11, 12 & 13. Emergencies Flashcards
What is the minimum mouth opening, sternomental distance and thyromental distances we are looking for when pre-assessing?
MO over 3cm
SM over 12.5
TM over 6.5
What should we ask about in pregnant patients to allow us to evaluate what tube size they need and why?
Prone to airway oedema so ask about snoring and voice changes.
What preparation do we need to do for an obstetric GA prior to induction?
Bra off, arms out and hair bobble out.
Sodium citrate 30ml of 3m
Z bed, tilt, suction under pillow. Monitors and BP 1 minute.
IV access working and grey +/- more or lines etc. fast fluids.
3m preoxygenate and unobstructed trace
Quiet please and tell plan.
10n while awake, 30n when asleep.
What are the doses of sux and thio?
Sux = 1 - 1.5 mg/kg (actual body weight)
Thio = 5mg/kg
What is the rate of difficult airway in obstetrics vs. normal?
1:250 vs 1:2000
What are the steps in a difficult obstetric airway?
Cricoid off
Retract breasts
McCoy = flip blade
Make sure declare failed after 2nd attempt.
DAS - if using igel, remove cricoid for insertion and the pan replace.
Always use OPA I’d bagging.
Wake unless surgery would help mum e.g. resuscitation
What do we need to ensure during maintenance of obstetric anaesthesia?
1 MAC with 50% nitrous and 50% O2. Prior to KTS
Aim normocarbia (too high = baby lost concentration gradient).
Ensure twitches before give ROC
Give more analgesia once baby out
What are the rules with for obstetric extubations?
Don’t reduce volatiles until fully reversed.
Deflate cough to check for leak if difficult or oedema.
Wide awake
What so Mendelsons syndrome and what has a higher risk of damage?
Aspiration under GA
Higher risk of damage if over 25ml or pH under 2.5
What prophylaxis do we give for aspiration in obstetrics?
Elective H2/PPI oral x2, 6h apart
Emergency = IV plus sodium citrate
How long does sodium citrate work for?
Raises pH for 20m
What do we do if an obstetric patient aspirates?
Head down/ lateral and suction prior to ventilating to avoid pushing down food stuffs.
How does epidural haematoma present and how do we treat it?
Severe localised back pain usually 12-24h post insertion
Radicular pain: sensory/motor +/- cauda equina
Needs urgent MRI and decompression a.s.a.p. Under 12h but over 6h after dx has worse outcomes
What are the steps in dealing with anaphylaxis?
- Note time and ask for arrest trolley and help
- Turn O2 up to 100% and give fluid bolus
- Remove the causative agent
- IV adrenaline 50mcg = 0.5 ml of 1:10,000 (- if beta blocked give IM glucagon 1mg)
- IM = 500mcg = 0.5ml of 1:1000
- up to three doses, if no response = infusion of 5mg in 500ml dextrose, titrate to response. - Treat other symptoms:
- bronchospasm = 250mcg IV, dilute and give slowly
- 2g mg over 20 mins (50mcg/kg)
- 20mg IV ketamine
- 4mg/kg hydrocortisone (adult 200mg)
- alter I:E ratio to avoid breath stacking - If still hypotension, think about other infusions e.g. norad.
- CTG
- Serum triptase, when stable, then at 1-2h, then over 24h.
- Critical care
In what groups of patient is latex allergy more common?
Fruit allergy e.g. avocado
Spina bifida
What is a high spinal?
Above the level for respiratory/ CVS stability (T4)
What are the different spinal levels that we can test for a high spinal?
T1-4 = cardiac accelerators = bradycardia and hypotension
C6-8 = shortness of breath (intercostals), parasthesia and hand weakness
C3-5 = shoulder and diaphragm weakness/arrest
Brain stem = slurring and loss of consciousness
Is shortness of breath normal during a spinal?
Can be as we can get some intercostal weakness, but they should be able to talk, not whisper.
How can a subdural block result in a high spinal and how can we spot one?
When do they present?
The thin arrachnoid mater can burst
Two patterns:
- extensive sensory +/- horners and cranial nerves
- very restricted spread
Usually present over 20-40mins with mild hypotension and mild motor block
How do high spinals present?
Hypotension
Brady
Respiratory weakness/apnoea
Inability to phonate
Arm changes
What is a total spinal?
What is the treatment?
Come from LA brain stem depression.
O2 and airway (decreased doses if intubate), aggressive vasopressors. Need to ensure good arm movement prior to extubation.
What is the risk of DPH?
When does it present?
How is it classified?
Treatments?
1% (80% of punctures get the headache)
Usually 24-48h later
Bilateral headache (anywhere), +/- shoulders, within 7 days of procedure, increases in under 15 mins of upright and decreases within 30m of lying. Gone in under 14 days. Caused by vasodilation and meningeal traction.
Rx: hydrate, analgesia and caffeine, blood patch 15-20ml (20% need repeat)
When does LA toxicity present?
What are the early and late signs?
What is the treatment?
How does intralipid work?
20-40m post large intravascular LA
Early CVS: hypo and Brady (opposite with adrenaline)
Early CNS: tinnitus, visual changes, peri-oral tingling/numbness, metallic taste, drowsy, twitchy
Late CVS: heart block, asystole, ectopics, VF/VT
Late CNS: loc and resp depression
Supportive (+/- arrest trolley and +/- help)
Left lateral and CTG +/- delivery
Dysrhythmias as per ALS
Benzo for seizure
Intralipid for significant CVS
-1.5ml/kg over 1m and infusion of 15ml/kg/h
- another bolus at 5-10 mins if unstable and can double rate
Max dose = 12ml/kg, for 70kg = 840ml
Intralipid counteracts the inhibition of myocardial fatty acid oxidation in the mitochondria
What is the mortality from an amniotic fluid embolism?
When does it occur?
What is the triad and pathophysiology?
How does we diagnose it?
What is the treatment?
25-60% are fatal
Triad = hypoxia, CVS collapse and coagulopathy
RV outflow obstruction leads to pulmonary vasoconstriction => ARDS => RV dysfunction
If survive = LVF, anaphylaxis/SIRS reaction and DIC
DX = high suspicion and TEG
Rx: oxygenate, aggressive fluid resus, pressors, invasive, monitoring and baby out
What are the most common causes of major haemorrhage?
What is the definition? And normals?
Tone, trauma, tissue (retained) and thrombin
Normal vaginal = 300-500ml. Section = 750-1000
Definition = over 1500 or 25-30%, Hb drop of over 4 or more than three units required.
What are the different types of PPH?
Primary = under 24h
Secondary 24h - 6w.
What are the steps in obstetric major haemorrhage?
1000ml = ?TXA and document
- ?group specific release
- ? Increase fluids
1500 = controlled, if not = MH, dad out and O2 (plus help)
- extra IV access and bloods plus gas and TEG
- extra fluids/o neg
- ?more uterotonics
- if no call = document why.
2000 = start any type of blood
- Prep for GA
2500 = more blood products
- asleep by then
Remember rapid infuser and scribe.
After every 4 units give 30ml calcium gluconate
What are the order and doses of uterotonics?
- 5iu IV of syntocinon and 15 over 30m
- 500 ergo IV IM
- not in high BP or pre-eclampsia or raised ICP
- can give IV, dilute and small increments.
- give anti-emetics as definite vomiting - Haemabate (carboprost)
- 250mcg IM every 15 mins, max 2g
- document times on board
- no in asthma - Misoprostol vaginal
What are the different classes of haemorrhage and results?
Class: 1. 2. 3. 4
%. 15. 15-30. 30-40. >40
Ml. 1000. 1500. 2000. 250p
HR. <100 100. 120. 140
BP. N. N. Down
RR. 20. 30. 40. >40
What are the goals in major haemorrhage transfusion?
How do we manage coagulopathy’s?
Volume
Normothermia
No coagulopathy
(Coag, cold, acid)
Platelets over 50 = platelets
Fibrinogen over 1 = cryo
PT under 18 and APPT under 45 = FFP (12-15ml/kg)
What is in the MH packs?
Pack A = 6 XM and 4 FFP if requested for obs. +/- platelets.
Pack B = 4 XM, 4FFP, 1 platelets and 2 cryo
How do we manage resus in arrest of pregnant people?
Manual displacement or 15 to 30deg from 20w.
30:2 or continuous.
Shockable: after 3 then every 2
1mg adrenaline (10mls 1:10,000)
300mg amiodarone after 3
Can give 150 after 5
Same pad position and voltage (150j)
Cannula above diaphragm due to ACC
ETT for normal CO2 4.5 - 5, may need increased minute volume
Perimortem c-section, start by 4min, out by 5.
- Vertical incision.
- over 20w
How do we manage magnesium sulphate overdose?
What are the signs and symptoms?
10ml, 10% calcium gluconate and ALS
Can be caused by AKI as renally excreted
Causes: uterine relaxation, hypotension, reduced RR, reduced muscle power, reduced reflexes, prolonged PR and wide QRS
How do we manage severe PET/seizure?
4g slow IV mg
- over 10m, use pump
Then 1g/h until delivered
(4.1mmol per gram)
What are the most common organisms in obstetric sepsis?
When should we consider this?
GAS or ecoli
Consider in: unexplained pain, sob, multiple non-specific issues
Always check ENT
What is the resus fluid volume in sepsis?
30ml/kg if hypotension or lactate over 4
