4. Resuscitation & Transfer Flashcards
- You attend a cardiac arrest call to a medical ward. You arrive to find
ward staff administering basic life support to an elderly gentleman with
a tracheostomy in situ. Cardiac arrest is confirmed. You are unable to
ventilate via the mouth or via tracheostomy. You cannot pass a suction
catheter via the tracheostomy. Your next action is:
A. Attempt oral intubation
B. Insert laryngeal mask
C. Remove tracheostomy
D. Place oxygen over both mouth and tracheostomy
E. Attempt stoma intubation
- C
It is unclear from the immediate history whether the patient has had a previous laryngectomy or
not.
There is a complete airway obstruction on the basis of inability to ventilate via either route.
The inability to pass a suction catheter down the tracheostomy implicates it as the immediate
candidate for source of obstruction.
It is likely the blocked tracheostomy is obstructing the airway and should therefore be removed first, prior to reassessing.
Ventilation via LMA or oral/ stoma intubation would be complicated by the original tracheostomy remaining in situ.
Placing oxygen
on a completely obstructed airway will not help. It would be useful to find out as soon as possible
whether the patient has had a previous laryngectomy and how mature the tracheostomy site is.
- A healthy volunteer is breathing 80% oxygen for 10 min at sea level.
What is the best estimation of partial pressure of oxygen in their alveoli assuming normal diet?
A. 90 kPa
B. 88 kPa
C. 74 kPa
D. 70 kPa
E. 61 kPa
D2. C
The alveolar gas equation can be used to estimate alveolar oxygen. It is commonly stated as
PAO2 = PiO2 – PACO2/ RQ. Where PAO2 = alveolar oxygen tension, PiO2 = inspired oxygen tension,
PACO2 = alveolar CO2 tension, RQ = respiratory quotient. Assuming mixed normal diet, RQ is
usually estimated at 0.8. PAO2 = 80 – (5/ 0.8) = 74 approximately.
3. Which of the following states produce the greatest rightward shift in the oxyhaemoglobin dissociation curve? A. Methaemoglobinaemia B. Carbon monoxide poisoning C. Hyperthermia D. Sickle cell anaemia E. Massive blood transfusion
- C
The question is asking in what states does oxygen become more available for tissues.
Hyperthermia decreases the oxygen affinity of haemoglobin and therefore makes more oxygen available for tissues. Transfused blood has reduced 2,3 diphosphoglycerate and is less able to deliver oxygen to
tissues. Carbon monoxide has 300 times greater affinity for haemoglobin than oxygen, shifting the
curve to the left. Similarly, Methaemoglobin (with iron in its oxidized form) is unable to bind with
oxygen. Sickle cell is a haemoglobinopathy with less ability to deliver oxygen than HbA.
- You anaesthetize a patient for elective DC cardioversion of atrial fibrillation. Which of the following has the least influence on transthoracic electrical impedance?
A. Obesity B. Emphysema C. Paddle position D. Repeated shocks E. Electrode surface area
- C
Impedance increases with obesity and emphysema. In repeat shocks, impedance reduces slightly
(9%).
Impedance reduces with increased electrode size although at the expense of current density.
Two paddle positions are commonly described: anteroposterior and anterolateral paddle positions
are similar with comparable success rates.
- You anaesthetize a 7- year- old boy for emergency exploration of scrotum. You perform rapid sequence induction with thiopentone and suxamethonium, followed by a single dose of rocuronium.
Anaesthesia is maintained with oxygen, air, and sevoflurane. You give 3 mg of morphine at the time of incision. After 30 min the groins appear red and warm and you notice blotches developing on the patient’s chest and abdomen.
You diagnose an allergic reaction. The most likely cause is:
A. Suxamethonium
B. Rocuronium
C. Morphine
D. Betadine prep
E. Latex allergy
- E
Despite the vogue for latex free environments, surgical gloves continue to be a source of latex as
non- latex gloves are subjectively deemed inferior for precision work. Latex allergy typically occurs
20– 40 min into the operation due to direct contact with latex in gloved hands or a reaction to
latex particles in the air.
Allergy to intravenous drugs used in this case would usually present hyper acutely following their injection. Allergy to betadine (iodine) is less common than latex. Late onset
skin irritation may be seen more commonly.
- A 54- year- old man has an out of hospital cardiac arrest. There was no bystander cardiopulmonary resuscitation (CPR) performed.
He then had 20 min of CPR as per advanced life support (ALS) guidelines until spontaneous return of circulation. He was intubated and ventilated and
has been cooled in the intensive care unit (ICU). Which would provide the most accurate predictor of poor neurological recovery?
A. Bilateral loss of somatosensory evoked potential responses
B. Seizure activity on electroencephalogram (EEG)
C. Fixed pupils at 24 hours
D. Glasgow Coma Scale E1, M2, V1 at 24 hours
E. Loss of grey– white differentiation on computed tomography (CT) scan at 48 hours
A
Accurate neurological prognostication after out of hospital cardiac arrest (OOHCA) is difficult.
Although somatosensory evoked potentials are not widely available in the UK, they would provide
the most accurate predictor of poor neurological recovery.
If they are demonstrated to be bilaterally absent.
One to 3 days after arrest there will be a poor neurological outcome with a false positive rate of
0%.
An EEG may unmask subclinical seizures and allow their treatment before neurological status
can be checked. Certain other EEG characteristics can be associated with a poor outcome— burst
suppression or an isoelectric EEG, but again EEG is not always available. Signs such as fixed pupils
and a motor score of 1 on the GCS require a prolonged period of at least 72 hours to be reliable.
Loss of differentiation between white and grey matter on a CT scan historically has been thought
of as a bad prognostic sign but studies have shown it is not a useful indicator of long- term poor
neurological outcome at an early stage.
- You have been called to the Emergency Department for a standby
call. A 7- year- old girl has become acutely unwell after ingesting some
peanuts. When she arrives her heart rate is 36 bpm and her blood
pressure is 8/ 32 mmHg. She has a widespread urticarial rash with
swelling of her lips and tongue. You put 5 L of O2 on via a trauma mask
and call for help. The best immediate action is:
A. Cannulate and give a 10 mL/ kg crystalloid bolus
B. Intubate with a size 5 endotracheal tube
C. Give intramuscular adrenaline (epinephrine) 10 μg/ kg bolus
D. Cannulate and give hydrocortisone 00 mg
E. Secure intra- osseous access and give a μg/ kg bolus adrenaline (epinephrine)
- C
Following the APLS algorithm for emergency treatment of anaphylaxis the first steps are to call for
help, remove allergen, administer oxygen via a face mask and administer intramuscular adrenaline
(epinephrine) even before assessing airway.
The other options are all appropriate management but
only after these first four steps have been carried out.
- A 40- year- old man is brought into the Emergency Department in pulseless electrical activity (PEA) arrest. He was found on the pavement after a night out.
There is no evidence of major injury. CPR was
commenced immediately and has been on- going for 15 min.
He is now intubated and ventilated and his core temperature is 28°C. Which is
the most appropriate statement regarding his ongoing resuscitation management?
A. Passive warming should be sufficient in raising his temperature
B. Active external rewarming is sufficient
C. Fluid restriction is necessary during rewarming
D. Adrenaline (epinephrine) should be withheld until his temperature is 30°C
E. Adult life support algorithms should be followed regardless of temperature
- D
In these circumstances rewarming would be best achieved by active internal and external warming
as this patient does not have a perfusing rhythm. During rearming vasodilatation will occur so
patients will require fluid resuscitation rather than fluid restriction. If the patient’s temperature
is severely hypothermic adrenaline (epinephrine) should be withheld until the patient has been
warmed to above 30°C, then double the interval between adrenaline (epinephrine) doses until
the temperature is above 35°C. This is because drug metabolism is slowed and potentially toxic
concentrations can be reached with any drug given repeatedly.
- A 64- year- old patient complains of central chest pain and nausea. He had a right hemicolectomy two days ago. The pain resolves with oxygen
and sublingual glyceryl trinitrate (GTN) spray. His electrocardiogram (ECG) shows flipped T waves in leads V2– V6. His troponin T level 2
hours later is 0.9 mmol/ L. His past medical history includes asthma.
Which of the following would be the best pharmacological agent to
reduce myocardial oxygen demand?
A. Propanolol
B. Aspirin
C. Diltiazem
D. Nifedipine
E. Atenolol
- C
The immediate management goals in NSTEMI are to prevent new thrombus formation and
reduce myocardial oxygen demand. Prevention of new thrombus formation is achieved using
platelet inhibition (e.g. aspirin and clopidogrel etc.), and anticoagulation with fondaparinux or sc
low molecular weight heparin. To reduce myocardial oxygen demand the first- line agent is a betablocker
unless contra- indicated. Asthma is a contra- indication to beta- blockers so diltiazem should
be used but avoid dihydropyridine calcium channel blocker like nifedipine. Also, if there are signs of
left ventricular impairment early introduction of an angiotensin- converting enzyme inhibitor should
be considered.
- A 26- year- old man has been injured in an explosion. You are the doctor
with the pre hospital retrieval team who attends. On examination the patient has suffered traumatic amputation of his right leg above the knee. He is alert and talking and you provide oxygen 100% using a
trauma mask. What is the next priority in managing his circulation?
A. Cannulate and give 20 mL/ kg crystalloid bolus
B. Cannulate and take blood for haemoglobin estimation and cross match
C. Apply a tourniquet to his thigh
D. Apply a pressure dressing to the stump
E. Cannulate and transfuse O negative blood
- C
The European Guidelines on Advanced Management of Bleeding Care in Trauma recommend prioritizing prevention of further bleeding by application of tourniquet to an open extremity which is bleeding in the pre surgical setting.
Pressure point control is inadequate
to control bleeding as collateral circulation is quickly observed. Subsequent management will include
estimation of haemoglobin and coagulation status and fluid replacement
11 A 29- year- old lady presents to the Emergency Department following a sudden collapse at home. She has an uneventful spontaneous vaginal delivery three weeks ago and has been well since. She has a body mass
index of 41 and is a smoker. On examination she has a heart rate of 127 bpm, a blood pressure of 65/ 39 mmHg and oxygen saturations of 87% on
15 L via a trauma mask. She is too unstable to be moved for scanning.
What would be the best investigation to help diagnose a pulmonary thromboembolism (PTE)? A. D- dimer level B. Chest X- ray C. 12 lead ECG D. Bedside echocardiography E. Arterial blood gas
- D
The radiological investigation of choice with a suspected PTE is computerized tomographic
pulmonary angiography (CTPA). However, this patient’s signs and symptoms suggest a massive
PTE.
When a patient is haemodynamically unstable they should not be moved for radiological
investigations.
A portable chest X- ray can be done in the emergency department but is often non- specific.
A bedside echocardiogram can assess for right heart strain/ failure which is more specific to the
diagnosis of PTE and may demonstrate a central pulmonary embolism.
If echocardiographic findings
are suggestive of a PTE, with this clinical picture thrombolysis treatment should be considered.
A 12- lead ECG again has insufficient sensitivity. The ECG may demonstrate sinus tachycardia, atrial
fibrillation, right ventricular overload, or right axis deviation. The S1Q3T3 sign is non- specific and is
present in <20% of patients with a PTE.
Plasma D- dimer level is only useful if there is low/ intermediate clinical probability of a PTE and
therefore not in this case.
- A 77- year- old man had a prolonged emergency abdominal aneurysm repair 24 hours ago. He is intubated and ventilated in ICU. You notice his abdomen is tense and distended. Over the last 6 hours his urine output has been 5– 15 mL/ h and his noradrenaline (norepinephrine) requirements have increased.
You check his bloods which show a
haemoglobin (Hb) of 101 g/ L, white cell count of 10.2 × 09/ L, and
platelets of 54. His urea is .6 mmol/ L, creatinine 39 μmol/ L, and
potassium is 5. mmol/ L. His temperature is 37.3°C. What is the most
likely diagnosis?
A. Sepsis
B. Paralytic ileus
C. Abdominal compartment syndrome
D. Pancreatitis
E. Disseminated intravascular coagulopathy
- C
This scenario describes abdominal compartment syndrome which could be secondary to bowel
oedema, massive fluid resuscitation, or intra- abdominal bleeding. It should be considered
when there is renal, cardiovascular, and respiratory instability. It can be treated with fluids and
vasopressors but may require abdominal decompression.
- You are called to the Emergency Department to review a 24- year old
man who has been involved in a road traffic accident. He has sustained a head injury and his current Glasgow Coma Scale (GCS) is 4.
His pupils are equal and reactive to light. His C- spine is immobilized in a hard collar and he has a 16G intravenous cannula in his right
arm. His observations are HR 90 bpm, mean arterial blood pressure
70 mmHg, RR 20, SaO2 00% on 5 L of O2 via a non- rebreathing mask,
temperature 35.5°C. There are no other major injuries apparent. The most appropriate next step in the management of this patient is:
A. Transfer to radiology for an urgent CT scan of his head and neck
B. Administration of 00 mL of Mannitol 0% IV
C. Give a 500- mL fluid bolus
D. Intubation and controlled ventilation
E. Discuss transfer with the local neurosurgical centre
- D
The patient has an isolated head injury and a low GCS. Therefore the first consideration is airway
protection and he requires immediate intubation and ventilation.
Optimizing oxygenation and
controlling CO2 will minimize secondary brain injury. Subsequent transfer for imaging will be
appropriate when the patient is stable. Discussion with the receiving neurosurgical team will be
required to discuss whether operative intervention or specialist management on neuro- intensive
care is required. There is no evidence of acutely raised intracranial pressure and no current
indication for mannitol to be given. Care should be taken not to fluid overload head injured patients
due to the risk of cerebral oedema and secondary hypoxic brain injury. Instead, cerebral perfusion
pressure is usually maintained with early use of vasopressors.
- You review a 29- year- old woman with brittle asthma on the medical
admissions ward. The medical FY2 is concerned as she is not responding
to initial treatment. Which feature is most suggestive of life- threatening
asthma?
A. Peak expiratory flow of 40% predicted
B. Respiratory rate of 38
C. Heart rate of 24 bpm
D. PaCO2 of 5.2 kPA
E. Patient unable to complete sentences in one breath
4. D The features of life- threatening asthma are any one of the following: Peak expiratory flow (PEF) <33% best or predicted SaO2 <92% PaO2 <8 kPA Normal PaCO2 4.6– 6.0 kPa Silent chest Cyanosis Arrhythmia Exhaustion Altered conscious level Hypotension Poor respiratory effort
A, B, C, and E are features of acute severe asthma. A normal or rising CO2 is a feature of life- threatening
asthma as it is likely to indicate tiring of respiratory effort and need for intubation and ventilation
- A 69- year- old lady presents with a three- day history of severe vomiting.
Her arterial blood gases are as follows on room air. pO2 13.2 kPa, pCO2 5.9 kPa, H+ 30, HCO3
– 37 mEq/ L. Her U&E are Na+ 39 mmol/ L, K+
2.9 mmol/ L, Cl– 90 mmol/ L, urea 8.0 mmol/ L, and creatinine 80 μmol/
L. What is the most likely diagnosis to account for this biochemical
picture?
A. Gastroenteritis
B. Pyloric stenosis
C. Diabetic ketoacidosis
D. Renal failure
E. Cushing’s syndrome
5. B
This clinical picture of hypokalaemic, hypochloraemic metabolic alkalosis fits with pyloric stenosis.
Loss of gastric fluid leads to dehydration and loss of sodium, chloride, acid (H+), and potassium.
The patient requires prompt and adequate fluid and electrolyte resuscitation. In adults this can be
secondary to tumours or severe ulcer disease.
