Anaesthetics Booklet

8/6/2019 Anaesthetics Booklet

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Coliste na hOllscoile Corcaigh

University College Cork

MED3/GM2 CLERKSHIP

IN

ANAESTHESIA & INTENSIVE CARE MEDICINE

AT

UNIVERSITY COLLEGE CORK MEDICAL SCHOOL

2010/11

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DEPARTMENT OF ANAESTHESIA & INTENSIVE CARE

MEDICINE

Med3/GM2 Medical Students

Module CP3002

Background

The anaesthetic/ICU component of module CP3002 will comprise two elements.

TERM 1

During Term 1 (Sept. to Dec.) it is proposed that students will attend the Operating

Theatres of either Cork University Hospital, South Infirmary/Victoria University

Hospital, Bon Secours Hospital or Mercy University Hospital on Tuesday,

Wednesday and Thursday mornings over a two week period. This is designed to

complement the intensive course on clinical skills offered during September.

Since this module is timed to occur at the introduction to the clinical curriculum, it is

appropriate and timely to expose students to the basics of clinical and practical skills,

BLS (Basic Life Support) and Resuscitation. Teaching of the theoretical concepts can

be followed by the demonstration and practice of skills in the Clinical Skills

Laboratory. Here students can develop and practise skills in a non-clinical

environment. The theoretical knowledge will then be reinforced and the clinical

skills demonstrated and applied in a clinical setting during the three weeks in the

hospital component of the module.

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Because the work of anaesthetists straddles a number of clinical areas in a hospital

setting eg perioperative care, intensive care, acute and chronic pain management it is

hoped that students will be exposed to some or all of these areas during the two week

component of the clerkship.

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TERM 2

In Term 2, students will attend the Department of Anaesthesia/Intensive Care of a

designated Acute Teaching hospital for one full week attachment. This will

comprise one of a four week surgical clinical attachment.

During that week students will be exposed to:

a) Further small group teaching in a theatre setting.

b) Principles/practice of preoperative Anaesthetic Evaluation of patients.

c) Patient care in post operative recovery room.

d) Have two tutorials (airway management, resuscitation).

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Educational Objectives

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1 To enable the student to understand the roles of the anaesthetist within

a hospital setting.

2 To enable the student to learn how to assess a patient for anaesthesia

and surgery.

3 To enable students to gain a basic understanding of induction, maintenance

and emergence from anaesthesia, including intraoperative monitoring and

post operative care.

4 To allow students to observe and understand the principles of fluid and

electrolyte management intra and post operatively.

5 To enable students to observe and understand the principles of pain

assessment and management.

6 To learn the principles and practice of Cardiopulmonary Resuscitation.

7 To learn the theory and gain practical experience in airway management,

bag and mask ventilation, LMA insertion, ETT intubation and IV access.

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Clerkship Content

The content of this clerkship can be divided into three areas:

1 Theory

2 Demonstration and practice of clinical and practical skills.

3 Assessment/Evaluation

Theory

Theoretical concepts will be taught both at tutorial sessions (at least two during the

three week hospital attendance) and on a one to one level in the Operating

Theatres.

Clinical /Practical Skills

Clinical skills such as history taking, preoperative patient assessment, patient

examination, interpretation of ECGs and Chest Xrays will be demonstrated and

discussed.

Practical Skills

CPR, airway management, bag/mask ventilation, intravenous access, LMA/ETT

insertion will be demonstrated and practised.

Management of specific situations

e.g. Choking

Drowning

Smoke inhalation

Burns

Electrocution

Drug overdose

Severe haemorrhage

Multiple InjuriesHead/Spinal Injuries.

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Assessment/Evaluation

In keeping with other clinical rotations anaesthesia assessment will be a part of

written/skill based assessment at end of year examinations (EMQ/OSCE).

Students are required to submit an essay following completion of clerkship

(which accounts for 30% of anaesthesia clerkship marks). See Gaffney Prize,

page 22.

Students will be asked to give an anonymous evaluation of the Anaesthesia clerkship

at the end of Term 2 attachment.

Recommended Reading:

How To Survive In Anaesthesia. Neville Robinson and George Hall, 2nd Edition.

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Core Topics

Below are listed a number of core topics under various headings. These are simply

guidelines for both students and teachers. It allows teachers to cover what we regard

as important areas in this clerkship and it allows students to ensure that different

topics are covered on different days in Theatre/ICU. It also gives students headings

underwhich questions may be asked of their teachers.

Knowledge and understanding:

Roles of anaesthetist

Patient assessment

Induction, maintenance, emergence

Post operative care

Monitoring

Fluid management

Electrolytes

ICU ABGs, shock, CCF, respiratory failure, ventilation

Anaphylaxis

Clinical Skills:

Pre-operative assessment

History taking

Examination CVS, respiratory, head and neck

CXR

ECG

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Technical Skills:

CPR

I.V. insertion

B-V-M ventilation

(LMA, ET tube insertion)

Attitudes

Standards of care

Vigilance

Appropriate behaviour to staff and patients

Problem Solving:

Simple anaesthetic plan

Management of clinical scenarios e.g. hypoxia, hypotension etc.

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FOR CUH STUDENTS ONLY

Theatre Assignments

Students Numbered 1 12

Week 1 of Term 1

Th.1/1a Th. 2 Th.3 Th.4 Th. 5 Th.6 Th.7 Th.8 Th. 9

Tuesday 1/12 2/11 3 5/6 7 8 9 10 4

Wednesday 10 5 8/9 1/2 4 6/7 3 12 11

Thursday 4/7 12/6 10 9/4 3/11 5 8 2 1

Week 2 of Term 1

Tuesday 5/6 8/9 7 3/10 1 2 4 11 12

Wednesday 3 10 5/6 7/8 2 11 12/4 1 9

Thursday 8/9 1/4 11 10 5/12 9 6/7 3 2

FOR CUH STUDENTS ONLY

Theatre Assignments

Term 2

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Manual ventilation (facemask/airway)

LMA Insertion

ETT Insertion

IV Insertion

Other e.g. Arterial Line

MED 111 ANAESTHESIA AND INTENSIVE CARE CLERKSHIP

COURSE EVALUATION FORM

Please rate the content of each of the core topics listed below as inadequate, adequate

or good by ticking the appropriate box.

Core Topic Inadequate Adequate Good

ResuscitationAirway Management

Perioperative Patient Monitoring

Applied Pharmacology

Applied Physiology

Procedural Skills

Please rate the importance and relevance to practice of each of the core topics

listed below as very important, fairly important or not important by ticking the

appropriate box.

Core Topic Very Fairly Important Not Important

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Important

Resuscitation

Airway Management

Perioperative Patient Monitoring

Applied Pharmacology

Applied PhysiologyIntensive Care Medicine

Procedural Skills

Any other comments

ERC Guidelines for Resuscitation 2005

Summary

Main changes in adult basic life support

The decision to start CPR is made if a victim is unresponsive and notbreathing normally.

Rescuers should be taught to place their hands on the centre of thechest, rather than to spend more time using the rib margin method.

Each rescue breath is given over 1 sec rather than 2 sec.

The ratio of compressions to ventilations is 30:2 for all adult victims ofcardiac arrest. This same ratio should also be used for children whenattended by a lay rescuer.

For an adult victim, the 2 initial rescue breaths are omitted, with 30compressions being given immediately after cardiac arrest isestablished.

Main changes in automated external defibrillation

Public access defibrillation (PAD) programmes are recommended forlocations where the expected use of an AED for witnessed cardiacarrest exceeds once in two years.

A single defibrillatory shock (at least 150J biphasic or 360Jmonophasic) is delivered, immediately followed by two minutes of

uninterrupted CPR, without a check for termination of VF or a check forsigns of life or a pulse.

Main changes in adult advanced life supportCPR before defibrillation

In out-of-hospital cardiac arrest attended, but unwitnessed, byhealthcare professionals equipped with manual defibrillators, give CPRfor 2 min (i.e. about 5 cycles at 30:2) before defibrillation.

Do not delay defibrillation if an out-of-hospital arrest is witnessed by ahealthcare professional.

Do not delay defibrillation for in-hospital cardiac arrest.

Defibrillation strategy

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Unconscious adult patients, with spontaneous circulation, after out-of-hospital VF cardiac arrest should be cooled to 32-34C for 12-24 h.

Mild hypothermia may also benefit unconscious adult patients, withspontaneous circulation, after out-of-hospital cardiac arrest from a non-shockable rhythm or after cardiac arrest in hospital.

Main changes in paediatric life support

Paediatric basic life support

Lay rescuers or lone rescuers witnessing or attending paediatriccardiac arrest will use a ratio of 30 compressions to 2 ventilations.They will start with 5 rescue breaths and continue with the 30:2 ratio astaught in adult BLS.

Two or more rescuers with a duty to respond will use the 15:2 ratio in achild up to the onset of puberty. It is inappropriate and unnecessary to

establish the onset of puberty formally; if the rescuer believes thevictim to be a child then they should use the paediatric guidelines.

In an infant (less than 1 year) the compression technique remains thesame: two-finger compression for single rescuers and two-thumbencircling technique for two or more rescuers. Above one year of age,there is no division between one- or two-hand technique. The one ortwo hands technique may be used according to rescuer preference.

AED may be used in children above one year of age. Attenuators of theelectrical output are recommended between 1 and 8 years of age.

For foreign body airway obstruction relief, in an unconscious child orinfant, attempt five rescue breaths and in the absence of response,proceed to chest compressions without further assessment of thecirculation.

Paediatric advanced life support

The Layngeal Mask Airway is an acceptable initial airway device forproviders experienced in its use. In hospital, a cuffed tracheal tube maybe useful in certain circumstances, e.g. in cases of poor lungcompliance, high airway resistance or large glottic air leak.The cuffinflation pressure should be monitored regularly and must remain

below 20 cm H2O .

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Hyperventilation is harmful during cardiac arrest. The ideal tidal volumeshould achieve modest chest wall rise.

When using a manual defibrillator, a dose of 4 J kg-1 (biphasic ormonophasic waveform) should be used for the first and subsequentshocks.

Asystole, pulseless electrical activity (PEA)

Adrenaline IV or IO should be given at the dose of 10 mcg kg-1 andrepeated every 3-5min. If no vascular access is available and atracheal tube is in-situ, adrenaline may be given at the dose of 100mcg kg-1 via this route until IV/IO access is obtained

Defibrillation strategy

Ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) shouldbe treated with a single shock, followed by immediate resumption of

CPR (15 compressions to 2 ventilations). Do not reassess the rhythmor feel for a pulse. After 2 min of CPR, check the rhythm and giveanother shock (if indicated).

Give adrenaline 10 mcg kg-1 IV if VF/VT persists after a second shock.

Repeat adrenaline every 3-5 min thereafter if VF/VT persists.

Temperature control

After cardiac arrest, treat fever aggressively.

A child who regains a spontaneous circulation but remains comatoseafter cardiac arrest may benefit from being cooled to a coretemperature of 32-34C for 12-24 h. After a period of mild hypothermia,

the child should be rewarmed slowly at 0.25-0.5C h-1.

Resuscitation of the newborn

Protect the newborm from heat loss. Premature babies should becovered with plastic wrapping on head and body (apart from the face),without drying the baby beforehand. The baby so covered should thenbe placed under radiant heat

Ventilation: an initial inflation for 2-3 seconds must be given for the firstfew breaths to help lung expansion

Trachal route for adrenaline is not recommended. If the tracheal route

must be used, a dose of 100 mcg kg-1 must be used. Suctioning meconium from the babys nose and mouth before delivery

of the babys chest (intrapartum suctioning) is not useful and no longerrecommended.

Standard resuscitation in delivery room should be made with 100%oxygen. However lower concentrations are acceptable.

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Figure 2.1 Adult basic life support algorithm.

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Figure 2.20 Algorithm for use of an automated external defibrillator.

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Figure 4.1 Algorithm for the treatment of in-hospital cardiac arrest.

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Figure 4.2 Advanced life support cardiac arrest algorithm.

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Figure 6.1 Paediatric basic life support algorithm.

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THE GAFFNEY PRIZE

An undergraduate prize in Anaesthesia and Intensive Care Medicine has been

established in honour of Dr. Desmond Gaffney, former Chairman, Department of

Anaesthesia, Cork University Hospital. A prize of 1000.00 will be awarded

annually for the best essay (1500 2000 words) on a topic relevant to the practice

of anaesthesia and/or intensive care medicine from registered medical undergraduates

at UCC. Submission of essays is mandatory for all Med3/GM2 students. The

successful applicant will be invited to present on the subject of their

essay at the following South of Ireland Anaesthetists Association Annual Scientific

Meeting.

The subject matter of the essay will relate to the clinical practice of Anaesthesia or

Intensive Care Medicine. Basic physiological or pharmacological topics can be

discussed, but only in so far as they relate to clinical practice. Candidates are

encouraged to select topics which are current and/or controversial. Submissions,

which include the application of new information (either recently published or

collected by the submitting student) or original ideas to well-established problems, are

encouraged.

Marks will be awarded according to the following criteria: Content (50%),

Presentation (20%), Originality (15%), Clinical Significance (15%). Students should

note that Originality may mean the presentation of an argument in favour or against

a proposed idea OR the presentation of original data collected by the submitting

student. Marks will also be awarded for attempts to demonstrate an understanding

of a topic rather than a recycling or assembly of previously published material.

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White A4 paper should be used with margins of at least 2.5 cms (1 inch), double-

spacing should be used throughout. All pages should be numbered consecutively,

beginning with the title page.

The title page should not include the authors name. A maximum of 20 references are

permitted. The essay should be accompanied by a cover letter stating the title of the

article and the name, address, telephone number, student number and medical class

year of the author.

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N.B. Students to submit their essays within four weeks of completion of their

Anaesthetic clerkship.

Essays to be submitted to the designated Gaffney Essay assignment

box in the Assessment area of Blackboard. (CP3002 / GM2004)

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NOTES:

Documents

Anaesthetics Booklet