Toronto Notes Gems

Question 1

6 As of General Anesthesia

Answer 1

Anesthesia
Anxiolysis
Amnesia
Areflexia (muscle relaxation not always required)
Autonomic Stability
Analgesia

Question 2

Discuss β-blockers (b1 vs. b2) & its cautions

Answer 2

• b1 receptors are located primarily in the heart and kidneys
• b2 receptors are located in the lungs
• Non-selective b-blockers block b1 and b2 receptors. Caution is required with non-selective b-blockers, particularly in patients with respiratory conditions
where b2 blockade can result in
airway reactivity

Question 3

Pre-Anesthetic Checklist

Answer 3

SAMMM

• Suction: connected and working
• Airways: laryngoscope and blades, ETT, syringe, stylet, oral and nasal airways, tape, bag and mask
• Machine: connected, pressures okay, all meters functioning, vaporizers full
• Monitors: available, connected and working
• Medications: IV fluids and kit ready, emergency medicines in correct location and accessible

Question 4

Suspect Difficult Bag-Mask Ventilation with:

Answer 4

BONES

Beard
Obesity/Obstetrics
No teeth
Elderly
Sleep apnea

Question 5

Differential Diagnosis of Poor Bilateral Breath Sounds after Intubation

Answer 5

DOPE

Displaced ETT
Obstruction
Pneumothorax
Esophageal intubation

Question 6

Causes of Intraoperative Shock

Answer 6

SHOCKED

Sepsis or Spinal shock
Hypovolemic/Hemorrhagic
Obstructive
Cardiogenic
anaphylactiK
Extra/other
Drugs

Question 7

Discuss Opioid Equivalency for morphine, codeine, oxycodone & hydromorphone

Answer 7

• 10 mg morphine
• 100 mg codeine
• 5 mg oxycodone
• 2 mg hydromorphone

Question 8

Use NSAIDs with Caution in Patients with:

Answer 8

• Asthma
• Coagulopathy
• GI ulcers
• Renal insufficiency
• Pregnancy, 3rd trimester

Question 9

Common Side Effects of Opioids

Answer 9

• Nausea and vomiting
• Constipation
• Sedation
• Pruritus
• Abdominal pain
• Urinary retention
• Respiratory depression

When prescribing opioids, consider:
• Breakthrough dose
• Anti-emetics
• Laxative

Question 10

Classic Presentation of Dural Puncture Headache

Answer 10

• Onset 6 h-3 d after dural puncture
• Postural component (worse sitting)
• Occipital or frontal localization
• ± tinnitus, diplopia

Question 11

Differential of ST Segment Changes

Answer 11

ST Elevation “I HELP A PAL”

• Ischemia with reciprocal changes
• Hypothermia (Osborne waves)
• Early repolarization (normal variant; need old ECGs)
• LBBB
• Post-MI
• Acute STEMI
• Prinzmetal’s (Vasospastic) angina
• Acute pericarditis (diffuse changes)
• Left/right ventricular aneurysm

ST Depression “WAR SHIP”

• WPW syndrome
• Acute NSTEMI
• RBBB/LBBB
• STEMI with reciprocal changes
• Hypertrophy (LVH or RVH) with strain
• Ischemia
• Post-MI

Question 12

Important Contraindications to

Exercise Testing

Answer 12

• Acute MI, aortic dissection,
pericarditis, myocarditis, PE
• Severe AS, arterial HTN
• Inability to exercise adequately

Question 13

Treatment of NSTEMI/Immediate Treatment of Acute MI

Answer 13

BEMOAN

β-blocker
Enoxaparin
Morphine
O2
ASA
Nitrates

Question 14

Complications of MI

Answer 14

CRASH PAD

Cardiac Rupture
Arrhythmia
Shock
Hypertension/Heart failure
Pericarditis/Pulmonary emboli
Aneurysm
DVT

Question 15

Use Ejection Fraction to Grade LV

Dysfunction

Answer 15

• Grade I (EF >60%) (Normal)
• Grade II (EF = 40-59%)
• Grade III (EF = 21-39%)
• Grade IV (EF ≤20%)

Question 16

Five Most Common Causes of CHF

Answer 16

• CAD (60-70%)
• HTN
• Idiopathic (often dilated
cardiomyopathy)
• Valvular (e.g. AS, AR and MR)
• Alcohol (dilated cardiomyopathy)

Question 17

Precipitants (c.f. exacerbations) of Heart Failure

Answer 17

HEART FAILED

• Hypertension (common)
• Endocarditis/environment (e.g. heat wave)
• Anemia
• Rheumatic heart disease and other valvular disease
• Thyrotoxicosis
• Failure to take meds (very common)
• Arrhythmia (common)
• Infection/Ischemia/Infarction (common)
• Lung problems (PE, pneumonia, COPD)
• Endocrine (pheochromocytoma,
  hyperaldosteronism)
• Dietary indiscretions (common)

Question 18

Features of Heart Failure on CXR

Answer 18

HERB-B

Heart enlargement (cardiothoracic ratio >0.50)
Pleural Effusion
Re-distribution (alveolar edema)
Kerley B lines
Bronchiolar-alveolar cuffing

Question 19

Discuss the regime with beta blocker use in acute on chronic HF patients

Answer 19

Patients on β-blocker therapy who have acute decompensated heart
failure should continue β-blockers
where possible (provided they are
not in cardiogenic shock or in severe pulmonary edema)

Question 20

Chronic Treatment of CHF

Answer 20

• ACE inhibitors*
• β-blockers*
• ± Aldosterone antagonists* (if severe CHF) e.g. spironolactone
• Diuretic
• ± Inotrope
• ± Antiarrythmic
• ± Anticoagulant

*Mortality benefit

Question 21

(4) types of Cardiomyopathy

Answer 21

HARD

• Hypertrophic cardiomyopathy
• Arrhythmogenic right ventricular cardiomyopathy
• Restrictive cardiomyopathy
• Dilated cardiomyopathy

Question 22

(3) Major Risks Factors for DCM

Answer 22

Alcohol, cocaine, family history

Question 23

Acute Pericarditis Triad

Answer 23

• Chest Pain
• Friction Rub
• ECG Changes

Question 24

Ewart’s Sign

Answer 24

Bronchial breathing and dullness to percussion at the lower angle of the left scapula in pericardial effusion due to effusion compressing left lower lobe of lung.

Question 25

Classic Quartet of Tamponade

Answer 25

* Hypotension * Increased JVP * Tachycardia * Pulsus paradoxus

Question 26

Beck’s Triad in cardiac tamponade

Answer 26

* Hypotension * Increased JVP * Muffled heart sounds

Question 27

DDx Pulsus Paradoxus

Answer 27

* Constrictive pericarditis (rarely) * Severe obstructive pulmonary disease (e.g. asthma) * Tension pneumothorax * PE * Cardiogenic shock * Cardiac tamponade

Question 28

Symptoms of Acute Limb Ischemia

Answer 28

6 Ps – all may not be present - Pain: absent in 20% of cases - Pallor: within a few hours becomes mottled cyanosis - Paresthesia: light touch lost first then sensory modalities - Paralysis/Power loss: most important, heralds impending gangrene - Polar/Poikilothermia (cold) - Pulselessness: not reliable

Question 29

Classic Triad of Ruptured AAA

Answer 29

* Pain * Hypotension * Pulsatile abdominal mass

Question 30

Trousseau’s disease/sign

Answer 30

Migratory superficial thrombophlebitis is often a sign of underlying malignancy

Question 31

Antiarrythmic Drug Classification

Answer 31

Some Block Potassium Channels I – Sodium channel blocker II – β-Blocker III – Potassium channel blocker IV – CCB

Question 32

The Cockcroft-Gault Equation (estimate creatinine clearance (CrCl) in adults 20 yr of age and older)

Answer 32

• For males CrCl (mL/min) = [(140 – age in yr) x Weight (kg)] x 1.2 / serum Cr (μmol/L) * For females, multiply above equation x 0.85 * Only applies when renal function is at steady state

Question 33

How many half lives does it need to reach steady state with repeated dosing or to eliminate a drug once dosing is stopped?

Answer 33

For most drugs it takes 5 half-lives

Question 34

Keloids vs. Hypertrophic Scars

Answer 34

``` • Keloids: extend beyond margins of original injury with claw-like extensions • Hypertrophic scars: confined to original margins of injury ```

Question 35

DDx of Hyperpigmented Macules

Answer 35

``` • Purpura (e.g. solar, ASA, anticoagulants, steroids, hemosiderin stain) • Post-inflammatory • Melasma • Melanoma • Fixed drug eruption ```

Question 36

ABCDE of Melanoma

Answer 36

``` Asymmetry Borders (irregular) Colour (variegated) Diameter (>6 mm) Evolution (over time) ```

Question 37

Triggers for Atopic Dermatitis

Answer 37

``` • Irritants (detergents, solvents, clothing, water hardness) • Contact allergens • Environmental aeroallergens (dust mites) • Inappropriate bathing habits (long hot showers) • Sweating • Microbes (S. aureus) • Stress ```

Question 38

PSORIASIS: Presentation and | Pathophysiology

Answer 38

- Pink papules/Plaques/Pinpoint bleeding (Auspitz sign)/Physical injury (Koebner phenomenon) - Silver scale/Sharp margins - Onycholysis/Oil spots - Rete Ridges with Regular elongation - Itching - Arthritis/Abscess (Munro)/Autoimmune - Stratum corneum with nuclei - Immunologic - Stratum granulosum absent

Question 39

PSORIASIS: Triggers

Answer 39

• Physical trauma (Koebner phenomenon) • Infections (acute streptococcal infection precipitates guttate psoriasis) • Stress (can be a major factor in flares) • Drugs (systemic glucocorticoids, oral lithium, antimalarial drugs, interferon) • Alcohol ingestion

Question 40

Drug Hypersensitivity Syndrome Triad

Answer 40

* Fever * Exanthematous Eruption * Internal Organ Involvement

Question 41

Risk Factors for Melanoma

Answer 41

no SPF is a SIN - Sun exposure - Pigment traits (blue eyes, fair/red hair, pale complexion) - Freckling - Skin reaction to sunlight (increased incidence of sunburn) - Immunosuppressive states (e.g. renal transplantation) - Nevi (dysplastic nevi; increased number of benign melanocytic nevi)

Question 42

Initial Management of Any Patient in Shock

Answer 42

* ABCs * IV fluids * Oxygen * Monitor (HR, BP, urine, mentation, O2 saturation) * Control hemorrhage

Question 43

NG Tube Contraindications

Answer 43

* Significant mid-face trauma | * Basal skull fracture

Question 44

Unilateral, Dilated, Non-reactive | Pupil, think:

Answer 44

* Focal mass lesion * Epidural hematoma * Subdural hematoma

Question 45

Signs of Increased Intracranial | Pressure (ICP)

Answer 45

* Deteriorating LOC (hallmark) * Deteriorating respiratory pattern * Cushing reflex (high BP, low heart rate, irregular respirations) * Lateralizing CNS signs (e.g. cranial nerve palsies, hemiparesis) * Seizures * Papilledema (occurs late) * Nausea/vomiting and headache

Question 46

Signs of Basal Skull Fracture

Answer 46

* Battle’s sign (bruised mastoid process) * Hemotympanum * Raccoon eyes (periorbital bruising) * CSF Rhinorrhea/Otorrhea

Question 47

Treatment of Increased ICP

Answer 47

* Elevate head of bed * Mannitol * Hyperventilate * Paralyzing/sedating agents

Question 48

Seatbelt Injuries may Cause:

Answer 48

* Retroperitoneal duodenal trauma * Intraperitoneal bowel transection * Mesenteric injury * L-spine injury

Question 49

Reasons for Emergent Orthopedic Consultation

Answer 49

* Compartment syndrome * Irreducible dislocation * Circulatory compromise * Open fracture * Injury requiring surgical repair

Question 50

Vascular injury/compartment syndrome is suggested by “The 6 Ps”:

Answer 50

- Pulse discrepancies - Pallor - Paresthesia/hypoesthesia - Paralysis - Pain (especially when refractory to usual analgesics) - Polar (cold)

Question 51

Acute Treatment of Contusions

Answer 51

RICE Rest Ice Compression Elevation

Question 52

Where NOT to use local anesthetic with epinephrine:

Answer 52

Ears, Nose, Fingers, Toes and Penis

Question 53

Gynecological Causes of Pelvic Pain:

Answer 53

* Ovarian cyst * Dysmenorrhea * Mittelshmerz * Endometriosis * Ovarian torsion * Uterine fibroids/neoplasm * Adnexal neoplasm * PID + cervicitis

Question 54

Signs of PE on CXR

Answer 54

Westermark’s sign: abrupt tapering of a vessel on chest film. Hampton’s hump: a wedge-shaped infiltrate that abuts the pleura.

Question 55

Causes of Syncope by System

Answer 55

HEAD, HEART, VeSSELS Hypoxia/Hypoglycemia Epilepsy Anxiety Dysfunctional brainstem ``` Heart attack Embolism (PE) Aortic obstruction Rhythm disturbance Tachycardia ``` ``` Vasovagal Situational Subclavian steal!! ENT (glossopharyngeal neuralgia) Low systemic vascular resistance Sensitive carotid sinus ```

Question 56

Treatment of Asthma

Answer 56

ASTHMA ``` Adrenergics (β-agonists) STeroids Hydration Mask (O2) Antibiotics (if concurrent bacterial pneumonia) ```

Question 57

If patient has Wolff-Parkinson-White and is in AFib use [...]. Avoid [...] agents as this can increase conduction through bypass tract leading to cardiac arrest

Answer 57

use amiodarone or procainamide. Avoid AV nodal blocking agents (adenosine, digoxin, diltiazem, verapamil, betablockers)

Question 58

Causes of CHF Exacerbation (c.f. precipitants)

Answer 58

FAILURE ``` Forgot medication Arrhythmia (Dysrhythmia)/Anemia Ischemia/Infarction/Infection Lifestyle (e.g. too much salt) Upregulation of cardiac output (pregnancy, hyperthyroidism) Renal failure Embolism (pulmonary) ```

Question 59

Acute Treatment of CHF

Answer 59

LMNOP ``` Lasix (furosemide) Morphine Nitroglycerine Oxygen Position (sit upright), Pressure (BiPAP) ```

Question 60

Risk Factors for VTE

Answer 60

THROMBOSIS ``` Trauma, travel Hypercoagulable, HRT Recreational drugs (IVDU) Old (age >60) Malignancy Birth control pill Obesity, obstetrics Surgery, smoking Immobilization Sickness (CHF, MI, nephrotic syndrome, vasculitis) ```

Question 61

Precipitating Factors in DKA

Answer 61

The 5 Is ``` Infection Ischemia Infarction Intoxication Insulin missed ```

Question 62

4 Criteria for DKA Dx

Answer 62

* Hyperglycemia * Metabolic acidosis * Hyperketonemia * Ketonuria

Question 63

``` HELLP Syndrome (seen only in preeclampsia/eclampsia) ```

Answer 63

Hemolytic anemia Elevated Liver enzymes Low Platelet count

Question 64

Causes of Acute Ataxia

Answer 64

UNABLE TO STAND - Underlying weakness (mimic ataxia) - Nutritional neuropathy (vitamin B12 deficiency) - Arteritis/vasculitis - Basilar migraine - Labyrinthitis/vestibular neuronitis - Encephalitis/infection - Trauma (post-concussive) - Other (rare genetic or metabolic disease) - Stroke (ischemia or hemorrhage) - Toxins (drugs, toluene, mercury) - Alcohol - Neoplasm/paraneoplastic syndrome - Demyelination (Miller Fisher, Guillain Barré, MS)

Question 65

(3) main types of Kidney Stones

Answer 65

* 80% Calcium * 10% Struvite * 10% Uric acid

Question 66

High Risk Criteria for Infection of wounds

Answer 66

``` Wound Factors • Puncture wounds • Crush injuries • Wounds >12 h old • Hand or foot wounds • Wounds near joints ``` Patient Factors • Immunocompromised • Age >50 yr • Prosthetic joints or valves