NM blocker

Longest acting NM blocker               ----------> PANCURONIUM
Shortest & fastest acting NM blocker ------------> Succinyl choline
Shortest acting competitive blocker -------------> Mivacurium
Fastest acting competitive blocker   -------------> Rocuronium
Maximal vagal block is seen in ------------------> Pancuronium
Max ganglionic blockade         -------------------> dTc
vagal and ganglionic stimulation -----------------> Succinyl choline
Mc muscle relaxant used for routine surgery ---> Vecuronium
Most potent skeletal muscle relaxant ------------> Doxacurium
least potent S.M.R                     ------------------>Sch
Least potent compititive blocker   -----------------> Rocuronium
only comp. blocker metabolized by plasma cholinesterase -->Mivacurium

Properties of halothane

Properties of halothane
Mnemonic-Halothane CC
H-hyperthermia(malignant)
A-analgesic action absent
L-liver toxic
O-orthostatic hypotension
T-Tocolytic
H-heart(decrease CO)
A-asthma(bronchodilator)
N}Non
E}explosive
C-chills
C-children(safe)
One more property of halothen is reduce portal blood flow...

2015 UPDATE- AHA CPR GUIDELINES

2015 UPDATE- AHA CPR GUIDELINES:
By Dr. Deepak Marwah

CHANGES FROM 2010:

●BASIC LIFE SUPPORT (BLS):

Compression rate is modified to a range of 100 to 120/min. (Should not exceed 120/min).

Compression depth for adults is modified to at least 2 inches (5 cm). (Should not exceed 2.4 inches (6 cm).

To allow full chest wall recoil after each compression, rescuers must avoid leaning on the chest between compressions.

Criteria for minimizing interruptions is clarified with a goal of chest compression fraction as high as possible, with a target of at least 60%.

For patients with ongoing CPR and an advanced airway in place, a simplified ventilation rate of 1 breath every 6 seconds (10 breaths per minute) is recommended.

For witnessed OHCA with a shockable rhythm, it may be reasonable to delay positive-pressure ventilation (PPV) by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts.

●ADVANCE CARDIAC LIFE SUPPORT (ACLS):

Vasopressin has been removed from the Adult Cardiac Arrest Algorithm.

In intubated patients, failure to achieve an ETCO2 of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitation efforts, but should not be used in isolation.

Steroids as part of bundle with vasopressin and epinephrine may be administered in IHCA. Though routine use in not recommonded. 
(Steroids may provide some benefit when bundled with vasopressin and epinephrine in treating IHCA).

Initiation or continuation of lidocaine may be considered immediately after ROSC from VF/pulseless ventricular tachycardia (pVT) cardiac arrest.

Initiation or continuation of an oral or intravenous (IV) ß-blocker may be considered early after hospitalization from cardiac arrest due to VF/pVT.

●POST CARDIAC ARREST CARE:

Emergency coronary angiography is recommended for all patients with ST elevation and for hemodynamically or electrically unstable patients without ST elevation for whom a cardiovascular lesion is suspected.

All comatose adults patients with ROSC should have TTM (target temperature management), with a target temperature between 32 to 36 C selected and achieved, then maintained constantly for at least 24 hours. 
Actively preventing fever in comatose patients after TTM is reasonable.

Routine prehospital cooling of OHCA patients with rapid infusion of cold IV fluids after ROSC is not recommonded.

Avoid and immediately correct (systolic BP less than 90 mmHg, mean arterial pressure less than 65) during post cardiac arrest care.

Prognostication is now recommended no sooner than 72 hours after the completion of TTM; for those who do not have TTM, prognostication is not recommended any sooner than 72 hours after ROSC.

All patients who progress to brain death or circulatory death after initial cardiac arrest should be considered potential organ donors.

Anasthesia Cylinders and gases

1) AIR :

grey body with white shoulder
Pin index 1,5
2)O2
   Black body with white shoulder
Pin index 2,5
3)N2O
Blue
Pin index 3,5
4)CO2
GREY
>7.5 = 1,6
<7.5 = 2,6
5)Cyclopropane
  Orange
   3,6
6)Helium and Heliox
   Brown
   >80.5 = 4,6
    <80.5 =2,4
7)entonox
   Blue body with white shoulder
    7
8) Halothane
AMBER color

Anaesthesia of choice

ANESTHESIA OF CHOICE::
▪Internal version:: halothane
▪Removal of placenta:: halothane
▪HOCM :: halothane
▪Children:: sevoflurane/ ketamine *
▪B/A::ketamine  > halothane
▪R»L shunt:: ketamine
▪L»R shunt:: isoflurane
▪Cardiac surgery:: isoflurane
▪Neurosurgery:: isoflurane
▪Controlled hypotension:: isoflurane
▪Renal disease:: Desflurane
▪Hepatic disease::Desflurane
▪IHD:: etomidate
▪Aneurysm surgeries:: etomidate
▪Malignant hyperthermia:: propofol
▪Hemorrhagic shock:: cyclopropane
▪Shock:: ketamine
▪CHF:: ketamine
▪ECT:: methohexitone
▪Thyrotoxicosis:: thiopentone
▪Epilepsy:: thiopentone

Malignant hyperthermia
Agent of choice
▪IV:: Propofol
▪Inhalation:: N2O
▪LA:: Procaine
▪MR:: d-TC

Maximum effect of GA::
▪Max respiratory depression:: enflurane
▪Max  decrease CO:: enflurane
▪Max. Decrease BP:: isoflurane
▪Max. Bronchodilator (asthamatic) :: halothane
▪Max intracranial flow:: halothane
▪Max intracranial tension:: halothane
▪Max. Bronchodilator (non- asthamatic):: sevoflurane
▪Max analgesic:: trielene
▪Max MR:: ether

CPR Guidelines

AHA CPR Guidelines 2010
NOTE: Sequence has changed from airway, breathing, chest compressions (ABC) to chest compressions, airway, breathing (CAB) per the 2010 AHA Guidelines
Untrained lay rescuers should do compression-only CPR; whereas, trained lay rescuers and healthcare providers (HCP) should include compressions and breathing
Compressions
check pulse at carotid
compression landmarks: lower half of sternum, between nipples just below intermammary line
do not press on the xiphoid or the ribs
compression method: 2-finger chest compression for lone rescuer or 2-thumbs encircling hands for 2 rescuers
compression depth: approximately 1.5 inches (about 4 cm) in most infants
allow complete chest recoil after each compression
compression rate: at least 100/min
compression-ventilation ratio: 30:2 (single rescuer); 15:2 (2 HCP rescuers)
minimize interruptions in compressions; limit interruptions to <10 seconds
Airway
head tilt-chin (HCP suspected trauma: use jaw thrust)
Breathing
ventilation with advanced airway: 1 breath every 6-8 seconds (8-10 breaths/min)
asynchronous with chest compressions
about 1 second per breath
visible chest rise
avoid excessive ventilation
Defibrillation
attach and use AED as soon as available
minimize interruptions in chest compressions before and after shock

COLOUR CODING OF MEDICAL GAS CYLINDERS

(1)"Oxygen : Black coloured with white shoulders", while ur walking thru the Casualty of any hosp u'll find this holstered on the bars beneath a stretcher.
(2) "Carbon - Dioxide : Grey Colour" just try writing Carbon diaxoide chemical formula on a paper i.e. CO2 , putting 2 as subscript of O, you'll notice that the O and the 2 form a lowercase "g" designating CO2 :-> C for CarbonDioxide and O2 for g i.e grey
(3) " Air : Grey body and black valve" just think of the hAIR on our head, its black first and then turns grey, similarly the valve is black and the body below the valve is grey.
(4) " Nitrous Oxide : Blue" this is damn easy, if you've watched the Movie Housefull (Akshay,Ritesh, Lara, Deepika), recall the last seen where there is a switch of cylinders at the Queen's Royal Palace Gathering and the 2 goons end up connecting the wrong tank flooding the reception with Nitrous Oxide , giving the laughter riot at the end of the movie because, Nitrous Oxide is Laughing Gas.
(5) "Cyclopropane : Orange" well orange is a fruit which is rich in Vitamin C and the name Cyclopropane starts witha C, so C for Vit.C is as to Orange is as to Cyclopropane.
(6) "Ethylene : Red" Well in PUC biology we had learn't the reason behind the one-liner "a few rotten apples spoils the entire lot" lets say the few rotten apples are at the bottom of the basket , when fruits and vegges are spoilt they release "Ethylene gas" which travels up and spoils the apples which are "RED" in colour causing them to inturn release the gas hence Ethylene "->Red.
(7) "Helium : Brown" I am a big fan of brownies and recently i wanted to learn how to prepare them by myself, so i googled and founf out that the easiest Brownie to prepare is the "Float Brownie" (you too can google) now what makes the baloons float, yes its Helium, So Helium: Float :: Float Brownies : Helium :-> Brown
(8) " Entonox : Blue body with Blue Quartered Shoulders" very simple what was the 2World cup frenzy, yes it was "BLEED BLUE", to bleed blue for the men who wear blue clothing on their body with blue clothing on their shoulders, now if we have to bleed blue it means we have blue "WITHIN" us and what does ENTO mean in greek, you guessed it right, it means within, For Ex. Entropion (Ento-ro-pion) meaning the eyelid folds within or eyelid folds inwards, hence, Entonox is Blue Body with Blue Shoulders.
(9) "Halothane: Amber" I'm a fan of Halo, in Halo2 while playing the Delta level the music is In Amber Clad, its gotta quite good tune to it (type '"In Amber Clad (extended) - Halo 2 soundtrack' on you tube to listen to it) Hence HALOthane :-> Amber. 
Moral of the story " What the mind does not know, the eyes do not see" if your mind knew that medicine existed everywhere then your eyes would by default see it and help you in crisis times.

KEY POINTS: Chronic Pain Management

KEY POINTS: Chronic Pain Management

Chronic pain is best treated using multiple therapeutic modalities. These include physical therapy, psychologic support, pharmacologic management, and the rational use of more invasive procedures such as nerve blocks and implantable technologies.
Patients suffering from cancer pain often exhibit complex symptomatology that includes various forms of nociceptive and neuropathic pain.
In patients suffering from chronic pain, underlying psychologic/psychiatric conditions should be addressed if any meaningful recovery is to be achieved.
Neuropathic pain is usually less responsive to opioids than pain originating from nociceptors.

Anesthesia Facts

Dioscorides-used the term anaesthesia

Oliver wendell holmes-1846 termed anesthesiology

William.T.G.Morton-demonstrated general anaesthetic effects of ether(oct 16 1846 world ether day)

Carl koller- 1884 introduced cocaine as ophthalmic anaesthetic

Niemann-1860 introduced cocaine as local anaesthetic

Joseph priestley- produced nitrous oxide 1772

Horace walls-1844 demonstrated use of nitrous oxide in tooth extraction

Robert liston-dec21 1846 performed first surgery under ether anaesthesia

August bier-1898 first spinal anaesthesia

Simpson-first to use chloroform

John lundy-1934 first to use i.v. anaesthetic thiopentone

Ferdinand cathelin-1901-caudal epidural anaesthesia

Fidel pages-1921-lumbar epidural anaesthesia

Alexander wood-1855-invented needle & syringe

Harold griffith-1942 used curare

Lofgren-1943 introduced lignocaine

John lundy & Ralph waters- coined balanced anaesthesia

Domino&corsen-first used ketamine

Bovet-synthesised succinylcholine

Edmund gaske boyle-1917 boyle's machine

Ivan magill-first endo tracheal intubation

Stanlers rowbothon-first nasal intubation

Anesthesia

PRESERVATIVES

• Halothane:0.01%thymol
• Ketamine:Benzethonium chloride
• Thiopentone:Anhydrous sodium carbonate(6%)&nitrogen gas
• Ether:Propyl galate/ hydroquinone/ diphenylamine

1. Post-op shivering: pethidine, pentazocine
2. inhalational anaesthetic that boils at room temp:desflurane
3. inhalational anaesthetic that causes coronary steal:isoflurane
4. anaesthesia of choice in hemorrhagic shock:cyclopropane
5. associated with post anaesthetic chills:halothane
6. agent of choice for cerebral protection:thiopentone
7. abnormal spike discharges in epileptic pts:methohexitone
8. thalamoneocortical junction is the primary site of action for:ketamine
9. steroid anaesthetic:althesin, minaxolone
10. anti-analgesic anaesthetic agent:thiopentone

One liners

1.Shortest acting SMR :sch

2.shortest acting ND SMR :Mivacurium

3.smr undergo hoffman elimination :Atracurium>cisatracurium

4.max.histamine release--d-TC

5.minimum histamine release --vecuronium

6.smr used in asthma-: Cisatracurium

7.smr used to BP--d-TC

8.smr used to maintain BP--pancuronium

9.smr c/i in renal failure n pregnancy--gallamine

10.which smr is cardiostable  --vecuronium

1. Ecg lead to be monitored for ischemia
 V5
2 for arrhythmia
 2
3. Capnography is to measure for
co2
4. Best site for temp measurement is
Lower oesophagus
5. Aspirin to be stopped before surgery  not to be stopped
6. Clopidogrel to be stopped b4  - 7daz
7. Normal breath holding spells is 25 sec
8. Frontal b waves indicate   - light anesthesia
9. Best monitor to see depth of anesthesia ?
  1.BIS✅
  2.Entopy
  3.Eeg
  4. Evoked response
10. Entonox is O2 + n2o

4) critical ph in mendelsons syndrome?2.5
5) best site for TPN is?subclavian vein
6) most frequent tooth to be impacted? lower third molar
7) floating teeth seen in? histiocytosis x
8) normal capacity of renal pelvis?7ml
9) irrigation solution used in TURP?1.5% glycine
10) most common complications of TURP?retrograde ejaculation

1. Oroya fever ? Bordotella
2. Brill zinsser ds ? R prowazecki
3. Weils ds ? L icterohemorhagica
4. Haverhill fever ? Streptobacillus monilifrmis
5. Rat bite fever ? "
6. Wasserman reaction ? Treponema
7. False positive wasserman rectn ? Mycoplasma
8. Fried egg colonies ? Mycoplasma
9. Frog egg colonies ? Coryne. Diphtheriae intermedius
10. Daisy head colonies ? C b gravis

Drugs to be stopped before anaesthesia

TIME PERIOD TO STOP CERTAIN DRUGS BEFORE SURGERY 

Lithium: stop 2 days before surgery (Remember the alphabet 'L' is formed by 2straight lines)

MAO-A irreversible inhibitors: 3 weeks (Remember, turn 'M'clockwise,
you get something like '3'; Alternatively MAO has 3 letters)

Estrogen pills: 4 weeks ( 'E' is formed by 4 straight lines)

CPR Guidelines

CPR Guidelines - Children (Aged 1 Year - Puberty)

AHA CPR Guidelines 2010

NOTE: Sequence has changed from airway, breathing, chest compressions (ABC) to chest compressions, airway, breathing (CAB) per the 2010 AHA Guidelines
Untrained lay rescuers should do compression-only CPR;
whereas, trained lay rescuers and healthcare providers (HCP) should include compressions and breathing
1- Compressions:
• check pulse at carotid
• compression landmarks: lower half of sternum, between nipples
• do not press on the xiphoid or the ribs
• compression method: heel of 1 hand or 2 hands (other hand on top)
• compression depth: about 2 inches (5 cm) in most children
• allow complete chest recoil after each compression
• compression rate: at least 100/min
• compression-ventilation ratio: 30:2 (single rescuer);15:2 (2 HCP rescuers)
• minimize interruptions in compressions; limit interruptions to <10 seconds
• no data to determine if the 1 or 2 hand compression method produces better compressions and better outcome in children; • AHA guidelines state "Because
children and rescuers come in all sizes, rescuers may use either 1 or 2 hands to compress the child's chest"
2- Airway
• head tilt-chin (HCP suspected trauma: use jaw thrust)
3- Breathing
• ventilation with advanced airway: 1 breath every 6-8 seconds (8-10 breaths/min)
• asynchronous with chest compressions
• about 1 second per breath
• visible chest rise
• avoid excessive ventilation
4- Defibrillation
• attach and use AED as soon as available
• minimize interruptions in chest compressions before and after shock
• resume CPR beginning with compressions immediately after each shock

Anesthesia High yield Points

Most cardiostable volatile agent? Isoflurane
Anaes causing coronary steal phenomena? Isoflurane
Robin hood phenomena is caused by? Thiopentone
Autoregulation is blunted by? Halothane
High output renal failure is caused by? Methoxyflurane
Retrograde amnesia is caused by? Diazepam
Most cardiostable agent is? Etomidate
Anaesthesia in child with Duchene's? Propofol
M/x used skeletal ms relaxant? Vecuronium.

Mnemonic for contraindications foruse of lignocaine with adrenaline is :

Digital PEN :
Digital PEN stands for:
D – Digits (Fingers and toes)
P – Penis
E – Ear
N – Nose tip