GOALS AND OBJECTIVES OF A TRAINING PROGRAM IN VETERINARY ANESTHESIOLOGY

Note!

This document is undergoing further editorial review by the ACVA, and has not be approved as an official document of the ACVA. It is provided here as a general guide only.

Table of Contents

Introduction

GOALS AND OBJECTIVES (I): The Management of Procedures for Rendering a Patient Insensible to Pain During Surgical Operations

GOALS AND OBJECTIVES (II): The Support of Life Functions Under the Stress of Anesthetic and Surgical Manipulations

GOALS AND OBJECTIVES (III): Demonstrate the specific skills required for safe and effective performance of anesthesia for:

1. abdominal surgery

2. cardiac surgery

3. ear, nose and throat surgery

4. eye surgery

5. neurosurgery

6. obstetrics

7. orthopedic surgery

8. outpatient and emergency surgery

9. pediatric surgery

10. urologic surgery

11. thoracic surgery

GOALS AND OBJECTIVES (IV): The Clinical Management of the Unconscious Patient

GOALS AND OBJECTIVES (V): The Management of Problems in Pain Relief

GOALS AND OBJECTIVES (VI): The Management of Problems in Cardiac and Respiratory Resuscitation

GOALS AND OBJECTIVES (VII): The Clinical Management of Various Fluid, Electrolyte and Metabolic Disturbances

GOALS AND OBJECTIVES (VIII): The Application of Specific Methods of Inhalational Therapy

Introduction

"Veterinary Anesthesiology is a practice of medicine in food, companion, sporting, and laboratory animals, and that deals with: (1) the management of procedures for rendering a patient insensible to pain during surgical operation; (2) life support functions under the stress of anesthetic and surgical manipulations; (3) the clinical management of a patient unconscious from whatever cause; (4) the management of problems in pain relief; (5) the management of problems in cardiac and respiratory resuscitation; (6) the application of specific methods of inhalational therapy; (7) the clinical management of various fluid, electrolyte, and metabolic disturbances; (8) the use of chemicals to immobilize and restrain a patient, and to capture and control wild and zoologic animals." (Modified from Introduction to Anesthesia, Dripps/Eckenhoff/Vandam, W.B. Saunders Company, p. 505 (1967).)

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GOALS AND OBJECTIVES (I): The Management of Procedures for Rendering a Patient Insensible to Pain During Surgical Operations

I. To select and justify appropriate anesthesia in clinical and experimental situations in horses, ruminants, swine, dogs, cats, birds, fish, laboratory, zoological and wild animals.

Behavioral Objectives

1. Given a list of anesthetic agents and adjuvant drugs, justify and define the applicability or rejection of each for typical clinical situations.

2. Given a list of surgical procedures to be performed on healthy adult patients (horse, ruminant, pig, dog and cat), select and justify an appropriate anesthetic sequence for each.

3. Given a surgical procedure to be performed on a list of patients (including horse, food animal, dog and cat) with life-threatening disease processes and extreme emergencies, select and justify an anesthetic sequence that is designed to minimize risk in each instance and that can be implemented within an appropriate time frame.

II. To demonstrate the purposes of preanesthetic medication, the drugs employed, and the hazards associated with their use.

Behavioral Objectives

1. Given an apprehensive, vicious, or difficult to restrain patient, select and justify an anesthetic procedure, and prescribe medications to bring the patient to surgery in a tranquil state.

2. Given an apprehensive owner of a patient to be anesthetized, explain the proposed anesthetic procedure understandably.

3. Modify preanesthetic medication for conditions and species where it must be substantially altered (e.g., extremes of age, hyperthyroidism, shock) and justify.

4. Identify overdosage and commonly observed side effects of preanesthetic medicants such as narcotics, anticholinergics, phenothiazines, barbiturates, benzodiazepines, and suggest accepted methods for dealing with such cases.

III. Explain essential physical principles concerning compressed gases and the vapors of volatile liquids employed as inhalation anesthetic agents.

Behavioral Objectives

1. Given a standard anesthetic machine, indicate the purpose and limitations of the following:

a. pressure reducing valves

b. flowmeters

c. liquid anesthetic vaporizers

d. canisters containing carbon dioxide absorbents

e. conducting conduits in circle and non-rebreathing systems

f. fail-safe devices

2. Tabulate the physical properties of medical gases (oxygen, nitrous oxide, cyclopropane, carbon dioxide), including molecular formula, physical state in cylinder, boiling point, and explosive range if flammable.

3. Tabulate the physical properties of volatile anesthetic liquids (diethyl ether, halothane, methoxyflurane, enflurane, isoflurane, sevoflurane, desflurane) that determine their delivery from vaporizing devices, including the molecular formula, boiling point, vapor pressure at ordinary temperatures, stability over soda lime, and explosive range if flammable.

4. Explain the operation of a mechanical ventilatory assister/controller, and its application to the problems of general anesthesia, respiratory and circulatory homeostasis.

IV. Explain and demonstrate appropriate administration of the common inhalational anesthetic agents.

Behavioral Objectives

1. List the factors that determine the rate of uptake from airway to alveoli, from alveoli to arterial blood, and from blood to brain.

2. List factors governing their elimination from the brain via venous blood and alveoli.

3. Tabulate and explain the significance to anesthetic practice of MAC values, blood/gas and brain/blood partition coefficients, and saturated vapor pressures (25 degrees C.) for the following:

a. nitrous oxide

b. cyclopropane

c. diethyl ether

d. halothane

e. methoxyflurane

f. enflurane

4. Briefly explain the theories of anesthesia.

5. Demonstrate the application of an anesthetic mask, and the maintenance of a clear airway while administering an inhalation anesthetic.

6. Considering each agent in turn listed in #3 above, state the effects on respiration, heart and vasculature, liver, urogenital system, bone marrow and reticuloendothelial system including defense mechanisms.

7. Define clearly and illustrate the following techniques of inhalation anesthesia.

a. insufflation

b. open

c. semi-open

d. semi-closed

e. closed

8. Describe the operation of common varieties of liquid anesthetic vaporizers, demonstrate the proper use of at least two of them, compare and contrast their use "in-circle" and "out of circle", and indicate limitations and problems which may arise during their use.

V. Demonstrate proficiency in the use of artificial airways and endotracheal tubes.

Behavioral Objectives

1. Given patients of varying species (including horse, ruminant, dog, cat, pig, bird) select an endotracheal tube of appropriate size and length, and perform endotracheal intubation. Describe the peculiarities relative to each species.

2. Be able to explain the hazards associated with intubation, including laryngoscopy, tube selection, tube placement, and cuff inflation.

3. Given a patient with gastric and/or intestinal distension, and/or ruminant patients, demonstrate performance of intubation.

4. Be able to describe and discuss five complications which may follow extubation.

VI. Employ neuromuscular blocking agents and other muscle relaxants in a manner which demonstrates knowledge of their pharmacologic properties, and their appropriate clinical application in small and large animal species (dog, cat, horse, ruminant).

Behavioral Objectives

1. Explain the sequence of neuromuscular transmission, the ways it may be pharmacologically interrupted, and the process by which neuromuscular blockade is reversed and assessed.

2. Define depolarizing and nondepolarizing neuro-muscular blockade, and the reactions to faradic nerve stimulation in each.

3. Describe the uptake, distribution, biotransformation and elimination of three neuromuscular blocking agents including succinylcholine, d-tubocurarine, gallamine, pancuronium, glyceryl guaiacolate, atracurium, and vecuronium.

4. Define physiologic factors which influence the action of neuromuscular blockers such as those in (3) above (temperature, electrolyte and acid-base disturbances, preanesthetic administration of anticholinesterases, etc.)

5. Prescribe and administer in an acceptable manner an appropriate neuromuscular blocking agent employing assisted and/or controlled ventilation and acceptable weaning techniques.

VII. Explain the action and uses of intravenous anesthetic agents.

Behavioral Objectives

1. Identify the significant pharmacologic actions of the following:

a. an ultrashort acting oxybarbiturate (methohexital)

b. an ultrashort acting thiobarbiturate (thiopental)

c. a narcotic=neuroleptic mixture (Innovar)

d. a phencyclidine (ketamine)

e. a substituted phenol (propofol)

2. Describe the uptake, distribution, biotransformation, and elimination of thiopental or thiamylal.

3. Given a suitable patient of various species (equine, ruminant, swine, small animal), demonstrate intravenous anesthesia:

a. alone for a short procedure

b. for induction, to be followed by inhalation anesthesia

c. in divided doses as part of a balanced regimen

d. as an emergency anticonvulsant.

4. Describe the indicated corrective measures following inadvertent extravasation or intra-arterial injection of thiopental.

VIII. Explain the pharmacologic actions, toxic effects, methods of administration, and demonstrate the uses of local anesthetic agents.

Behavioral Objectives

1. Discuss reasons why local anesthesia may or may not be appropriate for certain surgical procedures in selected species.

2. Explain the mode of propagation of the nerve impulse, and its inhibition by local anesthetic agents in various sizes and types of nerves.

3. Tabulate the properties of commonly used local anesthetic drugs, their concentrations for topical, regional, epidural and spinal block, their maximal safe dose, and their toxic side actions.

4. Given suitable patients (small animal or ruminant) for which spinal anesthesia is indicated for the proposed surgical procedure, demonstrate technical proficiency in lumbosacral puncture, and appropriate administration of spinal block to an appropriate level.

5. Given suitable patients (large and small animal) for which epidural block is indicated, demonstrate technical proficiency in administration and management.

6. Given a patient on which a spinal or epidural block has been performed, list the possible complications and their management.

7. Explain the anatomic landmarks and the technical sequence for performance of:

a. paravertebral nerve block (ruminant)

b. nerve blocks of the thoracic and pelvic limb (dog, horse, bovine)

c. mandibular (equine), maxillary (equine), auriculopalpebral (equine, bovine) and cornual nerve blocks (ruminant).

8. Given appropriate ruminant patients perform paravertebral, ocular, and corneal nerve blocks.

9. Given appropriate equine patients perform nerve blocks of the thoracic limb.

IX. The resident will be able to explain the current status of acupuncture theory and practice.

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GOALS AND OBJECTIVES (II): The Support of Life Functions Under the Stress of Anesthetic and Surgical Manipulations

I. Assess the risks of anesthesia and surgery, and explain the hazards and complications which may develop in commonly anesthetized species in any given clinical situation.

Behavioral Objectives

1. List important tests to indicate the functional status of the

a. cardiovascular system

b. respiratory system

c. renal and metabolic buffer system

in the preanesthetic period, stating normal parameters, and aberrations observed in the common disorders of these systems, in commonly anesthetized species.

2. Given patients (various species) with healthy viscera, for whom clean surgery is anticipated, state the risks of morbidity and mortality.

3. Given patients (various species) with concurrent pulmonary, cardiovascular, renal or metabolic disease, list the corrective measures to be carried out prior to surgery in order to optimize chances of a favorable outcome.

4. Given patients (various species) receiving medication prior to surgery, determine the additional hazards imposed, including the potential for and results of enzyme induction, and recommend remedial actions.

II. Explain the operation of equipment essential to the monitoring of vital functions during anesthesia and surgery.

Behavioral Objectives

1. Demonstrate and/or explain the following devices and/or methods for circulatory monitoring, and interpret the responses:

a. pulse (palpation, precordial or esophageal stethoscope, sound amplifiers

b. electrocardiograph

c. blood pressure (sphygmomanometry, direct transduction via strain gauge to polygraph, doppler system, capillary perfusion)

d. venous pressure (direct)

e. blood volume (dye, thermal, or radionuclide dilution)

f. blood loss

g. cardiac output

2. Demonstrate the following devices and methods for respiratory monitoring and interpret the results

a. spirometry (rate, pattern, volumes)

b. blood gases

c. end-tidal gas analyzer

3. Demonstrate additional monitoring devices and interpret the responses as follows:

a. telethermometer

b. electroencephalograph

III. Diagnose, explain, and treat effectively the complications of anesthesia.

Behavioral Objectives

1. List and explain causes of arterial hypotension during anesthesia, and their management (excessive premedication, vasodepressor medications prior to anesthesia, overdose of general or local anesthetic agents, sympathetic blockade due to spinal or epidural anesthesia, raised airway pressure, hemorrhage, surgical manipulation, interference with caval return, change in position of the patient, acute adrenal insufficiency, anaphylaxis).

2. List, explain and discuss management of physical injuries which may occur during any phase of anesthesia (ocular, nerve injuries, pneumo-thorax, mediastinal or subcutaneous emphysema, ulnar, musculocutaneous or radial nerve injury, common peroneal nerve injury, electrical hazards, fractures, dislocations, burns from heating devices, etc.).

IV. Outline measures to be followed which minimize the risks of fire and explosion.

Behavioral Objectives

1. Name the volatile agents which are flammable in the anesthetic range.

2. Name, describe, and explain five general principles of safe management of flammable vapors (storage facilities, vapor removal, closed system technique, removal of sources of ignition, power distribution to hazardous areas, behavior of personnel).

V. Indicate hazards which may result from the gaseous environment of the operating room, discuss current theory, and recommend protective measures.

VI. Outline and explain common hazards associated with the postoperative period.

Behavioral Objectives

1. List and explain causes of arterial hypotension in the postoperative period and describe remedial measures (inadequate volume replacement, rapid reduction in general anesthetic level, baroceptor paralysis due to general, spinal or epidural anesthesia, pulmonary embolism, vasodepressor effect of analgesics).

2. List and explain causes of respiratory failure in the postoperative period and describe remedial measures (post-extubation spasm or glottic edema, pharyngeal soft tissue obstruction, depression due to muscle relaxants, atelectasis due to hypoventilation or mucus plugs, splinting due to pain or restrictive dressing, aspiration of vomitus, prior administration of antibiotics).

3. State the differential diagnostic features of postanesthetic excitement; describe and justify prophylactic and remedial measures.

4. List and explain advantages of the recovery room and how it should be maintained (patient safety, skilled nursing care, anesthetic pollution, equipment for resuscitation).

5. Given an anesthetized animal (various species), describe and care for the patient during emergence from anesthesia.

VII. Explain the proper recording and record-keeping essential to good anesthetic practice.

Behavioral Objectives

1. List the information to be recorded:

a. on the face of the record

b. in the chart or graph

c. on the reverse of the record (preoperative and postoperative findings).

2. Explain the purpose of three types of entry in the progress notes of the patient's chart (preoperative, postoperative, respiratory function measurements and conclusion drawn from them, assessment of depth of coma).

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GOALS AND OBJECTIVES (III): Demonstrate the specific skills required for safe and effective performance of anesthesia for:

I. abdominal surgery

II. cardiac surgery

III. ear, nose and throat surgery

IV. eye surgery

V. neurosurgery

VI. obstetrics

VII. orthopedic surgery

VIII. outpatient and emergency surgery

IX. pediatric surgery

X. urologic surgery

XI. thoracic surgery

I. Anesthesia for Abdominal Surgery

Behavioral Objectives

1. List and explain the principles governing the judicious use of muscle relaxants for the control of abdominal muscle tone.

2. Define the sensory distribution of spinal nerves and the blockade required for upper and lower abdominal procedures.

3. Describe the anatomy of the epidural space, and relate this to the steps in performance of spinal and epidural blocks.

4. Describe techniques of lumbar and lumbosacral puncture, and the factors determining the height of a spinal anesthetic.

5. Outline and justify the steps in preoperative evaluation and preanesthetic medication of patients for abdominal surgery including ruminants.

6. Given a dehydrated, febrile, acidotic patient with acute surgical abdomen, define and justify the conditions necessary for safe anesthesia and the measures for their accomplishment.

7. Given a patient with intestinal obstruction, describe the necessary procedures for prevention of aspiration.

8. Given a normal healthy ruminant or a patient with upper gastrointestinal obstruction, list the anesthetic hazards and the principles of their control.

9. Describe mechanisms producing acute circulatory collapse during abdominal surgery (hemorrhage, desalting water loss, sympathetic over stimulation, inferior caval obstruction).

10. List and explain the factors which predispose to hypoventilation in the immediate postoperative period following abdominal surgery, and suggest prophylactic and remedial measures.

11. Tabulate the common immediate sequelae of intra-abdominal injury or surgery (visceral pain, distention, vomiting, occult bleeding), their clinical manifestations, and the principles of treatment.

12. Outline and explain criteria determining the necessity for prolonged mechanical ventilatory assistance (obesity, preexisting lung disease, muscular paralysis).

13. Explain the effects of irrigation via abdominal drains on fluids and electrolytes. Indicate preferred methods.

14. Outline and explain the criteria determining the necessity for mechanical ventilatory assistance.

15. Describe and explain the use and complications of suction via chest tubes following cardiac surgery.

16. Describe the pathogenesis of disrhythmias associated with anesthesia in cardiac surgical patients.

III. Anesthesia for Surgery of the Head (Nose, Mouth, Throat)

Behavioral Objectives

1. Describe and justify the proper management of problems that mechanically hinder the performance of anesthesia for a procedure on the nose, on the throat.

2. Outline the steps in preoperative evaluation and preanesthetic medication of such surgical patients.

3. Given a patient for pharyngeal surgery, describe an acceptable anesthetic procedure, and the additional functions to be performed during the operation.

4. Given a patient for laryngeal surgery, describe a general and local anesthetic technique and postoperative procedures which assure proper airway management. Discuss the advantages and disadvantages of these techniques.

5. Given a patient requiring tracheostomy, describe the management of anesthesia before, during and after the trachea is opened.

6. Given patients requiring dental, oral, and intranasal surgery, outline the measures necessary for airway control.

7. Describe procedures for relief of acute upper airway obstruction where tracheal intubation is impossible (tracheal cannulation, cricothyrotomy, tracheotomy).

IV. Anesthesia for Eye Surgery

Behavioral Objectives

1. List conditions (coughing, vomition, struggling and excitement, hypertension, hypoxia, hypercarbia) which may result in increased intraocular tension.

2. List and explain how intraocular pressure can be reduced (anesthetic selection, hyperventilation, hyperoxia, hypotension, retrobulbar block).

3. Explain the actions of two drugs employed in anesthesia which may present special hazards in ocular surgery (atropine, succinylcholine).

4. Outline the steps in preoperative evaluation and preanesthetic medication of patients undergoing eye surgery.

5. Describe the principles for managing general anesthesia in patients undergoing eye surgery.

6. Outline the essentials of proper postanesthetic care of eye surgery patients.

V. Anesthesia for Neurosurgery

Behavioral Objectives

1. List the classical signs of increased intracranial pressure.

2. Describe procedures for the control of intracranial pressure (hyperventilation, hypertonic intravenous solutions, spinal drainage, phlebotomy, ganglionic blockage, hypothermia).

3. Define the locations of the central respiratory centers, their functions, and the clinical manifestations observed when they are abnormal.

4. Define the locations of the central vasomotor pathways, and the common circumstances under which their functions may be disturbed.

5. Describe the hypothalamic thermoregulatory center and the conditions predisposing to development of hyperpyrexia.

6. Given patients with a spinal cord lesion, including high cervical spine instability, describe and explain a safe anesthetic management technique.

7. List the essentials of continuous ventilatory management of a patient with central respiratory disturbance (head injury, brain disease, drug depression).

8. Indicate cardiovascular changes and neurologic complications induced by use of contrast media in spinal canal and brain.

VI. Anesthesia for Obstetrics

Behavioral Objectives

1. Explain the principal physiologic changes attendant upon the transition from intra- to extrauterine life.

2. Explain the effects of analgesic drugs upon labor, maternal vital functions,and postnatal respiratory and circulatory changes.

3. Describe the general physiology and pharmacology of the placenta, including the transport of oxygen to the fetus, and the transmission of drugs from maternal to fetal circulation.

4. Describe the innervation of the birth canal and procedures for regional analgesia.

5. Explain the precautions necessary to prevent aspiration in the parturient receiving anesthesia.

6. Outline the steps in preanesthetic evaluation and medication of the parturient patient.

7. List the criteria determining selection of regional or inhalational anesthesia for obstetrical purposes.

8. Describe circumstances that indicate the need for a caesarean section.

9. Given patients (equine, ruminant, small animal) requiring anesthesia for obstetrical purposes, select and demonstrate preferred plan and technique.

10. Demonstrate principles of care and resuscitation of the newborn at the time of birth.

VII. Anesthesia for Orthopedic Surgery

Behavioral Objectives

1. List and explain the specific hazards attending the treatment of bone and joint trauma.

2. Outline and explain the steps in preoperative evaluation and preanesthetic medication of orthopedic surgical patients.

3. List the physical, laboratory and x-ray signs of fat embolism.

4. Enumerate and explain the hazards of multiple blood transfusions.

5. Explain the pathogenesis of shock accompanying major somatic injury.

6. List the diagnostic equipment essential for proper monitoring of orthopedic surgical patients.

7. Given patients with surgical problems of extremities (equine, and small animal), the resident will compare and contrast the alternative choices of anesthesia and demonstrate the most feasible methods.

8. Given patients with commonly occurring orthopedic surgical problems, discuss alternative choices of anesthesia and demonstrate the methods most feasible.

9. Given patients with surgical problems involving the spine, describe alternative choices for anesthesia and demonstrate the most feasible methods.

10. List the most common postoperative complications of orthopedic anesthesia and surgery encountered during recovery.

VIII. Anesthesia for Outpatient Surgery and Emergency Surgery

Behavioral Objectives

1. List the factors which determine the types of operation suitable for outpatient management.

2. State the limitations placed on preanesthetic medication and anesthetic selection by outpatient status.

3. Given patients for surgery (dental, wound, fracture) on an ambulatory basis, describe a suitable general anesthetic procedure.

4. Given patients receiving general anesthesia on outpatient basis, outline the necessary conditions for discharge and instructions to owner.

IX. Anesthesia for Pediatric Surgery

Behavioral Objectives

1. The resident will list hazards peculiar to anesthesia for the neonatal and young animal (small airway size, short trachea, small blood volume, rapid circulation time, high oxygen consumption, labile temperature, renal immaturity, irregularity of the signs of anesthesia, small tidal volume).

2. Outline the steps in preoperative evaluation and preanesthetic medication.

3. Describe methods for maintaining of body temperature.

4. The resident will describe three anesthetic systems that can be used in the pediatric patient (T-piece, Jackson-Rees, infant circle absorber).

5. Demonstrate the proper use of a humidifier in both circle and non-rebreathing systems.

6. Given a young animal with intestinal obstruction, describe the electrolyte and acid-base problems that may be encountered, describe and explain a corrective fluid regimen, and select an appropriate anesthetic regimen.

7. Given a young animal or neonate to be anesthetized, demonstrate methods of arterial pressure monitoring.

8. Given a young animal to be anesthetized, demonstrate induction by inhalation in a safe, orderly and tranquil manner.

9. Given a neonatal or young anesthetized animal demonstrate and justify appropriate post anesthetic care.

XI. Anesthesia for Thoracic Surgery

Behavioral Objectives

1. Describe hazards imposed by open pneumothorax on the performance of general anesthesia (massive collapse, venous admixture, ventilation-perfusion inequality, increased deadspace).

2. List pulmonary function tests which assess ventilation, one which measures alveolocapillary diffusion, and one which measures pulmonary blood flow. State normal values for each. Given abnormal values indicate their influence upon anesthesia.

3. Describe the technique of bronchoscopy, and draw the principal airways as visualized through the bronchoscope. Draw the appearance of the larynx in the horse, dog, cat and pig.

4. Outline and justify the steps in pre-operative preparation of a patient with (a) chronic emphysema, (b) diaphragmatic hernia, (c) pyothorax, (d) cardiac tamponade.

5. Select appropriate preanesthetic medication for the patient with severely limited respiratory reserve.

6. Given a patient with acute chest trauma, outline differential diagnosis to distinguish:

(a)tension pneumothorax (external or internal)

(b)hemothorax, chylothorax

(c)flail chest

(d)severe lung contusion

(e)avulsion of major airways

(f)diaphragmatic hernia

(g)cardiac tamponade

7. Given a patient with traumatic wet lung syndrome following surgery for chest trauma, order oxygen and assisted mechanical ventilation as indicated.

8. Describe four causes of hypotension following thoracotomy (hemorrhage, increased intrathoracic pressure, cardiac tamponade, shock).

9. Given a patient (small animal) requiring thoracotomy, demonstrate proper use of IPPV before, during and after thoracotomy, and indicate complications which may arise and why.

XII. Other Anesthetic Related Problems

Behavioral Objectives

1. List the hazards associated with anesthesia for geriatric patients.

2. Describe briefly the principal tests for preoperative assessment of renal function.

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GOALS AND OBJECTIVES (IV): The Clinical Management of the Unconscious Patient

I. Outline a comprehensive classification of the etiology of coma, and demonstrate its effectiveness in the diagnosis of unconscious patients.

Behavioral Objectives

Given a comatose patient:

1. Demonstrate the presence or absence of focal signs which identify the localization of a brain lesion.

2. Perform a spinal tap, explain the hazards attendant upon this procedure, and identify diagnostic changes commonly observed in cerebrospinal fluid.

3. List four signs of meningeal irritation and identify those exhibited by the patient.

4. Explain the actions of poisons which produce unconsciousness.

5. Identify the principal diagnostic signs of common metabolic disorders producing coma (uremia, hepatic ketoacidosis, hypocalcemia, hypoglycemia, hyponatremia, heat stroke, asphyxia).

6. Identify the signs of aspiration of foreign material or vomitus.

7. List conditions where the ordering of skull or chest films is essential (trauma, neoplasm, aspiration).

8. Draw an arterial blood sample for gas analysis, describe potential hazards, and explain and discuss the values obtained for pH, oxygen and carbon dioxide tensions.

II. Given a comatose patient institute appropriate measures to protect the patient's vital functions.

Behavioral Objectives

Upon proper indication:

1. Perform endotracheal intubation and demonstrate correct placement and cuff inflation.

2. Place the patient on continuous mechanical ventilation.

3. Place a large bore cannula in a vein preparatory to administration of fluids and medications, or in anticipation of immediate surgery.

4. Attach appropriate monitoring devices for continuous observation of pulse, blood pressure, ECG, respiration and temperature.

5. Prescribe respiratory care during the period of coma, including the appropriate weaning sequence where mechanical ventilation is required.

6. Demonstrate the operation of a thermal blanket for control of hypo- or hyperthermia.

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GOALS AND OBJECTIVES (V): The Management of Problems in Pain Relief

I. Review comprehensively the neuroanatomy and neurophysiology of pain.

Behavioral Objectives

1. Trace the principal nervous pathways for transmission of painful stimuli (somatic, autonomic).

2. Explain the morphology and functions of the sensory areas of the brain (central gray core, thalamus, hypothalamus, somesthetic areas).

3. Explain current theories regarding the mechanism of pain.

II. Review comprehensively the pharmacology of drugs employed for relief of pain.

Behavioral Objectives

1. List and explain pharmacologic and toxic properties, absorption, fate and excretion, routes of administration and dosage of:

a. antipyretic analgesics

b. narcotics and antinarcotics

c. tranquilizers and neuroleptics

d. dissociative anesthetics

2. Classify local anesthetic drugs (esters, amides) and list the pharmacologic and toxic properties of each.

3. List and describe the mechanisms of action of the principal chemical agents employed for neurolysis (benzyl alcohol, ethyl alcohol, phenol).

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GOALS AND OBJECTIVES (VI): The Management of Problems in Cardiac and Respiratory Resuscitation

I. Demonstrate the ability to apply effective cardiopulmonary resuscitation procedures.

Behavioral Objectives

1. List and explain the physical signs of cardiopulmonary arrest.

2. List and describe the anatomical and physiologic complications of the upper airway, which may prevent achieving a patent airway.

3. Given a variety of clinical situations requiring resuscitation, select the correct sequence of events in an appropriate time frame that match the specified circumstances.

4. Given a resuscitation model (animal or human) demonstrate how to achieve a patent airway and deliver a satisfactory breath within 5 seconds.

5. Given a resuscitation model (animal or human), perform respiratory resuscitation satisfactorily while another person is performing cardiac massage.

6. Given a resuscitation model (animal or human), perform external cardiac massage satisfactorily.

7. Given a resuscitation model (animal or human), perform both cardiac massage and resuscitation satisfactorily, for a period of five minutes.

8. Given a resuscitation model (animal or human), auscultate the chest and locate pulse points while another person is performing cardiopulmonary resuscitation.

9. Given a resuscitation model (animal or human) satisfactorily use a mechanical ventilator while another is performing external cardiac massage.

10. Given a resuscitation model (animal or human), perform both external cardiac massage and mechanical resuscitation.

11. List and explain the advantages and hazards of mechanical resuscitation in a cardiopulmonary arrest.

12. List, describe and explain the cardiac arrhythmias which commonly precipitate cardiac arrest - including those most frequently associated with anesthesia.

13. Describe the rationale, mechanism, and effect of defibrillation in cardiopulmonary resuscitation.

14. Given a list of drugs used during cardiopulmonary resuscitation, explain why they may be required; will know dosage, route and sequence of administration.

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GOALS AND OBJECTIVES (VII): The Clinical Management of Various Fluid, Electrolyte and Metabolic Disturbances

I. Demonstrate comprehension of the basic metabolic requirements, and their modes of correction when disturbed.

Behavioral Objectives

1. List the principal fluid compartments, their respective volume proportions, and the approximate electrolyte concentrations of each.

2. Define the parameters of adequate parenteral fluid maintenance.

3. Given a clinical situation, program the fluid orders for a 24-hour period.

4. Match a list of common disease states with another list of anticipated fluid and electrolyte disturbances.

5. Explain the operation of the bicarbonate buffer system in terms of the Henderson-Hasselbalch equation.

6. Given two of the following three clinical determinations: pH, PCO2, and HCO3-, calculate the third correctly.

7. Prepare a table showing anticipated changes of pH, PCO2 and HCO3- in metabolic acidosis and alkalosis, and in respiratory acidosis and alkalosis.

8. Given a clinical situation, prescribe and explain the appropriate therapy to correct an acid-base disturbance.

9. Given a clinical situation involving a mixed acid-base disorder, explain the stated values of pH, PCO2 and HCO3-.

10. List and explain the alterations in anesthetic management likely to be required in a variety of patients with acid-base imbalance.

11. List and explain the metabolic disturbances anticipated following an episode of hypoxia, and the corrective measure indicated in each instance.

12. Explain proper monitoring of fluid-electrolyte input-output during surgery and for long duration.

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GOALS AND OBJECTIVES (VIII): The Application of Specific Methods of Inhalational Therapy

I. Explain advantages and disadvantages of all types of artificial airways and demonstrate proficiency in their insertion and maintenance.

Behavioral Objectives

1. Given a list of clinical situations, select and explain the proper airway control device.

2. Given a suitable patient (horse, dog, cat, pig, ruminant, rabbit, bird) and the necessary equipment, successfully intubate the patient in an atraumatic manner within thirty seconds.

3. Assemble the proper equipment and perform atraumatic aspiration of the airway, to the satisfaction of the instructor.

II. Demonstrate comprehension of oxygen therapy techniques.

Behavioral Objectives

1. Given a list of patient situations requiring oxygen therapy and a list of modalities of therapy, match the lists and explain the rationale of therapy in each case.

2. Given the necessary equipment, assemble for patient use and describe the therapeutic value of the following apparatus:

a. catheter and cannula

b. oxygen masks

c. mist tents

d. incubators

e. direct airway connections

III. Classify and discuss uses of drugs related to respiratory therapy.

Behavioral Objectives

1. Given a list of bronchodilator drugs describe correct dosages, mechanisms of action, indications, contraindications,and hazards of each drug.

2. Given a list of commonly used mucolytic drugs, will be able to describe correct dosages, mechanisms of action, indications, contraindications, and hazards of each drug.

3. Given a list of antibiotic drugs and a list of patient situations, will match the appropriate drug to the indicated condition.

IV. Demonstrate comprehension of the functional characteristics of commonly used respiratory therapy equipment.

Behavioral Objectives

1. Given a list of situations requiring humidity and/or aerosol therapy identify the apparatus most suited for each situation.

2. Given situations requiring pressure and flow regulation, select the appropriate apparatus and explain each selection.

3. Given a series of statements of advantages and disadvantages of oxygen analyzers, match the appropriate type of analyzer to each situation.

4. Given a list of commercially available ventilators, will correctly classify them according to inspiratory and expiratory cycling mechanisms and methods of force generation.

5. Given a set of situations involving specific ventilators, will correctly predict the reaction of the ventilator to specified changes in operation.

6. Given a specific ventilator and a specific condition, will correctly draw the resultant pressure and flow curves.

7. Given a patient (horse, cat, dog) situation requiring mechanical ventilatory support will explain reason for selection of apparatus and technique.

V. Apply data about the rationale and techniques for ventilatory support.

Behavioral Objectives

1. Given a specific mechanical ventilator, demonstrate proper assembly of that ventilator for patient application.

2. Given a clinical situation, describe the correct sequence for initiating mechanical ventilation.

3. Given a specific set of patient data describe and justify the correct ventilator parameters (these should include assist, assist/control, rate, flow, tidal volume, O2%, maximum pressure, PEEP, IMV).

4. Given a specific patient situation, readjust the ventilator controls to assure satisfactory continuation of mechanical ventilation.

5. Given a specific patient situation, describe the necessary raw data required to monitor patient response, and compute this data to determine patient status.

6. Given a specific patient situation, describe and justify the preferred procedure for weaning from the ventilator.

VI. Apply data about acute respiratory failure to its treatment.

Behavioral Objectives

1. Given a list of specific causative factors and assuming all patients are in respiratory failure, describe and justify therapeutic measures for each.

a. acute respiratory failure secondary to restrictive defects

b. acute respiratory failure secondary to neuromuscular defects

c. acute respiratory failure secondary to respiratory center damage or depression

d. acute respiratory failure secondary to pulmonary edema

e. acute respiratory failure secondary to anatomic loss of functioning lung tissue

2. Given a description of a specific clinical situation, identify the probable clinical course which would lead to acute respiratory failure.

3. Given specific physiologic data and a specific regimen of therapy describe potential complications.

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