Action steps Flashcards
Intraop actue hypoxia actions
- check the color of the patient
- check for a pulse
- Check all vital signs
- check for ETCO2
- Take the patient off the ventilator and hand bag with 100% O2
- Call for help
- check the o2 monitor, peak airway pressure, and capnograph waveform
- listen to the chest for bilateral breath souds. note chest rise (unilateral breath sounds: ETT is too deep, PNX, or tension PNX)
- evaluate the ett. rule out kinking, mucus plug, herniated cuff. Pass the suction catheter or fiber optic scope. Check fro proper placement and position
- listen to the chest for wheezing. give aerosolized albuterol for wheezing
- if you thnk that the patient has bronchospasm, deepen the anesthetic
- if deepening the anesthetic does not treat the bronchospasm, give IV epinephrine
- order a chest x-ray
Approach to reading EKGs
Rhythm: sinus or non-sinus
Regularity: regular or irregular
P wave: generated by atrial depolarization, best in lead 2 and V2, should be 2.5mm long and 2.5mm high
PR interval: generated by conduction fo the elctrical impulse through the atria and the AV node. should not be longer than 0.2 sec (5mm). 2nd degree type 2 and 3rd degree heart block require pacing
Q wave: should not be longer than 0.03 sec (could be sign of prior transmural infarction
QRS complex: ventricular depolarization and contraction: normal duration up to 0.12 seconds. Longer duration sign of hemi-block in the His bundles.
ST segment should be isoelectric. If depressed there is myocardial ischemia. If elevated there is myocardial necrosis. This is measured by the computer on the monitors and we need to take them seriously. Most sensitive lead for diagnosis of ischemia is V5. Next most sensitive lead is V4.
T wave: ventricular repolarization: should not be longer than 0.2 seconds. Should be concordant with total amplitude of QRS complex.
Axis: normal values range between -30 and +110 degrees. Look at the total amplitude of lead 1 and lead aVf. The vector of these 2 leads is where the axis lies.
Anticipate massive blood loss
Large bore IV access
Large bore central introducer
Rapid transfuser and blood warming devices in room
10-15 units RBCs and 5 units FFP in room with additional in blood bank
Plan for intraop cell salvage
Discuss further possible interventions with surgeon: acute normovolemic hemodilution, administration of antifibrinolytic, such as aminocaproic acid or tranexemic acid.
QI Steps
-Measure current outcomes and benchmarks if appropriate
• Devise change in practice in collaboration with stakeholders if appropriate
• Educate and train clinicians regarding change in practice as appropriate
• Implement change in practice
• Measure outcomes after change in practice
Hypernatremia action steps
H&P: current meds, mental/neuro exam, determine volume status and water intake, signs and symptoms: thirst, diaphoresis, sweating, vomiting, polyuria
Measure urine osmolality, sodium concentration, integrity of ADH-renal system: urine osmolality should be 700-800 and additional ADH should not increase it.
Causes of hypernatremia with Uosm 700-800: unreplaced insensible loss: urine sodium concentratin should be less than 25 mEq/L, GI losses: urine sodium concentration should be less than 25 mEq/L, sodium overload: urine sodium concentration above 100mEq/L, defect in thirst: rare
If urine osmolality (Uosm less than 300 mOsm/L) is lower than plasma osmolality: consider diabetes insipidus
Administer ADH to distinguish between nephrogenic and central diabetes insipidus: give 10 mcg nasal synthetic desmopressin (DDAVP) or 5 units vasopressin subcutanesously.
Nephrogenic: little or no response to ADH
Central: appropriate increase in Uosm by greater than 50%
Consultation with nephrologist, endocrinologist, or neurologist to aid in diagnosis of diabetes insipidus
Measure urine solute concentration to confirm osmotic diuresis: gulcose and urea
PSVT treatment
vagal maneuvers
adenosine 6mg rapid, followed by second and third dose if needed at 12-18mg per bolus
verapamil 2.5-10mg IV
Amiodarone 150mg infusion over 10 min
esmolol 1mg/kg volus IV and 50-200 mg/kg/min infusino
edrophonium 5-10mg IV bolus
give phenylephrine 100mcg IV if the patient is hypotensive
digoxin 0.5-1.0 mg IV
rapid overt pacing ina n attempt to capture the ectopic focus
Synchronized cardioversion in incremental doses of 50, 100, 200, 300, 360 joules; this shol dbe done immediately if the patient is hemodynamically unstable.
treatment hypernatremia
determine volume status:
hypervolemia: diuretics and hemodialysis may be necessary
Free H2O deficit (in L of H2O) = {(plasma Na/140)-1} x kg x 0.6 in males (0.5 in females)
Goal less than or equal to 145
Replace half the deficit in first 24 hours, then other half over 2-3 days
Use 5% dextrose in water or 0.45% NaCl to correct the deficit
Monitor serum sodium every 1-2 hours to ensure a gradual correction (should not exceed 0.5 mEq/L per hour)
treatment of diabetes insipidus
DDAVP
IV dosing 2-4 mcg, 1-2 times per day
Nasal spray 10-40mcg 1-2 times per day
Titrate to urine output, serum sodium, osmolality
Low Na diet
Low-dose thiazide diuretic
Carbamazepine: enhances vasopressin secretion
NSAIDS: impair renal prostglandin syntehsis, potentiate ADH action resulting in incrased urine osmolality and decreased urine volume.
How would you awake intubate and induce this patient
I would
- optimize asthmatic condition with inhaled b-agonist
- provide aspiration ppx
- administer antisialogogue
- ensure adequate IV access, presence of fluids, emergency medications, difficult airway cart
- surgeon in room?
- place patient in position most comfortable (supine if no anterior mass etc)
- cannulate the femoral arteries with CPB on stand by
- provide adequate airway analgesia
- administer ketamine or dexmedetomidine
- eval airway with fiberoptic scope
- intubate with fiberoptic scope
- perform inhalational induction
laryngospasm action steps
I would: suction the airway apply positive pressure mask ventilation deepen anesthetic by... administer IV propofol (lido if spont resp) forceful jaw thrust call for help succinylcholine if no contraindication attempt to pass ETT through closed vocal cords
how will you induce cabg patient
assuming his airway were reassuring i would
place appropriate monitors
position in reverse t to improve resp mechanics, faciliate rapid intubation and reduce risk of passive regurg
note bseline cardiac function
preox with 100% fio2 and tight mask seal
provide aspiration ppx and apply cricoid pressure
induce with x meds and high dose of narcotics to avoid cv depression
intubate the patient
goals to provide a sufficient level of anesthesia to blunt the sympathetic response to intubation, while matinaining hemodynamic stability and safely securing the airway
acute hypotension after induction action steps
i would 100% o2 ensure adequate vent and oxyg auscultate the chest verify the BP check the ekg confirm ETT position obtain filling pressure and CO from PA cath check electrolytes
decrease volatile
fluid bolus
tburg
small dose direct acting vasopressor
treat conservatvely if concern from tachycardia/htn
how prepare to wean off cpb
ensure normothermia
correct any anemia, electrolte abnormalities/metabolic disturbances
turn on and check alarms and monitors
recalibrate and zero transducers
check lung compliance and initiate ventilation
snure the heart is de-aired
ensure adequate cardiac function using TEE and other hemodynamic data
administer benzos to preven awareness during reqarming
ensure availability of pacing device and resusciation drugs
during warming closely onitor cardiac fxn and administer inotrops and vasoactive drugs as necessary
manage intraop malignant hyperthermia
I would:
call for help
call the MH hotline
discontinue all triggering agents
change to a clean circuit (new machine or O2 tank with ambu bag)
hyperventilate with 100% o2
start IV dantrolene 2-2 mg/kg IV bolus q5min up to 10 mg/kg, then start an infusion of 1-2 mg/kg/hr
monitor and treat acidosis with sodium bicarbonate
cool the patient aggressively with cooling blankets, cold IV NS, cold body cavity lavage, ice bags to the body (goal temp 38-39)
closely monitor urine output with a foley catheter. Maintain goal UOP greater than 1-2 ml/kg/hr using fluids, furosemide (1mg/kg IV) and amnnitol (0.25gm/kg IV) and watch for signs of myoglobinuria
send off frequent labs, ABG/VBG, electrolytes, hepatic fxn, coag panel, CBC, CK, serum glucose, urine myoglobin (follow closely for 24-48 hours)
treat hyperkalemia with combo of 0.1-0.2 U/kg of regular insulin and 500mg/kg of dextrose IV, calcium or bicarb
treat any arrhythmias that develop using amiodarone, lidocaine, adenosine, procainamide, or any other drugs indicated according tot he ACLS protocol. Dysrhythmias usually subside with resolution of the hypermetabolic phase (DO NOT use calcium channel blockers to treat them bc can worsen hyperkalemia)
correct metabolic acidosis with 1-2 mEq/kg IV of sodium bicarb based on arterial pH
have the surgeon stop the surgery as soon as possible; expedite or abort
consider a-line and central line
manage post-op MH
alkalinize the urine and diurese, monitor for acute renal failure
follow CK levels to track the severity of the rhabdo
follow all labs and vital signs closely (watch out for hypothermia, hyperkalemia, hypokalemia, hypervolemic overshoot)
watch for signs of DIC, including thrombocytopnenia, hemolysis, abnormal bleeding
elevated liver fxns often in 12-36hrs post MH crisis
follow CNS serially
continue dantrolene 1mg/kg IV q4-6 hrs for up to 72 hrs after episode
submit forms to MH registry
continue to monitor the patient for upt o 72 hours in the SICU. measurements should include urine output, arterial blood gases, pH, serum electrolyte concentrations.
difficult airway algorithm
optimize oxygenation throughout
limit attempts
call for help
if can mask:
limit attempts and consider awakening the patient
consider alternative intubation approaches, invasive access, or feasibility of other options
if can’t mask -> LMA
if LMA fails, limit attempts and consider invasive access, call for help
alternative approaches as prepare for invasive airway
in peds consider ecmo
triggers for awake intubation
suspected difficult DL
suspected difficult ventilation with face mask/SGA
significant increased risk of aspiration
increased risk of rapid desaturation
suspected difficult emergency invasive airway
determine cause of elevated creatinine
review meds and history
check urine na levels, urine osmolality, urine-to-plasma Cr ratio, urinary sediment level
Fluid challenge: if improve then pre-renal
If urine Na >10 and granular casts then its ATN
Hepatorenal syndrome has no improvement with fluid challenge, no proteinuris, low urinary Na conc, serum sodium <130
Care for patient with hepatic encephalopathy
rule out other causes of mild confusion (drugs, wernicke’s for alcoholic)
treat inciting factors (bleeding varices, infection, hypovolemia, anemia)
eval for elevated ICP
avoid hypokalemia (increases ammonia production)
maintain normal art pH (alkalemia inc diffusion of mamonia accros blood brain barrier)
correct hypovolemia/anemia (optimize liver metabolisim of circulating toxins
cautious with psychoactive drugs (benzos)
induce with aspiration risk
assuming reassuring airway, hemodynamic stability, appropriate monitors
administer metoclopramide H2 blocker sodium citrate reverse trendelenburg pre-oxygenate 100% for 5 min cricoid pressure lidocaine/fentanyl propofol paralytic rapidly secure the airway
treat hyperkalemia
calcium chloride or gluconate
ensure access to defibrillator and prepare to treat dysrhythmias
correct contributing factors (acidosis, hyponatremia, hypocalcemia)
administer insulin and glucose, b2 adrenergics (albuterol), sodium bicarb
hyperventilate the patient to promote alkalosis
consider hemodialysis
neonatal resuscitation
warm, clear airway prn, dry/stimulate/reposition
evaluate respirations, HR, color
if apnea, HR < 100, or persistent cyanosis, then positive pressure ventilation
then if HR > 100, post-resus care
but,
if HR <60, chest compressions,
then epi (0.01mg/kg IV or 0.1mg/kg ETT) and/or volume (10 ml/kg o-neg blood, NS, or LR; albumin icnr mortality)
drugs in neonatal resuscitation
bicarb - 4.2%, only if prolonged resuscitation and documented acidosis, 2 mEq/kg via umbilical catheter
naloxone - 0.01 mg/kg IV/IM/SQ/ETT but not if opioid addicted mother cuz could withdraw
epi - (0.01mg/kg IV or 0.1mg/kg ETT) for asystole or persistent bradycardia despine 30 sec of effective ventilation and chest compressions. can repeat q 3-5 min
atropine - 0.02mg/kg IV or 0.03 mg/kg ETT for bradycardia
calcium gluconate - 100mg/kg over 5-10 min for low CO IF FROM MAGNESIUM TOXICITY (mom on Mg infusion); keep on continuous EKG
fluids - o-neg or maternally cross-matched blood 10 ml/kg; or NS/LR 10 ml/kg; def not albumin (increased mortality)
HELLP tx
mg
control bp (SBP<160 and DBP<105)
correct coagulopathy
corticosteroids for fetal lung maturity as time permits
How to diagnose a PE
gold standard in pulmonary angiogram
Lab not typically used
Imaging: V/Q scan for patients with renal failure, CT scan is faster though, CT angiogram combined with CT venography has a higher sensitivity for VTE but does not rule out PE if negative
Actions to reduce ICP
make sure no venous obstruction
elevate head 15-30 degrees
mannitol (only if BBB intact)
furosemide (unless hypovolemic)
barbiturate (reduce ICP and CMRO2)
periop glucose actions
2/3 dose nigiht prior no short-acting insulin morning of 1/2 usual morning dose intermediate/long check level when arrive at hospital check glucose at least hourly in periop period maintain between 120-180
consider 2 continuous concurrent separate infusions of regular insulin and D5 1/2 NS
recent stent, how eval cardiac status preop?
careful H&P - focus on comorbidities that can be cardiac related, obtain details on stent location and stent type and timing
review previous medical records/tests related to cardiac fxn
determine severity of CAD, what vessels, coag status, if he is optimized
if diabetic assess for signs of autonomic neuropathy (could have painless MI), CV instability, myocardium at risk (angina, SOB, exercise intolerance)
if elevated risk of MACE:
determine functional capacity
if less than 4 METS consult with surgeon if results would alter care (delay case vs undergo CABG/PCI)
if positive results would alter care, then consider stress testing
if negative, then would bedside echo prior to proceeding
treat sepsis
obtain blood cx
find source (imaging)
empiric broad spectrum abx, narrow when able
control source
administer fluids (start with crystalloids)
vasopressors (start norepi)
inotropes (start dobutamine if norepi not working)
maintain CVP 8-12, MAP greater than 65, UOP > 0.5 ml/kg/hr, maintain O2 sat, normal serum lactate
transfuse PRN RBC, PLT, FFP
consider corticosteroids, insulin, bicarb
mechanical ventilation w PEEP, lung protective
head up position reduce aspiration and VAP
minimal sedation to shorten ICU stay
avoid paralytic
DVT ppx
stress ulcer ppx
daily spont vent trials
Approach for preop hypertension
delay elective surgery 6-8 weeks to optimize BP of any patient who:
- has SBP readings >180 or DBP >110
- has stage 1 or stage 2 HTN with concomitant end-organ damage
- Is undergoing cardiac surgery, carotid surgery, or pheochromocytoma resection (weigh risks/benefits obvi)
Peds difficult airway
limit attempts, call for help
assess oxygenation/ventilation with face mask/SGA
if adequate: consider emerging the pateint, limit attempts, be aware of passage of time, reassess ventilation after each attempt, consider alternative intubation approaches or feasibility of other options
if marginal or impossible: exclude/treat anatomical and fxnl obstruction, consider calling for invasive access or ECMO
if impossible, or becomes cannot intubate/cannot ventilate scenario, then: call for help/for invasive access, alternative intubation approaches as prepare for emergency invasive airway
adult difficult airway
lkjh
a-fib treatment priorities
1 find the cause 2 fix the cause 3 slow the rate - (maybe dilt or beta blocker) 4 convert the rhythm 5 prevent thromboembolism
neonate unable to ventilate after intubation
100% fio2
check circuit
ensure patent ETT
verify proper ETT placement (auscultation and fiberoptic scope)
if correct, assume bronchospasm:
identify and clear gastric material in oropharynx (could have caused bronchospasm)
apply positive airway pressure
deepen anesthetic with inhalational or other
administer b2 agonist
if persisted,
administer small dose of epinephrine
post extubatino croup action steps
dexamethasone
humidify inspired gases
nebulized racemic epi
consider light sedation to improve patient cooperation
ensure adequate hydration
consider reintubation if cyanosis/hypoxic (use smaller tube and keep in place until swelling resolved)
preop actions to reduce risk of carcinoid crisis
octreotide (somatostatin analogue) (preferably start 2 days prior) to reduce tumor secretion of serotonin
optimize IV fluid volume
anxiolytic to prevent stress-induced release of hormones from tumor
H1 and H2 blockers to attenuate effects of histamine
alpha and beta adrenergic receptor blockers to prevent catecholamine mediated release of vasoactive substances from teh tumor
steroids may be beneficial 2/2 inhibition of the kallikrein cascade
the thing i always forget to consider prior to induciton
consider decompressing stomach with OG or NG tube
concern about obsese patient cardiac status, how evaluate
H&P: rule out active cardiac conditions (unstable/severe angina, arrhythmia, valvular disease)
assess MACE risk with RCRI
assess fxnl capacity
ask about prior cardiac w/u
if fxnl capacity <4 METS discuss further w/u (stress test) with surgeon and patient if it would impact decision making
note:
diabetes may mask angina
what should you do before deep extubation
suction the stomach
acls drugs
add them all
stuff to always examine
airway, cv, pulm
monomorphic vs polymorphic VT defib
monomorphic synchronized cardioversion
polymorphic - unsynchronized often required
ACLS Cardiac arrest PEA and asystole
Perform the initial assessment
Perform high-quality CPR
Establish an airway and provide oxygen to keep oxygen saturation > 94%
Monitor the victim’s heart rhythm and blood pressure
If the patient is in asystole or PEA, this is NOT a shockable rhythm
Continue high-quality CPR for 2 minutes (while others are attempting to establish IV or IO access)
Give epinephrine 1 mg as soon as possible and every 3-5 minutes
After 2 minutes of CPR, check rhythm
If the monitor and assessment show VTach or VFib, move to VTach/VFib algorithm
Evaluate and treat reversible causes
If the patient attains Return of Spontaneous Circulation (ROSC), provide Post Cardiac Arrest Care
ACLS Bradycardia Algorithm
Treatment for bradycardia should be based on controlling the symptoms and identifying the cause using the Hs and Ts
Do not delay treatment but look for underlying causes of the bradycardia using the Hs and Ts.
Maintain the airway and monitor cardiac rhythm, blood pressure and oxygen saturation.
Insert an IV or IO for medications.
If the patient is stable, call for consults.
If the patient is symptomatic, administer atropine 1.0 mg IV or IO bolus and repeat the atropine every 3 to 5 minutes to a total dose of 3 mg:
If atropine does not relieve the bradycardia, continue evaluating the patient to determine the underlying cause and consider transcutaneous pacing
Consider an IV/IO dopamine infusion at 2-10 mcg/kg/minute
Consider an IV/IO epinephrine infusion at 2-10 mcg/minute.
In the cases of Mobitz type II second-degree heart block, third-degree AV block, or third-degree AV block with new widened QRS complex, atropine is unlikely to be effective. Consider transcutaneous pacing immediately or a beta-adrenergic infusion to increase heart rate.
ACLS Tachycardia Algorithm
The ACLS Tachycardia Algorithm is used for patients who have marked tachycardia, usually greater than 150 beats per minute, and a palpable pulse.
Some patients may have cardiovascular instability with tachycardia at heart rate less than 150 bpm. It is important to consider the clinical context when treating adult tachycardia.
If a pulse cannot be felt after palpating for up to 10 seconds, move immediately to the ACLS Cardiac Arrest VTach and VFib Algorithm to provide treatment for pulseless ventricular tachycardia.
The immediate response to an adult patient with tachycardia and a palpable pulse is
To maintain an open airway
Assist breathing if necessary
Apply monitors to assess cardiac rhythm, blood pressure, blood oxygenation
Provide supplement oxygen to maintain O2 saturation between 94% and 99%
The main assessment in adult patients with tachycardia is to determine whether the patient is stable or not. Signs of cardiovascular instability are hypotension, signs of shock or acute heart failure (flash pulmonary edema, jugular venous distention), altered mental status, or ischemic chest pain.
Unstable patients with tachycardia should be treated with synchronized cardioversion as soon as possible.
Stable patients with tachycardia with a palpable pulse can be treated with more conservative measures first.
Attempt vagal maneuvers
If unsuccessful, administer adenosine 6 mg IV bolus followed by a rapid normal saline flush
If unsuccessful, administer adenosine 12 mg IV bolus followed by a rapid normal saline flush
Beta-blockers and calcium channel blockers may be considered for narrow QRS tachycardia (QRS <0.12 sec)
For stable, wide QRS complex tachycardia (QRS ≥0.12 sec)
Strongly consider expert consultation
Consider procainamide 20-50 mg/min IV, OR
Amiodarone 150 mg IV over 10 minutes, OR
Sotalol 100 mg (1.5 mg/kg) over 5 minutes
cardioversion rules
Cardioversion Rules
QRS narrow and regular 50-100 Joules
QRS narrow and irregular 120-200 Joules
QRS wide and regular 100 Joules
QRS wide and irregular Turn off the synchronized mode and defibrillate immediately
ACLS In-Hospital Cardiac Arrest in Pregnancy Algorithm
Cardiac arrest that occurs in the hospital is handled differently than it is in other adults in some important ways. Cardiac arrest resuscitation of pregnant women focuses on resuscitating the mother primarily. Fetal monitoring should not be used during cardiac arrest in pregnant women, and if fetal monitors were in place, they should be removed during resuscitation. When possible, a specialized maternal cardiac arrest team should conduct the resuscitation. This team can take over for the first ACLS providers on the scene if they are not part of the maternal cardiac arrest team. Since pregnant women are more likely to have hypoxia in general, oxygenation and airway management should be prioritized over circulation, in some respects, like it is in the care of pediatric patients.
Perform BLS/ACLS as would occur in any adult patient
When possible, hand off care to the maternal cardiac arrest team
For the mother:
Support the airway and provide one breath every 6 seconds
Give 100% oxygen
If magnesium is being administered, stop it, and provide calcium chloride or calcium gluconate
For the fetus:
Relieve aortocaval compression by moving the uterus laterally
Detach or do not use fetal monitors
Prepare for Cesarean delivery
If ROSC occurs, move to post-cardiac arrest care
Pregnant women who remain comatose after resuscitation from cardiac arrest should receive targeted temperature management and fetal heart rate monitoring with OB/GYN support
If ROSC does not occur within 5 minutes, consider perimortem Cesarean delivery
The neonate should be evaluated for neonatal resuscitation
ACLS Cardiac Arrest VTach and VFib Algorithm
Perform the initial assessment
Perform high-quality CPR
Establish an airway and provide oxygen to keep oxygen saturation > 94%
Monitor the victim’s heart rhythm and blood pressure
If the patient is in VTach or VFib, this IS a shockable rhythm
Apply defibrillator pads (or paddles) and shock the patient with 120-200 Joules on a biphasic defibrillator or 360 Joules using a monophasic.
Continue High Quality CPR for 2 minutes (while others are attempting to establish IV or IO access).
After 2 minutes of CPR, check rhythm
If the monitor and assessment show asystole or PEA, move to Asystole/ PEA algorithm
Give epinephrine 1 mg every 3-5 minutes
Continue High Quality CPR for 2 minutes (while others are attempting to establish IV or IO access).
After 2 minutes of CPR, check rhythm
If needed, administer shock
Amiodarone IV 300 mg (preferable to lidocaine); May repeat 150 mg OR may use lidocaine 1-1.5 mg/kg
After 2 minutes of CPR, check rhythm
If needed, administer shock
If the patient attains Return of Spontaneous Circulation (ROSC), provide Post Cardiac Arrest Care
ACLS Post Cardiac Arrest Care Algorithm
Treatment for a victim of cardiac arrest must continue post resuscitation in order to optimize the outcomes. The post cardiac arrest care algorithm includes the following steps:
Verify ROSC.
Manage the airway including ETT placement and provide 10 breaths per minute.
Using quantitative waveform capnography, titrate the oxygen to maintain a PETCO2 of 35-40 mm Hg. If you do not have access to a waveform capnography machine, titrate oxygen to keep the oxygen saturation 92% to 98%.
Insert and maintain an IV for medication administration. Maintain systolic blood pressure above 90 mm Hg and/or mean arterial pressure above 65 mm Hg. For a low blood pressure, consider one or more of these treatments:
Give 1 to 2 liters of saline or Ringer’s lactate IV fluid.
Start an epinephrine IV or a dopamine IV infusion
Consider norepinephrine for extremely low systolic blood pressure.
Obtain a 12-lead ECG and rule out myocardial infarction. If myocardial infarction is suspected, consider percutaneous coronary intervention (PCI) to open the coronary arteries.
Determine if the patient is comatose.
If comatose:
Targeted temperature management ASAP keeping body temp 32-36°C for 24 hours initially.
Monitor EEG and assess for nonconvulsive seizures (treat if present)
Obtain head CT
Maintain oxygen, glucose, carbon dioxide, etc.
Avoid barotrauma
If NOT comatose (awake):
Maintain oxygen, glucose, carbon dioxide, etc.
Avoid barotrauma
ACLS Acute Coronary Syndrome Algorithm
- Assess patient for symptoms of acute coronary syndrome (ACS)
Crushing chest pain Pain radiates to jaw, arm, back Nausea/vomiting Sweating Shortness of breath 2. Rapid sequence of interventions and additional assessments
If no aspirin allergies, administer aspirin (patient should chew)
If no contraindications, administer nitroglycerin
Administer morphine, if needed
Obtain 12-lead ECG
Apply oxygen via nasal cannula if O2 <94%
3. Trained professional should assess ECG; ST-segment elevation myocardial infarction (STEMI)
STEMI
Complete fibrinolytic checklist
Determine precise onset of symptoms, if possible
Initiate Fibrinolysis/PCI protocol immediately
Antiplatelet therapy
Aspirin
Platelet P2Y12 receptor blocker
GP IIb/IIIa inhibitor (If destined for PCI)
Anticoagulation
Consider intravenous nitrates
Consider morphine
Beta-blockers (if no contraindications)
Statin therapy
Non-ST elevation ACS (unstable angina or non-ST elevation myocardial infarction (NSTEMI))
Antiplatelet therapy Aspirin Platelet P2Y12 receptor blocker Anticoagulation Admit to monitored bed Consult Cardiology
PALS Cardiac Arrest Algorithm
- Activate emergency medical services, call a pediatric “code blue”, obtain AED or defibrillator
- Is the rhythm shockable?
Rhythm IS shockable (ventricular fibrillation or unstable ventricular tachycardia)
- Administer shock at 2 Joules/kg
- Administer high-quality CPR for 2 minutes
- Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, continue
- Administer shock at 4 Joules/kg
- Administer epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes
- Administer high-quality CPR for 2 minutes
- Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, continue
- Administer shock at >4 Joules/kg
- Administer amiodarone 5 mg/kg IV (repeat 2 times if needed) or lidocaine 1 mg/kg IV
- Administer high-quality CPR for 2 minutes
- Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, repeat steps 8-11
Rhythm IS NOT shockable (asystole or pulseless electrical activity)
- Administer high-quality CPR for 2 minutes
- Administer epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes
- Check rhythm
If shockable, move to VF/VT rhythm protocol
If not shockable, continue
- Administer high-quality CPR for 2 minutes
- Check rhythm
If shockable, move to VF/VT rhythm protocol
If not shockable, continue
- Administer amiodarone 5 mg/kg IV (repeat 2 times if needed)
- Administer high-quality CPR for 2 minutes
- Check rhythm
If shockable, move to shockable rhythm protocol
If not shockable, continue CPR and medications
extra monitor for aortic dissection
lumbar csf drain
Epiglottitis management
supplemental o2
call ENT for possible surgical airway
no invasive procedures (IV) until after airway mgmt)
bag mask with 100% FiO2
If not oxygenating: one attempt at intubation by RSI, then surgical airway
If oxygenating, move to OR for controlled intubation with ENT present
DO NOT PLACE LMA
Then abx are the treatment
Oliguria management
AKI if increase serum cr by 0.3 in 48 hrs or 1.5x baseline
H&P History: med review vitals/hypotension review contrast?
Physical: signs of volume contraction - pre renal; give volume drug rash - AIN blue toes - cholesterol emboli volume overload - cardiorenal syndrome ascites/jaundice - hepatorenal
labs:
dipstick, albumin to cr ratio
FeNa
bradycardia with a pulse
check pulse
airway 100% O2, confirm adequate vent and ox
stop vagal stimuli (desufflate, remove pressure, remove retractors, drain bladder)
ensure IV access
meds: decrease anesthetic? atropine 0.5-1 q3 min max 3mg then epi 5-10mcg consider dopamine gtt if stable consider glyco
pacing: place pads
consider transcut, transvenous, esoph pacing
consult ICU or cards
consider a-line
ABG, hgb, lytes, trop
ischemia: 12-lead, BNP, serial trops
DKA action steps
notify surgeon
10U IV insulin bolus
NS fluid replacement
check serum/urine ketones
ABG, BUN, Cr, lytes
anion gap
insulin infusion (decr 75-100/hr so no cerebral edema)
add 5% dextrose infusion when glucose reaches 250 (prevent hypoglyc and have energy source)
replace potassium, phosphate, magnesium PRN
monitor labs
DKA risks arrhythmias and hypotesnion intraop
mnemonic to come off pump
Temp - core >35.5
HCT hct>21
electrolytes - hypoCa, HyperK, hyperglycemia
inotropes - esp with clamp>90m, preop dysfxn, poor protection
Vasopressor - low SVR rewarming, frequent vasopressor by perfusion
pacer/rate: intrinsic/paced 80-90, DDD unless sig bovie interference, always DDD to leave OR
vent: recruitment (watch IMA), on
vapor - on
monitors - back to normal, paced mode
TEE - eval for air, assess repair, bi-v fxn
protamine: ask perfusion for correct dose, confirm surgeon ready, announce half-in and all-in
mnemonic to go on pump
Perfusion - full flow, iso on, goal MAP
Ventilator - off: manual mode, apl open, air/o2 50%, cpb mode. (on: decrease Vt and RR)
Vapor - off
Monitors: switch to bypass mode
Fluids: continue carrier, stop others
Patient: assess bilateral perfusion: skin color, cerebral ox, no vein congestion; confirm paralysis; bis <60
Urine: measure and empty
Drugs: Stop inotropes (except milrinone), discuss vasopressin with perfusion if needed
TEE: Freeze
jaunidce action steps
prehepatic, hepatic or posthepatic
prehapatic caused by increased production bilirubin from hemolysis or absorption of hematoma
hepatic: hepatic injury (ischemia, drugs), intrinsic disorder, infection, hepatic congestion, halothane
posthepatic: mechanical obstruction such as a stone
H&P, look for hypotension, transfusion, medications, hepatomegaly, coagulopathy
labs: LFTs (with conjugated and unconjugated bili), alk phos, H/H, abdominal ultrasound
WPW tachyarrhythmia management
stable narrow complex (orthodromic): adenosine, then procainamide, then cardioversion
stable wide complex (antidromic): procainamide, then cardioversion
unstable: cardioversion
PFT pearls
Obstructive: FEV/FVC ratio less than 0.7
severity indicated by FEV %age (moderate 60-70, moderately severe 50-60%)
Restrictive: normal FEV/FVC ratio (>70%)
reduction in TLC <80% predicted
How to optimize COPD preop
smoking cessation 8 weeks preop chest physiotherapy bronchodilators glucocorticoids abx if infxn
If emergent: bronchodilators supplemental O2 inhaled steroids abx if infxn
Peds URI delay guidelines
(asthma does not have fever)
elevated risk laryngospasm, bronchospasm, O2 desat events
delay 4-6 weeks to allow pulm fxn return to nml if:
- fever >38.5
- productive cough
- mucopurulent secretions
- malaise
- pulm involvement (wheezing does not clear w cough)
delay 2-4 weeks for mild sx IF require ETT and have additional risk factor (2nd hand smoke, underlying dz like asthma):
sneezing
mild nasal congestion
nonproductive cough
proceed w surgery if mild sx but does not requre ETT
severe masseter muscle rigidity action
assume MH and begin MH treatment; cancel case if elective
drug to not admin with dantrolene for MH
calcium channel blocker; can lead to hyperkalemia
