Lecture 4: Patient Monitoring and induction

where do you typically place pulse ox

on the hand with the IV

where do you typically place bp cuff

arm without the IV

limb restrictions for bp cuff

if they have lymph node dissections or AV fistula

when to place ECG leads on back

if doing a breast case, ant laparoscopic procedures

Order that ECG fires in

sinus node, AV node, Bundle of His, left and right bundle branches, purkinje fibers

Bipolar leads measure

potential difference between 2 recording electrodes

Bipolar leads placement is based on

Einthoven’s Triangle

what happens when wave moves from right arm (negative) to left leg (positive)

impulse toward a positive

you get a positive upstroke; up swing

-create an upward deflection

impulse goes away from positive toward negative

you get a downstroke; down swing

-create a downward deflection

J point

junction point, located at junction of S wave and start of ST segment

bipolar leads

measure potential difference between two recording electrodes

I, II, III

P wave

atrial depolarization

-two atria are contracting

SA Node

pacemaker, found within right atrium

Junction point

located at junction of S wave and start of ST segment

V1

4th intercostal space at right margin of sternum

V2

4th intercostal space at left margin of sternum

V3

Midway between V2 and V4

V4

5th intercostal space, left midclavicular line

V5

Same level as V4 (fifth intercostal space), anterior axillary line

V6

same level as site of V4, at midaxillary line

what causes differences in action potentials in different parts of heart

differences in sodium, calcium, potassium

QRS complex

ventricular depolarization

-ventricles are contracting

-looks like inverted V-> v for ventricles

T wave

ventricular repolarization

-when ventricles are relaxing

what is every depolarization followed by

a depolarization

where is atrial repolarization

hidden in QRS

PR interval

0.12-0.20 seconds

what does lidocaine block

sodium

-this is why lidocaine is choice for V tach

how long is time in big block

0.2 seconds

how do you calculate rhythm in EKG

divide 300 by the number of big boxes between 2 Rs

Sinus Tachycardia

normal rhythm, high heart rate

-could be indicative of systemic vascular resistance

sinus bradycardia

less than 60 beats per minute

-could be an athlete, pt on beta blockers, or heart block

atrial fibrillation

"irregular regular"

- SA node is firing at different rTES

-HAS NO P WAVES

which two rhythms do not have P waves

junctional rhythms and fib (junctional rhythm is much slower)

how does oscillometry measure BP

mean BP

how does korotkoff sounds measure BP

measures systolic and diastolic pressures

Where does a Swan-Ganz catheter sit?

pulmonary artery

etomidate is an adrenal (supressant/agonist)

suppressant

Ketamine is a (vasodilator/vasoconstrictor)

vasodilator

What drug helps with hallucinations brought on by Ketamine

versed

which arm (dependent/non-dependent) is pulse ox and BP on in lateral decubitus

dependent

Premature Ventricular Complex Couplet

2 beats in a row

Trigeminy

every third beat is a PVC

Bigeminy

every other beat is a PVC

ventricular tachycardia

can still be pulsatile

(rate control)

PEA and systole

which rhythms do you shock

V fib and pulseless V tach

ventricular fibrillation

quivering ventricle

-non pulsatile

-start chess compressions, throw epi, chest compressions

ST segment elevation

T wave is very high

ST segment depression

seen in lateral leads, which section has supply and demand issues

Invasive blood pressure

hooks up to transducer to give proper reading of BP

-has an inverse relation (placed to high drops BP reading)

-in radial or femoral artery

What can Zofran cause?

QT prolongation (issue with depolarization)

Beers-lambert Law

-relationship of solute (hemoglobin) concentration to intensity of light transmitted through solution

-absorption of light 660nm and 940nm

which is the "weird" number to watch for in pulse ox

85%

what is included in respiratory gas anaylysis

end tidal CO2, inhalation agent, fresh gasses inspired and expired levels

Capnometry

Measure of expired carbon dioxide

capnography

display of CO2 wave form

how many phases from capnogram have

four

Is asthma obstructive or restrictive?

obstructive

what are the nerves we check in neuromuscular monitoring? When is it used?

ulnar and facial

measures effect of paralytic agents

train of four

4 equal stimuli

sustained tetany

continuous stimulus

5 seconds with no fade

How do you keep FiO2 the same while blowing off leftover CO2

increase flow rate

what does 70% indicate during muscle twitches

4 out of 4 twitches

-up to 70% of receptors block

what protein cleaves acetlycholine

acetylcholinesterase

what does anti cholinesterase do?

decreases cleavage of Ach to overcomes NDMR by building up as much Ach in muscle junction as possible

what is an example of acetylcholinesterase inhibitor

neostigime

What does Suggamadex do

binds to rocuronium and makes it inactive

What is the Bispectral Index (BIS)? When is it often used?

level of depth on anesthesia outside of using anesthetic gas

often used in TIVA

what number on BIS indicates general anesthesia

under 60

Transesophageal echocardiography (TEE)

measures cardiac functional, regional wall motion abnormalities, and monitors volume status

Central venous pressure

right ventricular filling pressure and indicator of cardiac volume

Monitor wave parts of CVP

a- atrial contraction

c- ventricular contraction

x- ventricular systole

v- atrial filling

y-atrial emptying

wave parts of CVP in systole

c,x,v

(S-T on ECG)

how does swan-ganz position itself

wedges when the tip is inflated

sniffing postion

trigs of air is on plane with sternum

three things to do at pre-oxygenation

good mask seal, at least 85% EtO2, APL valve setting at minimum

possible induction drugs

fentanyl, lidocaine, propofol, etomidate, ketamine, sux, rox

how to check if patient is concious

try to speak, palpebral reflex, eyelash reflex, flinching

what is the gold standard in anesthesia

ETCO2 is continuous (confirms ETT in trachea)

how do you confirm where ETT tube is

bilateral breath sounds (BBS)

what is a difference between LMA and ETT

LMA has lower settings on the vent by using pressure control (set below 20)

where is a good place to anchor tape

maxilla

anesthesia time out

introduction, identification, correct procedure, correct side/site, need for imaging, allergies, antibiotics, safety concerns, verbal agreement

propofol

rapid onset, short duration, anti mimetic, pain on injection, cardiovascular/respiratory depressant

what temp probe do you use for LMA and ETT?

LMA: nasopharyngeal

ETT: endotracheal

etomidate

rapid onset, cardiovascular stable, increased PONV, adrenocortical suppression, Pain on injection, myoclonic movement

which drug causes myoclonic moveemtn

etomidate

ketamine

hemodynamically stable, preserves respiratory drives, potent analgesic, increases secretions, bronchodilator, hallucinations

describe propfol

2 mg/kg, 30 seconds onset, 3-8 minutes action

describe etomidate

0.2-0.3 mg/kg, 30 seconds onset, 3-8 minutes

ketamine description

1-2 mg/kg, 60-90 seconds, 5-10 minutes

contradictions of succinycholine

MH, pseudocholinesterase deficiency, burns, spinal cord injuries

succinylcholine description

Rapid onset (RSI), short duration, fasculatations, rise in K+, can increase intracranial pressure

how do non-depolarizing muscle relaxants work

competitive antagonists of Ach receptors at motor end plate (nicotinic)

intermediate acting NDMR

cistracurium, rocuronium, vecuronium, atracurium

long lasting NDMR and how long is duration?

Pancuronium

60-90 minutes

succinylcholine description

1 mg/kg

0.5-1 seconds

9-13 minutes

Rocuronium description

0.6 mg/kg

1-2 minutes

20-35 minutes

RSI rocuronium

1.2 mg/kg

1-2 mins

60-90 minutes

Vecuronium description

0.1 mg/kg

3-5 minutes

20-35 mins

Cistracurium description

0.1 mg/lkg

3-5 minutes

20-35 minutes