is ___

VI

2 main techniques for regional anesthesia

neuraxial and peripheral nerve block

___ anesthesia includes spinal, epidural, and caudal

neuraxial