Addisons
Conns
Graves
Hashimoto
Addison is a hypochondriac
Hyopadrenalism
ConN Big Na
HyperaldosteroNism
Graves
Hyperthyroidism
HasimotO
HypOthyroidism
6 P's of spinal cord injury
Paralysis
Pain
Paresthesias
Priapism
Ptosis
Position (Arms crossed, head erect, arms over head)
Aldrete. What keeps you in PACU?
Too many NARCS!!
Neuro
No response Arousable
Activity
0 extrem
2 extrem
Resp
Apnea
dyspnea
Circ Pre BP +/- 50
+/- 20-50
Saturation
<90 w O2
>90 w O2
EMLAp
Awake
4 extrem
C&DB
+/- 20
>92 RA
Eez a Mixture of Lidocaine And prilocaine
Beta 1 receptor agonism?
CRID from my Gut when I figured this out
>Chronotropy
>Renin release
>Inotropy
>Dromotropy
Beta 2 agonism?
2, 3 and 4.
2 things increase:
>Insulin Beta cells pancreas
>Glucose Liver
3Ds make me Dilate:
Myocardial vasc dilation
Skeletal vasc dilation
Bronchial tree dilation
4 things relax when I CDUGG:
Ciliary muscle=tense tendons for far vision
Detrusor
Uterus
GI Motility and tone
Gall bladder and ducts
Alpha 1 agonism
1 thing is odd
1 thing obvious
$2000 CRUSTS
Odd that gut motility decreases
Obvious that alpha 1 constricts a>v
2Gs for 2 glands that increase
>Glucose from liver
>Sweat
CRUSTS
Constricts/contracts:
Radial muscle for mydriasis
Uterus
Sphincters in GI tract
Trigone and Sphincter in bladder
Alpha 2 agonism is as easy as 1, 2, 3 4?
1 <Salivation
2 things:
>Platelet aggregation
Constriction v>a
3 Organs are MIA
<Motility in gut
<Insulin from pancreas
<ADH at tubules so > UO
What 3 places are alpha 2's found
1. Presynaptic NE neurons to <NE
2. Post synaptic on effector organs
3. Non-synaptic on platelets
Eye muscles innervation
Sphincter (Iris)
No SNS
M=contraction/miosis
Radial (Iris)
No PNS
Alpha 1=contraction/mydriasis
Ciliary
Beta 2=relaxation/far vision
M=contraction/near vision
Where are no PNS innervations?
Know Pns LUV:
Kidneys
Pancreas
Liver
Uterus
Vessels
Amide Local pKa
Local Bupivacaine Really Likes PKa Measurements
• Levobupiv 8.1 98%
• Bupiv 2.5 8.1 96%
• Ropiv 3 8.1 94%
• Lidocaine 7.9 65%
• Prilocaine 7.9 55%
• Mepiv 7.6 78%
Amide Local Max doses
Local Bupivicaine Really Lowers Myocardia-L Performance
• Levobupiv 2mg/kg 150 mg
• Bupiv 2.5 175 mg
• Ropiv 3 200
• Lidocaine wo 5 300
• Mepiv 7 400
• Lido w 7 500
• Prilocaine 8 500 <70 kg >600
Local Anesthetic - Order of *Protein Binding* from Most to Least
*B*ob *e*ats *r*eally *t*ough *m*eat *l*ike *ch*opped *p*ork
*B*upivacaine
> *E*tidocaine
> *R*opivacaine
> *T*etracaine
> *M*epivacaine
> *L*idocaine
> *Ch*loroprocaine
> *P*rilocaine
Ester Local Max doses
Gotta be PC to Clerk at 7-11 unless you're 14!
• Cocaine 3 mg/kg 150 200 mg
• Procaine 7 mg/kg 350-600
• Chloroprocaine 11 wo 800
• Chloropro 14 w 1000
LAST
Roman numeral L=50
50=5x10
5-10 mcg/ml are the warning signs:
You want to "Be LAST To Have Myocardial depression"
• Blurred vision
• Lips tongue numbness
• Anxiety Restless
• Staggering/Vertigo
• Twitching
• Tinitis
• Hypotension
• Myocardial depression
LA Uptake
I Think Idiot Imposters Can't Educate But Fabulous Schools Should
• IV
• Tracheal
• Intrapleural
• Intercostal
• Caudal
• Epidural
• Brachial plexus
• Femoral
• Sciatic
• Subcutaneous
Beta 1 blockers
BBAAME
• Betaxolol
• Bisoprolol
• Acebutalol
• Atenolol
• Metoprolol
• Esmolol
Non-selective Beta Blockers
Beta Blockers Can Lower Pt Pressure To Normal
• Carvedilol
• Labetalol
• Propranolol
• Pindolol
• Timolol
• Nadolol
Antiplatelet drugs
Are Good for Cessation of Coagulation
ADP receptor inhibitors
GIIb/IIIa receptor antagonists
COX 1&2 inhibitors
COX 2 inhibitors
ADP receptor inhibitor DC before surgery
ADP Receptor inhibitors: Just remember Plavix
• Plavix=clopidigrel and -grel leads to:
• Tica-grel-or the grel is early 1-2 days
• Prasugrel grel comes later 2-3 days
• Clopidogrel 3 syllables + grel =7 days
• TiclodipEEN for fourtEEN days
GIIb/IIIa receptor antagonist DC before surgery
GpIIb/IIIa R antagonists: 3a=123/MAB
• AbcixiMAB 1 2 3 days
• Eptifibatide and tirofiban 1 day
COX 1&2 (1-2 days) inhibitors DC before surgery
Aspirin 7 days
NSAIDs 1-2 D
COX 1 inhibitors
Refocoxib and Celecoxib
no need to DC
Anticoagulants
Heparin Takes Fun out of Koagulation
Heparins
Thrombin inhibitors
Factor X inhibitors
Vit K antagonists
Heparins DC before surgery
*U*nfractionated
*D*rugs
*T*ake
*L*ike 6 hours
Unfractionated 6 hours
Dalteparin 1-2 D
Tinazparin 1-2 D
Lovenox (Enoxaparin) 1-2 D
Thrombin inhibitors are rude
When to DC before case
Are as easy as 2 4 6 8
• Bivalirudin 5 syllables 2+3 2-3 hrs
• Argatroban 4 syllables 4-6 hrs
• Hirudin 8 hrs stopped before case
Factor X inhibitors DC be4 surgery
4orndoparinux stopped 4 days be4!!!
Vit K antagonist dc before surgery Warfarin 2-4 days
ADP receptor inhibitor DC before Neurax
Same as for surgery
ADP Receptor inhibitors: Just remember Plavix
• Plavix=clopidigrel and -grel leads to:
• Tica-grel-or the grel is early 1-2 days
• Prasugrel grel comes later 2-3 days
• Clopidogrel 3 syllables + grel =7 days
• TiclodipEEN for fourtEEN days
GIIb/IIIa receptor antagonist hold before Neurax?
GpIIb/IIIa R antagonists: 3a=123/MAB
• AbcixiMAB 1-2 not 3 days
• Eptifibatide and tirofiban 8 hours
Unfractionated heparin SQ for DVT prophylaxis hold for Neurax?
No need if pt has normal clotting mechanisms. AND
If not on blood thinners.
IV Heparin hold for Neurax?
Heparin binds? AT3 and At 3 you block so hold heparin:
From 11-1
1+1+1=3 o'clock block
Add another 1 hour to starting heparin
Hold 11-1 restart at 4
Restart 2-4 hours after catheter removal
LMWH hold times for Epidural
Before block:
Pro dose (1x/D) 12
Ther dose (2x/D) 24
Before removal:
Both 12 hours
After removal:
Both 2 hrs
LMWH dosing wait times after Single shot block
Pro dose 6-8 hours after
Ther dose 24 hours after
Block times with Warfarin Hold 5 days to block
Remove catheter if INR <1.5
Block hold times with Herbals that inhibit platelet aGGreGation
Proceed if no other blood thinners
Which thrombolytics can you continue with a block?
tPA
Urokinase
Streptokinase
Alteplase
These are all absolute contraindications to blocks!!
Garlic, Ginko and Gensing
NONE of them:
3 Main P-450 enzyme groups
3A4
2D6
1A2
CYP 3A4 Substrates
"3" for 3 groups "ABO"
1. Amide locals: Lido, Bupiv and Ropi
2. Benzos MDs: Midaz and Diaz
3. Opioids in Group 3 - Fent, Sufent, Alfent and methadone
CYP3A4 Inducers/convincers
Chronic alcoholics Read WSJ To Beat the Clock
• Chronic ETOH
• Rifampin
• St John's Wort
• Tamoxifen
• Barbiturates
• Carbamazepine
3A4 Inhibitors
• SSRIs
• Azole antifungals
• Cimetidine
• Emycin
• Grapefruit juice
SSRIs are Azoles Causing Enzymes Grief
CYP 2D6 substrates
2 for...?
Group 2 opioids (Plus codeine)
Oxycodone
Hydromorphone
Codeine
All metab to Morphine
CYP 2D6
2 is di6 sounds like Sick or SIQ
Inducers - Disulfiram
Inhibitors are SIQ:
SSRI
Isoniazid
Quinidine
CYP 1A2 subsTrate Theophylline
CYP 1A2 Inducers
1 drink or 2??!!
One drink!? hey have 2 and its a party!
Smoking Toking and drinking!!
Smoking
Weed
ETOH
CYP 1A2 Inhibitors
Emycin and Cipro
Fluvoxamine
Opioid Potency Order
*S*ome *F*eelings *R*eally *A*re *H*ard, *M*aybe *T*ry *M*anly *C*rying
*S*ufentanil
>*F*entanyl = *R*emifentanil
>*A*lfentanil
>*H*ydromorphone
>*M*orphine
>*T*ramadol
>*M*eperidine
>*C*odeine
LMA "15 Rule" for Laproscopic Surgery
• surgery not to exceed *15 minutes duration*
• *tilt* of the bed be less than *15 degrees*
• intraabdominal *pressure* be less than *15 cm H2O*.
Respiratory Center in the tractus solitarius.
Dorsal vs Ventral Respiratory Group Apneustic vs Pneumotaxic Center
Dorsal Resp Center - Drives Resp Cadence - Inspiratory pacemaker
Ventral Resp Center - Volume Releasing Center - Releases/causes active exhalation
Apneustic Center - Apnea triggers inhalation
Pneumotaxic Center - Too much volume taxes the lungs. - Triggers end inhalation.
Causes of anion gap acidosis
*SLUMPED*
*S*alicylate
*L*actate
*U*remia
*M*ethanol
*P*araldehyde
*E*thanol & Ethylene Glycol
*D*iabetic ketoacidosis
Causes of Non-Gap acidosis Loss of bicarb:
HAARDUPS
Hyperalimentation
Acetazolimide
Amphotericin B
Renal tubular acidosis
Diarrhea
Uteterosigmoidostomy
Post-hypocapneic state
Sulfamyalon
CYP 450 Inhibitor
*A*dam *A*lways *C*omes *P*issed *E*very *F*reaking *D*ay *V*ery *V*iolent
*A*cute Alcohol,
*A*miodarone,
*C*imetidine,
*P*rotease Inhibitors,
*E*rythromycin,
*F*luoxetine,
*D*iltiazem,
*V*erapamil,
*V*alproic Acid
Neuraxial Anesthesia
*CHAIR*
• *C*oagulation Problems
• *H*ypotension
• *A*ortic/Spinal Stenosis
• *I*nfection
• *R*efusal (only Absolute)
Intrinsic Laryngeal Muscles - Function
•*P*osterior *C*rico*A*rytnoids = *P*ulls *C*ords *A*part
•*L*ateral *C*rico*A*rytenoids = *L*ets *C*lose *A*irway
•*C*rico*T*hyroid = *C*ords *T*ighten
•*T*hyroa*r*ytenoids = They Relax
Mallampati Classification *PUSH*
• *P*illars = I
• *U*vula = II
• *S*oft Palate = III
• *H*ard Palate = IV
Predicting Difficult Masking
• *B*eards
• *O*besity
• *N*o Teeth
• *E*lderly
• *S*nores
Cricoid Pressure
• *B*ackward
• *U*pwards
• *R*ight
• *P*ressure
*BURP*
*BONES*
Alpha-Agonist Potency Order
• *E*very *N*udist *D*emands *I*nclusion
*E*pinepherine
> *N*orepinepherine
> *D*opamine
>*I*soproterenol
Beta-Agonist Potency Order
• *I* *E*at *N*utty *D*onuts
*I*soproterenol
>*E*pinepherine
>*N*orepinepherine
>*D*opamine
Pacemaker Code
*PaSeR*
• First Letter = Chamber *Pa*ced
• Second Letter = Chamber *Se*nsed
• Third Letter = *R*esponse to sensing
Cranial Nerves & Sensory or Motor
*S*ome *S*ay *M*arry *M*oney *B*ut *M*y *B*rother *S*ays *B*ig *B*oobs *M*atter
*M*ost
I = *O*lfactory - *S*ensory
II = *O*ptic - *S*ensory
III = *O*culomotor - *M*otor
IV = *T*rochlear - *M*otor
V = *T*rigenial - *B*oth
VI = *A*bducen - *M*otor
VII = *F*acial - *B*oth
VIII = *A*coustic - *S*ensory [vestibulocochlear]
IX = *G*lossopharyngeal - *B*oth
X = *V*agus - *B*oth
XI = Spinal *A*ccessory - *M*otor
XII = *H*ypoglossal - *M*otor
Coags
*F*oolish *P*eople *T*ry *C*limbing *L*arge *S*lopes *A*fter *C*hristmas; *S*ome
*P*eople *H*ave *F*allen
I - *F*ibrinogen
II - *P*rothrombin
III - *T*issue *T*hromboplastin Factor
IV - *C*alcium
V - *L*abile Factor [proaccelerin]
VI - Not involved in the cascade
VII - *S*table Factor [proconvertin]
VIII - *A*nti-hemophilic Factor *A*
IX - *C*hristmas Factor [Anti-hemophilic Factor B]
X - *S*tuart Power Factor [autoprothrombin III]
XI - *P*lasma Thrombinplastin Antecedent (PTA) [*P*rotein]
XII - *H*ageman Factor [glass or contact factor]
XIII - *F*ibrin stabilizing Factor [*F*ibrinase]
Neurotransmitter - Excitatory
*G*reat *DANES*
• *G*lutamate
• *D*opamine
• *A*cetylcholine & *A*spartic *A*cid
• *N*orepinephrine
• *E*pinephrine
• *S*erotonin
Neurotransmitter - Inhibitory
*Gl*eeful *Ga*ngster
• *Gl*ycine
• *GA*BA
C5 to L1 Nerve Branches
(lateral to medial)
*MAMRU*
• *M*usculocutaneous
• *A*xillary
• *M*edian
• *R*adial
• *U*lnar
Layers of the scalp *SCALP*
• *S*ubcuntaneous
• *C*onnective Tissue
• *A*poneurosis
• *L*oose Connective Tissue
• *P*ericranium
CSF Flow from the Choroid Plexus
*L*ove *M*y *3* *S*illy *4*-*l*egged *M*ammals
• *L*ateral
• *M*onroe (Foramina of)
• *3*rd Ventricle
• *S*ylvian Aqueduct
• *L*uschka (Foramina of)
• *M*agendie (Foramen of)
Asthma Treatments *ASTHMA*
• *A*drenergic (B2 adrenergic)
• *S*teroids
• *T*heophylline
• *H*ydration
• *M*ask (oxygen)
• *A*ntibiotics, *A*nticholinergics
Oxyhemoglobin Dissociation Curve
*CADET*
Right Shift
• *C*O2
• *A*cid
• *D*PG (2,3 DPG)
• *E*xercise
• *T*emperature
Fetal Acceleration and Decelerations
*VEAL CHOP*
• *V*ariable Deceleration = *C*ord Compression
• *E*arly Deceleration = *H*ead Compression
• *A*accelerations = *O*kay
• *L*ate Declerations = *P*lacental Insuffiency
Preeclampsia Management *M*y *L*oving *B*aby *H*as *D*emands
• *M*agnesium
• *L*abetalol
• *B*etamethasone
• *H*ydralazine
• *D*examethasone
Pitocin Side Effects and Uses
*PITOCIN* *AIDS*
• *P*ressure is elevated
• *I*ntake and Ouput
• *T*etanic Contractions
• *Oxygen decrease in fetus
• *C*ardiac arrhymia
• *I*rregular fetal heart beat
• *N*ausea and Vomiting
• *A*fter suction D&C
• *I*induction of Labor
• *D*ecrease postpartum uterine bleeding
Barbituates Mechanism of Action *E*very *G*irl *D*eserves *R*oses
• *E*nhances *G*ABA
• *D*epresses *R*AS
Ketamine
*SUPER* *BRAINS*
• *S*timulates SNS
• *U*rinary Retention
• *P*hencyclidine (PCP) deriative
• *E*mergence Delirium
• *R*espiratory Depression Minimal
• *B*ronchodilator
• *R*ecreactional Abuse
• *A*nalgesic
• *I*ncreases BP, HR, CO/CI, ICP, CVP, PAP
• *N*MDA receptor antagonist
• *S*alivation
Two Zebras Bit My Cat
Temporal
Zygomatic
Buccal
Mandibular
Cervical
Branches of facial nerve (7)
Carcinoid Crisis Is.... made worse with?
Is NASTE.
Norepi
Isoproterenol
Atracurium
Succ
Thiopental
Epi
Oh Oh, fix that.
Ondansetron and Octreotide treat it.