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OMS Board Review > 25. Medical Emergencies > Flashcards

25. Medical Emergencies Flashcards

1
Q

Which two dysrhythmias can be treated with an AED?

A

Pulseless ventricular tachycardia
Ventricular fibrillation

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2
Q

Drugs that can be given via ETT

A

NAVEL acronym
In general, 2-2.5x IV dose

  • Naloxone
  • Atropine
  • Vasopressin
  • Epinephrine
  • Lidocaine
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3
Q

What is hypertensive urgency?

A

BP >180/120 mmHg without organ damage. Treated with oral/IV medications.

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4
Q

What is hypertensive emergency?

A

BP >180/120mmHg with end organ damage (chest pain, changes in vision, confusion, nausea/vomiting).

Requires hospitalization and rapid decrease in BP (MAP reduction 25% first hour and to target BP over the next 6 hours) to limit organ damage with IV medications.

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5
Q

Esmolol

A

Ultra short acting beta-1 selective blocker.

Broken down via RBC esterase in cytosol (not dependent on renal or hepatic clearance)

5-10mg over 1 minute every 3 minutes with a max dosage of 300 mg.

Onset within 1 minute, duration 10-20 minutes.

Excellent for HTN with tachycardia.

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6
Q

Labetalol

A

Non-selective beta-blocker and selective alpha-1 blocker

Good for HTN with tachycardia.

5-10mg IV every 10 minutes with a maximum dosage of 300mg.

Onset within 5 minutes with duration 3-6 hours.

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7
Q

Hydralazine

A

Direct arterial vasodilator
Causes reflex sympathetic activation and tachycardia

Good for HTN with bradycardia (avoid in patients at risk for myocardial ischemia)

2.5-5mg IV over 2 minutes (redose every 10 minutes) with maximum dosage of 25mg.

Onset 5 minutes with duration of action of 2 hours

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8
Q

Nitroglycerin

A

Venodilator at low doses, which reduces preload and cardiac output

Arterial vessel dilator at high doses, which decreases afterload allowing blood entry to the aorta.

5-10mcg/min with increase by 5-10 mcg/min every 5 minutes IV

Onset 2-5 minutes with duration 10-20 minutes.

Must ask if patient has used erectile dysfunction medications within 48 hours as it can lead to hypotension unresponsive to vasopressors.

May use 0.5mg sublingual every 5 minutes for total of three doses

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9
Q

Ultra-short acting beta-1 selective blocker

A

Esmolol

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10
Q

Non-selective beta-blocker and selective alpha-1 blocker

A

Labetalol

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11
Q

Direct arterial vasodilator

A

Hydralazine

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12
Q

Venodilator at low doses, arterial vessel dilator at high doses

A

Nitroglycerine

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13
Q

Dose of esmolol

A

5-10mg over 1 minute every 3 minutes with maximum dose of 300 mg

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14
Q

Dose of labetalol

A

5-10mg IV every 10 minutes with a maximum dose of 300mg

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15
Q

Dose of hydralazine

A

2.5-5mg IV over 2 minutes (redose every 10 minutes) with a maximum dose of 25mg

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16
Q

Dose of nitroglycerin

A

5-10 mcg/min with increase by 5-10 mcg/min every 5 minutes IV

May use 0.4 mg sublingual every 5 minutes for total of 3 doses.

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17
Q

Hypotension definition

A

Generally BP <90/60 but no widely accepted definition intraoperatively. A drop of systolic arterial blood pressure >25% from baseline.

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18
Q

Immediate management of hypotension intraoperatively

A

Supine, elevate legs
100% O2
250-500cc NS or LR infusion (caution with CHF or severe renal disease)
Auscultate heart and lungs
Recheck BP often
Determine source (allergic reaction, hypovolemia, anesthesia depth, pulmonary embolism, pneumothorax, etc.)

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19
Q

Atropine

A

Cholinergic antagonist
Useful for hypotension with bradycardia

0.5mg increments every 2-3 minutes to a max of 3mg

0.5 mg IM or sublingual every 5 minutes to max 3mg

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20
Q

Ephedrine

A

Alpha and beta agonist
Hypotension with normal heart rate

2.5-5mg IV every 5-10 minutes to a 50mg max dose

25mg IM or sublingual q 5-10 minutes to a 50mg max dose

Onset 1 minute (peak 15 minutes) with duration 1 hour

Available as 50mg/mL (need to dilute 9cc of sterile saline with 1 mL solution to obtain a concentration of 5mg/mL)

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21
Q

Phenylephrine

A

Selective alpha agonist
Used to treat hypotension with tachycardia or if an increase in HR should be avoided

Available as 10mg/mL (need a 1% solution, dilute 1mL in 9mL of saline, then take 1cc and further dilute in 9mL saline allowing for 100mcg/mL)

100mcg/mL q 5 minutes

Onset 2-3 minutes

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22
Q

Cholinergic antagonist

A

Atropine

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23
Q

Alpha and beta agonist

A

Ephedrine

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24
Q

Selective alpha agonist

A

Phenylephrine

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25
Q

How do you prepare phenylephrine (dilution?)

A

Available as 10mg/mL

Need a 1% solution
Dilute 1mL in 9mL of saline
Then take 1cc and further dilute in 9mL saline
Allows for 100mcg/mL

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26
Q

The most common correctable causes of arrhythmias (Hs and Ts)

A

Hypoxia
H+ (acidosis)
Hyper/hypokalemia
Hypothermia
Hypovolemia

Tension pneumothorax
Tamponade (pericardial)
Toxins (overdose, digoxin, Ca2+ blockers, beta-blockers)
Thrombosis (PE or MI)

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27
Q

What is angina?

A

Chest pain due to inadequate blood flow to the myocardium as a result of demand-supply imbalance within the coronary arteries

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28
Q

Chest pain DDx

A

Angina
Esophageal disorders
Esophageal motility disorders
Biliary colic
Costrochondritis
Pericarditis
Pulmonary embolism

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29
Q

Classifications of angina

A

Stable angina (chronic stable ischemic heart disease follows precipitating event and is relieved by rest or use of sublingual nitroglycerin)

Unstable angina (occurs at rest, usually prolonged >20 minutes) - considered an acute coronary syndrome secondary to partially occlusive coronary thrombus

Prinzmetal (occurs at rest, cyclicical, caused by coronary artery vasospasm).

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30
Q

Patient has angina. How do you manage?

A
  • Pulse ox, EKG, BP monitors
  • O2 4L/min NC or 6L/min nasal hood
  • 0.4mg SL nitroglycerine or spray q5 mins (ensure systolic BP >90 mm Hg and no ED agents within 24 hours for sildenafil (Viagra) or 48 hours for tadalafil (Cialis)
  • EMS called if 3 doses of nitroglycerin over 15-20 minutes fails to relieve symptoms or if after one dose for unstable angina
  • Non-enteric coated ASA (325mg or 4 tabs 81mg) crushed or chewed
  • Morphine 2-4mg IV initial, 2-8mg IV subsequent if unresponsive to nitroglycerin
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31
Q

What to look for on EKG for patient with angina

A
  • ST elevation of 2 or more leads of 2mm+ in leads V2, V3 and 1mm+ in all other leads
  • Hyperacute T waves (earliest EKG finding)
  • ST segment depression (horizontal or down sloping)
  • Q waves or T wave inversions should alert for transfer to acute care setting.
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32
Q

What is myocardial infarction

A

Myocardial necrosis that occurs secondary to an occlusive thrombus. Must have two of the following three criteria (WHO)
1. Angina consistent with ischemia
2. Elevation of cardiac markers in blood (Troponin-I, CK-MB, myoglobin)
3. Characteristic changes on ECG tracings taken serially

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33
Q

Types of MI

A
  • Non-ST segment elevated myocardial infarction (NSTEMI): results in a subendocardial infarct
  • ST segment elevated myocardial infarction (STEMI): results in a transmural infarct
34
Q

When is fibrinolysis an option for MI?

A

Fibrinolysis: option for patients with STEMI and symptoms within 12 hours and if percutaneous coronary intervention is not available within 90 minutes of arrival to ED.
(1) rTPA
(2) streptokinase (activates plasminogen to plasma.

Contraindicated if systolic BP >185 or diastolic >110, right vs. left BP differential >15, stroke within 3 months, closed head trauma within 3 months, history of intracranial hemorrhage, blood thinners, pregnancy, clotting issues,

35
Q

When should PCI be performed for MI?

A

PCI: percutaneous coronary intervention - a procedure to open narrow coronary arteries via catheterization of a peripheral artery leading to deployment of a stent or balloon.

Superior to fibrinolytic therapy if greater than 3 hours from onset. Ideal door to balloon inflation time goal <90 mins.

36
Q

What are troponins?

A

Troponins are cardiac-specific proteins not normally present in the serum of healthy individuals (troponin I and troponin T)
- Presence of either troponin levels are equally diagnostic and levels rise 3 hours after onset, remain elevated for 7-14 days after.

37
Q

What is the best cardiac marker to test for early reinfarction?

A

Creatine Kinase-Myocardial Band (MB)
- Found mainly in the heart muscle
- Best marker to test for early reinfarction
- Starts to rise 3 hours after onset, peaks at 24 hours, and normalizes within 48-72 hours.
- Facilitation of MI diagnosis by calculating CK index (Index >2.5 suggests cardiac muscle damage)

38
Q

What are premature ventricular complexes?

A

PVCs are ectopic impulses originating in the ventricular myocardium.

Widened QRS without a preceding P wave.

  • Hypoxemia, catecholamine excess (pain, anxiety, caffeine, cocaine, amphetamines), MI, valvular heart disease, electrolyte imbalances, or digitalis toxicity.
39
Q

When should PVC be treated?

A

6 or more PVCs/min
Polymorphic
Runs of >3
R-on-T phenomenon
Increased risk of developing life-threatening ventricular dysrhythmia

40
Q

How are PVCs treated if indicated?

A

Beta-blockers such as esmolol (500mcg/kg IV) or metoprolol (5-10mg IV q15 mins).

Antidysrhythmics are indicated if VT develops

41
Q

What is ventricular tachycardia?

A

VT is a rapid heartbeat that originates in one of the ventricles of the heart that occurs when three or more consecutive beats occur at a HR of more than 120 (usually between 150 and 200).

42
Q

What is sustained vs. non-sustained VT?

A

Sustained is >30 seconds

43
Q

What is torsades de pointes?

A

POlymorphic VT when multiple ectopic foci or there is presence of a re-entry circuit

44
Q

How do you differentiate monomorphic VT from SVT?

A
  • SVT more likely if: (1) QRS morphology closely resembles ECG in sinus rhythm, (2) dysrhythmia responds to vagal maneuvers
  • VT more likely if: (1) no relationship P wave/QRS complexes, (2) QRS in chest leads all similar appearance with dominant positive or negative deflection.
45
Q

Treatment of VT

A

Immediate CPR with early defibrillation (within 3-5 mins)

46
Q

What is ventricular fibrillation?

A

VF is uncoordinated fluttering of ventricles leading to cessation of cardiac output

47
Q

What is anaphylaxis?

A

Life-threatening condition with cardiovascular collapse, interstitial edema, and bronchospasm.

48
Q

How is mild allergy treated?

A

Diphenhydramine 50mg IV/PO or 100mg IM

Histamine may circulate for 3 days or more, so oral diphenhydramine should be given Q4H for the first 2 days. Warn patient of sedative effects.

49
Q

How is anaphylaxis treated?

A

Secure and maintain airway. ACLS protocols.

FLUIDS: 1L bolus LR for adults or 20mL/kg LR or NS in children

EPINEPHRINE:
-IM 1:1000 0.15mg if 10-25 kg or 0.3mg >25 kg in vastus lateralis or deltoid muscles. Repeat q5-15 mins based on response.
-IV 10mcg to 1mg bolus q2mins in adults, or 1-10mcg/kg bolus q1-2 mins for children.

B2 AGONIST: inhaler for bronchospasm such as albuterol.

ANTIHISTAMINES: Histamine 1 blocker (diphenhydramine 0.5-1mg/kg IV for children or 50mg for adults. Children 5-12 yrs 25mg IV)
Histamine 2 blocker (famotidine dosage for adults is 20mg IV, or children 0.5mg/kg IV)

STEROIDS: hydrocortisone 1-2.5mg/kg IV or 100mg IV over 1 minute, methylprednisolone 1mg or dexamethasone 4-12mg IV slowly over 1 minute.

Admit or transfer for further monitoring.

50
Q

What is malignant hyperthermia?

A

MH is a hypermetabolic state that occurs on exposure to volatile anesthetics agents (except nitrous oxide) and succinylcholine.
- Due to a genetic mutation in the ryanodine receptor, found on the sarcoplasmic reticulum of skeletal muscle, which lowers the threshold of calcium release channel activation.
- Elevated calcium levels lead to sustained muscle contraction.

51
Q

Early signs of MH

A

Sinus tachycardia, hypercarbia with no improvement of compensatory increase in minute ventilation, and masseter spasm

52
Q

Later signs of MH

A

Dysrhythmias, peaked T waves due to hyperkalemia, increase in core temperature, dark blood in surgical site, and whole-body spasm

53
Q

How is MH tested?

A

Caffeine-halothane contracture test and RYR1 gene testing

54
Q

How is MH managed

A
  • Stop procedure, discontinue volatile agents, call for assistance (911)
  • Call MH hotline early (1-800-MHHYPER)
  • Hyperventilate 100% O2
  • Dantrolene 2.5mg/kg IV bolus q 5-10 mins up to 10mg/kg (prepared with 20mg dantrolene bottle mixed with 60mL sterile water and 3g mannitol.
  • IV fluids to maintain urine output
  • Surface ice packs, intracavity lavage of stomach and bladder with cold saline (cool core to 38C)
  • Correct metabolic acidosis with sodium bicarbonate 1-2 mEq/kg IV
  • Hyperkalemia treated with calcium chloride 5-10mg/kg IV or regular insulin 0.15 U/kg in 1mL/kg of 50% dextrose
  • Frequent blood gases Q15mins until abnormality is stopped.
  • Treat cardiac dysrhythmias as needed
  • Observe in ICU, monitor for renal failure, recurrence, myoglobinuria, and DIC
55
Q

What is laryngospasm

A

Spasm of the glottis muscles including false and true vocal cords
- More common during light sedation than deeper planes.
- Classified as complete or incomplete.

56
Q

Treatment of laryngospasm

A

Stop surgery, suction airway, pack off surgical site.
- 100% O2 with full positive pressure ventilation (consider deepening level of sedation).
- May attempt to depress chest to force air to elicit a patent airway.
- Consider succinylcholine 10-2mg (subparalyzing dose) IV if partial obstruction. Rocuronium 0.6-1.2mg/kg IV if history or suspicion of MH
- 1-2mg/kg succinylcholine (intubating dose) should be administered and ETT placed if complete spasm. Consider administration of atropine 0.02mg/kg to prevent bradycardia.
- Concern for post obstructive pulmonary edema (can occur hours later). Consider hospital admission for monitoring.

57
Q

What is bronchospasm?

A

Lower airway obstruction due to contraction and spasm of bronchial smooth muscle.
- Wheezing, both inspiratory and expiratory, fixed thoracic cage in an inspiratory position, and cyanosis.

58
Q

Treatment of bronchospasm

A
  • Stop surgery, suction airway, pack of surgical site
  • Administer 100% O2 with full positive pressure ventilation
  • B2 agonist (albuterol)
  • EPINEPHRINE IM 1:1000 0.15mg if 10-25 kg or 0.3mg >25 kg in vastus lateralis or deltoid muscles. Repeat q5-15 mins based on response.
  • EPINEPHRINE IV 10mcg to 1mg bolus q2 mins in adults or 1-10 mcg/kg bolus q1-2 minutes for children
  • Diphenhydramine 25-50 mg IV for histamine control
  • 1-2mg/kg succinylcholine (intubating dose) for facilitation of ETT placement. Consider administration of atropine 0.02 mg/kg to prevent bradycardia.
59
Q

Treatment of intraoperative emesis

A

Turn patient to right side and in Trendelenburg position to spare left lung.

Suction oral cavity

100% O2, auscultate lungs for wheezing and rhonchi

If patient cannot maintain O2 saturation, transfer to ED

Consider monitoring in hospital setting for serial CXR and blood gas analysis as aspiration pneumonitis can present hours later.

60
Q

Intra-arterial injection management

A

Leave catheter in place.
10cc 1% lidocaine or procaine as vasodilation may decrease arteriospasm
Consider transfer to hospital for vascular surgery consultation

61
Q

Treatment of hypoglycemia

A

Glucose measurement
IV access
Supplemental O2
EKG and BP monitoring
- If able to swallow, give 15g of simple carbohydrate (6 oz regular soda or 1 tbsp honey)
- If unable to swallow, IV access, D50W, 1 amp. Unpredictable rise in glucose levels 40 to 350 mg/dL
- Children should be given D25W, 2-5mL/kg. Due to hypertonicity of solution, small veins may sclerose. Response to IV dextrose is within 5 minutes but peaks at 30 minutes.
- If no IV access, glucagon SC or IM 1mg for adults or 0.5mg for children (response within 10 minutes, peaks at 30 minutes, duration 1-2 hours)

62
Q

ASA classifications

A

I. Excellent; no systemic disease; excludes persons at extremes of age. No underlying disease. No limitations on activities. Minimal risk of adverse effects.

II. Disease of one body system; well-controlled underlying disease; no limitations on activities; minimal risk of adverse effects.

III. Disease of more than one body system or one major system; controlled underlying disease; limitation on activity but not incapacitated; no immediate danger.

IV. Poor with at least one severe disease; poorly controlled or end stage disease; incapacitated; possible risk of adverse effects.

V. Very poor, moribund; poorly controlled or end stage disease; incapacitated; imminent risk of adverse effects

63
Q

An SpO2 of 90% correlates to a PaO2 of ____mmHg

A

60mmHg
Values below this correspond to the steep portion of the oxygen-hemoglobin dissociation curve

64
Q

Most sensitive leads in detecting myocardial hypoxia

A

Leads II and V5

65
Q

Benzodiazepine reversal

A

Flumazenil (Romazicon) reverses sedative effects of benzodiazepines. It is a competitive antagonist to benzodiazepines at the central benzodiazepine receptor (alpha subunits or the GABA receptor).

0.2mg IV (0.01-0.02mg/kg in small children) Q 1 minute up to five doses (max dose 1mg) until desired reversal of sedation.

May be repeated every 20 minutes for resedation.

66
Q

Opioid reversal

A

Naloxone (Narcan) is an opioid antagonist that reverses the sedative, respiratory depressant, and analgesic effects of opiates.

Low doses are recommended (to prevent adverse effects of reversal) at 0.04 mg IV (or 0.001mg/kg) Q 2-3 minutes until reversal is accomplished (a higher dosing schedule is used in narcotic overdose).

67
Q

Differences in the pediatric airway

A

Larger tongue, lymphoid hypertrophy, more rostrally positioned larynx, long and floppy epiglottis, narrowest at cricoid cartilage, more compliant tracheal walls, more caudal anterior cord attachment, underdeveloped accessory muscles.

68
Q

Phases of capnography

A
  • Phase I is beginning of exhalation
  • Phase II (ascending phase) is increase in CO2 concentration in the breath stream as the CO2 reaches the upper airway.
  • Phase III (alveolar plateau) is the CO2 concentration reaching uniform level in entire breath stream (alveolus to nose) and is the point of maximum CO2 concentration (the value displayed on the monitor)
  • Phase IV is the inspiratory cycle, in which the CO2 concentration drops to zero.
69
Q

Earliest signs of MH

A

Unexplained tachycardia
Elevation in end-tidal CO2

70
Q

Inheritance of MH

A

Autosomal dominant inherited disorder (however many patients present with MH without any prior documented family history)

71
Q

What is malignant hyperthermia?

A

MH is a life-threatening pharmacogenetic hypermetabolic state

72
Q

What labs do you order after diagnosis of MH?

A

Serum electrolytes
LFTs
Urinalysis
ABG

To aid in correction and diagnosis of electrolyte and acid-base disturbances.

73
Q

Laboratory findings in MH

A
  • Acidemia (elevated PCO2 and metabolic acidosis)
  • Hyperkalemia (secondary to acidosis)
  • Hypercalcemia (secondary to reduced uptake of calcium from the sarcoplasmic reticulum of skeletal muscles)
  • Elevated serum transaminases and creatinine kinase (CK) and subsequent rhabdomyolysis, causing myoglobinuria (secondary to hypermetabolic skeletal muscle activity)
74
Q

Treatment MH

A
  1. Activate EMS
  2. Discontinue surgery
  3. Discontinue triggering agents
  4. Hyperventilate 100% O2 3-4x normal minute ventilation
  5. Dantrolene sodium 2.5mg/kg IV Q5-10mins (reconstituted in sterile water)
  6. Obtain ABGs, treat hyperkalemia (glucose, insulin, calcium) and acidosis (bicarbonate 1-2mEq/kg)
  7. Cooling measures for hyperthermia (cold IV fluids), external ice packs to groin and axilla, gastric lavage with cold solutoins.
  8. Call MH hotline
75
Q

Age “limit” for cricothyroidotomy

A

Tracheostomy is used for patients younger than 10-12 years (small size of cricothyroid membrane - 3mm - and poorly defined anatomic landmarks make performing a cricothyroidotomy extremely difficult in children). Increased risk for laryngeal or vocal cord injury.

76
Q

How do you perform a needle cricothyroidotomy?

How long can adequate oxygenation be maintained?

A

Extend neck, palpate cricothyroid membrane, direct puncture (thick neck may require small incision).

3cc syringe attached to 14-gauge angiocath inserted through cricothyroid membrane at a 45 degree angle caudally. Negative pressure while needle advanced to confirm entry into tracheal lumen.

Needle removed, leaving angiocatheter in trachea. Various “kits” for ventilation. Attach O2 to 3cc syringe, can cut small hole in tubing near attachment to syringe and occlude 1 second, leave open 4 seconds to allow for some passive exhalation.

Adequate oxygenation maintained 30-45 minutes; hypercarbia results from inadequate ventilation.

77
Q

How do you perform surgical cricothyroidotomy?

A
  • Stabilize laryngeal cartilage
  • Vertical skin incision over cricothyroid membrane (skin, superficial fat layer to cricothyroid membrane, whish is also vertically incised with the blade)
  • Insert scalpel handle and rotate 90 degrees for access into tracheal lumen
  • Lumen dilated with finger dissection
  • Small cuffed ET tube inserted.
78
Q

Anaphylaxis signs/symptoms

A

Hypotension, tachycardia, tachypnea

Syncope, dizziness, hypotension
Wheezing, congestion, stridor, SOB, cough
Nausea, vomiting, diarrhea, abdominal pain
Urticaria, flushing, swollen lips, tongue, uvula, periorbital edema, conjunctival swelling.

79
Q

Management of anaphylaxis

A
  1. Remove exposure to the trigger
  2. Assess circulation, airway, breathing, mental status, skin, and body weight
  3. Call for help
  4. Epinephrine IM mid-anterolateral aspect of thigh, 0.01mg/kg of 1:1000 (1mg/mL) solution, max 0.5mg (adult) or 0.3mg (child). Record time and repeat in 5-15 mins if needed. Most patients respond to 1-2 doses.
  5. Place patient on back, elevate lower extremities
  6. High-flow supplemental oxygen 6-8L/min by facemask
  7. Establish IV access with wide-bore cannulae (14-16 gauge). Give 1-2L 0.9% saline rapidly (5-10mL/kg in the first 5-10 mins to an adult, 10mL/kg to a child)
  8. When indicated, perform CPR
  9. At regular intervals, measure BP, cardiac rate and function, respiratory status, and oxygenation

Note on epi: 1:1000 epi is 1mg/mL

80
Q

Therapeutic effects of epinephrine

A

Alpha 1 adrenergic agonist: increased vasoconstriction, increased peripheral vascular resistance, decreased mucosal edema (in the upper airway)

Beta 1 adrenergic agonist: increased inotropy and chronotropy

Beta 2 adrenergic agonist: increased bronchodilation and decreased release of mediators from mast cells and basophils

81
Q

Patients with severe upper airway edema, bronchospasm, or significant hypotension or who do not respond to IM injection (may not be perfusing muscle tissue) and fluid resuscitation should receive _____

A

0.5 to 1mL of 1:10,000 epinephrine IV at 5-10 minute intervals.

1:10,000 epinephrine is 0.1mg/mL = 100mcg/mL
So 50-100 mcg epinephrine

82
Q

Other adjunctive treatment of anaphylaxis (beyond ACLS, epinephrine, fluids, etc.)

A
  1. Nebulized albuterol (B2 agonist)
  2. Antihistamines (diphenhydramine 25-50mg IV Q4-6h AND cimetidine 300mg IV Q8-12h)
  3. Corticosteroids (methylprednisolone 1-2mg/kg/day) - benefit not realized for 6-12 hours but can be helpful in prevention of biphasic reactions.

OMS Board Review (29 decks)

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