Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
103 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
SC - in the cardiac cath lab |
1. C arm gantry may make chest compressions difficult and complicate airway control. 2. Table less stable. 3. Interventionalist usually heavily task loaded. 1. Spontaneous VT/VF due to myocardial irritability and provoked by coronary contrast dye - often involves RCA: rapid defib alone. 2. VT/VF secondary to coronary ischaemia and injury: early defib and treatment of ischaemic substrate. 3. Arriving to lab after prolonged arrest: revascularisation last resort. -consider tamponade or ventricular rupture: ECHO +/- percardiocentesis |
3 + 3 |
|
|
SC - arrest in the operating theatre |
-5-7/20,000 -survival to discharge 30% (with 2/3 having good neuro outcomes) -PEA or asystole -4H and 4T plus think: CO2 embolus, cement embolus, LA toxicity, malignant hyperthermia 1. Interruptions in compressions may be necessary to achieve surgical control of cause. 2. Manual hyperventilation common in stressed environment. 3. Leadership issues with task overloading seniors |
|
|
|
SC - following cardiac surgery |
1. Peri-OP MI most common i.e graft occlusion. 2. Post-OP: MI, shock (haemorrhage or hypovolaemic), tamponade, pacing system disconnect, tension pneumothorax, electrolyte imbalance (potassium) 1. Tamponade, haemorrhage and graft occlusion require re-opening and therefore internal cardiac massage 2. Reopen chest if; no output with compressions, shockable rhythm refractory to defib, asystole unresponsive to internal pacing 3. Adrenaline and resulting hypertension may cause failure of graft anastomosis 4. Consider emergency cardiopulmonary bypass |
Peri-op: 1 Post-op: 6 4 |
|
|
SC - on intubation of critically ill |
-complications in 78% of Emergency intubation -3% of critically ill inpatients die within 30 mins of intubation -15% if hypotensive at time <90 -PEA (cardiovascular collapse) usually |
4 |
|
|
SC - Anaphylaxis |
1. Remove source 2. Adrenaline 3. Standard ALS protocol in arrest 4. May need large vol fluids 5. Prolonged resus may be necessary |
5 |
|
|
SC - Asthma |
Near fatal: raised arterial CO2 and/or requires high pressure ventilation. Life-threatening: PEFR <33%, SpO2 <92, normal CO2, silent chest, cyanosis, feeble resp effort, bradycardia, arrhythmias, hypotension, exhaustion, confusion, coma 1. Critical care area 2. IV access 3. Senior help early 4. O2 to maintain sats >92% 5. Salbutamol nebs 6. Hydrocortisone 200mg IV 7. Neb ipratropium 8. Magnesium sulphate 2g IV over 20 mins 9. IV salbutamol 250-500 micrograms IV slowly then infusion 3-20mic/min 10. Fluids 11. Arterial line for repeat ABGs Other: aminophylline 5mg/kg loading over 20-30min followed by infusion 500-700 micrograms/kg/hr. Heliox. Ketamine. NIV. Causes: 1. Severe bronchospasm and mucous plugging - hypoxia 2. Gas trapping and hyperinflation 3. Tension pneumothorax 4. Arrhythmias from hypoxia/drugs/electrolyte disturbances SC 1. Intubate early 2. Gas trapping - apnoea or external decompression 3. Early needle decompression and chest drain (may need bilateral) if necessary |
11 Causes: 4 SC: 3 |
|
|
SC - drowning |
The process of experiencing respiratory impairment from submersion/immersion in liquid. (Drowing or non-fatal drowning) If found within 60 mins of submersion start CPR. No difference between salt and fresh water. RESCUE BREATHS in water. High oxygen concentration. LMA may fail due to high airway pressures or decreased lung compliance. No evidence to suggest drowing in cold water has better survival outcome. Delayed lung complications. |
|
|
|
SC - pregnancy |
Cardiac arrest incidence 1:20,000 - poor outcomes. Post-mortem caesarean: if rosc not achieved within 4 mins. Survival can occur up to 15 mins from arrest. Higher sternum compressions to adjust for elevated diaphragm. Lateral displacement of uterus to left in over 20 weeks. Can improve CO 20-30%. 2 or 1 handed technique. Rapid securement of airway. May need smaller tracheal tube. Cricoid pressure recommended. Causes of collapse: 1. Amniotic fluid embolism 2. PE 3. Haemorrhage 4. Pre-eclampsia/eclampsia 5. Cardiac disease (peri-partum cardiomyopathy) 6. Sepsis 7. Toxicity |
|
|
|
TCA - causes |
Most common - hypoxia from airway obstruction and blood loss Others - tension pneumothorax, tamponade, hypothermia |
5 |
|
|
TCA - usual rhythms |
PEA and asystole |
|
|
|
TCA - considerations |
1. Jaw thrust preferred to avoid hyperextension of neck 2. Potential for tension pneumothorax, do bilateral decompression with fibger/needle thoracostomy followed by bilateral chest drains 3. Control catastrophic external haemorrhage 4. Use blood early to correct hypovolaemia 5. If pericardial tamponade, thoracotomy and pericardiotomy may be indicated outside theatre if the right expertise is present |
5 |
|
|
Trauma care sequence |
1. Primary survey 2. Resus 3. Adjuncts to primary survey 4. Secondary survey 5. Definitive care |
5 |
|
|
Trauma primary survey SC - A and c-spine |
A - jaw thrust over head tilt - oropharyngeal over NP if risk of basal skull fracture C-spine - assume all neck pain, neuro deficit, and/or impaired consciousness to have c-spine injury unless proven otherwise - semi-rigid collars no longer recommended pre-hospital, risk; moving head while sizing, discomfort and pain, airway compromise if vomits, pressure on neck veins causing raised ICP, hiding other injuries. -in-line bimanual stabilisation, head blocks or Philadelphia collar ok -intubate with someone providing manual stabilisation from side or below. |
2, 4 |
|
|
Trauma primary survey SC - B |
- insert chest drain for significant haemothorax, if >1500ml drained immediately or ongoing >200ml/hr then rapid transfer to theatre -open pneumothorax treatment is assisted with bag to mask device then chest drain. 3-way occlusive dressing no longer initial management. |
|
|
|
Trauma primary survey SC - C |
- earliest sign of hypovolaemia = progressively narrowing pulse pressure - systolic hypotension occurs late after 30-40% blood loss - shock with a high JVP suggests tamponade, tension pneumothorax or pump failure - permissive hypotension higher in head injury (110) vs non head injury (90) |
3 |
|
|
Trauma primary survey SC - D |
- AVPU (GCS secondary survey) - severe hypotension ie from blood loss can cause severe brain dysfunction and fixed dilated pupils - don't assume brain injury until other causes ruled out and managed. |
|
|
|
Trauma primary survey adjuncts |
ECG - dysrhythmias, tachycardia, AF, ventricular ectopic and ST change may indicate blunt cardiac trauma. Bradycardia, aberrant conduction and premature beats may mean hypoxia and hypoperfusion. PEA may indicate tamponade, tension pneumothorax or profound hypovolaemia. Ventilatory rate and waveform capnography Pulse oximetry BP Xrays - only CXR and pelvic xray useful in initial management USS Cathaterisation to monitor UO PR exam only consider if; incubated, perineal trauma, penetrating groin injury, spinal cord injury Orogastric over nasogastric tube in incubated pt: Size 14 or 16FG preferable |
|
|
|
Secondary survey sequence |
1. Head 2. Face 3. Neck 4. Chest and shoulder girdle 5. Abdomen 6. Pelvis 7. Perineum and rectum 8. Lower limbs 9. Upper limbs 10. CNS incl GCS 11. Back 12. History 13. Tubes 14. Investigations |
|
|
|
Best chance of neuro intact survival |
1. Witnessed collapse 2. CPR started immediately 3. Rhythm is VF or pVT 4. Defib performed early |
|
|
|
What is targeted temperature management |
Maintaining constant temp 32-36 with strict avoidance of hyperthermia for those who have arrested and remain unresponsive during ROSC. Rapid infusion of ice-cold IV fluids up to 30ml/kg or ice packs are safe to lower temp by up to 1.5 degrees C. Not recommended pre-hospital. |
|
|
|
Causes of arrest in infants (0-1) |
- hypoxia - resp failure - SUDI - airway obstruction - sepsis - drowning - poisoning - neuro disease |
8 |
|
|
Causes of arrest in older children |
- trauma |
|
|
|
At what age does adult protocol 30:2 take over child 15:2? |
9 |
|
|
|
Continuous ventilation no longer recommended |
Simultaneous ventilation and compression reduces survival |
|
|
|
What rhythm might you suspect gas trapping |
PEA |
|
|
|
Drug doses in children |
-Adrenaline 10microgram/kg (0.1ml/kg of 1:10000) -Amiodarone 5mg/kg -Atropine (bradycardia caused by vagal stimulation or cholinergic drug toxicity) 20 micrograms/kg (bradycardia caused by hypoxia treat with vent and o2, severe Brady or with hypotension treat with adrenaline- not atropine) -Glucose (hypoglycemia) 0.25g/kg by IV/IO I.e 0.5ml/kg of 50% or 2.5ml/kg of 10% -Glucose (maintainence) in infants 5-8mg/kg/min |
2 |
|
|
Shock joules in children |
4J/kg |
|
|
|
Low CO2 (<10mmHg) in expired breath from a child during CPR may indicate |
. A treatable condition: pneumothorax, hypovolaemia, tamponade . Inadequate compression . Excessive ventilation |
3 |
|
|
High CO2 (>60mmHg) in expired breath implies |
Inadequate ventilation |
|
|
|
IO placement in children |
18-gauge needle or IO cannula inserted perpendicular into anterior surface of tibia 1-3cm below tibial tuberosity. All drugs followed by 5-10ml flush |
|
|
|
Alternative to Amiodarone if not available shock-resistent arrest |
Lignocaine - 1mg/kg IV/IO |
|
|
|
How to avoid dosing errors in children |
1. Rounding weight to nearest 5kg 2. Use resus chart with printed drug doses 3. Rounding doses to nearest whole milligram 4. Double check drugs |
4 |
|
|
Correction of hypovolaemia in children |
-0.9% saline 20ml/kg bolus (25% of childs blood vol) -blood products are required if 40-60ml/kg of saline failed to reverse hemorrhagic shock |
2 |
|
|
PEA or VT |
Don't need to waste time feeling for a pulse - if unresponsive and not breathing normally treat as arrest |
|
|
|
Describe the types of VF |
Coarse- usually earlier and more responsive to defib Fine - may be indistinguishable from asystole - if unsure continue CPR as it may increase the amplitude Decreasing amplitude assoc with 5-10% decrease in likelihood of successful defib with each minute of arrest Recurrent VF/VT with ROSC inbetween indication for earlier amiodarone |
4 |
|
|
Defib energy in adults |
200J or max energy |
|
|
|
Rhythms that may resemble VF |
. Polymorphic VT . AF with WPW However if either of these rhythm present and pt is in arrest then defib indicated. Very fast SVT may also cause shockable arrest. |
|
|
|
When to do a pre cordial thump |
. Monitored . Defib not immediately available . Onset of VT is witnessed NOT for VF, if defib immediately available or VT without arrest. |
3 |
|
|
Precordial thump - steps |
. Clenched fist held approx 25-30cm above sternum . Fist brought down sharply so ulnar side hits mid-sternum . Immediately afterwards begin chest compressions (don't feel for pulse) |
3 |
|
|
Tachycardia |
>120/min |
|
|
|
Bradycardia |
<60/min |
|
|
|
Evidence of low CO |
. Pallor . Sweating . Cold extremities . Impaired consciousness or agitation . Hypotension . Chest pain |
6 |
|
|
Evidence of Heart Failure |
. Pulmonary oedema . Raised JVP . Peripheral oedema |
3 |
|
|
Extreme tachycardia |
Narrow complex >200 Broad complex >150 |
2 |
|
|
Excessive bradycardia |
<40 |
|
|
|
OPA size |
Ear lobe to corner of mouth 3 and 4 for average adults |
|
|
|
Fitting an LMA |
. Size 4 whores and 5 guys . Fully deflate cuff with 30ml syringe . Lubricate the back . Hold like a pen with opening to chin . Insert along hard palate . Press down and backwards until will go no further (may need assistant to apply jaw thrust) . Inflate cuff to (size-1) x 10 (or whatever is on tube) . Connect self-inflating bag and ventilate gently (<20cm water pressure and slow) . Place waveform capnography between LMA and the bag to ensure ventilation |
9 |
|
|
Intubation assistance |
Prepare equipment and drugs Be ready to inflate cuff Apply capnography Keep track of time to avoid prolonged attempts |
4 |
|
|
Common mistakes managing an airway |
. Removing the pillow . Inadequate jaw thrust . Using an OPA the wrong size . Inadequate seal with the mask . Attaching the oxygen to the wrong place . Not enough oxygen . Focusing on airway at expense of other aspects of care . Incubating oesophagus . Failure to assess airway patency with waveform capnography . Hyperventilation |
10 |
|
|
Suction flow rate and pressure |
Flow >40L/min Pressure 300mmHg when tubing occluded |
|
|
|
NPA size |
6.5 - 8mm |
|
|
|
Capnography - normal waveform and ETCO2 |
|
|
|
|
Intubation |
|
|
|
Oesophageal intubation |
|
|
|
What will happen to ETCO2 when CO is reduced? |
Will decrease as heart not delivering CO2 to the lungs |
|
|
|
ETCO2 of what level indicates ineffective resuscitation |
<10mmHg -> push harder and faster! |
|
|
|
Loss of CO |
|
|
|
Primary action of adrenaline in shockable arrest |
Peripheral vasoconstriction to increase coronary perfusion pressure (also may improve cerebral blood flow) |
|
|
|
Adrenaline use in non-shockable arrest |
Improving coronary and cerebral blood flow through peripheral vasoconstriction. Overcome cholinergic induced profound bradycardia or asystole. If in PEA, may improve cardiac contractility. |
|
|
|
Adrenaline |
1mg IV every 4 mins. Kids - 10microgram/kg (0.1ml/kg 1:10000)
Shockable - after 2nd shock and every other loop
Non-shockable - immediately after rhythm recognition and every other loop.
Follow each dose by flush to reach central circulation. |
5 |
|
|
Amiodarone |
Shockable rhythm - after 3rd shock
Earlier if shock appears to be transiently successful.
300mg IV. Second dose of 150mg may be considered.
5mg/kg in kids. Lignocaine 1mg/kg as alternative |
5 |
|
|
Causes of arterial hypoxia |
1. Low inspired oxygen 2. Diffusion abnormalities 3. Ventilation/perfusion mismatch 4. Shunt |
4 |
|
|
Such PEEP be used to overcome hypoxia? |
100% oxygen should be given to overcome hypoxia. If someone arrests from a disease responsive to PEEP use with extreme caution as increasing intra-thoracic pressure impedes venous return and therefore CO |
|
|
|
What rhythms might hypovolaemia cause? |
PEA with progressively more abnormal complexes until asystole. Occasionally may be VF/VT due to myocardial ischaemia, especially if underlying IHD. |
|
|
|
How to rewarm at 30-32 degrees |
Passive using blankets. Active using hot air blankets, warm baths, warm packs on truncal areas. |
2 |
|
|
Rhythms in hypothermia |
Sinus Brady 》 AF 》 VF 》 asystole |
|
|
|
Rewarding techniques in arrest due to hypothrmia |
. Cardiopulmonary bypass ideal . Warmed saline lavage of peritoneal and thoracic cavities . Warmed IV/IO fluids |
3 |
|
|
What is malignant hyperthermia? |
A life-threatening generic generic sensitivity of skeletal muscles to volatile anesthetics and depolarisaing neuromuscular blocking drugs (suxamethonium) occurring during or very soon after anaesthesia |
|
|
|
How to manage malignant hyperthermia |
1. Stop triggering agents 2. Call for help (senior anaesthetist) 3. Dantrolene 2-5mg/kg repeated as necessary 4. Correct accompanying acidaemia and electrolyte imbalance |
|
|
|
Causes of hyperkalaemia |
. Excessive production - oral intake in renal failure . Tissue breakdown - rhabdomyolysis, tissue necrosis, burns, tumour loss syndrome . Ineffective elimination - aldosterone deficiency . Impair excretion by kidneys |
4 |
|
|
ECG findings in hyperkalaemia |
Mild-mod - reduced size of p waves and peaked t waves Severe - widening of QRS complex |
9 |
|
|
Management of hyperkalaemia |
. Reduce myocardial contractility: calcium chloride 10% (x3 calcium than calcium gluconate), onset less than 5 mins, duration 30-60 mins. Repeat if ECG doesn't normalise in 3-5 mins . Lower K temporarily: - insulin 10 units IV insulin with 50ml of 50% dextrose. - bicarbonate 50ml (50mmol) over 5 mins - salbutamol neb 10-20mg . Increase elimination: haemodialysis/haemofiltration. Furosemide. |
6 |
|
|
ECG finding hypokalemia |
U waves T wave flattening Arrhythmias (ventricular) |
|
|
|
Management of hypermagnesaemia |
Calcium chloride 10% 5-10ml Calcium gluconate 10% 15-30ml |
2 |
|
|
Management hypomagnesaemia |
1-2g MgSO4 as IV bolus Far more common than hypermagnesaemia. Associated with pVT incl torsades de pointes |
3 |
|
|
Needle thoracostomy steps |
. 14-16G cannula into 2nd space mid clavicular line . Advance needle until air aspirated into syringe attached to needle . Leave cannula in . Follow with chest drain |
4 |
|
|
Finger thoracostomy steps |
. Identify 4th or 5th ICS mid axillary line . Clean skin . LA in conscious patient . Scalpel incision along upper border of rib . Blunt dissection into pleural cavity . Finger inserted into pleural cavity . Follow with chest drain |
7 |
|
|
Causes of tamponade |
. Infection (TB) . Trauma . Tumour . Aortic dissection . Post cardiac surgery |
5 |
|
|
What is Beck's Triad? |
Clinical signs of tamponade . Hypotension . JVP distension . Absent or distant HS |
|
|
|
Management of tamponade |
Pericardiocentesis |
|
|
|
Antidote to beta blockers |
Glucagon Milrinone Insulin Calcium Bypass |
5 |
|
|
Antidote to benzos |
Airway and vent support Flumazanil may precipitate seizures so should generally be avoided |
2 |
|
|
Antidote to calcium channel blockers |
Calcium Glucagon Milrinone Bypass |
4 |
|
|
Antidote to carbon monoxide |
100% oxygen |
1 |
|
|
Antidote to cyanide |
Oxygen Amyl nitrate Sodium thiosulphate Sodium nitrate Hydroxycobalamin |
5 |
|
|
Antidote to digoxin |
Correct hypomagnesaemia/hypokalaemia Digoxin Fab fragments Cardiac pacing |
3 |
|
|
Antidote to ethylene glycol |
Alcohol Hemodialysis |
2 |
|
|
Antidote to iron |
Whole bowel irrigation Desferrioxamine |
2 |
|
|
Antidote to lithium |
Hemodialysis Whole bowel irrigation |
2 |
|
|
Antidote to LA |
Intralipid |
1 |
|
|
Antidote to methanol |
Alcohol Dialysis |
2 |
|
|
Antidote to opiates |
Ventilation Naloxone |
2 |
|
|
Antidote to organophosphates |
Atropine Pralidoxime Benzos |
3 |
|
|
Antidote to paracetamol |
N-acetyl cysteine |
1 |
|
|
Antidote to salicylates |
Haemodialysis |
1 |
|
|
Antidote to TCA |
NaHCO3 Intralipid |
2 |
|
|
Where should the tip of the endotracheal tube sit? |
At least 2cm above the carina |
|
|
|
How to alter oxygenation in the incubated person |
1. Altered inspired oxygen 2. Alter the PEEP up to 15cmH20 if normovolaemic. Cautious in cardiac arrest or hypovolaemia as increasing intra thoracic pressure may impede venous return and thus CO. 3. Recruitment manoeuvres 4. Inhaled pulmonary vasodilators ie nitric oxide 5. Prone positioning 6. Alternate ventilation strategies ie inverse ratio ventilation |
6 |
|
|
Normocapnia |
35-40 mmHg |
|
|
|
Hypocapnia may cause |
Cerebral vasoconstriction (Hypercapnia may cause cerebral vasodilatation) |
|
|
|
How is ventilation altered? |
1. Alter RR 2. Alter volume of each breath Ventilation = tidal vol x RR Ventilation is inversely proportional to PaCO2 (doubling ventilation halves PaCO2 and vice versa) |
4 |
|
|
Ventilation rate |
5-6ml/kg at rate of 15 breaths/min |
|
|
|
How different is ETCO2 to arterial CO2? |
Lower by 5-6mmHg in healthy individuals (more following arrest) |
|
