31 “The Essential Oral Board Review Memorized Responses Rote memorization is not an essential Consultant attribute, One wonders, then, why there is 's0 much emphasis on memorization from “experts” in other courses. The obvious answer: They do not understand the oral Boards. ‘There are several real dangers in advocating a memorization approach to the orals. First, gives examiners the impression that you are reading a script or a list, cannot think on your own, and Cannot make your own Judgments or Adapt. Examiners may feel that this mindless, robotic way of thinking and speaking is how you appear to others. (\s this also the way you practice anesthesia?) ‘Second, by frantically trying to dig up memorized responses when you should be engaged in ‘problem-solving and conversation, you give filing (or fail to give) meaningful responses. Canned, (generic responses, which you may not even retrieve in time, do not really address specific questions. Third, tying to memorize an exact answer to every oral Board question is folly — not because exact answers are'too numerous, but because exact answers do not even exist! Itis infinitely more: preferable to learn how to think on your foet and hold a conversation. Finally, a memorization approach misrepresents and trivializes the oral Board process, which is only partly about memorization. The oral Board exam is mainly about the way you think, solve problems, respond to new situations, organize your thoughts, and communicate with others. By spending your time memorizing spells, you miss out on a golden opportunity to become a perioperative Consultant, Nevertheless, rote memorization does have a limited place. Just as clinical treatment algorithms serve as useful guidelines for patient management, so can memorization of certain facts, concepts, and approaches guide you towards the an acceptable test response. This is not the same ‘2s memorizing the entire answer. Instead, itis laying down a framework on which you can organize thoughts and phrase answers. Thus, if memorization is to be used, itis only with the ultimate goal of facilitating Judgment, Adaptabilty, and Communication. ‘The next section contains several answers that you will be tempted to memorize. Please do and remember that your memorized response will probably never be used verbatim during a real exam. The Sample Responses can be cited verbatim when problem is generic. Verbatim responses may also be useful, when, after exhausting all possible specific diagnoses, the problem persists (perhaps you have missed something). However, your actual Board question will be based on a specific case scenario, the details of which often make parts of the memorized response incorrect or incomplete. For example, you would not “check the pulse oximeter and ETCO,’ if a person passed ut and turned blue at a restaurant ~ most restaurants do not carry pulse oximeters or capnograms. Similarly, if a patient came into the emergency room had a knife sticking out of his head, “intracranial foreign body" would be high in your list of reasons for altered mental status, even though it was not ‘on your memorized list. As you learn to apply the algorthims, you will learn to quickly add and subtract items that either do or do not belong, respectively. For better, not for worse, memorization does not relieve you of the need to think.32 ‘The Essential Oral Board Review Sample Responses to Adverse Events Hypoxia ‘a. First |, would check the patient's pulse oximeter and color to make sure the hypoxia was real b. Then, | would look at the presence and pattem of expired COs to make sure the patient was boeing ventilated and no airway obstruction was occurring. c. Noxt, | would hand ventiate with 100% O,, listen for bilateral breath sounds, look for symmetric chest wall excursion, and check the patient's peak airway pressure and tidal volume, d. Depending on what | found, | would consider suctioning the ETT. looking down the ETT with a fiberoptic bronchoscope, andlor obtaining a CXR. . Hypotension a. First, | would confirm the BP value by palpating the pulse at 2 separate sites and repeat the NIBP reading, b. Atthe same time, | would look at his other vital signs, including HR, saturation, ETCO2, and temperature. Depending on my findings, | may consider chest auscultation and ‘examination. . Then, | would look for a specific cause. + I would look at the ECG for heart rate rhythm, and ST segment changes. | would examine the surgical field for signs of bleeding or IVC compression. + Alldrugs given to the patient and relevant history should be reviewed, If present, invasive monitors should be checked for filing pressures and CO. 4. Critically low BPs should be treated acutely with epinephrine or ephedrine if there were bradycardia and phenylephrine or atropine if there is tachycardia. e. An initial fluid bolus may also be indicated unless itis strongly suspected that fluid will worsen CHF. {. CPR is necessary for life-threatening hypotension, Hypertension: a. First, | would first make certain the value was real by repeating a noninvasive reading and flushing the AL, if one were present. . Then, | would make certain there was no change in the patient's oxygenation and ventilation by looking at the pulse oximeter, patient's color, and capnogram. cc. Next, | would determine the heart rate to determine whether there was tachycardia, bradycardia, or dysrhythmias, d. Ifthe hypertension were critically high, | could initiate treatment with a drug such as nitroglycerine, nitroprusside, labetolol, nifedipine, or nicardipine. However, | prefer to treat the exact cause, the possibilities for which include hypoxia, hypercarbia, pain, fluid overload or unintended pressor administration, fe. The need for acute treatment depends on whether the BP is a baseline condition or causing any harm (such as ischemia, dysrhythmias or bleeding). Hypercarbia Hypercarbia is due to an increase in CO2 production or a decrease in CO, elimination. a. First, | would check the ather vital signs, including the pulse oximeter, HR, BP, and temperature, to make sure the condition was not an emergency. b. Next, | would hand ventilate with 100% O,, listen for bilateral breath sounds, look for symmetric chest wall excursion, and check the peak airway pressure and tidal volume, ¢. Causes of increased production include fever, shivering, MH, neurolept malignant syndrome, seizures, thyroid storm, high carbohydrate diat - all hypermetabolic conditions. 4d. Causes of decreased elimination include improper ventilator settings, leaks or obstruction in the breathing system, rebreathing in the circuit, changes in lung compliance or function (eg., bronchospasm, mucous plugs, pneumonia, aspiration, right mainstem intubation, and a patient fighting the ventilator). e. Afler hyperventilation, other specific therapy depends on making an exact diagnosis.33 The Eosatal Oral Board Review 5, Tachycardia 4. First, | would palpate the pulse to determine if the tachycardia was real and look at the ECG to determine the underlying rhythm. | would also determine its relative significance by determining the baseline HR. bb. Next, | would make certain there was no change in the patient's oxygenation and ventilation by looking at the pulse oximeter, patient’s color, and capnogram. . Tachycardia can be due to hypoxia, hypercarbia, pain, anxiety, hypovolemia, anemi fever, endogenous catecholamines, exogenous sympathomimetics, anticholinergics, dysrhythmias, or pacemaker malfunction (if present), G. Ifimmediate therapy were required (as with worsening myocardial ischemia), but the exact cause still unknown, | may consider administering esmolol, a short-acting beta-blocker. Bradycardia 2. First, | would look at the ECG to determine the underlying rhythm and palpate the pulse to determing if the bradycardia was real. | would also determing its relative significance by determining the baseline HR. b. Next, | would make certain there was no change in the patient's oxygenation and ventilation by looking at the pulse oximeter, patient's color, and capnogram. . Bradycardia can be due to hypoxia, vagal or parasympathetic reflexes (e.g,, from hypertension), drug effect (e.g., acetylcholinesterases, beta-blockers), pacemaker failure, or a baseline condition (e.g. athlete, acquired, or congenital heart block). d. Ifimmediate therapy were required (as with hypotension) but the exact cause still unknown, | would consider using atropine, ephedrine, epinephrine, isoproterenol, followed by transcutaneous or intravenous pacing, Delayed Emergence Delayed emergence can be due to problems with ABCs, medications, an adverse neurologic event, or metabolic conditions. a. First, addressing the ABCs, | would make cortain the patient's oxygenation, ventilation, and vital signs were acceptable by looking at the patient's color, pulse oximeter, HR, BP, ‘temperature, and capnogram (hypocarbia removes the drive to breathe and hypercarbia ‘can cause CO; narcosis) . Then, | would review the patient's exposure to medications, including neuromuscular blockers (twitch stimulator), residual inhalational agent (sampling exhaled gases), intraoperative drugs (type and dose of narcotics, benzodiazepines, and ones continuously infused), and premedications (like scopolamine and droperidol) cc. Next, | Would examine his pupils and review the chart for conditions that could affect mental status, such as seizures, or a stroke (embolic, ischemic, hemorrhagic, or thrombotic). d. Ifo diagnosis were apparent, | would consider metabolic causes and consider obtaining an ABG, electrolytes, glucose, e. Ifall else failed, | may consider a head CT and/or a neurologic consult. In the mean time, the patient may need to have his airway controlled and protected, and Ventilation controlled or assisted Oliguri The causes of cliguria can classified as prerenal, renal, or postrenal. 2, First, | would quickly rule out postrenai causes by checking the Foley catheter, if one is in place, and palpating the bladder. ». Then, | would evaluate prerenal causes by assessing the possibilty of hypovolemia, vasoconstriction, or mechanical restriction of renal blood flow. Vital signs and any hemodynamic or respiratory parameters should be used to help investigate these possiblities. If aortic surgery had been performed, the possibilty of emboli should be ‘considered, even though no specific therapy may exist.34 ‘The Essential Oral Board Review . Renal causes include intrinsic renal injury from ischemia, toxins, or mechanical damage. 1 would review the anesthetic record and history for hypotensive episodes, antibiotic or dye ‘exposures, transfusion reactions, possible muscle injury, and blunt or penetrating trauma. 4, Laboratory studies are usually not immediately helpful. Inspection of the urine may ‘suggest the presence of blood, heme, or myoglobin. A BUN, Cr, and fractional excretion of Na’ are not helpful in the setting of acute injury since changes in these values take hours to develop. If renal vein or artery thrombosis are considered, @ renal ultrasound and urology consult may be needed. ©. Ifimmediate therapy were required but the exact cause still unknown, the patient's volume status and hemodynamic stability would should be assured. | would consider administering aifluid challenge. Mannitol, furosemide, and dopamine may also be given, but without proof that they can prevent renal failure from occurring. They may, however, prevent total anuria, decreasing the need for later dialysis. 9. Jaundice The causes of jaundice can be classified as prehapatio, hepatic, or posthepatic. 2. Prehepatic causes are due to the increased production of bilirubin from a hemolysis or absorption of a hematoma, . Hepatic causes are due to hepatic injury from ischemia: hepatotoxic drugs including antibiotics (tetracycline, isoniazid, rifampin, sulfonamides), phenothiazines, alpha- methyldopa, salicylates, acetaminophen, anabolic steroids, oral contraceptives, and, alcohol; intrinsic disorders (Gilbert's is most common, Dubin-Johnson produces a conjugated hyperbilrubinemia, Crigler-Naljar is fatal in childhood); infections; hepatic, congestion; and rarely halothane hepatitis, cc. Posthepatic causes are due to mechanical obstruction, such as a stone, stricture, or atresia d. The most useful way to manage jaundice is to obtain a thorough history and physical exam, ‘concentrating on perioperative events (such as hypotension or recent transfusions), recent medications, and physical findings (such as hepatomegaly or signs of coagulopathy). . Important labs may include LFTS (including conjugated and unconjugated bilirubin), alkaline phosphatase (for obstruction), a H/H (for hemolysis), and possibly abdominal ultrasonography. 10. Nausea Nausea occurs from a varity of stimuli acing on the chemotrigger zone in the medulla, 2. The most important causes to rule out and reat are hypoxia and hypotension . Other important and readily treatable causes include pain and anxiety, narcotio, movement, and vagal stimulation (e.g, visceral traction). 6. Acute treatment consists of eliminating specific causes. Etfective medications include butyrophenones (croperida), phenothiazines (promethazine, perchloperazine), seloctiva 5-HTS antagonists (ondansetron), and even propofol. 411, Routine Monitoring and induction a. First, | would place monitors on the patient, including an ECG, NIBP, and pulse oximeter. '. Then, I would preoxygenate the patient with 100% O;,. Small amounts of fentanyl and midazolam could be titrated at this time to treat anxiety and facilitate induction. c. Next, | would then administer an induction dose of propofol, test my ability to mask ventilate, administer rocuronium and addtional fentanyl, and deepen anesthesia with sevoflurane. 4. Once an adequate level of anesthesia and neuromuscular was achieved, | would perform direct laryngoscopy and intubate the trachea. Proper endotracheal positioning would then be confirmed by auscultation and capnography.35 ‘The Essential Oral Board Review Differential Diagnoses 1. Hypoxia a. Low inspired Oz concentration b. Hypoventiation Central or obstructive causes with spontaneous ventilation Mechanical causes with controlled or spontaneous ventilation ¢. Shunt-V/Q mismaten Atelectasis Mucous plugs + Pneumo-/hemor(chylothorax. + Pleural effusion + Pulmonary contusion + Endobronchial intubation Pulmonary edema + Pneumonia/neumonitis Aspiration + Bronchospasm + Pulmonary embolism Inhibition of hypoxic pulmonary vasoconstriction * Decreased MVO2 + Intracardiae shunt + Pulmonary arterio-venous fistulae During one-tung ventilation 4, Increased diffusion barrier @. Baseline condition 2. Hypercarbia a. Increased production Fever Excessive carbohydrate intake + Malignant hyperthermia Neurolept malignant syndrome + Thyroid storm + Bicarbonate administration Release of tourniquet or aortic crossclap b. Hypoventiation Significant dead space ventilation Large pulmonary embolus Significant hypotension + No! usually one lung ventilation . Rebreathing + Incompetent inspiratoryfexpiratory check valve Exhausted soda lime + Inadequate flow with Mapleson system36 ‘The Essential Oral Board Review 3. Wheezing a. Lower Airway kinked tube Mucous plug + Hemiated cuff + Foreign body + Endobronchial intubation + Pneumothorax s Bronchospasm Pulmonary embolism + Cardiogenic + Anaphylaxis + Aspiration + Carcinoid Baseline concition b. Upper Airway + Laryngeal edema + laryngospasm i + Laryngomalacia + Foreign body ' Vocal cord paralysis, + Infection Tumor Polyps Baseline condition 4, Hypotension a. Hypoxia b. Hypercarbia (very late) cc. dysrhythmia Bradycardia + Tachycardia Nonsinus rhythm Asystole + Pacemaker failure J. Decreased afterload + Vasodilation - Hypovolemic shock + Septic shock = Anaphylactic shock + Neuragenic shock (high spinal or cord injury) ©, Decreased preload All types of shock above + Aortic crossclamp or unclamping + Pneumothorax Embolism (pulmonary, air, fat, amniotic fluid) + IVC occlusion Tamponade (high airway pressures)ee aid 37 k. Impaired myocardial function + Ischemia + Acidosis + Hypocalcemia Cardiomyopathy + Electrolyte disorder (hypocalcemia) + Valvular heart disease + Congenital heart disease + Vegetation or myxoma 1. Carcinoid orisis m, Addisonian crisis 1. Drug effect ©. Erroneous value p. Baseline condition Hypertension a. Hypoxia b. Hypercarbia . Inadequate anesthesia d. Pain e. Anxiety f, Drug withdrawal g. Increased ICP h. Hypervolemia Bladder distention j. Pheochromocytoma k Thyroid storm |. Malignant hyperthermia m. Carcinoid n. Drug effect + Sympathomimetic (e.g. cocaine) MAO! + Demerol Pheochromocytoma + droperidol ©. Erroneous value p. Baseline condition Tachycardia Hypoxia Hypercarbia . Inadequate anesthesia Pain Anxiety Drug withdrawal + Clonidine, ETOH, ete. dysrhythimia SVT, AF, A fut, VT, PAT Electrolyte h._Hypovolemia or hypotension |. Fever j. Malignant hyperthermia k. Pheochromocytoma I. Thyroid storm m. Carcinoid 1, Myocardial ischemia ©. Bladder dissension The Essential Oral Board Review38 p. Drug effect + MAO! + Demerol Pheochromocytoma + droperidol + Pancuronium q. Erroneous value = Counting T waves. '. Baseline condition 7, Bradycardia a. Hypoxia b. Hypercarbia (late) c. Anesthetic overdose 4. dysrhythmia ANB Sick sinus syndrome Pacer malfunction Electrolyte @. Myocardial infarction (especially with Wl) f. High spinal or spinal shock 9. Vagal refiex Hypertension (autonomic hyperrefiexia) + Ocullocardiac Visceral traction + Right atrial dissension + Increased ICP h. Bladder dissension i. Hypothermia J. Suctioning of airway (especially with pediatrics) Drug effect Opiates + Beta biocker + Calcium channel blocker + Potent inhalational agents Anticholinesterase inhibitor Succinyicholine |. Erroneous value m. Baseline condition 8, Altered Mental Status/Delayed Emergence a. ABCs + Hypoxia Hypercarbia (CO. narcosis) Hypocarbia (insufficient CO, stimulus) b. Medication effect Premedications (sedatives, scopolamine, droperidol, benzodiazepines) + Central anticholinergic syndrome (atropine, scopolamine, organophosphates, TCA) + Neuromuscular blocker + Anesthetic (inhaled, intravenous) Usual medications (narcotics, sedatives, tranquilizers, lithium, reserpine, clonidine, alpha-methyldopa, steroids, amphetamines, etc.) Substance abuse (alcohol, cocaine, LSD, heroin, etc.) c. Endoctindoicimetboto Hyponatremia + Hypocalcemia Hypoglycemia + Hypothermia Onl Board Review39 The Essential Oa Board Review + DKA + Hepatic encephalopathy (chronic problem) Renal encephalopathy (chronic problem) Hypothyroidism (chronic problem) + Addison's Disease (chronic problem) + Cushing's Disease (chronic problem) 4. Neurologic 7 lctal or post-ictal state + GVA (ischemic, thrombotic, embolic, hemorrhagic) « Cerebral edema e. Baseline condition 9. Agitation a. ABCs (see item 8 above) 'b. Medication effect (see item 8 above) Withdrawal (alcohol, narcotics) ©. Pain, anxiety, discomfort, disorientation, distended bladder d. Movement disorder (Parkinsonism, metoclopramide, droperidol) e. Baseline condition 10. Oliguria a. Prerenal Hypovoleria Hypotension Hypoperfusion Renal vein or artery thrombosis b. Renal ~ATN (ischemia; toxin - dye, abx, myoglobin, hemoglobin) Intrinsic disease (vascular, glomerular, thromboembolism, interstal nephritis) ©. Postrenal + Obstructed catheter Urethral or uretal obstruction 4. Baseline condition 11. Nausea/Vomiting Pain Hypoxia Hypotension . Vagal Drug + Anesthetic agents (narcotics, inhalation agents, etomidate) + Chemotherapy Other f. Surgery 9. Anxiety fh. Obstruction i. Infection j. Baseline condition40 ‘The Essential Oral Board Review Consultant Phrases Even though relying on memorized answers is not to be recommended, certain patterns of speech (reflecting certain pattems of though!) begin to emerge with repeated mock oral practice The following phrases are among the most common. As you study them, bear in mind that they are ‘not meant to represent gimmicks or shortcuts, Quite the opposite, when used properly, they reflect the essential attributes of a Consultant described previously. As you become more accustomed to their use, your responses should become less short and choppy and more continuous and smooth- flowing. Eventualiy diferent phrases will blend together as seamiess, effortless explanations, as they may seem to do in the following examples. 1. Always State Why When: Any question, any time, How: Before/during a response, provide your rationale as part of your answer. Example: “I would perform an awake intubation because the patient has a difficult airway and a full stomach...” 2. Offer Factual information When: Any question, any time. How: Bofore/during a response, provide factual information as part of your answer. Example: “Because patients with severe HTN are often hypovolemic, | would hydrate the patient before proceeding...” 3, State Your Goals When: Any question, any time. How: State your goals as part of your answer, especially before your plan. Example: "My goals for induction are to prevent bronchospasm in this asthmatic p Therefore, | would...” 4, Provide Perspective When: Any question, any time. How: Before/during a response, state your perspective as part of your answer. Example: “This is a bleeding patient who is oritcallyil, for whom surgery is life-saving and should proceed immediately...” 5. Making Choices When: Asked to make a choice. How: State whether that alternative would be acceptable or not, and, most importantly, why. Example 4: “Propofol is not my first choice for an induction agent because it is more likely to cause hypotension, an important consideration in this hypovolemic, elderly patient. That's why I chose etomidate, which causes less cardiovascular depression Example 2: “Propofol would be acceptable, but because the patient is elderly and possibly hypovolemic, | would use a low dose titrated to effect...” 6. RiskiBenefits When: Any question, any time, especially if asked to defend a decision, How: State the risks and benefits, including which is more important, defending your plan. Example: “The risk of performing a rapid sequence induction is losing control of the airway if intubation were unsuccessful. The beneft is minimizing the risk of aspiration Because it does not seem like it would be difficult to intubate the patient's airway, but the patient is actively vomiting, a rapid sequence induction is my first plan for induction..."