Pages 14–21: physics – basic principles of measurement

Measuring system characteristics

measurement: converts physical quantity into observable, ·

.repeatable, calibrated form

transducer: converts input (e.G., temp, pressure) into electrical ·

.signal

.signal-to-noise ratio (snr): signal power / noise power ·

text{snr (db)} = 20 \log_{10}\frac{\text{signal amplitude}}{\text{noise\

amplitude}}

improve snr: eliminate noise, differential amplifiers, filters, ·

.averaging

Static characteristics

.)%( accuracy: closeness to true value ·

.precision (reproducibility): similarity of repeated measurements ·

.validity: accurate + precise ·

.sensitivity: change in output per unit change in input ·

.linearity: output proportional to input ·

.non-linearity: e.G., rotameter ·

hysteresis: difference in reading when input increasing vs. ·

.Decreasing (due to energy loss as heat/friction)
 .drift: change over time (correct by zeroing) ·

Dynamic characteristics

.zero-order: exact tracking ·

.first-order: exponential approach (e.G., temp probe) ·

.second-order: may oscillate (e.G., invasive bp) ·

:step response ·

.response time: to 90% of final value ·

.rise time: 10%–90% of final value ·

.phase shift: different frequency delays → distortion ·

Basic measurement concepts – system components

Input → transducer → transmission path → signal conditioning

.(amplify, filter, a/d convert) → display/storage → output

Resonance, damping, frequency response

natural (resonant) frequency: where system oscillates; Causes ·

.waveform distortion in invasive bp monitoring

fourier analysis: waveform = fundamental frequency + harmonics. ·

.Need up to 10th harmonic for accurate invasive bp

to avoid resonance: use short, stiff, wide catheters; No air ·

.bubbles/clots; Minimal connections

.bandwidth for invasive arterial bp: 0–20 hz ·

.damping: decrease oscillation amplitude via energy dissipation ·

 .underdamped: falsely high systolic, low diastolic ·

overdamped: falsely low systolic, high diastolic; Accurate map. ·

.Caused by air bubbles/clots

optimal damping: damping factor d = 0.64 → fastest response ·

.without excessive oscillation

.critical damping: d = 1.0 , rapid fall without overshoot ·

Calibration

.goal: remove drift effects ·

:drift types ·

.gradient drift (non-proportional increase) ·

.offset drift (constant shift) ·

.calibration types: one-point (offset) or two-point (offset + gradient) ·

Pages 22–35: physics – mathematical concepts&statistics

Mathematical concepts

.sinusoids: represent repetitive body processes (ecg, bp) ·

.amplitude: max displacement from axis ·

.wavelength: distance between corresponding points ·

.frequency (hz): cycles per second. Period = 1/frequency ·

.velocity = frequency × wavelength ·

.parabolas: y = ax^2 + bx + c ; Used in theatre light reflectors ·

 .differentiation: finds slope (rate of change) ·

.integration: finds area under curve ·

Logarithms&exponentials

. logarithm: if y = a^x , then x = \log_a y ·

.natural log (ln): base e (≈2.718) ·

.exponential decay: y = ae^{-kt} (e.G., drug elimination, n₂ washout) ·

.exponential build-up: y = (1 – ae^{-kt}) (e.G., volatile wash-in) ·

.positive exponential: y = ae^{kt} (e.G., bacterial growth) ·

.half-life: time to decrease to half ·

time constant (τ): time to complete if initial rate continued. After ·

.1τ, quantity = 37% of initial

.lung time constant = compliance × resistance ·

Clinical nugget: high compliance + high resistance (emphysema +

.bronchoconstriction) → long τ → slow gas emptying

Hierarchy of evidence

Systematic reviews / meta-analyses .1

Rcts .2

Cohort studies .3

Case-control studies .4

Cross-sectional surveys .5

Case reports .6
 systematic review: explicit methods, widespread search, meta- ·
.analysis, forest/funnel plots

.funnel plot: detects publication bias ·

Randomised controlled trials (rcts)

.gold standard for eliminating bias ·

requirements: clear aims, ethics approval, power analysis, strict ·

.inclusion/exclusion, randomisation, blinding

blinding: single-blind (patient unaware); Double-blind (patient + ·

.investigator unaware)

.bias types: selection, ascertainment, drop-out ·

.power analysis: sample size calculation to detect true difference ·

.endpoint: predefined; May use interim analysis ·

Errors&statistical measures

.type i error (α, false positive): p-value; Max acceptable usually 0.05 ·

.type ii error (β, false negative): max acceptable usually 0.2 ·

power = 1 – β: probability of correctly rejecting null hypothesis (≥0.8 ·

.desirable)

.sensitivity = a/(a+c): true positive rate ·

.specificity = d/(b+d): true negative rate ·

.positive predictive value (ppv) = a/(a+b) ·

.negative predictive value (npv) = d/(d+c) ·

.accuracy = (a+d)/total ·

.relative risk reduction (rrr) = (a–b)/a ·

 .%absolute risk reduction (arr) = (a–b) ·

.number needed to treat (nnt) = 1/arr ·

Types of data&representation

.null hypothesis: no difference between samples ·

p-value: probability of result occurring by chance;<0.05 → ·

.statistically significant

:data types ·

qualitative: nominal (no order, e.G., operation type), ordinal ·

.(sequential but not numerical, e.G., pain scores)

quantitative: continuous (any number), discrete (whole numbers), ·

.ratio (true zero, e.G., kelvin), interval (no true zero, e.G., celsius)

normal (gaussian) distribution: bell-shaped, mean = median = mode, ·

.68% within 1 sd, 95% within 2 sds

.standard error of mean (sem) = sd/√n; 95% ci = mean ± 2×sem ·

Choice of statistical tests

qualitative data: chi-squared test (expected frequency ≥5) or ·

.fisher’s exact

:quantitative data ·

.two groups, normally distributed: student’s t-test ·

.two groups, non-normal: mann-whitney u-test ·

.two groups, normal: anova> ·

.two groups, non-normal: kruskal-wallis> ·

.paired data, normal: paired t-test or paired anova ·

paired data, non-normal: wilcoxon signed-rank (two groups) or ·
.friedman’s (>two groups)

Pages 36–49: physics – si units, simple mechanics&pressure

Base si units

length: metre (m) ·

mass: kilogram (kg) ·

time: second (s) ·

current: ampere (a) ·

temperature: kelvin (k) ·

luminous intensity: candela (cd) ·

amount of substance: mole (mol) ·

Derived si units

temperature: degree celsius (°c = k – 273.15) ·

force: newton (n = kg·m·s⁻²) ·

pressure: pascal (pa = n·m⁻²) ·

energy/work: joule (j = n·m) ·

power: watt (w = j·s⁻¹) ·

frequency: hertz (hz) ·

volume: litre (l = 10⁻³ m³) ·

charge: coulomb (c = a·s) ·

 potential: volt (v = j·c⁻¹ = w·a⁻¹) ·

resistance: ohm (ω = v·a⁻¹) ·

capacitance: farad (f = c·v⁻¹) ·

inductance: henry (h = v·s·a⁻¹) ·

magnetic flux: weber (wb = v·s) ·

flux density: tesla (t = wb·m⁻²) ·

Non-si units in anaesthesia

pressure: atm (101.325 kpa), bar (10⁵ pa), mmhg (133.322 pa), cmh₂o ·
.(98.06 pa), psi (6.894×10³ pa), torr (≈mmhg)

.energy: calorie (4.184 j), electronvolt (1.602×10⁻¹⁹ j) ·

.magnetic: gauss (10⁻⁴ t), maxwell (10⁻⁸ wb) ·

Simple mechanics

.mass: quantity of matter (kg) ·

.force: changes motion (n) ·

.work = force × distance (j) ·

.power = work/time (w) ·

.newton’s 1st law: body at rest/constant velocity unless acted on ·

. newton’s 2nd law: f = ma ·

Pressure definitions

.pressure = force/area ·
 atmospheric pressure ≈ 101.3 kpa ≈ 760 mmhg ≈ 1033 cmh₂o ≈ ·
.1.013 bar

partial pressure: pressure exerted by single gas in mixture (dalton’s ·

.law)

.tension: partial pressure of gas in solution (e.G., o₂ in blood) ·

.clinical nugget: myocardial work = pressure × volume ·

Gas laws (ideal gases)

.boyle’s law: v ∝ 1/p (t constant) ·

.charles’s law: v ∝ t (p constant) ·

.gay-lussac’s law: p ∝ t (v constant) ·

avogadro’s hypothesis: equal volumes contain equal molecules at ·

.same t&p; 1 mole gas = 22.4 l at stp

. ideal gas equation: pv = nrt ·

.dalton’s law: total pressure = sum of partial pressures ·

.henry’s law: amount dissolved ∝ partial pressure ·

Pressures&temperatures

.gauge pressure = total – atmospheric ·

.absolute pressure = gauge + atmospheric ·

critical temperature: above this, substance cannot be liquefied ·

.(becomes gas)

.critical pressure: pressure needed to liquefy at critical temperature ·

.pseudocritical temperature: above this, gas mixture won’t separate ·

 clinical nugget: n₂o critical temp = 36.5°c; Entonox pseudocritical ·
temp = –5.5°c at cylinder pressure (137 bar). Risk of separation in
.cold

Pressure measurement in gases

.manometer: liquid column (h₂o or hg), no calibration needed, bulky ·

aneroid gauge (e.G., bourdon): mechanical, robust, no power, not ·

.for very low pressures

piezoresistive strain gauge: versatile, needs power, susceptible to ·

.interference

Pressures of anaesthetic equipment

.cylinder pressures: o₂ 137 bar, n₂o 44 bar, entonox 137 bar ·

.pipeline pressure: 4 bar (except air for tools: 7 bar) ·

.flow restrictors: protect machine from surges (100–200 kpa) ·

.non-return pressure relief valve: opens at 35 kpa ·

.oxygen failure alarm:<200 kpa ·

.apl (heidbrink) valve: opens at<1 cmh₂o, max 70 cmh₂o ·

.reservoir bag: max 60 cmh₂o (protects patient) ·

Gases vs. Vapours

.gas: above critical temperature ·

.vapour: below critical temperature; At svp, coexists with liquid ·

.flow through tube ∝ 1/viscosity; Through orifice ∝ 1/√density ·

 Pages 50–61: physics – thermodynamics

Heat&laws of thermodynamics

.heat: vibrational kinetic energy of particles ·

.specific heat capacity: heat to raise 1 kg by 1 k ·

.temperature: thermal state; Ability to transfer heat ·

.calorimetry: measures chemical energy via combustion ·

:laws ·

.zeroth: defines temperature ·

.first: conservation of energy ·

.second: entropy increases ·

.third: entropy → constant as t → 0 k ·

Heat transfer methods

.conduction: through adjacent molecules (poor in air) ·

.convection: via fluid/gas movement ·

.radiation: electromagnetic waves ·

.evaporation: phase change; Cooling via latent heat loss ·

Temperature definitions

.freezing point: liquid → solid at given pressure ·

 .boiling point: liquid → gas when svp = ambient pressure ·

latent heat of fusion/vaporization: energy for phase change ·

.without t change

.vapour pressure (vp): pressure from escaping molecules ·

.saturated vapour pressure (svp): vp at equilibrium ·

colligative properties: depend on solute particle number: ↑ osmotic ·

.pressure, ↓ freezing point, ↑ boiling point, ↓ vp (raoult’s law)

osmolarity vs. Osmolality: per litre vs. Per kg solvent; ·

.Interchangeable below 500 mosm

.tonicity: effective osmolarity across specific membrane ·

clinical nugget: plasma/urine osmolality patterns indicate ·

.dehydration, renal disease, siadh, etc

.triple point of water: 0.01°c, 611.7 pa (ice, water, vapour coexist) ·

Measurement of temperature

:contact thermometers ·

.physical: bimetallic strip, liquid-in-glass, bourdon gauge ·

electrical: platinum resistance, thermistor (resistance decreases ·

.with t), thermocouple (seebeck effect)

.non-contact: thermopile (tympanic infrared) ·

Clinical aspects of heat&temperature

:heat loss distribution in anaesthetised patient ·

Radiation 40–50%, convection 30%, evaporation 20–25%, respiration

.5–10%, conduction 3–5%
 causes of peri-op hypothermia: cold theatre, vasodilation, cold ·
iv/irrigation fluids, evaporation from gases, depressed
.thermoregulation

.surgical patients have t<36°c 20% ·

consequences: ↑ infection risk, ↑ cardiac events, left-shifted odc, ·

.prolonged drug effects, ↓ mac, coagulopathy, shivering

core t sites: nasopharynx, lower oesophagus, pa catheter, bladder ·

.(high flow), cpb

.near-core: axillary, oral, bladder (low flow), rectal (unreliable) ·

Patient warming systems

forced air warmers (faws): convection; Recommended for ops>30 ·

.min. Risks: burns, pressure ulcers

.ambient t: 22–24°c, humidity ~50% ·

.fluid warmers: for>500 ml in adults ·

.humidified gases (hme) ·

.invasive: warmed irrigation, cpb/ecmo ·

Humidity

.absolute humidity: mass of water vapour per volume (g·m⁻³) ·

Inspired air (20°c): 17 g·m⁻³; Upper trachea (34°c): 34 g·m⁻³; Alveoli

.(37°c): 44 g·m⁻³

.relative humidity (%) = (actual vp / svp at same t)×100 ·

measurement: hair hygrometer, wet-and-dry bulb, regnault’s ·

.hygrometer (dew point), capacitance/resistance change
 Humidifiers

:passive ·

.tracheal instillation (inefficient) ·

.bottle humidifier (max 40% rh) ·

.soda lime (60–70% rh) ·

.hme (up to 90% efficient) ·

:active ·

.hot water bath (100% rh; Risk scalding, infection) ·

.nebulisers (no saturation limit; Risk water overload) ·

Fires&explosions

.requirements: combustible material, ignition source, oxygen ·

:fire vs. Explosion ·

.Fire: flammability ratio, 1 bar, 200–500°c, m·s⁻¹ speed

.Explosion: stoichiometric ratio, 25 bar, 3000°c, mach 8 speed

.flammability limits: fuel:oxygen ratio beyond which no ignition ·

.stoichiometric mixture: all reactants consumed; Maximal energy ·

.ignition sources: static electricity, diathermy, lasers, hot surfaces ·

combustible materials: historical agents (ether, cyclopropane), ·

ethyl chloride, surgical spirit, gut gases (ch₄, h₂), oil/grease on o₂
.cylinders

Pages 62–86: physics – electricity&magnetism

 Basic concepts

.potential difference (v): work per coulomb ·

.current (i): charge flow per second ·

.resistance ® = v/i (ohm’s law) ·

.power (w) = v×i ·

.charge (q) = i×t (coulombs) ·

.resistors in series: r_total = r₁ + r₂ ·

.resistors in parallel: 1/r_total = 1/r₁ + 1/r₂ ·

.impedance (z): ac equivalent of resistance; Depends on frequency ·

. capacitor: stores charge; Ac passes, dc blocked. C = q/v ·

inductor: opposes current change; Basis of transformers. Unit: ·

.henry (h)

.magnetic flux density: earth ~60 μt; Mri 0.4–4 t ·

Electrical interference

.sources: mains (50 hz), radio/tv/mobile, diathermy (0.5–1 mhz), mri ·

diathermy: heating, charting, explosions; High frequency minimises ·

.muscle/nerve stimulation

.mri room: faraday cage (copper mesh) prevents rf ingress/egress ·

Biological signals

.small voltages need amplification ·

 .bandwidth: frequency range for accurate amplification ·

filters: e.G., notch filter (blocks 48–52 hz to remove mains ·

.interference)

:signal ranges ·

.Eeg: 0.5–100 hz, 0.5–100 μv

.Ecg: 0.5–30 hz (monitor), 100 μv–3 mv

.Emg: 1–20,000 hz, ~1 mv

Measurement of neuromuscular blockade

.clinical signs: head lift, grip, coughing, eye opening ·

.nerve stimulator: supramaximal, square wave, 0.1–0.3 ms ·

sites: ulnar (adductor pollicis), facial (orbicularis oculi), common ·

.peroneal (ankle dorsiflexion), posterior tibial (plantar flexion)

diaphragm: 80% receptor block for paralysis; Recovers faster than ·

.adductor pollicis

.train of four (tof): 4 stimuli at 2 hz ·

.Non-depolarizing: fade present

.Depolarizing: no fade

.Tof count: 3 = 75% block, 2 = 80%, 1 = 90%, 0 = 100%

.Tof ratio>0.7 indicates clinical recovery

.tetanic stimulation: 50 hz for 5 s ·

.Non-depolarizing: fade + post-tetanic facilitation

.Depolarizing: no fade/facilitation

.double-burst stimulation: two 50 hz bursts; Easier fade detection ·

objective methods: acceleromyography, mechanomyography, ·

.evoked emg
 Electrical hazards – causes

.mains: 240 v ac, 50 hz ·

.effects: electrocution, burns, fire/explosion ·

:current effects (hand-to-hand) ·

.ma: tingling 1

.ma: max safe 5

.ma: tetanic contraction (“let-go” current) 15

.ma: ventricular fibrillation (vf) risk 75

.microshock: 50 μa via central line/pacemaker can induce vf ·

.sparks: ignite flammable vapours ·

capacitive coupling: patient acts as capacitor plate; Ac causes ·

.ongoing current (risk in mri)

Electrical hazards – prevention

general: regular testing, high-impedance shoes, avoid patient ·

.contact with earthed objects

:equipment classes ·

.class i: earthed conductive parts ·

.class ii: double/reinforced insulation (no earth) ·

.class iii: battery-powered (<safety voltage) ·

:types (leakage current) ·

.type b: 100 μa (iib) or 500 μa (ib); Not for direct cardiac connection ·

.type bf: floating circuit + type b ·

 type cf: floating circuit + max 10 μa (iicf) or 50 μa (icf); Safe for ·
.cardiac

circuit breakers: current-operated earth leakage type; Trip on ·

.imbalance between live/neutral

Principles of lasers

.laser: light amplification by stimulated emission of radiation ·

properties: monochromatic, non-divergent, high-intensity, ·

.coherent, small cross-section

mechanism: stimulated emission → amplification → directional ·

.emission

:types ·

.argon (blue-green): retinal surgery, birthmarks ·

co₂ (infrared): vaporises water; Cutting/haemostasis; Not for ·

.endoscopy

.nd:yag (near-infrared): coagulation/deep cutting; Endoscopic use ·

Laser safety

.burns: retina (blindness), skin, cornea ·

fire prevention: use air/o₂ (not n₂o/o₂), fio₂ ≤0.25, non-flammable ett ·
.with saline cuff, non-reflective instruments, wet swabs

:airway fire management ·

.Turn off laser, flood with saline .1

.Disconnect circuit, remove ett if possible .2

.Bag-mask with air .3

.Bronchoscopy .4
 .Icu observation, steroids, humidified o₂ .5

safe use: operator responsibility, eye protection, locked doors, fire ·

.extinguisher/saline syringe available

Electrical symbols

standard symbols for cell, battery, resistor, variable resistor, switch, ·

voltmeter, ammeter, ac supply, capacitor, inductor, diode, transistor,
.transformer, ground, fuse, thermocouple, thermistor

Wheatstone bridge

used in pressure transducers: strain gauges change resistance with ·

.diaphragm movement

null deflection system: variable resistor balances bridge → no ·

.current flow

amplification: two strain gauges increase resistance while two ·

.decrease → amplified signal

Circuit breakers, fuses, transformers, transistors, diodes

.fuse: melts at specific current ·

.circuit breaker: resettable via thermal/magnetic trip ·

transformer: steps voltage up/down via induction; Only works with ·

.ac

diode: allows current one direction (ac→dc conversion, back-current ·

.protection)

.transistor: semiconductor switch/amplifier (npn/pnp) ·

 Mri scanners&anaesthesia

principles: protons align in strong magnetic field (b₀), excited by rf ·

.(b₁), emit signal during relaxation (fid)

:t1/t2 weighting ·

.T1: good for white/grey contrast (fat short t1)

.T2: good for oedema

.scanner strength: 1–3 t (earth = 0.00005 t) ·

.superconducting magnets cooled by liquid helium ·

:anaesthetic considerations ·

.sedation vs. Ga ·

remote location, limited access, projectile risk, device interference, ·

.acoustic noise, contrast reactions (gadolinium)

safe monitoring: fibre-optic leads, slave monitors in control room, ·

.avoid burns from induced currents

.patient populations: children, icu, claustrophobic, psychiatric ·

Principles of cardiac pacemakers

indications: brady/tachyarrhythmias, heart block, sick sinus ·

.syndrome

temporary pacing: transvenous (central line, x-ray) or ·

.transcutaneous (large electrodes, up to 50 ms pulse)

.permanent pacing: endocardial wire + subcutaneous generator ·

pacemaker code (5 letters): chamber paced, chamber sensed, ·

.response, programmability, antiarrhythmic function
 demand-mode: sensing electrodes; Interference from diathermy, ·
.mri, motors may inhibit pacing

diathermy precautions: have programmer available, limit use, place ·

indifferent electrode far from pacemaker, use bipolar, low current,
.continuous ecg

Defibrillators

purpose: convert vf to sinus rhythm via simultaneous myocardial ·

.depolarization

. stored energy: e = ½cv² ·

.monophasic: single direction shock ·

biphasic: two oppositee pulses; Lower energy needed, less ·

.myocardial damage

transthoracic impedance: reduced by first shock; Internal ·

.defibrillation needs lower energy

.synchronized mode: shocks on r-wave to avoid vf induction ·

Diathermy

unipolar: forceps (high current density) + patient plate (low ·

.density)

bipolar: between forceps tips; No plate; Lower power; For delicate ·

.areas

.cutting: continuous sine wave (0.5 mhz) ·

.coagulation: pulsed sine wave (1–1.5 mhz) ·

:problems ·

.interference with monitoring ·

.burns from faulty plate, capacitive coupling, accidental activation ·

.ignition of flammable substances ·

.pacemaker malfunction ·

.frequency>1 mhz avoids muscle/nerve stimulation ·

Pages 87–101: physics – fluids&flow

Laminar&turbulent flow

.laminar: smooth, parabolic profile, fastest in centre ·

. hagen-poiseuille equation: flow = (pπr⁴)/(8ηl) or (pd⁴)/(128ηl) ·

.Flow ∝ r⁴, depends on viscosity, not density

.turbulent: eddies; Occurs if reynolds number>2000 ·

. Re = (vρd)/η

.Flow ∝ √(δp); Depends on density

.critical flow (l/min) ≈ airway diameter (mm) ·

.Peak flow often turbulent

clinical nugget: heliox (low density) reduces turbulence in upper ·

.airway obstruction

Bernoulli principle&venturi masks

bernoulli effect: pressure decreases where velocity increases ·

.(constriction)

.venturi device: uses subatmospheric pressure to entrain air ·

 .venturi mask (hafoe): fixed entrainment ratio → consistent fio₂ ·

.Entrainment ratio = entrained flow / driving flow

.Example: 4 l/min o₂, 9:1 ratio → total flow 40 l/min, fio₂ 28%

Surface tension&surfactant

surface tension: inward force at air-liquid interface; Minimises ·

.surface area (spherical droplets)

:laplace’s law ·

. Cylinder: p = t/r

. Sphere: p = 2t/r

.Explains reservoir bag safety (tension increases with radius)

surfactant: phospholipid from type ii pneumocytes; Reduces surface ·

tension more in small alveoli, prevents collapse, improves
.compliance, keeps alveoli dry

.fetal production: starts 26 weeks, mature by 32 weeks ·

Measurement of volume&flow

volume: benedict-roth spirometer, vitalograph, wright respirometer ·

.(underestimates low, overestimates high volumes)

:gas flow ·

.rotameter (variable orifice, constant pressure) ·

.wright peak flow meter (spring-loaded vane) ·

.mass flow meter (thermistor constant t) ·

pneumotachograph (constant orifice, variable pressure): screen, ·

.fleisch, hot-wire, pitot types
 The rotameter

.design: tapered tube + bobbin; Flow moves bobbin up ·

calibration: gas-specific (laminar at low flow depends on viscosity; ·

.Turbulent at high flow depends on density)

safety features: finned bobbin (prevents sticking), conductive strip ·

(anti-static), o₂ knob large/left, o₂ inlet downstream, anti-hypoxia
.device (<25% o₂ prevented)

problems: vaporizer downstream affects accuracy, must be vertical, ·

.specific to gas/t/p

Ultrasound&doppler

.ultrasound:>20 khz; 1–10 mhz clinical ·

.attenuation: low in water, high in bone/air ·

.frequency trade-off: lower → better penetration, poorer resolution ·

scan types: a-mode (depth), m-mode (movement), b-mode (2d ·

.image)

doppler effect: frequency shift from moving reflector (e.G., blood ·

.flow)

uses: imaging, doppler flow (vessels, fetal heart, oesophageal ·

.doppler for co), duplex (echo + doppler)

Simple pulmonary function tests

:spirometry ·

.Obstructive (e.G., asthma): ↓ fev₁, normal fvc, ↓ fev₁/fvc

 .Restrictive (e.G., fibrosis): ↓ fev₁, ↓ fvc, normal fev₁/fvc

:flow-volume loops ·

.Obstructive: scooped expiratory limb

.Restrictive: small loop, high late expiratory flow

Tests of gas exchange

.blood gases, pulse oximetry ·

.v/q mismatch: radioisotope scanning ·

diffusion capacity (dlco): volume of co transferred per min per ·

.mmhg alveolar partial pressure

.Normal: 17–25 ml/min/mmhg

Decreased in: thickened membrane (fibrosis), reduced membrane

.area (pneumonectomy)

Coanda effect

.tendency of fluid to attach to and follow a surface ·

mechanism: low pressure at constriction (bernoulli) persists if flow ·

.attaches

proposed role in: uneven ventilation, myocardial ischaemia distal to ·

.coronary bifurcation

fluid logic: switching flow via side tubes; Fewer valves but extra gas ·
.consumption

Pages 102–121: physics – clinical monitoring&measurement

 Minimum monitoring standards (aagbi)

essential parameters: o₂ inspired concentration, capnography, ·

pulse oximetry, ecg, nibp, airway pressure, temperature (>30 min),
.nerve stimulator (quantitative if possible), depth monitor for tiva

principles: anaesthetist must be present; Alarms set; Record at least ·

.every 5 min; Clinical observation still vital

limitations: devices must be correctly used/calibrated; Not all ·

.adverse events preventable

Ecg – principles&lead placement

.signal: ~1–2 mv (attenuated from 90 mv) ·

.electrodes: ag/agcl with gel; Adhesive surround ·

.interference: muscle, diathermy, mri ·

.lead vectors: positive deflection if depolarization toward lead ·

.lead ecg: 10 electrodes (4 limb, 6 precordial)-12 ·

.inferior: ii, iii, avf ·

.anterior: v3, v4 ·

.lateral: i, avl, v5, v6 ·

.septal: v1, v2 ·

.monitoring: usually lead ii or cms ·

Principles of pressure transducers

.strain gauge in wheatstone bridge; Zeroing required ·

 :invasive bp (ibp) ·

.continuous beat-to-beat ·

.flush at 200–300 mmhg, 2–4 ml/hr to prevent clotting ·

peripheral (radial) vs. Central (aortic): higher systolic, lower ·

.diastolic peripherally; Map constant

derived info: outflow resistance, myocardial work/o₂ consumption ·

(systolic area), myocardial perfusion (diastolic area), stroke
.volume/contractility (waveform analysis)

Nibp measurement

.manual (auscultatory): korotkoff sounds ·

.Phase i (systolic), iv/v (diastolic)

.Cuff width = 40% limb circumference, length = 2×width

.Errors: wrong cuff size, arrhythmias, hypotension

automatic (oscillometric): detects pressure oscillations; Less ·

.accurate than ibp

continuous non-invasive: e.G., finapres (vascular unloading ·

.technique)

Pulmonary artery (pa) catheter

components: distal lumen, proximal lumen, balloon (1–1.5 ml air), ·

.thermistor, fibre-optics for svo₂

insertion: via introducer sheath (usually ij), balloon inflated in ra, ·

.floated to pa

.measurements: pcwp, cardiac output, svo₂, svr, pvr ·

 complications: infection, thrombosis, pa rupture, arrhythmias, no ·
.proven mortality benefit

.pcwp: reflects lvedp (if in west zone 3). Normal 6–12 mmhg ·

Inaccuracies if: lv failure, non-compliant lv, peep, mitral valve

.disease, ar

Measurement of cardiac output

. fick principle: co = o₂ consumption / (cao₂ - cvo₂) ·

.Not routine due to steady-state requirement

thermodilution: cold saline injectate via pa catheter; Stewart- ·

.hamilton equation

.Continuous version uses thermal filament

.indicator dilution: lithium, indocyanine green ·

.echocardiography: lvot cross-sectional area × flow velocity ·

oesophageal doppler: descending aortic flow velocity × estimated ·

.area

clinical nugget: pulse pressure variation (ppv) predicts fluid ·

.responsiveness

Capnography

.principle: co₂ absorbs ir at 4.28 μm; Double-beam for accuracy ·

.sidestream: samples 150 ml/min; Response time<1 s; Risk occlusion ·

.mainstream: in-line; Shorter delay but bulky/fragile ·

uses: estimate paco₂, detect disconnection, rebreathing (↑ ·

baseline), mh (gradual ↑ etco₂), oesophageal intubation (↓ etco₂),
.embolism/↓ co (↓ etco₂)
 clinical nugget: bronchospasm → no plateau due to long time ·
.constants

Pulse oximetry

principle: beer-lambert law; Differential absorption of red (660 nm) ·

.vs. Ir (940 nm) by hbo₂ vs. Hb

.isosbestic points: 590 nm, 805 nm ·

.ac/dc separation: pulsatile component used ·

inaccuracies: motion, poor perfusion, abnormal hb (cohb → falsely ·

high, methb → tends to 85%), nail varnish, ambient light, diathermy,
.dyes (methylene blue)

response time: instrumental + circulatory delay (ear<15 s, finger>60 ·

.s)

.harmful effects: pressure burns, mri burns, infection ·

Measurement of gas&vapour concentrations

fuel cell: lead anode/gold cathode; O₂ specific; Slow (30 s); ·

.Exhausted over time

.ir spectrophotometry: for co₂, n₂o, volatiles ·

.uv absorption: for halothane ·

.mass spectrometry: separates by mass/charge ratio ·

paramagnetic cell: o₂ attracted to magnetic field; Fast, needs dry ·

.sample

.haldane apparatus: volume change after o₂/co₂ absorption ·

.katharometer: thermal conductivity change ·

.raman scattering: absorption depends on molecular bonds ·

 .interferometer: light phase shift; Used to calibrate vaporizers ·

Measurement of ph

ph electrode: h⁺-sensitive glass, ag/agcl electrodes, buffer solution, ·

.37°c

.equation: ph = pka + log([hco₃⁻]/[0.2×pco₂]) ·

Measurement of pco₂ (severinghaus)

modified ph electrode: co₂ diffuses through membrane, reacts with ·

.h₂o → h⁺ measured

.calibration/temperature control essential ·

.excess heparin → falsely low ·

Measurement of po₂ (clark electrode)

polarographic cell: pt cathode, ag/agcl anode, kcl electrolyte, ·

.membrane

:reactions ·

.⁻Cathode: o₂ + 4e⁻ + 2h₂o → 4oh

.⁻Anode: ag + cl⁻ → agcl + e

.must keep membrane clean, sample anaerobically ·

other methods: intravascular probes, transcutaneous (heating coil), ·

.fibre-optic sensors

Derived measurements – bicarbonate&base excess

 actual bicarbonate: calculated from ph&pco₂ via henderson- ·
.hasselbalch

.standard bicarbonate: calculated for normal pco₂ (5.3 kpa) ·

.actual base excess: metabolic contribution (using actual o₂ sat) ·

standard base excess: corrected for hb = 50 g/l (better for ecf ·

.buffering assessment)

O₂ consumption, co₂ production, respiratory quotient

o₂ consumption methods: closed spirometer, fick principle (co × ·

.(cao₂ - cvo₂))

.co₂ production: end-tidal sampling ·

.respiratory quotient (rq): co₂ produced / o₂ consumed ·

.Depends on substrate: carbs 1.0, fat 0.7, protein 0.8

respiratory exchange ratio (rer): estimated from expired co₂ / ·

.inspired o₂; Influenced by ventilation

Pages 122–136: physics – equipment

Classification of vaporizers

plenum: high resistance, outside circle (voc), positive pressure ·

.driven

drawover: low resistance, inside circle (vic) or drawover techniques, ·

.patient effort driven
 Factors affecting delivered concentration

.Svp: higher svp → more volatile .1

.Splitting ratio: vaporizing chamber vs. Bypass flow .2

.Fresh gas flow: modern vaporizers stable between 0.5–15 l/min .3

Temperature: svp decreases with cooling; Compensated by .4

.bimetallic strip, heat sink, etc

.Surface area: wicks/baffles maximise .5

Pumping effect: ventilator may force gas back into chamber → ↑ .6

.concentration

Pressurizing effect: high flows raise vaporizer pressure → .7

.expansion at outlet ↓ concentration

Types of vaporizers

tec (temperature compensated): splitting ratio, bimetallic strip, ·

.heat sink

desflurane (tec 6): boiling point 22.8°c; Heated to 39°c (svp 200 kpa); ·
Vapor added to carrier gas via pressure-controlled resistors; Requires
.mains electricity

Methods of killing organisms

.decontamination: cleaning (removes infected material) ·

disinfection: kills organisms (not spores): pasteurization (70°c/20 ·

min, 80°c/10 min), chemicals (chlorhexidine, ethanol, glutaraldehyde,
.hypochlorite)

:sterilization: kills all (including spores) ·

 .dry heat (160°c/1 hr) ·

.moist heat: autoclave (122°c/30 min, 126°c/10 min, 134°c/3 min) ·

.chemical: ethylene oxide ·

.γ-irradiation ·

Classification of ventilators

.by power: electrical, pneumatic, combined ·

:by cycling ·

.Inspiratory: volume, time, pressure, flow

.Expiratory: time cycling allows expiratory pause

by function: jet ventilation, minute volume dividers (e.G., manley, ·

.servo), intermittent blowers (e.G., penlon-nuffield)

.additional features: peep, cpap, bipap, simv, pressure support ·

Breathing systems (mapleson classification)

mapleson a: efficient for spontaneous (fgf = alveolar minute ·

.volume). Inefficient for ippv

.mapleson b&c: rarely used; Inefficient ·

.mapleson d: efficient for ippv; Inefficient for spontaneous ·

mapleson e (ayre’s t-piece): low dead space/resistance; Good for ·

.children; Needs fgf 2–3× minute volume

.mapleson f (jackson-rees): bag for observation/ippv ·

coaxial versions: lack (mapleson a), bain (mapleson d); Risk if inner ·
.tube damaged
 Scavenging

components: collecting system, tubing (30 mm connectors), ·

.receiving reservoir with pressure relief, disposal

passive: wide-bore to outside; Least efficient; Max resistance 0.5 ·

.cmh₂o at 30 l/min

active: fan suction; Handles 75 l/min (peak 130 l/min); May use ·
.venturi ejector

.difficult areas: paediatrics, recovery, obstetrics (entonox) ·

.coshh limits: n₂o 100 ppm, isoflurane 50 ppm (8-hr average) ·

adverse effects of chronic exposure: spontaneous abortion, ·

congenital abnormalities, leukaemia/lymphoma, female births,
.infertility

Carbon dioxide absorbers

.soda lime: 75% ca(oh)₂, 20% h₂o, 3% naoh, 1% koh, silicates ·

.Reaction: co₂ + ca(oh)₂ → caco₃ + h₂o (exothermic)

.kg absorbs ~250 l co₂ 1

Exhaustion indicators: phenolphthalein (pink→white), ethyl violet

.(white→purple)

baralyme: 80% ca(oh)₂, 20% ba(oh)₂; Less efficient, more stable ·

.when dry

:dangers ·

.co production with dry absorbent + isoflurane/desflurane ·

.compound a from sevoflurane (nephrotoxic in rats) ·

.neurotoxin from trichloroethylene ·

.caustic dust (waters canister) ·

 .granule size affects resistance/surface area ·

Suction

vacuum source: electrical pump (piston, rotary, diaphragm) or ·

.venturi injector

.performance: 0.67 bar below atm, 25 l/min free flow ·

.collection vessel: appropriate size, float valve, filter ·

catheters: yankauer (rigid), flexible for bronchial. Size = 2×ett size. ·

.Pre-oxygenate and recruit before/after suction

Co₂ removal systems

.to-and-fro (waters): canister near patient; 500 g soda lime ·

.circle system: larger canister (1–2 kg), unidirectional valves ·

Pages 136–141: physiology – general principles

Effects of old age on anaesthesia

.increased comorbidities: copd, ihd, htn, dementia, diabetes, frailty ·

.physiological reserve ↓ ·

.airway: edentulous, ↓ muscle tone, cervical spondylosis ·

respiratory: ↓ pao₂, ↓ hypoxic/hypercapnic drive, ↓ compliance, ↑ ·

.closing capacity, ↑ v/q mismatch, ↑ atelectasis/pneumonia risk
 cvs: ↓ hr, sv, contractility, co; ↓ lv compliance; ↓ inotrope ·
.sensitivity; ↑ vte risk

cns: cerebral atrophy, ↓ cbf, ↓ mac, ↓ memory, ↑ drug sensitivity, ↑ ·

.confusion risk

autonomic: orthostatic hypotension, ↓ bmr, impaired ·

.thermoregulation

.gi: hiatus hernia, slower gastric emptying, ↓ hepatic metabolism ·

renal: ↓ rbf, ↓ gfr (30–45%), ↓ concentrating ability, ↓ drug ·

.clearance

Paediatric anatomy&physiology

.neonate: ≤1 month; Infant: ≤1 year ·

high surface area:mass ratio → ↑ heat loss, ↑ bmr, ↑ o₂ ·

.consumption, ↑ hr/rr

airway: large head, narrow upper airway, large tongue, lymphoid, ·

long u-shaped epiglottis, anterior larynx (c3–4), obligate nasal
.breathers, cricoid narrowest

respiratory: short/narrow trachea, equal bronchial angles, 50% ·

resistance in small airways, horizontal ribs, diaphragmatic
breathing, fixed tidal volume (rate compensation), closing
.capacity>frc until age 6, expiratory cord adduction → auto-peep

cvs: co 30–50%>adults, fixed sv (rate compensation), small limbs → ·

.low volume reserve

.renal: ↓ gfr, ↓ tubular function, ↓ concentrating ability ·

nervous: myelination complete by 6 months, spinal cord ends l3–4 ·

.at birth (adult l1–2 by age 2), immature sns
 Pages 142–160: physiology – biochemistry

Acid-base balance

.normal ph: 7.35–7.45 (h⁺ 35–45 nmol/l) ·

.lungs: excrete 15,000–20,000 mmol h⁺/day as co₂ ·

.kidneys: excrete 60–80 mmol h⁺/day (non-volatile acids) ·

.buffers: immediate chemical, respiratory (fast), renal (slow) ·

Henderson-hasselbalch equation

text{ph} = \text{pk}_a + \log\frac{[\text{hco}_3^-]}{0.2 \times\

\text{pco}_2}

.pka for h₂co₃ ≈ 6.1 ·

.hco₃⁻ or ↓ pco₂ → alkalosis ↑ ·

.hco₃⁻ or ↑ pco₂ → acidosis ↓ ·

Anion gap

text{anion gap} = (\text{na}^+ + \text{k}^+) - (\text{hco}_3^- +\

\text{cl}^-)

.normal 8–16 mmol/l ·

.in: ketoacidosis, lactic acidosis, renal failure, toxins ↑ ·

 Buffers

.ecf: hco₃⁻ (major, open system), hb (in rbcs), plasma proteins, bone ·

.icf: proteins, phosphates ·

.renal: phosphate (titratable acidity), ammonia (nh₄⁺ formation) ·

Sodium (na⁺)

.main ecf cation; Determines ecf volume/osmolality ·

.normal: 135–145 mmol/l ·

.regulation: osmoreceptors (adh), baroreceptors (raas, anp) ·

Hyponatraemia

.hypovolaemic: renal/extrarenal losses (diuretics, vomiting, burns) ·

euvolaemic: siadh, hypothyroidism, glucocorticoid deficiency, ·

.excess hypotonic fluid

.hypervolaemic: ccf, cirrhosis, nephrotic syndrome, renal failure ·

Hypernatraemia

.hypovolaemic: losses>na⁺ (diarrhoea, diabetes insipidus) ·

.euvolaemic: insensible losses, diabetes insipidus ·

.hypervolaemic: hyperaldosteronism, iatrogenic (nacl, nahco₃) ·

Potassium (k⁺)
 .main icf cation; Critical for membrane potentials ·

.normal: 3.5–5.0 mmol/l ·

.regulation: aldosterone, insulin, catecholamines, acid-base balance ·

Hypokalaemia

causes: ↓ intake, renal losses (diuretics, hyperaldosteronism), ·

extrarenal losses (diarrhoea, vomiting), intracellular shift (alkalosis,
.insulin, β-agonists)

Hyperkalaemia

causes: ↑ intake, ↓ renal excretion (renal failure, acei, k⁺-sparing ·

diuretics), extracellular shift (acidosis, rhabdomyolysis,
suxamethonium), pseudohyperkalaemia (haemolysis, high
.platelets/wbc)

Causes of acid-base disturbances

respiratory acidosis: hypoventilation (drugs, cns injury, lung/chest ·

.wall disease, airway obstruction)

respiratory alkalosis: hyperventilation (anxiety, head injury, ·

.hypoxaemia, pe, ippv)

metabolic acidosis (normal anion gap): diarrhoea, renal tubular ·

.acidosis, ammonium chloride

metabolic acidosis (↑ anion gap): ketoacidosis, lactic acidosis, renal ·

.failure, toxins
 metabolic alkalosis: loss of h⁺ (vomiting, diuretics), gain of alkali ·
.(nahco₃, citrate)

Bicarbonate&phosphate

.bicarbonate: main ecf buffer; Renal reabsorption regulated ·

.phosphate: intracellular buffer; Component of atp, 2,3-dpg ·

.hyperphosphataemia: renal failure, hypoparathyroidism, cell lysis ·

hypophosphataemia: refeeding syndrome, respiratory alkalosis, ·

.alcoholism, malnutrition

Calcium (ca²⁺)

.normal ionized: 2.12–2.65 mmol/l ·

functions: muscle contraction, coagulation, second messenger, ·

.inotropy

regulation: vitamin d (↑ absorption), pth (↑ bone resorption, renal ·

.reabsorption), calcitonin (↓ bone resorption)

hypercalcaemia: “bones, stones, groans, psychic moans”; Treat with ·

.hydration, bisphosphonates, steroids

.hypocalcaemia: tetany, prolonged qt; Treat with iv calcium ·

Magnesium (mg²⁺)

.normal: 0.7–1.0 mmol/l ·

functions: na⁺/k⁺ atpase cofactor, ca²⁺ antagonist, membrane ·

.stabilizer, anticonvulsant, bronchodilator, tocolytic
 hypomagnesaemia: causes similar to hypokalaemia; Features: ·
.hyperexcitability, arrhythmias, hypocalcaemia

hypermagnesaemia: iatrogenic; Features: weakness, respiratory ·

.depression, bradycardia, cardiac arrest at>10 mmol/l

Chloride (cl⁻)

.⁻main ecf anion; Inversely related to hco₃ ·

.chloride shift: exchange with hco₃⁻ in rbcs ·

hyperchloraemic metabolic acidosis: excess normal saline, severe ·

.diarrhoea

Enzymes

.biological catalysts; Sensitive to ph/t ·

classification: oxidoreductases, transferases, hydrolases, lyases, ·

.isomerases, ligases

.models: lock-and-key, induced fit ·

.catalysis: lowers activation energy ·

Pages 160–190: physiology – body fluids, haematology, immunology,

nervous system (continued in next message due to length)

Would you like me to continue with the remaining sections (body

fluids to nervous system) in the same detailed, exam-focused
?format

Pages 160–169: physiology – body fluids

 Body fluid compartments

total body water (tbw): 45–75% body weight (~60% men, ~50% ·
.women)

.intracellular fluid (icf): ~40% body weight (~28 l in adult male) ·

:extracellular fluid (ecf): ~20% body weight (~14 l) ·

.plasma: ~5% (~3.5 l) ·

.interstitial fluid: ~15% (~10 l) ·

transcellular fluid: csf, intraocular, pleural, peritoneal, synovial; Not ·

.readily exchangeable

Measurement of fluid compartment volumes

.dilution principle: volume = amount of tracer / concentration ·

.tbw: deuterium oxide (d₂o) or tritiated water ·

ecf: ionic tracers (⁸²br, ³⁵so₄) – overestimates; Inulin/mannitol – ·

.underestimates

.plasma volume: evan’s blue dye or radiolabelled albumin ·

blood volume: plasma volume × (100 / (100 – hct)) or ⁵¹cr-labelled ·

.rbcs

.interstitial fluid: ecf – plasma volume ·

Osmolality&osmolarity

osmole: amount of solute exerting 1 atm osmotic pressure in 22.4 l ·

.at 0°c
 .osmolarity: osmoles/l solution ·

osmolality: osmoles/kg solvent (measured by freezing point ·

.depression)

.normal plasma osmolality: 280–300 mosm/kg ·

.calculated osmolality: 2[na⁺ + k⁺] + [urea] + [glucose] (all mmol/l) ·

osmolar gap: measured – calculated; Increased by alcohols, ·

.mannitol, glycine (turp syndrome)

.tonicity: effective osmolarity across a membrane ·

osmoreceptors: anterior hypothalamus (outside bbb) → control ·

.thirst&adh

Starling’s forces

:net fluid movement across capillary ·

Q = k[(p_c - p_i) – σ(π_c – π_i)]

.p_c : capillary hydrostatic pressure ·

.p_i : interstitial hydrostatic pressure (≈0 to -6 mmhg) ·

.π_c : capillary colloid osmotic pressure (~25 mmhg) ·

.π_i : interstitial colloid osmotic pressure (~5 mmhg) ·

.k : filtration coefficient (leakiness) ·

.σ : reflection coefficient (protein permeability) ·

.arteriolar end: net outward pressure ·

.venous end: net inward pressure ·

oedema: ↓ π_c (hypoalbuminaemia), ↑ p_c (venous obstruction), ↑ ·

.k (inflammation)

Cerebrospinal fluid (csf)

 .volume: ~150 ml (1/3 spinal) ·

.production: 0.3 ml/min (choroid plexus 2/3, ependyma 1/3) ·

.absorption: arachnoid villi (90%) → dural venous sinuses ·

functions: mechanical protection (buoyancy), intracranial pressure ·

.buffer

:composition: ultrafiltrate of plasma ·

.higher pco_2 , lower ph (7.33) ·

.very low protein (<0.3 g/l) ·

.⁺higher cl⁻, lower k ·

.glucose 2–5 mmol/l ·

circulation: lateral ventricles → foramina of monro → third ventricle ·

→ aqueduct of sylvius → fourth ventricle → foramina of
.magendie&luschka → subarachnoid space

Blood-brain barrier (bbb)

structure: tight junctions between capillary endothelial cells + ·

.astrocytes

functions: regulates ion/nutrient/drug passage; Enzymes (mao) ·

.provide chemical barrier

.free diffusion: water, o_2 , co_2 , lipid-soluble drugs ·

.restricted: large molecules, charged ions, water-soluble drugs ·

.deficient areas: hypothalamus, chemoreceptor trigger zone (ctz) ·

.reduced efficacy: neonates, meningitis ·

Specific gravity (sg)

 .density relative to water ·

examples: plasma 1.010, csf 1.004–1.007, 0.5% bupivacaine 1.004, ·

.0.5% bupivacaine + 4% glucose 1.026

Other body fluids

pleural fluid: serous; Low protein (<1.5 g/dl); Ph 7.62; Reduces ·

.friction

:pleural effusions ·

.transudate (low protein): ccf, cirrhosis, nephrosis ·

.exudate (high protein): infection, malignancy, tb ·

pericardial fluid: 15–50 ml; Lubricates; Tamponade if rapid ·

.accumulation

lymph: interstitial fluid → lymphatic capillaries (one-way valves) → ·

.nodes → thoracic duct → subclavian vein

functions: returns protein/fluid, fat transport (chyle), immune ·

.surveillance

:intraocular fluid ·

aqueous humour: secreted by ciliary body, drains via canal of ·

.schlemm

.vitreous humour: gel-like, maintains shape, keeps retina in place ·

peritoneal fluid: serous; Lubricates bowel; Ascites in rhf, cirrhosis, ·

.malignancy

Pages 170–181: physiology – haematology&immunology

 Blood groups

:abo system ·

.naturally occurring igm antibodies (absent at birth) ·

.universal donor: o ·

.universal recipient: ab ·

:rhesus (rh) system ·

.”rh d antigen → “positive ·

anti-d igg can cross placenta → haemolytic disease of newborn ·

.+(hdn) if mother rh–, baby rh

minor groups: kell, duffy, lewis, kidd → delayed haemolytic ·

.reactions

:transfusion complications ·

.immunological: acute/delayed haemolysis, fnhtr, trali, allergic ·

.infective: bacterial contamination, viral (hiv, hep b/c), prions (cjd) ·

metabolic: hyperkalaemia, hypocalcaemia (citrate), acidosis, ·

.hypothermia

cardiovascular: fluid overload, impaired o₂ delivery (left shift), ·

.microaggregates

Immune responses

innate (non-specific): barriers, inflammation, complement, ·

.phagocytes

:adaptive (specific) ·

.humoral: b cells → antibodies (memory cells) ·

cellular: t cells (cytotoxic cd8+, helper cd4+, suppressor, memory), ·

.natural killer cells
 :t cell functions ·

.cytotoxic (cd8+): kill infected cells via mhc i ·

.helper (cd4+): regulate via mhc ii ·

.suppressor: negative feedback ·

.memory: rapid response on re-exposure ·

Hypersensitivity (gell&coombs)

.type i (ige-mediated): anaphylaxis, asthma, hay fever ·

type ii (antibody-mediated cytotoxic): transfusion reactions, hdn, ·

.autoimmune haemolysis

.type iii (immune complex): serum sickness, sle, glomerulonephritis ·

.type iv (cell-mediated): contact dermatitis, tb ·

type v (autoimmune): antibodies to receptors (graves’, myasthenia ·

.gravis)

Inflammation

.cardinal signs: redness, heat, swelling, pain, loss of function ·

.components: hyperaemia, exudation, leucocyte emigration ·

:mediators ·

.kinin system: bradykinin → vasodilation, pain ·

histamine/leukotrienes: from mast cells/basophils → ↑ ·

.permeability, chemotaxis

.neutrophils: release paf, proteases ·

.tnf-α: from macrophages → endothelial activation, septic shock ·

.complement: opsonisation, chemotaxis, cell lysis ·

sirs&sepsis: sirs = ≥2 of: t>38 or<36°c, hr>90, rr>20, wbc>12 or<4 ·
.×10⁹/l. Sepsis = sirs + infection

Haemostasis

:platelet plug formation ·

.Vessel damage exposes collagen (binds gpia)&vwf (binds gpib) .1

.Platelet activation → shape change, release of adp, 5-ht, txa₂ .2

.Aggregation via gpiib/iiia binding fibrinogen/vwf .3

.Prostacyclin (pgi₂) from endothelium limits spread .4

.clot formation: thrombin converts fibrinogen → fibrin ·

.fibrinolysis: plasminogen → plasmin via t-pa ·

Peripheral circulation

vessel layers: intima (endothelium), media (smooth muscle), ·

.adventitia (connective tissue)

endothelial functions: vasomotor control (no, pgi₂, endothelins), ·

.non-thrombogenic surface, regulates growth

:capillary types ·

.continuous (brain): tight junctions ·

.fenestrated (kidney, intestine): pores for small molecules ·

.sinusoidal (liver, spleen): large gaps for proteins/cells ·

vascular tone control: autonomic (α/β), metabolic (↓o₂, ↑k⁺, h⁺, ·

.adenosine), myogenic

Coagulation cascade
 .tissue factor (extrinsic) pathway: main initiation ·

.contact (intrinsic) pathway: minor role ·

.cofactors: ca²⁺, vitamin k ·

.regulators: protein c/s, antithrombin iii, tfpi ·

:tests ·

.aptt: intrinsic pathway; Monitors heparin ·

.pt/inr: extrinsic pathway; Monitors warfarin ·

.thrombin time: fibrinogen deficiency/thrombin inhibitors ·

cell-based model: emphasizes tf-viia complex and thrombin’s ·

central role (initiation, amplification, propagation, stabilisation,
.inhibition)

Haemoglobin (hb)

.structure: 2α + 2β chains, 4 haem groups (fe²⁺) ·

.cooperative binding: tense (deoxy) → relaxed (oxy) → sigmoid odc ·

.fetal hb (hbf): 2α + 2γ; Higher o₂ affinity ·

sickle cell disease: hbs (β6 glu→val) → polymerises when ·

.deoxygenated → painful crises

:thalassaemias ·

.α: gene deletions; Hb bart’s (4 deletions) fatal in utero ·

β: reduced β-chain production; Major (homozygous) severe ·

.anaemia; Trait mild

Red blood cells (rbcs)

 structure: biconcave disc → high surface area:volume, ·
.deformability

.lifespan: 120 days ·

erythropoiesis: controlled by erythropoietin (kidney) in response to ·

.tissue hypoxia

functions: o₂/co₂ transport, carbonic anhydrase (co₂ ↔ hco₃⁻), ·

.chloride shift

destruction: macrophages in reticuloendothelial system → haem → ·

.bilirubin → bile

Pages 182–190: physiology – nervous system

Resting membrane potential (rmp)

.value: –70 mv (neurones), –85 mv (muscle) ·

:determined by ·

.differential ion distribution (high k⁺ inside, high na⁺ outside) ·

.membrane permeability (100× more permeable to k⁺) ·

.na⁺/k⁺ atpase pump (3na⁺ out, 2k⁺ in) ·

.gibbs-donnan effect (non-diffusible intracellular anions) ·

:nernst equation (single ion equilibrium) ·

E = \frac{rt}{zf} \ln\frac{[c]_o}{[c]_i}

goldman-hodgkin-katz equation: considers multiple ·

.ions&permeabilities

Neurones&nerve fibres
 structure: cell body, dendrites (input), axon (output), myelin ·
.(schwann cells), nodes of ranvier

conduction speed: increases with diameter&myelination (saltatory ·

.conduction)

:fibre classification ·

.aα: motor, proprioception (12–20 μm, 70–120 m/s) ·

.aβ: touch, pressure (5–12 μm, 30–70 m/s) ·

.aγ: muscle spindle (3–6 μm, 15–30 m/s) ·

.aδ: fast pain, temperature (2–5 μm, 12–30 m/s) ·

.b: preganglionic autonomic (<3 μm, 3–15 m/s) ·

.c: slow pain, autonomic (unmyelinated, 0.4–1.2 μm, 0.5–2 m/s) ·

Action potentials

:phases ·

Depolarisation: threshold reached → voltage-gated na⁺ channels .1

.open → rapid na⁺ influx → peak +35 mv

Repolarisation: na⁺ channels inactivate, k⁺ channels open → k⁺ .2

.efflux

.Hyperpolarisation: k⁺ channels slow to close → undershoot .3

.Restoration: na⁺/k⁺ pump .4

:refractory periods ·

.absolute: no stimulus can trigger (na⁺ channels inactivated) ·

relative: stronger-than-normal stimulus needed (some na⁺ channels ·

.recovering)

.all-or-none law: supra-threshold stimulus → full amplitude ap ·

 propagation: local currents depolarise adjacent membrane; ·
.Unidirectional due to refractoriness

Organisation of the nervous system

.central (cns): brain + spinal cord ·

:peripheral (pns) ·

.somatic: sensory afferents, motor efferents to skeletal muscle ·

autonomic: sympathetic (fight/flight), parasympathetic ·

.(rest/digest)

:brain divisions ·

forebrain: cerebrum (cortex, basal ganglia, hippocampus, ·

.amygdala), diencephalon (thalamus, hypothalamus)

.midbrain: tectum (visual/auditory reflexes), tegmentum ·

hindbrain: pons, cerebellum, medulla oblongata ·

.(cardiac/respiratory/vomiting centres)

Motor pathways

:pyramidal (corticospinal) ·

.origin: motor cortex (precentral gyrus) ·

path: internal capsule → cerebral peduncle → medullary pyramids → ·

.80% decussate → lateral corticospinal tract (fine movement)

.anterior corticospinal tract (axial muscles) 10% ·

extrapyramidal: basal ganglia, substantia nigra, brainstem nuclei → ·

rubro-, vestibulo-, reticulo-, tectospinal tracts. Controls posture,
.balance, coarse/axial movement
 cerebellar: coordination, timing, precision via thalamus, red ·
.nucleus, cortex

Special senses

vision: light → cornea/lens → retina photoreceptors → optic nerve ·

(partial decussation at chiasm) → lateral geniculate nucleus → visual
.cortex

taste: chemoreceptors on tongue/oral cavity → cn vii (ant 2/3), ix ·

.(post 1/3), x (pharynx) → gustatory cortex

smell: olfactory neurones → cribriform plate → olfactory bulb → ·

.cortex

hearing: sound → pinna → tympanic membrane → ossicles → cochlea ·

(organ of corti) → auditory nerve → cochlear nucleus → midbrain →
.thalamus → auditory cortex

Somatic sensation

:pathways ·

dorsal columns (posterior): fine touch, vibration, proprioception → ·

ipsilateral ascent → decussate in medulla (cuneate/gracile nuclei) →
.thalamus → sensory cortex

spinothalamic tracts: pain, temperature, crude touch → decussate ·

.at spinal level → contralateral ascent → thalamus → cortex

.lateral: pain&temp ·

.anterior: crude touch/pressure ·

:sensory lesions ·

.cortex: paraesthesia, sensory discrimination loss ·

.thalamus: complete hemisensory loss, central pain ·

 .spinothalamic: contralateral loss of pain/temp below lesion ·

dorsal column: ipsilateral loss of proprioception/vibration (positive ·

.romberg)

.nerve root: dermatomal pain/paraesthesia ·

.peripheral nerve: distribution loss ·

Intracranial pressure (icp)&cerebral blood flow (cbf)

.normal icp: 7–11 mmhg (10–15 cmh₂o) ·

:cbf regulation ·

.autoregulation: maintains constant flow over map 50–150 mmhg ·

chemical: \text{paco}_2 (strong; 2 ml/min/mmhg change), ·

.\text{pao}_2 (<50 mmhg → vasodilation)

.metabolic: ↑ metabolites → vasodilation ·

.neural: sympathetic (mild constriction) ·

monro-kellie doctrine: skull fixed volume (brain + blood + csf); ↑ one ·

.component → compensatory ↓ others → ↑ icp if compensation fails

cerebral perfusion pressure (cpp) = map – icp (normal 70–100 ·

.mmhg)

I will continue extracting all remaining key exam points from the
rest of the book, focusing strictly on high-yield, exam-critical
.information in clear medical english

Pages 190–210: physiology – nervous system (continued)

The vasomotor centre&autonomic nervous system (ans)

 .vasomotor centre: located in the medulla oblongata ·

function: primary regulator of arterial blood pressure via ·

.sympathetic outflow

inputs: baroreceptors, chemoreceptors, higher centres ·

.(hypothalamus, cortex)

output: sympathetic fibres → vascular smooth muscle ·

.(vasoconstriction/vasodilation)

:autonomic nervous system (ans) ·

:division ·

."sympathetic (sns): "fight or flight ·

."parasympathetic (pns): "rest and digest ·

:neurotransmitters ·

.preganglionic: acetylcholine (nicotinic receptors) ·

:postganglionic ·

.sns: noradrenaline (α/β adrenoceptors) ·

.pns: acetylcholine (muscarinic receptors) ·

.higher control: hypothalamus, brainstem, cortex ·

Sympathetic nervous system (sns)

preganglionic neurons: originate in intermediolateral column of ·

.spinal cord (t1–l2)

.postganglionic neurons: paravertebral/prevertebral ganglia ·

:effects ·

cardiovascular: ↑ hr, ↑ contractility, vasoconstriction (α₁), ·

.vasodilation in muscle (β₂)
 .respiratory: bronchodilation (β₂) ·

.metabolic: glycogenolysis, lipolysis ·

.other: mydriasis, ↓ gi motility, ↑ sweating ·

adrenal medulla: modified sympathetic ganglion; Secretes ·

.adrenaline (80%), noradrenaline (20%)

Parasympathetic nervous system (pns)

preganglionic neurons: cranial nerves (iii, vii, ix, x) and sacral spinal ·
.cord (s2–s4)

.postganglionic neurons: near or within target organs ·

:effects ·

.cardiovascular: ↓ hr (vagal), vasodilation in some beds ·

.respiratory: bronchoconstriction, ↑ secretions ·

.gi: ↑ motility/secretion ·

.other: miosis, salivation, lacrimation, bladder contraction ·

vagus nerve (cn x): major parasympathetic supply to ·

.thorax/abdomen

Spinal cord

:gross anatomy ·

.length: ~45 cm adult ·

.termination: conus medullaris at l1/l2 in adults (l3/l4 in neonates) ·

.meninges: dura, arachnoid, pia mater ·

:internal structure ·
 grey matter: dorsal horn (sensory), ventral horn (motor), lateral ·
.horn (autonomic t1–l2)

.white matter: ascending/descending tracts ·

:blood supply ·

anterior spinal artery (single, from vertebral arteries) → anterior 2/3 ·

.of cord

.posterior spinal arteries (paired) → posterior 1/3 ·

artery of adamkiewicz (t8–l1): major segmental feeder; Damage ·

.risks anterior cord syndrome

Spinal cord injury

.complete transection: loss of all motor/sensory below level ·

:syndromes ·

anterior cord: loss of motor, pain/temp sensation (spinothalamic); ·

.Preserved proprioception/vibration (dorsal columns)

.central cord: sacral sparing; Upper limb>lower limb weakness ·

brown-séquard: ipsilateral motor loss (corticospinal) + ·

proprioception/vibration loss (dorsal column); Contralateral
.pain/temp loss (spinothalamic)

spinal shock: initial flaccid paralysis, areflexia, hypotension (loss of ·

.sympathetic tone); Lasts days–weeks

Pain pathways

.nociceptors: aδ fibres (fast, sharp pain) and c fibres (slow, dull pain) ·

:spinothalamic tract ·
1st order: dorsal root ganglion → synapse in dorsal horn (laminae i, ·
.ii, v)

2nd order: decussate at same segment → ascend contralaterally in ·

.spinothalamic tract → thalamus (vpl nucleus)

.3rd order: thalamus → primary sensory cortex ·

modulation: descending pathways (periaqueductal grey, raphe ·

.nuclei) release serotonin/noradrenaline → inhibit pain transmission

Gate control theory of pain

.proposed by melzack&wall (1965) ·

mechanism: non-painful aβ fibre input inhibits pain transmission ·

.(c/aδ fibres) in dorsal horn via inhibitory interneurons

clinical application: transcutaneous electrical nerve stimulation ·

.(tens), rubbing

Intraocular pressure (iop)&pupillary responses

.normal iop: 10–21 mmhg ·

regulation: balance between aqueous humour production (ciliary ·

.body) and drainage (trabecular meshwork → schlemm’s canal)

:pupillary light reflex ·

.afferent: cn ii (optic nerve) ·

efferent: cn iii (oculomotor) → constrictor pupillae ·

.(parasympathetic)

accommodation reflex: near vision → pupil constriction, lens ·

.thickening, convergence
 Nausea&vomiting

.vomiting centre: located in medulla (nucleus tractus solitarius) ·

:trigger zones ·

chemoreceptor trigger zone (ctz): area postrema (outside bbb) → ·

.responds to drugs, toxins, metabolic disturbances

.vestibular apparatus: motion sickness ·

.gi tract: vagal afferents (stretch, irritation) ·

.higher centres: emotion, pain, smell ·

efferent pathway: vagus, phrenic, spinal nerves → coordinated ·

.diaphragm, abdominal muscle, gastric/oesophageal contraction

Pages 211–235: physiology – muscle

Neuromuscular junction (nmj)

.structure: motor neuron terminal + synaptic cleft + motor endplate ·

:process ·

.Ap → voltage-gated ca²⁺ channels open → ach release .1

Ach binds nicotinic receptors (pentameric, na⁺/k⁺ channel) → .2

.depolarisation (endplate potential)

.If threshold reached → muscle ap .3

.Ach degraded by acetylcholinesterase in cleft .4

:drug effects ·
depolarising blockers: suxamethonium (binds receptor → persistent ·
.depolarisation)

non-depolarising blockers: competitive antagonists (rocuronium, ·

.atracurium)

anticholinesterases: neostigmine → ↑ ach → reversal of non- ·

.depolarising block

Muscle types&contraction

skeletal: striated, voluntary, multinucleated; Ca²⁺ from sr ·

.(ryanodine receptors)

cardiac: striated, involuntary, intercalated discs, pacemaker cells; ·

.Ca²⁺ induced ca²⁺ release

smooth: non-striated, involuntary; Ca²⁺ from ecf/sr; Slow, sustained ·

.contraction

:contraction mechanism (sliding filament theory) ·

ap → ca²⁺ release → ca²⁺ binds troponin c → tropomyosin shift → ·

.myosin binds actin → cross-bridge cycling → sarcomere shortening

Muscle components&sarcomere

.sarcomere: basic contractile unit (z-disc to z-disc) ·

:proteins ·

.thick filaments: myosin ·

.thin filaments: actin, tropomyosin, troponin (t, i, c) ·

.titin: elastic, maintains structure ·

.nebulin: regulates actin length ·

 bands: i-band (actin only), a-band (myosin ± actin), h-zone (myosin ·
.only), m-line (myosin cross-links)

Disorders of neuromuscular function

myasthenia gravis: autoantibodies vs. Ach receptors → fatigable ·

.weakness

lambert-eaton myasthenic syndrome: autoantibodies vs. Voltage- ·

.gated ca²⁺ channels → reduced ach release

malignant hyperthermia: ryanodine receptor mutation (ryr1) → ·

uncontrolled ca²⁺ release → hypermetabolism, rigidity, hyperthermia.
.Trigger: volatile anaesthetics, suxamethonium

myopathies: muscular dystrophies, mitochondrial myopathies, ·

.critical illness myopathy

Sphincters

.upper oesophageal (cricopharyngeus): skeletal muscle (voluntary) ·

lower oesophageal (cardiac): smooth muscle (involuntary); Prevents ·

.reflux

.pyloric: controls gastric emptying ·

sphincter of oddi: controls bile/pancreatic secretion into ·

.duodenum

.internal/external anal sphincters: smooth/skeletal muscle ·

bladder sphincters: internal (smooth, sympathetic control), external ·

.(skeletal, somatic control)
 Pages 236–260: physiology – heart&circulation

Cardiac action potentials

:nodal cells (sa/av node) ·

phase 4: spontaneous depolarisation ("pacemaker potential") due ·

.to iₓ ("funny" current, na⁺ influx)

.phase 0: ca²⁺ influx (l-type) ·

.phase 3: k⁺ efflux (repolarisation) ·

.no phase 1 or 2 ·

:ventricular myocytes ·

.phase 0: fast na⁺ influx ·

.phase 1: early repolarisation (k⁺) ·

.phase 2: plateau (ca²⁺ influx, k⁺ efflux) ·

.phase 3: rapid repolarisation (k⁺) ·

.phase 4: resting membrane potential ·

Cardiac definitions

.stroke volume (sv): volume ejected per beat (~70 ml) ·

.cardiac output (co) = hr × sv (~5 l/min) ·

.ejection fraction (ef) = (sv / edv) × 100% (normal>55%) ·

.preload: ventricular filling pressure (end-diastolic volume) ·

afterload: resistance against which ventricle ejects (aortic pressure, ·

.svr)
 .contractility: inotropic state (independent of preload/afterload) ·

Control of blood pressure

short-term: baroreflex (carotid sinus, aortic arch) → fast adjustment ·

.via ans

long-term: renin-angiotensin-aldosterone system (raas), adh, atrial ·

.natriuretic peptide (anp)

.equation: bp = co × svr ·

Cardiac cycle

:phases ·

.Atrial systole: "atrial kick" → contributes 20–30% filling .1

.Isovolumetric contraction: valves closed, pressure rises .2

.Rapid ejection: av valves open, blood ejected .3

.Reduced ejection: pressure falls .4

.Isovolumetric relaxation: valves closed, pressure falls .5

.Rapid filling: av valves open, passive filling .6

.Reduced filling (diastasis) .7

:heart sounds ·

.s1: mitric/tricuspid closure (start systole) ·

.s2: aortic/pulmonary closure (start diastole) ·

s3: rapid ventricular filling (normal in young, pathological in ·

.adults)

s4: atrial contraction against stiff ventricle (e.G., hypertension, ·

.hypertrophy)
 Pressure-volume loop&autoregulation

.pv loop: plots ventricular pressure vs. Volume through cycle ·

:points ·

.A: end-diastole (edv)

.B: isovolumetric contraction

.C: end-systole (esv)

.D: isovolumetric relaxation

.area inside loop = stroke work ·

autoregulation: heart maintains constant sv over range of filling ·

.pressures (frank-starling mechanism)

Cardiovascular responses

haemorrhage: ↓ preload → ↓ sv → sympathetic activation → ↑ hr, ·

.vasoconstriction, fluid retention

rapid saline infusion: ↑ preload → ↑ sv (starling), transient ↓ svr ·

.(haemodilution), ↑ co

Frank-starling law&heart failure

.law: force of contraction ∝ initial fibre length (preload) ·

heart failure: impaired contractility → ↓ sv → compensatory ·

mechanisms (↑ hr, raas activation, ventricular
.hypertrophy/dilatation) → eventual decompensation
 Valsalva manoeuvre

:phases ·

.I: ↑ intrathoracic pressure → ↑ bp (compression of great vessels)

.Ii: ↓ venous return → ↓ bp, reflex tachycardia

.Iii: release → ↓ bp further (blood pools in lungs)

.Iv: overshoot (↑ bp, bradycardia) due to sympathetic activation

.clinical use: assess autonomic function ·

Exercise

cardiovascular changes: ↑ co (up to 5×), ↑ hr, ↑ sv, skeletal muscle ·

.vasodilation, cutaneous vasoconstriction then dilation

metabolic: ↑ o₂ consumption, ↑ co₂ production, respiratory ·

.alkalosis early then metabolic acidosis

Pressures in normal heart&pulmonary circulation

.ra: 2–6 mmhg ·

.rv: 25/4 mmhg ·

.pa: 25/10 mmhg (mean 15) ·

.pcwp: 6–12 mmhg ·

.la: 4–12 mmhg ·

.lv: 120/8 mmhg ·

.ao: 120/80 mmhg ·

shock: inadequate tissue perfusion; Types: hypovolaemic, ·

.cardiogenic, obstructive, distributive
 Coronary circulation

:supply ·

left coronary artery → lad (anterior lv, septum) + circumflex (lateral ·

.lv)

.right coronary artery → rv, inferior lv, sa node (60%), av node (90%) ·

flow: predominantly during diastole (ventricular compression in ·

.systole)

.regulation: metabolic (adenosine, k⁺, h⁺, co₂, low o₂) → vasodilation ·

Special circulations

.cerebral: high flow, tight autoregulation, sensitive to paco₂ ·

.coronary: high o₂ extraction, diastolic flow ·

.cutaneous: thermoregulatory (sympathetic control) ·

splanchnic: large capacitance, sensitive to sympathetic ·

.(vasoconstriction in shock)

renal: high flow, autoregulated (myogenic, tubuloglomerular ·

.feedback)

Pulmonary vascular resistance (pvr)

. equation: pvr = (mpap - pcwp) / co ·

.Normal: 1–3 mmhg·min/l (≈ 100–300 dyn·s·cm⁻⁵)

factors increasing pvr: hypoxia, hypercapnia, acidosis, lung inflation ·

(high or low volumes), sympathetic stimulation, drugs
.(noradrenaline, serotonin)
factors decreasing pvr: oxygen, alkalosis, nitric oxide, prostacyclin, ·
.phosphodiesterase inhibitors

Central venous pressure (cvp)&venous waveform

.cvp: pressure in svc/ra; Reflects rv preload (normal 2–6 mmhg) ·

:waveform (a, c, v waves, x, y descents) ·

.a wave: atrial contraction ·

.c wave: rv contraction (tricuspid bulging) ·

.v wave: atrial filling against closed tricuspid ·

.x descent: atrial relaxation ·

.y descent: ventricular relaxation, rapid filling ·

cannon a waves: av dissociation (atria contract against closed ·

.tricuspid)

Pages 261–285: physiology – renal

Renal structure&raas

.nephron: functional unit (glomerulus + tubule) ·

:renin-angiotensin-aldosterone system (raas) ·

.renin (juxtaglomerular cells) → converts angiotensinogen to ang i ·

.ace (lungs) → ang i → ang ii ·

.ang ii effects: vasoconstriction, ↑ aldosterone, ↑ adh, thirst ·

 .aldosterone: na⁺ reabsorption, k⁺/h⁺ excretion (distal tubule) ·

The glomerulus

filtration barrier: fenestrated endothelium, basement membrane, ·

.podocytes

.glomerular filtration rate (gfr): ~125 ml/min (180 l/day) ·

determinants: hydrostatic pressure (glomerular capillary), colloid ·

.osmotic pressure, filtration coefficient

autoregulation: myogenic + tubuloglomerular feedback (macula ·

.densa) → constant gfr over map 80–180 mmhg

Renal tubular function

:proximal convoluted tubule (pct) ·

.⁻reabsorbs 65% na⁺, water, glucose, amino acids, hco₃ ·

.secretes h⁺, organic acids/bases ·

:loop of henle ·

.descending limb: permeable to water only → concentration ·

ascending limb: impermeable to water; Active na⁺/k⁺/2cl⁻ ·

.reabsorption (site of loop diuretics) → dilution

distal convoluted tubule (dct): na⁺/cl⁻ reabsorption (thiazide ·

.diuretics), ca²⁺ reabsorption (pth)

collecting duct: final regulation of water (adh), na⁺ (aldosterone), k⁺, ·

.⁺h

⁺Renal handling of glucose, na⁺, k

 glucose: reabsorbed in pct via sglt2/1; Glycosuria if plasma ·
.glucose>10–12 mmol/l (transport maximum)

.na⁺: reabsorbed throughout (pct 65%, loop 25%, dct/cd 10%) ·

k⁺: filtered, mostly reabsorbed in pct/loop; Secretion regulated in cd ·

.by aldosterone

Renal blood flow&clearance

.rbf: ~1.2 l/min (20–25% co) ·

.clearance: volume of plasma cleared of substance per minute ·

.inulin: marker for gfr (filtered only) ·

.pah: marker for renal plasma flow (filtered + secreted) ·

.creatinine: approximates gfr ·

Assessment of renal function

.gfr estimation: creatinine clearance, egfr (ckd-epi, mdrd equations) ·

.urinalysis: protein, blood, glucose, casts ·

.biochemistry: urea, creatinine, electrolytes, osmolality ·

Micturition

storage: sympathetic (β₃ relaxation of detrusor, α₁ contraction of ·

.internal sphincter)

voiding: parasympathetic (detrusor contraction), somatic (external ·

.sphincter relaxation)

.centre: pontine micturition centre ·

 Pathophysiology of acute kidney injury (aki)

pre-renal (70%): hypoperfusion (hypovolaemia, ↓ co, renal ·

.vasoconstriction)

.urea:cr ratio (>20:1), low urinary na⁺ (<20 mmol/l), high osmolality ↑ ·

:intrinsic renal ·

.atn: ischaemic/toxic (e.G., contrast, sepsis) ·

.glomerulonephritis, interstitial nephritis ·

.post-renal: obstruction ·

.biomarkers: ↑ creatinine, ↓ urine output. Novel: ngal, cystatin c ·

Pages 286–310: physiology – respiration

Oxygen dissociation curve (odc)

.sigmoid shape: due to cooperative binding ·

.p₅₀: po₂ at 50% saturation (normal ~3.5 kpa/26 mmhg) ·

right shift (↓ affinity, ↑ o₂ unloading): ↑ h⁺ (acidosis), ↑ co₂, ↑ ·

.temperature, ↑ 2,3-dpg

left shift (↑ affinity, ↓ o₂ unloading): alkalosis, ↓ co₂, ↓ ·

.temperature, ↓ 2,3-dpg, fetal hb, cohb

bohr effect: co₂ effect on o₂ binding (right shift in tissues, left shift ·
.in lungs)

.⁺haldane effect: deoxyhaemoglobin binds more co₂/h ·

 Work of breathing

components: elastic work (overcoming lung/chest wall recoil), ·

.resistive work (overcoming airway resistance)

increased in: restrictive disease (↑ elastic), obstructive disease (↑ ·

.resistive)

Shunt

.definition: blood passing lungs without oxygenation ·

:types ·

.anatomical: right-to-left cardiac shunt (e.G., vsd, asd) ·

physiological: alveolar collapse/consolidation (e.G., atelectasis, ·

.pneumonia)

.effect: ↓ pao₂, not corrected by ↑ fio₂ ·

.calculation: q_s/q_t = (cc'o₂ - cao₂) / (cc'o₂ - cvo₂) . Normal<10% ·

Functional residual capacity (frc)&closing capacity

.frc: volume at end of normal expiration (~2.2 l adult) ·

functions: o₂ reservoir, prevents atelectasis, reduces work of ·

.breathing

.closing capacity: volume at which small airways begin to close ·

.cc>frc in elderly, supine position, anaesthesia → risk of atelectasis ·

Hyperbaric&hypobaric pressure
 .hyperbaric: ↑ ambient pressure (e.G., diving, hyperbaric o₂) ·

effects: ↑ dissolved o₂ (henry’s law), nitrogen narcosis, o₂ toxicity, ·

.decompression sickness

.hypobaric: ↓ ambient pressure (altitude) ·

effects: hypoxia, hyperventilation, respiratory alkalosis, ·

.polycythaemia

Co₂&o₂ stores&transport

:co₂ transport ·

.dissolved (10%) ·

.bicarbonate (60%) via carbonic anhydrase in rbcs ·

.carbamino compounds (30%) with hb ·

:o₂ transport ·

.dissolved (1–2%) ·

.bound to hb (98–99%) ·

total body o₂ store: ~1 l (lungs 450 ml, blood 850 ml, tissues ·
.negligible); Exhausted in ~4 min if apnea

Control of breathing

central chemoreceptors: ventral medulla; Respond to csf ph ·

.(influenced by paco₂)

peripheral chemoreceptors: carotid/aortic bodies; Respond to ↓ ·

.⁺pao₂ (<8 kpa), ↑ paco₂, ↑ h

other inputs: pulmonary stretch receptors, irritant receptors, ·

.higher centres
 Ventilation-perfusion (v/q) relationships

.normal v/q: ~0.8 ·

.high v/q (dead space): ventilation>perfusion (apex of lung, pe) ·

.low v/q (shunt): perfusion>ventilation (base of lung, atelectasis) ·

:west zones ·

.zone 1: pa>pa>pv (apex, alveolar dead space) ·

.zone 2: pa>pa>pv (mid, flow determined by pa-pa) ·

.zone 3: pa>pv>pa (base, flow determined by pa-pv) ·

Dead space

.anatomical: conducting airways (~150 ml) ·

.alveolar: ventilated but unperfused alveoli ·

.physiological = anatomical + alveolar ·

.bohr equation: v_d/v_t = (paco₂ - peco₂) / paco₂ . Normal ~0.3 ·

Lung volumes&capacities

.volumes: tidal (500 ml), irv, erv, rv ·

.capacities: tlc, vc, frc, ic ·

.spirometry: see earlier ·

Respiratory failure
 type i (hypoxaemic): pao₂<8 kpa, normal/low paco₂. Causes: v/q ·
.mismatch, diffusion defect, shunt

type ii (hypercapnic): pao₂<8 kpa, paco₂>6.5 kpa. Causes: alveolar ·

.hypoventilation (cns, neuromuscular, chest wall, airways)

.treatment: o₂, cpap/niv, intubation/ventilation, treat cause ·

Oxygen cascade&alveolar gas equation

.cascade: atmospheric → tracheal → alveolar → arterial → tissue ·

:alveolar gas equation ·

]\ pao₂ = fio₂ (p_{atm} - p_{h₂o}) - (paco₂ / rq) [\

.Where rq ≈ 0.8

a-a gradient: pao₂ – pao₂ (normal<2 kpa on room air). Increased in ·

.v/q mismatch, shunt, diffusion defect

dpg&myoglobin-2,3

dpg: produced in rbc glycolysis; Binds β-chains of hb → right-2,3 ·

.shift → ↑ o₂ unloading

.in: anaemia, chronic hypoxia, alkalosis ↑

.in: stored blood, acidosis ↓

myoglobin: muscle o₂ store; Hyperbolic dissociation curve (high ·

.affinity at low po₂)

Airway resistance&compliance

.resistance: predominantly in medium-sized bronchi ·

 .Increased in: bronchoconstriction, secretions, oedema, tumours

.compliance: δvolume/δpressure ·

.Static: lung + chest wall

.Dynamic: affected by resistance

.compliance curve (pressure-volume): hysteresis due to surfactant ·

intrapleural pressure: negative (~ –5 cmh₂o at rest); Becomes ·

.positive during forced expiration/cough

Flow-volume loops

.see earlier ·

Non-respiratory functions of lungs

metabolic: ace (angiotensin i → ii), inactivation of bradykinin, ·

.serotonin, prostaglandins

.filter: traps microemboli ·

.blood reservoir: ~10% blood volume ·

.acid-base balance: co₂ excretion ·

Pages 311–340: physiology – liver, gi&metabolism

The liver: functions

 metabolic: carbohydrate (glycogenesis/gluconeogenesis), fat (β- ·
.oxidation, lipoprotein synthesis), protein (synthesis, deamination)

synthetic: albumin, clotting factors (except iii, iv, viii), complement, ·

.transport proteins

detoxification: phase i (oxidation, reduction, hydrolysis via ·

.cytochrome p450) and phase ii (conjugation) reactions

.storage: glycogen, vitamins (a, d, b12), iron ·

bile production: for fat digestion, excretion of ·

.bilirubin/cholesterol/drugs

The pancreas

exocrine: acinar cells → digestive enzymes (amylase, lipase, ·

.proteases) via duct to duodenum

→ endocrine: islets of langerhans ·

.α cells: glucagon (↑ blood glucose) ·

.β cells: insulin (↓ blood glucose) ·

.δ cells: somatostatin (inhibits insulin/glucagon) ·

.pp cells: pancreatic polypeptide ·

Gastric secretion

.parietal cells: hcl (via h⁺/k⁺ atpase) + intrinsic factor ·

.chief cells: pepsinogen ·

.g cells: gastrin (stimulates acid secretion) ·

.mucous cells: mucus, bicarbonate ·

control: cephalic (vagal), gastric (distension, peptides), intestinal ·

.(inhibitory)
 Gut motility&functional anatomy

layers: mucosa, submucosa, muscularis (inner circular, outer ·

.longitudinal), serosa

:innervation ·

enteric nervous system (myenteric/auerbach’s plexus, ·

.submucosal/meissner’s plexus)

autonomic: parasympathetic (↑ motility/secretion), sympathetic (↓ ·

.motility, vasoconstriction)

motility patterns: mixing (segmentation), propulsion (peristalsis), ·

.mass movement (colon)

Nutrition overview

.carbohydrates: 4 kcal/g; Digested to monosaccharides ·

.proteins: 4 kcal/g; Digested to amino acids ·

.fats: 9 kcal/g; Digested to fatty acids + monoglycerides ·

.energy requirements: bmr (~25 kcal/kg/day) + activity + stress ·

Essential amino acids&fatty acids, vitamins&minerals

.essential aa: cannot be synthesised (e.G., leucine, valine, lysine) ·

essential fatty acids: linoleic, α-linolenic (precursors for ·

.eicosanoids)

.vitamins: fat-soluble (a, d, e, k), water-soluble (b complex, c) ·

.minerals: macro (na, k, ca, mg, p), trace (fe, zn, cu, se) ·
 Carbohydrate metabolism overview

.glycolysis: glucose → pyruvate (2 atp, 2 nadh) ·

krebs cycle: acetyl-coa → co₂ + reducing equivalents (gtp, nadh, ·

.fadh₂)

oxidative phosphorylation: nadh/fadh₂ → atp via electron transport ·

.chain

gluconeogenesis: synthesis of glucose from non-carb precursors ·

.(lactate, glycerol, amino acids)

Metabolism&starvation

.fed state: insulin dominates → anabolism (storage) ·

.fasting (24–48h): glycogenolysis, gluconeogenesis ·

starvation (>72h): lipolysis → ketone bodies (acetoacetate, β- ·

.hydroxybutyrate) as fuel; Protein sparing after adaptation

Obesity&anaesthesia

.definition: bmi ≥30 kg/m² ·

:physiological changes ·

respiratory: ↓ frc, ↑ closing capacity, ↑ work of breathing, osa, ·

.obesity hypoventilation syndrome

.cardiovascular: ↑ blood volume, co, hypertension, ihd ·

.metabolic: insulin resistance, dyslipidaemia ·

.airway: difficult intubation risk ·

anaesthetic management: ramped position, pre-oxygenation, dose ·
.adjustment (ideal vs. Total body weight), vigilant monitoring

Temperature regulation

.hypothalamus: thermoregulatory centre (set point ~37°c) ·

responses to cold: vasoconstriction, shivering, non-shivering ·

.thermogenesis (brown fat)

.responses to heat: vasodilation, sweating, behavioural ·

hypothermia: stages: mild (32–35°c), moderate (28–32°c), severe ·

(<28°c). Complications: coagulopathy, arrhythmias, ↑ drug duration,
.↑ o₂ affinity

Control of blood glucose

insulin: ↓ blood glucose (↑ uptake in muscle/fat, ↑ glycogenesis, ↓ ·

.gluconeogenesis)

.glucagon: ↑ blood glucose (↑ glycogenolysis, gluconeogenesis) ·

counter-regulatory hormones: adrenaline, cortisol, growth ·

.hormone

Stress response

surgical stress: ↑ sympathetic activity, ↑ cortisol, ↑ glucagon, ·

.insulin resistance, catabolism

effects: hyperglycaemia, lipolysis, protein breakdown, na⁺/water ·

.retention, immunosuppression

.modification: regional anaesthesia, opioids, α₂-agonists ·

 Pages 341–370: physiology – endocrinology

Hormones&control of secretion

types: peptide (water-soluble, membrane receptors), steroid (lipid- ·

soluble, intracellular receptors), amine (catecholamines, thyroid
.hormones)

control: feedback loops (negative most common), neural, rhythmic ·

.(circadian)

Hypothalamus&pituitary

hypothalamic hormones: releasing/inhibiting hormones → anterior ·

.pituitary via portal system

:anterior pituitary ·

.gh, tsh, acth, fsh/lh, prolactin ·

.posterior pituitary (storage): adh (vasopressin), oxytocin ·

Adrenal gland

:cortex ·

.zona glomerulosa: aldosterone (mineralocorticoid) ·

.zona fasciculata: cortisol (glucocorticoid) ·

.zona reticularis: androgens ·

 .medulla: catecholamines (adrenaline, noradrenaline) ·

Catecholamines&adrenergic receptors

synthesis: tyrosine → dopa → dopamine → noradrenaline → ·

.adrenaline

:receptors ·

.α₁: vasoconstriction, gi relaxation, mydriasis (gq → ip₃/dag → ca²⁺) ·

.α₂: pre-synaptic inhibition, sedation, vasodilation (gi → ↓ camp) ·

.β₁: heart (↑ hr, contractility), renin release (gs → ↑ camp) ·

.β₂: bronchodilation, vasodilation, glycogenolysis (gs) ·

.β₃: lipolysis ·

Thyroid gland&hormones

.hormones: t4 (thyroxine, prohormone), t3 (active) ·

functions: ↑ bmr, ↑ thermogenesis, ↑ catecholamine sensitivity, ·

.essential for growth/cns development

.control: hypothalamus (trh) → pituitary (tsh) → thyroid ·

Pages 371–390: physiology – pregnancy

Changes in pregnancy
 cardiovascular: ↑ blood volume (40–50%), ↑ co (30–50%), ↓ svr, ↑ ·
heart rate, supine hypotension (aorticcaval compression from 20
.weeks)

respiratory: ↑ minute ventilation (↑ tidal volume), ↓ frc (↑ risk of ·

hypoxia), respiratory alkalosis (compensated by renal hco₃⁻
.excretion)

.renal: ↑ gfr, ↓ plasma creatinine/urea, glycosuria ·

gi: ↓ lower oesophageal sphincter tone (↑ reflux), delayed gastric ·

.emptying (especially in labour)

haematology: dilutional anaemia, hypercoagulable state (↑ factors, ·

.↓ protein s), leucocytosis

Placenta

functions: gas/nutrient/waste exchange, endocrine (hcg, ·

progesterone, oestrogen, hpl), barrier (imperfect – drugs/alcohol
.cross)

blood flow: ~700 ml/min at term; Affected by maternal bp, uterine ·

.contractions, vasoconstrictors

Fetal circulation&changes at birth

:fetal circulation ·

.high pvr, low svr ·

shunts: ductus venosus (bypasses liver), foramen ovale (ra→la), ·

.ductus arteriosus (pa→aorta)

.right ventricle dominant ·

:changes at birth ·

.lung expansion → ↓ pvr ·

 .placental clamping → ↑ svr ·

.shunts close functionally (anatomical closure later) ·

.left ventricle becomes dominant ·

Lactation

.prolactin: milk production ·

.oxytocin: milk ejection ("let-down") ·

anaesthetic drugs: most appear in milk but low amounts; Consider ·

.timing/feeding

Massive obstetric haemorrhage (moh)

.definition:>1.5 l blood loss or continuing bleeding>150 ml/min ·

causes: uterine atony (most common), placental abruption, ·

.placenta praevia, uterine rupture, coagulopathy

management: multidisciplinary, massive transfusion protocol, ·

uterotonics (oxytocin, ergometrine, carboprost), surgical (b-lynch
.suture, hysterectomy), interventional radiology

Pages 391–420: pharmacology – principles

Drug interactions
 pharmacokinetic: absorption (e.G., antacids ↓ absorption), ·
distribution (protein binding displacement), metabolism (enzyme
.induction/inhibition), excretion (competition)

pharmacodynamic: synergism (e.G., opioids + benzodiazepines), ·

.antagonism (naloxone vs. Opioids)

Lipid solubility&protein binding

lipid solubility: ↑ penetration of bbb, placental, renal tubular ·

.reabsorption

protein binding: mainly albumin (acidic drugs) and α₁-acid ·

.glycoprotein (basic drugs)

.only free drug is active ·

.displacement can transiently ↑ effect ·

Drug mechanism of action

.receptors: agonists, antagonists, partial agonists, inverse agonists ·

.enzymes: inhibitors, false substrates ·

.ion channels: blockers, modulators ·

.transporters: inhibitors (e.G., ssris) ·

.non-specific: e.G., antacids, osmotic diuretics ·

Isomerism

enantiomers (optical isomers): differ in rotation of plane-polarized ·

.light
 importance: different pharmacokinetics (metabolism) and ·
.pharmacodynamics (potency, toxicity)

.example: s(-)-bupivacaine more cardiotoxic than r(+)-bupivacaine ·

Malignant hyperpyrexia (mh)

.trigger: volatile anaesthetics, suxamethonium ·

pathophysiology: ryanodine receptor (ryr1) mutation → ·

.uncontrolled ca²⁺ release from sr → hypermetabolism

signs: ↑ etco₂, tachycardia, rigidity, hyperthermia, acidosis, ·

.hyperkalaemia

treatment: stop trigger, dantrolene (2.5 mg/kg repeated), ·

.supportive cooling, correct acidosis/hyperkalaemia

Materno-fetal drug distribution

placental transfer: determined by lipid solubility, molecular weight ·

(<500 da cross easily), ionization (non-ionised crosses), protein
.binding

fetal effects: depressants (e.G., opioids), teratogenicity (1st ·

.trimester), placental vasoconstriction (e.G., noradrenaline)

Addiction&dependence

.addiction: compulsive drug use despite harm ·

physical dependence: withdrawal symptoms on cessation (e.G., ·

.opioids, benzodiazepines)

.tolerance: need for higher dose for same effect ·

anaesthetic implications: increased dose requirements, withdrawal ·
.risk perioperatively

Pages 421–450: pharmacology – pharmacokinetics

Absorption of drugs&entry into cells

routes: enteral (oral, rectal), parenteral (iv, im, sc, inhalation, ·

.transdermal)

factors affecting oral absorption: ph, gastric emptying, first-pass ·

.metabolism, food

cell entry: passive diffusion (lipid-soluble), facilitated diffusion, ·

.active transport, pinocytosis

Drug distribution

volume of distribution (vd): theoretical volume into which drug ·

.distributes

. Vd = \text{dose} / \text{plasma concentration}

.high vd: lipid-soluble, extensive tissue binding (e.G., digoxin) ·

.low vd: water-soluble, confined to plasma (e.G., heparin) ·

.compartmental models: one-, two-, three-compartment ·

.dose-response curves: graded (continuous) vs. Quantal (all-or-none) ·

Drug metabolism
 .phase i: oxidation (cyp450), reduction, hydrolysis → more polar ·

phase ii: conjugation (glucuronidation, sulfation, acetylation) → ·

.water-soluble for excretion

enzyme induction: e.G., rifampicin, phenytoin, carbamazepine → ↑ ·

.metabolism of other drugs

enzyme inhibition: e.G., erythromycin, cimetidine, fluconazole → ↑ ·

.levels of other drugs

Elimination&excretion

.routes: renal (most important), biliary, pulmonary, sweat, milk ·

renal excretion: glomerular filtration (free drug), tubular secretion ·

(active), reabsorption (passive, depends on lipid
.solubility/ionization)

.clearance (cl): volume of plasma cleared per unit time ·

. text{cl} = \text{rate of elimination} / \text{plasma concentration}\

.half-life ( t_{1/2} ): time for plasma concentration to halve ·

. T_{1/2} = 0.693 \times vd / cl

Pages 451–480: pharmacology – pharmacodynamics

Agonists&antagonists

.full agonist: produces maximal response ·

 partial agonist: submaximal response even at full receptor ·
.occupancy; Can act as antagonist in presence of full agonist

.inverse agonist: produces opposite effect to agonist ·

competitive antagonist: shifts dose-response curve right (parallel), ·

.surmountable by ↑ agonist

non-competitive/irreversible antagonist: depresses maximal ·

.response

Ionization&pka

. henderson-hasselbalch: \text{ph} = \text{pka} + \log([a^-]/[ha]) ·

for weak acids: more ionised in alkaline medium (e.G., urine ·

.alkalinisation ↑ excretion of salicylates)

for weak bases: more ionised in acidic medium (e.G., urine ·

.acidification ↑ excretion of amphetamines)

clinical relevance: determines drug absorption, distribution, ·

.excretion

Receptors

:types ·

.ligand-gated ion channels (e.G., nicotinic, gabaₐ): fast ·

.g-protein coupled (e.G., adrenoceptors, opioids): slower ·

.enzyme-linked (e.G., insulin, growth factors) ·

.intracellular (e.G., steroids, thyroid) ·

G protein-coupled receptors&nmda receptors

 gpcrs: 7 transmembrane domains; G-proteins (gs, gi, gq) → second ·
.messengers (camp, ip₃, dag)

nmda receptor: glutamate-gated, ca²⁺ channel; Involved in pain, ·

.memory, excitotoxicity. Blocked by ketamine, magnesium

Gaba&adverse drug reactions

.gaba: major inhibitory neurotransmitter in cns ·

gabaₐ receptor: ligand-gated cl⁻ channel; Enhanced by ·

benzodiazepines (↑ frequency), barbiturates (↑ duration), propofol,
.volatile anaesthetics

:adverse drug reactions (adrs) ·

.type a (augmented): predictable, dose-related (e.G., hypotension) ·

.type b (bizarre): unpredictable, immunological (e.G., anaphylaxis) ·

.type c (chronic): long-term use (e.G., opioid dependence) ·

.type d (delayed): carcinogenicity, teratogenicity ·

.type e (end of treatment): withdrawal ·

Pages 481–530: pharmacology – analgesia, iv & inhaled anaesthetics

given length, i will summarise absolute key drug points essential for (
).exam

Analgesia
 aspirin: irreversible cox-1 inhibitor; Antiplatelet, analgesic, anti- ·
.inflammatory; Risk gi bleed, reye’s syndrome

paracetamol: central cox inhibition; Minimal anti-inflammatory; ·

.Hepatotoxic in overdose (treat with n-acetylcysteine)

:opioids ·

receptors: μ (analgesia, respiratory depression), κ (analgesia, ·

.sedation), δ

effects: analgesia, sedation, respiratory depression, nausea, ·

.constipation, miosis, dependence

examples: morphine (prototype), fentanyl (lipophilic, fast), ·

.remifentanil (esterase metabolised, ultra-short)

.antagonist: naloxone (competitive μ) ·

nsaids: reversible cox inhibitors; Side effects: gi ulceration, renal ·

impairment, platelet dysfunction, bronchospasm in aspirin-sensitive
.asthma

Iv anaesthetics

propofol: gabaₐ agonist; Rapid onset/offset; Side effects: ·

hypotension, pain on injection, propofol infusion syndrome (long-
.term, high dose)

thiopentone: barbiturate; Gabaₐ; Redistribution → short action; ·

.Caution in porphyria

ketamine: nmda antagonist; Dissociative anaesthesia, ·

bronchodilation, analgesia, ↑ bp/hr; Side effects: hallucinations, ↑
.secretions

etomidate: gabaₐ; Minimal cardiovascular effects; Suppresses ·

.adrenal cortex (single dose effect debated)

benzodiazepines: gabaₐ; Anxiolysis, sedation, amnesia, ·

.anticonvulsant; Reversal: flumazenil
 Inhaled anaesthetics

minimum alveolar concentration (mac): concentration preventing ·

.movement to surgical stimulus in 50% patients

factors affecting mac: ↑ with hyperthermia, hypernatremia, cns ·

catecholamines; ↓ with age, hypothermia, opioids, pregnancy,
.anaemia, hypoxia

speed of onset: determined by blood:gas solubility (lower solubility ·

.= faster onset, e.G., desflurane, sevoflurane)

common properties: myocardial depression, vasodilation, ·

bronchodilation, ↑ cerebral blood flow, dose-dependent respiratory
.depression

nitrous oxide: low potency (mac 104%); Second gas effect; Diffusion ·
hypoxia; Expands closed gas spaces; Inhibits methionine synthase
.(prolonged use)

Pages 531–600: pharmacology – other drugs

Muscle relaxants

non-depolarising (ndmr): competitive antagonists at nicotinic ·

.receptor; Reversed by anticholinesterase + anticholinergic

.rocuronium: rapid onset, intermediate duration ·

atracurium: hofmann elimination (spontaneous at ph/temp) → ·

.laudanosine (cns excitation)
 sugammadex: selective encapsulator of rocuronium/vecuronium → ·
.rapid reversal

depolarising (suxamethonium): agonist → persistent depolarisation; ·

Rapid onset/ultra-short; Side effects: fasciculations, hyperkalaemia,
bradycardia, malignant hyperthermia trigger, suxamethonium
.apnoea (pseudocholinesterase deficiency)

Local anaesthetics

.mechanism: block voltage-gated na⁺ channels (use-dependent) ·

:classification ·

esters (cocaine, amethocaine): metabolised by plasma ·

.cholinesterase

.amides (lidocaine, bupivacaine, ropivacaine): hepatic metabolism ·

toxicity (cns then cvs): timitius, perioral tingling, seizures, coma, ·

myocardial depression, arrhythmias (bupivacaine particularly
.cardiotoxic). Treatment: stop injection, lipid emulsion (intralipid)

Cardiovascular drugs

:inotropes ·

.adrenaline (α, β): ↑ hr, contractility, vasoconstriction ·

.noradrenaline (α>β): potent vasoconstrictor ·

.dopamine: dose-dependent (renal → β → α) ·

.dobutamine (β₁>β₂): ↑ contractility, some vasodilation ·

.milrinone (pde iii inhibitor): inotropy + vasodilation ·

antihypertensives: β-blockers, acei, arbs, ca²⁺ channel blockers, ·

.vasodilators (gtn, snp, hydralazine)
 .antiarrhythmics: vaughan williams classification (class i–iv) ·

Cns drugs

antidepressants: tcas (anticholinergic, cardiac toxicity), ssris ·

.(serotonin syndrome risk)

anticonvulsants: phenytoin (zero-order kinetics), valproate, ·

.levetiracetam

antiemetics: 5-ht₃ antagonists (ondansetron), d₂ antagonists ·

(metoclopramide, prochlorperazine), antihistamines (cyclizine),
.anticholinergics (hyoscine), nk₁ antagonists (aprepitant)

Miscellaneous drugs

anticoagulants: heparin (monitor aptt, reverse with protamine), ·

.warfarin (monitor inr, reverse with vitamin k, pcc)

insulin/oral hypoglycaemics: insulin, metformin (risk lactic ·

.acidosis), sulfonylureas

diuretics: loop (furosemide), thiazide, k⁺-sparing (spironolactone), ·

.osmotic (mannitol)

steroids: glucocorticoids (anti-inflammatory, immunosuppressive; ·

.Adrenal suppression risk), mineralocorticoids (fludrocortisone)

colloids vs. Crystalloids: colloid osmotic pressure, volume effect, ·

.side effects (anaphylaxis, coagulopathy, renal)

Pages 601–end: anatomy

 anatomy is highly visual; Key exam points are relationships,(
).landmarks, and clinical relevance

Respiratory system anatomy

larynx: cartilages (thyroid, cricoid, arytenoid), vocal cords, ·

innervation (recurrent laryngeal nerve except cricothyroid – external
.laryngeal nerve)

tracheobronchial tree: carina at t4/t5; Right main bronchus wider, ·

.shorter, more vertical → aspiration risk

diaphragm: central tendon at t8, domes at t9 (right higher), ·

.openings (t8 ivc, t10 oesophagus + vagi, t12 aorta + thoracic duct)

Cardiovascular anatomy

heart borders: right atrium (right border), left ventricle (apex), ·

.great vessels (superior)

.coronary arteries: as above ·

conduction system: sa node (junction svc/ra), av node (koch’s ·

.triangle), bundle of his, purkinje fibres

Nervous system anatomy

brachial plexus: roots (c5–t1) → trunks → divisions → cords → ·

.branches

Landmark for block: interscalene groove (roots/trunks),

supraclavicular (divisions), infraclavicular (cords), axillary (terminal
.nerves)
 stellate ganglion: fusion of inferior cervical + t1 ganglia; Block → ·
.horner’s syndrome (ptosis, miosis, anhidrosis)

epidural space: between ligamentum flavum and dura; Contains ·

.fat, veins, nerves; Negative pressure

spinal cord levels vs. Vertebral levels: in adult, cord ends at l1/l2; ·
.Caudal equina below

Surface anatomy

.internal jugular vein: between sternal + clavicular heads of scm ·

femoral triangle: navel (lateral to medial: nerve, artery, vein, empty ·

.space, lymphatics)

sciatic nerve: midpoint between greater trochanter and ischial ·

.tuberosity

.axilla: axillary artery/vein/brachial plexus; Cord relationship ·