0 Fontanelle or fontanel

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Normal full term baby has 6 fontanelle :
  • Anterior
  • Posterior
  • 2 Mastoid
  • 2 Sphenoidal



Posterior :
  • Close at birth
  • In only 3% it is open (here it just admits tip of finger)

Anterior : 
  • Diamond shape
  • Open at birth
  • 2.5 x 2.5 cm
  • Pulsatile
  • Closes at 18 - 24 months life.



Causes of Delayed closure of Anterior fontanelle :
  1. Down's Syndrome
  2. Hypothyroidism
  3. Hypophosphatasia
  4. Rickets
  5. Cleidocranial dysostosis

First four (1-4) and idiopathic are causes of delayed dentition. (Delayed dentition is non eruption of teeth by 13 months life )



Early closure of Anterior fontanelle : Craniosynostosis
Complications :
  • Microcephaly
  • Increased ICT - Optic atrophy
  • Cosmetic - head shape (if only one suture fuses early)
Associated syndromes :
  • APERT (AD)
  • CROUZON (AD)
  • CARPENTER - Autosomal recessive
  • PFIFFER (AD)



Increased ICT : Anterior fontanelle - bulging & non pulsatile
Dehydration : Depressed Anterior fontanelle



Img source : http://en.wikipedia.org/wiki/File:Gray197.png

0 Pediatrics - General Info

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Neonate ( <28days )

  • Early (less than equal to 7)
  • Late (8 - 28 days)


Term Baby : 37 - 42 weeks

PreTerm Baby: before 37 weeks completed

PostTerm Baby : >42 weeks completed

Normal birth weight : 2.5 - 4 kg

Low Birth weight (LBW) : <2.5 kg   (Can be Preterm or Short for date babies)

Very LBW : <1.5 kg ------- PreTerm babies
Extremely LBW : <1 kg----  PreTerm babies

Appropriate for gestational age (AGA) - between 1oth - 90th percentile
Short for GA (SGA) : <10th percentile
Large for GA (LGA) : >90th percentile

Macrosomia : Birth weight greater than equal to 4 kg

Term Baby Length - 50 cm

Head Circumference (HC) - 35 cm
HC > CC at birth (but not greater than equal to 3 cm difference) (CC = Chest Circumference)
If difference > 3 cm : Hydrocephalus , Asymmetric IUGR
CC exceeds HC by 1year.

Upper Segment (Head to Pubic Symphysis) : Lower Segment (Total Length - Upper segment) = 1.7-1.9 : 1
US : LS = 1 : 1 at approx. 7 years.




CONSTITUTIONAL is
  • Most common cause of LGA
  • Most common cause of Short stature
  • Most common cause of Delayed Puberty



0 Contact Factor deficiency without bleeding

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Contact Factor deficiency without bleeding :

Includes deficiency of
  • Factor XII
  • Prekallikrein

  • High-molecular-weight kininogen

With severe deficiency (contact factor activity less than 1% of normal ) , there is marked increase in aPTT.
This results in a Paradoxical situation showing marked increase aPTT with NO bleeding.

Note : Here No treatment is required even if Major surgery is to be Undertaken.





0 Prune belly syndrome

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Prune belly syndrome = Eagle-Barrett Syndrome

is a rare, genetic birth defect affecting about 1 in 40,000 births. About 97% of those affected are male.

  • Deficient abdominal wall
  • Urinary tract abnormalities , Posterior Urethral Valve , ARPKD
  • Undescended Testis





0 World Leprosy Day

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World Leprosy Day is observed internationally
on January 30 or its nearest Sunday (27th Jan 2013)
to increase the public awareness of the Leprosy or Hansen's Disease.





3 Edwards Syndrome

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Edwards Syndrome :

  • Trisomy 18 {2nd MC trisomy after Down's syndrome(21) }
  • Mental Retardation 
  • Micrognathia
  • Low set ears
  • Clenched fist with Overlapping fingers (Index overlying the 3rd and 4th ; Fifth overlying the 4th ) 
  • Polyhydroamnios
  • Hypotonia followed by Hypertonia
  • Single umblical arteries


It has been found that many features overlap in Different Trisomies and when a question comes in exam then we need to catch the typical features.
Down's Syndrome is one which most of the people easily make out.

To help remember Edwards syndrome , Mnemonic story by DrAyushGoel :

  • Imagine a baby in mother's uterus who is holding the alphabet E (Edwards) with Clenched fist and Fingers are overlapping. 
  • This E is like a knuckle with which baby starts to warm up slowly (Hypotonia) for boxing in utero.
  • Later the baby is more energetic and boxes very fast (Hypertonia)
  • For this boxer baby , the Mother( as always Goddess for the baby ) makes some space for the baby to do boxing (Polyhydroamnios)
  • Now imagine what kind of baby would hit/do boxing in a mother's womb : Definitely he/she is Mentally Retarded.




0 Patau Syndrome

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Patau Syndrome : 
Important points to remember

  • Trisomy 13
  • Mental retardation.
  • Cleft Lip and palate.
  • Polydactyly.
  • Microcephaly.
  • Holoprosencephaly (fused frontal lobes with single ventricle) , in severe cases Single central eye (cyclops)
  • Ectodermal scalp defect.





2 Werdnig – Hoffmann disease

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Location of neurons affected by spinal muscular atrophy in the spinal cord

Werdnig – Hoffmann disease = SMA type I (Infantile)

  • Autosomal Recessive.
  • Usual age of onset : 0-6months
  • Marked hypotonia, Sluggish movement and fasciculation of tongue (Floppy Neonate).
  • Atrophy of spinal anterior horn cells.
  • Sparing : Extraoccular muscles and sphincters.
  • Death by 2-4yr age




Dubowitz disease = SMA type II (Intermediate)

Kugelberg – Welander disease = SMA type III (juvenile)


Adult onset - Type IV



Img source: http://en.wikipedia.org/wiki/File:Polio_spinal_diagram.PNG

0 MN FB page MCQs 81-90

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81. All of the following act on GABA receptors except ?
a. Thiopentone
b. Propofol
c. Ketamine
d. Midazolam


82. Combination of Droperidol and fentanyl is ?
a. Used for long surgeries
b. N2O is contraindicated with combination
c. also called TIVA
d. is called Neurolept Analgesia


83. Which of the following is true ?
a. MRI is superior to CT at demonstrating extracerebral fluid collections.
b. Acute cerebral haemorrhage (<3days) appear hyperintense on T2 weighted MRI.
c. Old cerebral hematoma (weeks to months) will appear hypointense on T2 weighted MRI with a thin rim of hyperintensity.
d. All of the above statements are false.


84. A Lower Segment Caesarean section (LSCS) can be carried out under all the following techniques of anaesthesia except:
A. General anaesthesia
B. Spinal anaesthesia
C. Caudal anaesthesia
D. Combined Spinal Epidural anaesthesia


85. The following are used for treatment of postoperative nausea and vomiting following squint surgery in children except:
A. Ketamine
B. Ondansetron
C. Propofol
D. Dexamethasone


86. The most appropriate circuit for ventilating spontaneously breathing infant during anaesthesia
A. Jackson Rees modification of Ayre T piece
B. Mapleson A or MgiIl’s circuit
C. Mapleson C or Waters’ to and fro canister
D. Bains circuit


87. The following modes of ventilation may be used for weaning off patients from mechanical ventilation except:
A. Controlled Mechanical ventilation (CMV)
B. Synchronized intermittent mandatory ventilation (SIMV)
C. Pressure support ventilation (PSV)
D. Assist-control ventilation (ACV)


88. Induction agent of choice for LMA insertion ?
a. Thiopentone
b. Halothane
c. Propofol
d. Althesin


89. Propofol infusion syndrome consists of all except ?
a. Nephropathy
b. Acute cardiomyopathy
c. Skeletal myopathy
d. Metabolic acidosis


90. Which of the following cause least resperatory depression ?
a. Thiopentone
b. Ketamine
c. Propofol
d. Enflurane



ANSWERS ( 81-90 ):
81c , 82d , 83a , 84c , 85a , 86a , 87a , 88c , 89a , 90b




1 One Liners 86-100

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86. N2O can be Teratogenic

87. Central pontine myelinolysis seen with correction of hyponatremia.

88. Best test for Malignant Hyperthermia - "Caffeine-halothane contracture test".

89. Neuroaxial block - INR should be < 1.4.

90. Protein intake in ICU : 1 - 1.5 g/kg/day.

91. Most common ophthalmic complication during anaesthesia : Corneal abrasion.

92. History of Post dural puncture headache is NOT a contraindication of Epidural block.

93. Flat Capnogram 

  • Accidental Extubation
  • Dissociation of anaesthetic tube
  • Mechanical ventilation failing
94. O2 content of anaesthetic mixture : 33%

95. Preanaesthetic drug which causes longest amnesia : Lorazepalm

96. Anaesthetic with Least decrease in Systemic vascular resistance : Halothane

97. Malignant Hyperthermia :
  • Hyperthermia
  • DIC
  • Respiratory Acidosis

98. Dextrose fluid is NEVER used for Resuscitation.

99. Opioid given as transdermal : Fentanyl

100. Drug of choice for Asystole and Cardiac arrest : Adrenaline





0 EMLA - Eutectic Mixture of Local Anesthetics

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EMLA - Eutectic Mixture of Local Anesthetics 


  • Combination  Lidocaine/prilocaine is a eutectic mixture of equal quantities (by weight) of lidocaine and prilocaine. A 5% emulsion preparation, containing 2.5% each of lidocaine/prilocaine.
  • Dermal Anaesthesia : Used to decrease needle phobia.





0 IVRA Intravenous Regional Anaesthesia

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IVRA = Bier block anesthesia :


1. Both for Upper limb and Lower limb

2. Drugs : Lignocaine , Prilocaine

3. Bupivacaine is Contraindicated

4. Contraindications of IVRA :
  • Sickel cell disease
  • Raynaud's disease
  • Scleroderma




0 Celiac plexus block

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Celiac plexus block :

MC complication : Hypotension (because of lumbar sympathetic block) (MCQ)

Used for pain relief in Pancreatic and Gastric Malignancies.




0 Stellate ganglion block

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Stellate-ganglion block :
The stellate ganglion (or cervicothoracic ganglion or inferior cervical ganglion) is a sympathetic ganglion formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. Stellate ganglion is located at the level of C7.

Although located at C7 , the needle is inserted at the level of anterior tubercle of transverse process of C6 ( Chassaignac tubercle ) to avoid the piercing the pleura.

Used for upper extremity sympathetic dystrophies.

Signs of successful block :
  1. Horner's syndrome (miosis , ptosis , enophthalmos)
  2. Conjunctival Congestion
  3. Nasal Stuffiness ( Guttmann's Sign )
  4. Mueller's syndrome - injection of tympanic membrane and warmth of face.
  5. Vasodilatation
  6. Skin temperature increase.
MCQ point : NO Bradycardia




0 Epidural Anaesthesia

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Epidural Anaesthesia :

Epidural space has Negative pressure.

Drugs:
Lignocaine : 1-2%
Bupivacaine : 0.25 - 0.5%

Drug required is high - 15 - 20ml (Penetrates intervertebral foramina into CSF)
So there are high chances of Total Spinal anaesthesia and LA toxicity.
Also epidural space has large number of veins - Venous plexus of Batson

Needle : Tuohy Needle , Crowford Needle

How to know if we are in the Epidural space ?
1. Loss of resistence (On piercing Ligamentum flavum)
2. Hanging drop technique. ( Gutierrez's sign )
3. Rapid injection in the space causes increase in rate and depth of respiration. ( Duran's Sign )
4. Absence of knee jerk after epidural block. (Westphal sign )


Advantages over Spinal Anaesthesia:

  • Less Hypotension
  • No headache
  • Level block can be done
  • Any duration can be performed.


Disadvantages :

  • Patchy block (therefore give fentanyl)
  • Chances of Unsuccessful block
  • High chance of total spinal
  • Expensive
  • Effect starts in 15-20mins [ therefore use combine Spinal and Epidural (CSE) ]




Caudal Block = Sacral epidural block :  LSCS  NOT Possible with this.

Drug injected - Xylocaine 2mg/kg , in Sacral hiatus.

Most commonly used in children

Good for Perineal surgeries and infra-umblical pain relief in children.






0 Brain MRI - MCQ

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Q. Which of the following is true ?

a. MRI is superior to CT at demonstrating extracerebral fluid collections.

b. Acute cerebral haemorrhage (<3days) appear hyperintense on T2 weighted MRI.

c. Old cerebral hematoma (weeks to months) will appear hypointense on T2 weighted MRI with a thin rim of hyperintensity.

d. All of the above statements are false.


ANSWER:
Ans: A
Ref: Sutton  7th ed , Pg 1782 , 1768
MRI is superior to CT at demonstrating extracerebral fluid collections.
Acute cerebral  haemorrhage (<3days) appear HYPOINTENSE on T2 weighted MRI.
Old cerebral hematoma (weeks to months) will appear HYPERINTENSE on T2 weighted MRI with a thin rim of HYPOINTENSITY.




0 Hepatic extraction ratio

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Q. Which of the following has lowest hepatic extraction ratio ?

a. Thiopentone
b. Etomidate
c. Propofol
d. Ketamine


ANSWER:
Ans: A (Thiopentone)




0 Pin Index

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Q. Pin Index for Nitrous Oxide is ?

a. 2 , 5
b. 3 , 5
c. 2 , 6
d. 1 , 5


ANSWER:
Ans : B 3 , 5
7 -- Entonox
1 , 5 -- Air
2 , 5 -- O2
2 , 6 -- CO2
3 , 5 -- N2O
3 , 6 -- Cyclopropane





0 Spinal Anaesthesia

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Spinal anaesthesia also called sub-arachnoid block (SAB)


Needles used :
  • Whitacre
  • Sprotte

These have pencil tip point end (therefore decrease post puncture headache)


Layers pierced :
  1. Skin
  2. Subcutaneus
  3. Supraspinous ligament
  4. Interspinous ligament
  5. Ligamentum flavum (loss of ressistance felt as it is pierced)
  6. Dura
  7. Arachnoid - subarachnoid space

Drugs :
  • Lignocaine (5%- heavy due to dextrose )
  • Tetracaine (0.5% in 5% dextrose)
  • Bupivacaine (0.5% in 8% dextrose)

Factors affecting height of anaesthesia :
  • Dose (most important)
  • Baricity of solution
  • Volume of drug
  • Position of patient
  • Age
  • Height
  • Pregnancy
  • Abdominal Tumors

Effects of Spinal Anaesthesia :
Blocks Sympathetic system at the concerned level (therefore Increases Parasympathetic)

Thus Hypotension with Tachycardia (Marey's law) (tachycardia because T1-T4 sympathetic is intact and so there is compensatory tachycardia)

But with High Spinal Block -- there is Hypotension with Bradycardia (as T1-T4 sympathetic also blocked)


Other points to remember :
  • Autonomic block is 2 segments higher than sensory.
  • Maximum breathing capacity and active exhalation decrease because of intercostal paralysis.
  • Respiration is severely affected only if C3,4,5 involved (i.e very high spinal block)
  • Nausea, Vomiting
  • Vasodialator , therefore heat loss - shivering (T/t - Pethidine)
  • Successful sign -- Flacid and engorged Penis (due to paralysis of  Nervi Ergentis )
  • Most Common Complication : Hypotension 
  • Management for this : Prophylaxis - Preloading 1 - 1.5 L Coloid
                                     Curative : Foot end elevation
                                                    Colloids , Vasopressor
                                     If Bradycardia - Atropine



Post Spinal Headache : (Usually Occipital)

1. Low - pressure headache because of leak of CSF
    Therefore structures in brain are dragged down.

2. Presents :

  • 24 - 48hrs
  • Mostly > 90% in 7-10days
  • Almost all by 3weeks
3. Prevention : Use pencil tip needle


4. Curative T/t :

  • IV fluids
  • Analgesics
  • Inject 25 - 50 ml NS in epidural space
  • BEST -- Inject 15 - 20 ml autologus blood in epidural space (blood patch)



Other Complications (of Spinal Anaesthesia)
  • Cauda equina syndrome
  • Paraplegia
  • 6th Nerve paralysis
  • 1 , 9 , 10 nerve involvement
  • Anterior spinal artery syndrome
  • Meningitis
  • Backache


Contraindications :

  • Raised ICT
  • Refusal of patient
  • Infection at local site
  • Bleeding diasthesis
  • Hypotension , hypovolemia
  • Spinal deformities
  • Hypertension



Saddle block anesthesia :

  • A form of spinal anesthesia that produces loss of sensation in the buttocks, perineum, and inner thighs.
  • If a patient is kept sitting for several minutes after the injection of a small volume of a hyperbaric solution of local anaesthetic, a classical "saddle block" affecting only the sacral nerve roots will result.




0 Local Anaesthetic Drugs - Important points

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Procaine :

  • 1-2% for nerve block
  • Metabolized by Pseudocholinesterase
  • LA of choice in Malignant Hyperthermia

Chloroprocaine :
  • Shortest acting
  • High pKa but still Fast acting (this is an exception)
  • Most acidic of all LA
  • Contraindicated for spinal anaesthesia

Lignocaine
  • 5% - heavy - spinal
  • 4% - Surface
  • 2% - Jelly for uretheral
  • 1-2% - Extradural
  • 1% - Nerve block
  • 0.5% - IVRA
  • Maximum safe dose : 3mg/kg ,( if with adrenaline - 7mg/kg)

Bupivacaine :
  • Long acting
  • Dose : 2mg/kg (max. safe dose) , ( if with adrenalin - 3mg/kg.)
  • Never IV


Prilocaine : 
  • S/E - Methemoglobenemia (T/t - Methylene blue)






0 LA - Salient points

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The mechanism of local anesthetic(LA) action.
"B" represents an unionized local anesthetic and "BH+" represents an ionized.The blue is a voltage gated sodium channel(NaV) and the ionized anesthetic inhibits it in the intracellular fluid.
When the influx of sodium is interrupted, an action potential cannot arise and signal conduction is inhibited.


Non Ionized - enters at Node of Ranvier

Ionized - blocks Na+ Channel

pKa -- is pH at which Ionized = Non Ionized



Anaesthetic Potency (related to) Hydrophobicity

Drug with lower pKa is Fast acting (exception - Chloroprocaine which has rapid onset and high pKa)



To increase Duration 
1. Add Adrenaline

  • in Lignocaine - increases both sensory and motor block
  • in Bupivacaine - increases Only Sensory block
2. Add phenylephrine

Sodium bicarbonate : Decreases pKa -- increasing availability of unionized form , therefore increase onset of action.



CNS toxicity  -- Bupivacaine > Etidocaine > Lidocaine  =  4:2:1


All Local Anaesthetics are Negative Ionotropic
All are Vasodialator except Cocaine

Bupivacaine --} CNS:CVS = 1:3
Lignocaine ---} CNS:CVS = 1:7

Large dose of Prilocaine -- causes Methemoglobinemia (Treatment - Methylene Blue )



LA with Adrenaline is Contraindicated in :
  1. Finger
  2. Toes
  3. Penis
  4. Pinna




0 Peak plasma concentration after single shot LA

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Peak plasma concentration after single shot LA
Maximum to Minimum (according to site of administration)

Intrapleural > Intercostal > Lumbar epidural > brachial plexus > Subcutaneus > Sciatic > Femoral





0 Local Anaesthetics

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Local Anaesthetics :


ESTERS

AMIDES
Procaine
Chloroprocaine (shortest acting)
Tetracaine
Lidocaine
Mepivacaine
Prilocaine
Bupivacaine
Etidocaine
Dibucaine (Longest acting)
Metabolized by Pseudocholinesterase( Plasma)   (except Cocaine which is metabolized in liver)

Metabolized in Liver
Unstable

Stable
Metabolized to PABA – therefore Allergy

Low incidence of allergy

Mnemonic : EPPP
Bind to Alpha1 glycoprotein in plasma

More intense and longer lasting anaesthesia






MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Sequence of block by Local Anaesthetics

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Sequence of block by Local Anaesthetics :

  • Temperature (Cold > Hot) - Pain - Touch - Deep pressure - Proprioception
  • Autonomic > Sensory > Motor

Recovery is opposite i.e  Motor > Sensory > Autonomic






0 Pediatric Congestive heart failure (CHF)

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Pediatric Congestive heart failure (CHF) :

IN
CAUSE

Preterm
PDA
Fluid Overload

Term
Asphyxiated Cardiomyopathy

In Utero
Hydrops Foetalis

1st week life
Atresias
Malpositions

6-10 weeks
Acynotic heart disease

Infant
Coxsackie type B -  Myocarditis

Older >5yr
Renal Failure








0 MN fb page MCQs (71-80)

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71. Keloid is an abnormal amount of which collagen ?
a. Type I
b. Type II
c. Type III
d. Type IV

72. All are true about parathyroid hormone except :
a. it is an 84 amino acid peptide hormone
b. it increases calcium absorption from the gastrointestinal tract
c. it acts on a cell surface receptor that decreases intracellular cyclic AMP
d. it increases calcium release from bone

73. “Crazy Paving” appearance on HRCT can be seen in
a. Alveolar Proteinosis
b. Pneumocystis jiroveci pneumonia
c. acute respiratory distress syndrome [ARDS]
d. All of the above.

74. Lower limb buds bulge from the lateral aspect of which segments of the trunk ?
a. C5-T1
b. T7-L2
c. L1-S5
d. L2-S2

75. Which of the following is does not have a CAG repeat
a. Huntington disease
b. Spinal and bulbar muscular atrophy
c. Haw River syndrome
d. Myotonic dystrophy

76. Pallister-Killian Syndrome has been associated to which chromosome ?
a. 11
b. 12
c. 13
d. 14

77. Which of the following drugs is not given in AIDS?
a. Rifampicin
b. Ethambutol
c. Thioacetazone
d. INH

78. Subarachnoid space extends to the region of the lower border of ?
a. L2
b. L4
c. S2
d. S4

79. Nerve fiber’s order of sensitivity to Local anaesthetic is ?
a. A>B>C
b. B>C>A
c. C>B>A
d. C>A>B

80. Which of the following fiber (numerical classification) is unmyelinated ?
a. I b
b. II
c. III
d. IV


ANSWERS (71-80):
71c , 72c , 73d , 74d. , 75d , 76b , 77c , 78c , 79a (ref: click here) , 80d.




5 Nerve Fibers

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Sensitivity to Pressure : A > B > C

Sensitivity to Hypoxia : B > A > C

Sensitivity to Local Anaesthetic : A gamma & A delta > A alpha & A beta > B > C 
(Ref: Read text below)





Miller's Anaesthesia (7th ed , pg 921 , 922 ) 
"Different fiber types are differentially sensitive to local anesthetic blockade.
In vivo experiments in which continuous superperfusion of peripheral nerve allows equilibration with drug and experiments in which a drug bolus is delivered by percutaneous injection, analogous to clinical peripheral nerve block, show unequivocally that small myelinated axons (Aγ motor and Aδ sensory fibers) are the most susceptible to impulse annihilation. Next in order of block are the large myelinated (Aα and Aβ) fibers, and the least susceptible are the small, nonmyelinated C fibers.
In fact, in this last group, impulses in the slowest conducting population (conduction velocity of 0.5 to 0.8 msec) are the most resistant to local anesthetic.
The generalized notion that local anesthetics block the smallest fibers first or most is clearly wrong. "












0 Some important Antibodies

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Here is a list of some important antibodies - 


ANTIBODY

CONDITION
Anti Scl70 = Anti DNA Topoisomerase 1

Systemic sclerosis (Scleroderma)
Anti Jo1 = Histidyl tRNA synthetase antibody
Inflammatory myopathies (Polymyositis)

Anti Histone
Drug induced Lupus

Anti SSa (=Ro) and SSb (=La)
Sjogren’s Syndrome

Anti DsDNA , Anti Smith
SLE

Anti Centromere
CREST

Anti endomysial antibody , Anti TTG
Celiac disease , Dermatitis herpatiformis

Anti Mitochondrial Antibody
Primary Biliary Cirrhosis

C-ANCA
Wegner’s Granulomatosis

P-ANCA
Microscopic  Polyangitis & Churg strauss






0 Citric Acid Cycle - Mnemonic

Reactions: 


Oh Citric Acid Is Ofcourse A Silly Stupid Funny Molecule



O xaloacetate

C itrate

A conitate

I socitrate

O xalosuccinate

A lpha ketoglutarate

S uccinyl CoA

S uccinate

F umarate

M alate

NOTE: (SiLly & sTupid helps to differentiate succinLy coA & succinaTe)





2 Heart Sound S2

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Heart Sound S2:



From top to bottom :
1. Increased Component (intensity)
2. Decreased Component
3. A2 delayed , P2 early (narrow split)
4. A2 early , P2 delayed (Wide Split)

Wide and Fixed split -- ASD
-------------------------------------------------
Physiological Split : During Inspiration
It induces an increase in venous blood return from the body into the right atrium.
Simultaneously, there is a reduction in blood volume returning from the lungs into the left ventricle
Since there is an increase in blood volume in the right ventricle during inspiration, the pulmonary valve (P2 component of S2) stays open longer during ventricular systole due to an increase in ventricular emptying time, whereas the aortic valve (A2 component of S2) closes slightly earlier due to a reduction in left ventricular volume and ventricular emptying time.
Thus the P2 component of S2 is delayed relative to that of the A2 component.



0 Medical One Liners (51-85)

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51. Three important syndromes of the first and second pharyngeal arches:
  • Treacher Collins syndrome (TCS), 
  • Oculo-auriculo-vertebral syndrome (AOVS) and 
  • Auriculo-Condylar syndrome (ACS) or question mark ear syndrome.

52. Achlasia Cardia - uncoordinated, non-progressive contraction within the esophageal body
      BUT The hallmark symptom of achalasia is progressive dysphagia.

53. The mandible is not part of the cranium nor part of the facial skeleton.

54. There are 2 things - Threshold level and a discriminatory level for the appearance of a gestational sac 
      on USG
      The threshold level identifies the earliest one can expect to see a sac (4 weeks, 3 days), and 
      The discriminatory level identifies when one should always see the sac (5 weeks, 2 days).

55. Fluoroscopy is a real-time x-ray viewed on a video monitor, provides information about moving organs.
      Examples include motion of the diaphragm or chest wall during respiration and left ventricular
      contraction during systole. During fluoroscopy, the patient can be turned obliquely, to eliminate
      overlapping of structures.

56. Digitalis toxicity is precipitated by HypoKalemia , but its manifestation is HyperKalemia.

57. Beta Thallesemia minor -- HbA2 increased
      Beta Thall interm/major -- HbF increased

58. The left pulmonary artery lies above the left main bronchus before passing posteriorly, whereas on
      the right side the artery is anterior to the bronchus resulting in the right hilum being the lower.

59. Least CO2 -- in Anatomical Dead Space -- At the END Inspiratory Phase.

60. Central Chemoreceptors are not sensitive to Hypoxia.

61. Middle genicular artery pierces the oblique popliteal ligament of the knee joint.

62. Among Benzodiazepine - Lorazepam causes the longest duration of antegrade amnesia.

63. Pressure relief valve is not required for Cyclopropane.
     (Pressure relief valve is a mechanical device that eliminates system overpressure by allowing the
     controlled or emergency escape of liquid or gas from a pressurized system. The relief valve may or may
     not be adjustable.)

64. Each 1ml of O2 liquid -- 840 ml gas.

65. The auricular branch of the vagus nerve is often termed the Alderman's nerve or Arnold's nerve.

66. Failure of the sinus of His to obliterate that is believed to be the cause of the development of branchial cleft cysts, fistulas, or sinuses.

67. Red Ribbon -- Aids Awareness.
      Pink Ribbon -- Breast Cancer Awareness.

68. Father of Orthopaedics -- " Sir Nicholas Andre "

69. Blair's procedure -- Arthrodesis of ankle joint.

70. Darrach osteotomy -- done in Made Lung Deformity.

71. Partial or Complete loss of bone seen on X-Ray is Pathognomonic of Fracture. 

72. Godfrey Hounsfield won the 1979 Nobel Prize for Physiology or Medicine for developing CT, shared with Allan M. McCormack.


73. The atypical ribs : 1st, 2nd, 11th, and 12th ribs.

74. Cuffed ET tube - Cuff pressure should never exceed 30 cm of H2O (preferably 25cm).

75. PVC - ET tubes use High Volume Low Pressure cuffs. (therefore suitable for long duration).

76. FDA approved Raxibacumab to treat " inhalational anthrax " - First monoclonal antibody approved
      using the Animal Efficacy Rule.

77. Major carrier of Nitrogen by products from most tissues in the body is Glutamine.

78. Keloid is a result of an overgrowth of granulation tissue (collagen type 3) at the site of a healed skin injury which is then slowly replaced by collagen type 1.

79. Median umbilical ligament is the remnant of the urachus, which joined the apex of the fetal bladder to the umbilicus.

80. Medial umbilical ligaments are formed by occluded parts of the Umbilical arteries.

81. Hilar cholangiocarcinoma is the most common among Cholangiocarcinomas.

82. Maximum content of tryglyceride is found in- Chylomicrons

83. Maximum content of Exogenous tryglyceride is found in-Chylomicrons

84. Maximum content of Endogenous tryglyceride is found in- VLDL

85. Maximum content of Cholesterol is found in- LDL



1 Main sites of metastases for common cancer types

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Main sites of metastases for common cancer types :





















  • Lung cancer, mainly to brain, adrenal glands, and bone.
  • Breast cancer, mainly to bone, liver, lung and brain.
  • Colon cancer, mainly to liver.
  • Pancreatic cancer, mainly to liver and lungs.
  • Melanoma, mainly to brain
  • Ovarian cancer, mainly to pleural cavity and liver.





0 Rapid sequence induction

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Rapid sequence induction is used in cases of Full Stomach :

Normally induction sequence is

  1. Pre O2 (3-4mins)
  2. IV induction
  3. Muscle relaxant
  4. Bag + Mask IPPV
  5. Intubation

In Rapid Sequence induction
  1. Pre O2 (3-4mins)
  2. IV induction
  3. Fast Acting Muscle Relaxant
  4. No Bag & mask
  5. Intubate





0 Some Diseases and Anaesthesia

Reactions: 


Porphyria :

Contraindicated drugs - 
  • Thiopentone
  • Etomidate
  • Pentazocine
DOC - Propofol


Myesthenia Gravis :
  • Increased sensitivity to NDMR
  • Resistance to DMR
  • Sevoflurane is inhalational agent of choice
  • Atracurium (1/10th normal dose) is Muscle relaxant of choice.
  • Risk of post-op Respiratory failure.

Dystrophia Myotonica:
  • Tendency of Obstructive sleep apnea
  • Sch is Contraindicated (as it causes prolonged contraction)
  • Rapid sequence induction with Propofol and Rocuronium is used.

Duchenne Muscular Dystrophy :
  • Abnormal response to Sch and Volatile agents
  • IV induction preferred
  • Hyperkalemia common
  • NDMR duration is prolonged.




0 Muscle Relaxants - Important Points

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Drugs NOT having Renal excretion : (SMAC)
  • Sch
  • Mivacurium
  • Atracurium
  • CisAtracurium

Histamine Release (MAST)
  • Mivacurium
  • Atracurium
  • Sch
  • Tubocurrarine

Ganglionic effects
  • Stimulation - Sch
  • Block - Tubocurrarine

Vagolytic Activiy
  • Gallamine
  • Pancuronium

Sympathetic Stimulation
  • Gallamine
  • Pancuronium

Metabolized Completely by Renal
  • Gallamine




MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 NDMR (some more points)

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Non-depolarizing Muscle relaxants :

This is the second post on NDMR.
For Previous post - Click here


Drugs which antagonize the NDMR block :
  1. Phenytoin
  2. Carbamazepine
  3. Calcium

Reversal of Block by :

1. Neostigmine
  • does not cross BBB
  • Muscarinic side effects - therefore give Atropine along with it.
2. Edrophonium
  • Short duration of action (therefore chances of recurarization)
3. Pyridostigmine
  • Longer duration

Signs of Adequate reversal :
  1. Lift head for >5sec - Best Clinical Sign
  2. Regular respiration
  3. Spontaneous eye opening
  4. Spontaneous Limb movements
  5. Can protrude tongue
  6. Able to cough
  7. No Cyanosis





4 Non Depolarizing Muscle Relaxants (NDMR)

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Non Depolarizing Muscle Relaxants (NDMR) :
  • No Muscle fassiculation.
  • Slow onset and slow dissociation.
  • Reversed by Neostigmine.
  • Muscle remains responsive to other stimulus (Therefore Neuromuscular monitor used).
  • Fade & Post tetanic stimulation.
  • Mild hypothermia antagonizes block.


Atracurium :

  • Metabolism - 75% by Hoffman degradation, 25 % by  ester hydrolysis.
  • Metabolite - Laudanosine (pro convulsant)
  • Does not require any reversal agent
  • DOC in :
  1. Renal and Hepatic failure cases.
  2. Myesthenia Gravis - Use 1/10 th of normal dose

CisAtracurium :
  • 3 times more potent
  • No histamine release
  • Non cumulative
  • Only Hoffman degradation
  • Laudanosine levels are lower.

Mivacurium :
  • Ultra Short
  • Metabolism - Plasma Cholinesterase (=Pseudo)
  • Ideal Muscle relaxant for Continuous infusion , day care surgery.

Doxacurium :
  • Most Potent
  • Long acting
  • Metabolism - Kidney

D Tubocurarine :
  • Long acting 
  • Cause hypotension by ganglionic block

Vecuronium Bromide :
  • Most Haemodynamically stable
  • Minimum Vagolytic
  • Metabolism - Liver

Pancuronium :
  • Causes Hypertension and tachycardia (therefore good in Shock)
  • Long acting
  • Vagolytic
  • Causes Nor-epinephrine release

Rocuronium bromide :
  • Rapid onset (therefore can be used in full stomach)
  • Slightly vagolytic
  • Largely excreted unchanged in bile

Pipecuronium :
  • Longest acting
  • No vagolytic activuty

Rapacuronium :
  • Fastest Onset (among NDMR) ( Note: Overall Fastest Onset Muscle relaxant is Sch )
  • Increases incidence of bronchospasm.

Gallamine:
  • Maximum propensity for vagal blockade
  • Cross Placenta (therefore contraindicated in Pregnancy)
  • Also Contraindicated in Renal disease.

Alcuronium :

  • Anaphylaxis is common
  • Deterioration on exposure to sunlight.



Fastest onset agents are used in full stomach : (preference order as mentioned below)
  1. Succinylcholine
  2. Rapacuronium
  3. Rocuronium




2 Top Medical PG Coaching Institute - Survey Results

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Top Medical PG Coaching Institute - Survey Results (INDIA)


AcrossPG Team has conducted the survey for selecting The Best Medical PG Coaching Institute in Dec ’12-Jan 2013 (Best PG Entrance coaching - Opinion Poll). 

Here are the highlights of the survey.
  • Totally >400 medicos participated in survey, from various medical colleges of all states, ranging from batches 2000 to 2006. 
  • Received votes for >7 PG Coaching Institutes from across the country including Bhatia, DAMS, IAMS, Speed PG Institute, MIMS Calicut, MEDPGTHRISSUR and others. 
  • Many students were in favour that rigorous self-study is important if NEET happens, and coaching is useful only with self-study.
How the result is calculated?
  • We have calculated the results by counting votes from only unique IPs to remove bias from multiple votes casting.
  • An effective score is calculated institute-wise from the total votes submitted. This is to remove any bias occurred due to difference in number of votes for each institute.
  • The effective scores are then compared under 4 broad categories – Faculty, Study Material, Tests and Effectiveness for NEET PG.
RESULT

Delhi Academy of Medical Sciences occupied the top position followed by Dr Bhatia Medical Coaching Institute.



Category wise comparisons:

DAMS excelled in Faculty, IAMS in Quality of Study Material, Bhatia tops in Quality of Tests, whereas NEET effective coaching is marginally shared by DAMS and Bhatia.


To read about Complete Survey & some Comments by Participants-- Go to http://www.exams.acrosspg.com/2013/01/top-medical-pg-coaching-institute.html 



2 Succinylcholine

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Succinylcholine = Suxamethonium chloride 

Succinylcholine acts as a Depolarizing neuromuscular blocker (=DMR - Depolarising muscle relaxant)

Mnemonic : SSSS
  • FasSiculations
  • FaSt dissociation at receptors (Therefore Short acting )
Mnemonic : DND
  • Not reversed by Neostigmine
  • No fade or Post tetanic stimulation. 

Potentiated by
  1. Isoflurane
  2. Respiratory Alkalosis
  3. Hypothermia
  4. Mg
Antagonised by : Acidosis and NDMR

Repeated use  - causes Phase II block (similar to NDMR) -- (MCQ)

Other points about Sch :
  • Onset within 30 sec --- lasts 10-12 mins.
  • Bradycardia in children (especially after 2nd dose) (MCQ)
  • All presures are increased ( BP , ICP , IOP , Intra gastric )
  • Enzyme metabolism - by PseudoCholinestrase (= plasma = Butyrylcholinesterase) (read below in short about Cholinestrases )

Dibucaine Number :

  • The Dibucaine Number is a measure of the qualitative activity of Pseudocholinesterase and is the percentage of inhibition of the enzyme by the local anesthetic Dibucaine.
  • Normally 75 - 85 % inhibition , But if homozygous defficiency - then 30%
  • It is used to differentiate individuals who have substitution mutations of the Butrylcholinesterase enzyme.


Side effects :
  • Increase K+ (especially after Burns , spinal cord injury , stroke , cerebral palsy )
Therefore Sch is Avoided 48hrs - 9months after acute injury. 
  • Post Op muscular pain which can be decreased by :
                                  1. Self Taming (Pretreatment with small (10 mg) doses of succinylcholine)
                                  2. Precurarization (NDMR + Sch)
                                  3. Lignocaine
  • Malignant Hyperthermia
Note: 
  1. Sch is the MC drug which causes Malignant Hyperthermia.
  2. All Fluranated inhalational anaesthetics & Lignocaine are other drugs which can cause Malignant Hyperthermia.
  • Allergy - releases histamine.
  • Contraindicated in Myotonic Dystrophy : as it causes severe muscle rigidity , preventing respiration and intubation.
  • Can cause Masseter spasm in children.


NeuroMuscular monitoring (Adductor Pollicis , Ulnar Nerve)  (No use in Sch block)

  1. TOF (Train of 4)
  2. PTC ( Post tetanic count )
  3. DBS ( Dual burst stimulation )
  4. Tetanus

Cholinesterases :
  1. True :  RBC and Grey Matter.
  2. Pseudo/False :  Liver and Plasma.



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