Acute resuscitation OSCE's Flashcards
General approach to Adult Cardiac Arrest?
Initial
- Declare cardiac arrest and call code blue
- Attach defibrillator and monitoring
- Start CPR at ratio 30:2
- Fast: CPR 100-120 compressions per minute
- Hard: Lower half of the chest to 1/3rd depth of the chest (or 5cm)
- Use BVM
VF/VT
- Immediate shock
- Adrenaline after 2nd shock
- Amiodarone after 3rd sjock
- Adrenaline every 3-5mins (every 2nd shock) thereafter
- Consider Lidocaine
PEA/Asystole
- Immediate Adrenaline
- Adrenaline every 3-5mins (every 2nd cycle) thereafter
- Seek and treat reversible causes
Airway
- If hypoxic cause of arrest or issues with ventilation (ie bronchospasm or angioedema) then ETT is indicated
- If above not present then BV< is considered adequate as ETT placement in arrest has high rates of misplacement and interrupts CPR
- SGA’s have theoretical benefits but are unproven, not helpful in severe bronchospasm
- Once advanced airway in place change ventilation to 6-10/min and do continuous CPR
General approach to Paediatric cardiac arrest?
Initial
- Declare cardiac arrest and call paediatric code blue
- Attach defibrillator and monitoring
- Give 2 rescue breaths
- Start CPR at ratio 15:2
- Fast: CPR 100-120 compressions per minute
- Hard: Lower half of the chest to 1/3rd depth of the chest (or 5cm)
- Use BVM to deliver 100% 02, be careful not to overinflat
- Consider use of Ayers T-Piece if available to guide positive pressure delivered
Differences to Adults
- Most likely causes of arrest are hypoxia and hypovolaemia
- More likely to be non-shockable
- Higher priority to secure the airway for improved oxygenation (LMA or ETT)
- 6Hs and 5T’s
VF/VT
- Immediate shock 4J/kg
- Adrenaline 10mcg/kg after 2nd shock
- Amiodarone 5mg/kg after 3rd shock
- Adrenaline every 3-5mins (every 2nd shock) thereafter
- Consider Lidocaine 1-1.5mg/kg
PEA/Asystole
- Immediate Adrenaline 10mcg/kg
- Adrenaline every 3-5mins (every 2nd cycle) thereafter
- Seek and treat reversible causes
General approach to Newborn cardiac arrest?
Indications
- NeoResus only indicated in the peri-birth period, unclear exact cut off but >4-6hrs should change to paeds ALS
Equipment (see pic)
- Resuscitaire and warmer
- Neopuff and/or neonatal BVM at 20 IPAP and 8 PEEP
- Consider higher IPAP for initial breaths of 30cmH20 or higher to overcome atelectasis and lung fluid
- ETT uncuffed 3.0, 3.5 and 4.0
- size 1 LMA (2 - 5kg baby)
- size 0 and 1 miller blades, V/L size 1/0 Mac blade
- introducer, mec aspirator
- 10mcg/kg Adrenaline (30-50mcg)
- N. Saline, 10% dextrose and PRBC
- Umbilical line, 24g cannula, pink intraosseous needle
Steps for compromised baby
- Warm, briskly stimulate and dry the baby
- If preterm place in polyethylene bag and dry head/stimulate through bag
- If inadequate respiration then place in neutral position, may also jaw thrust/chin lift and put towel under shoulders
- Only suction airway if obvious evidence of obstruction
- Trial CPAP (PEEP) at 5cm/H20
- If insufficient add PPV (IPAP) 30cm/H20 at a rate of 40-60 breaths per minute
- Use room air at 21% 02 initially, max 30% 02 if sats failing to respond
- If requiring CPR switch to 100% 02
Neonatal CPR
- Indicated if HR <60 despite good assisted ventilation for >30secs
- 2 thumbs adjacent to each other over the lower 1/3rd of the sternum, with fingers around the thorax to support the back
- Compress chest 1/3rd of the anterior-posterior diameter
- Ratio of 3 compressions to 1 breath, 1/2 second pause to deliver breath
- 3:1 ratio delivers 90 compressions per minute
- If intubated can consider 120 compressions per minute with no break for ventilation (ie simultaneous) with 40 breaths per minute
- Still doing 2 minute cycles
Special points
- Any compromised baby should have their cord clamped ASAP, a low SVR placenta attached will render CPR ineffective
- If the neopuff flow rate is 10L/min (usual initial setting), then 30% Fi02 will be done with 9L/min air to 1L/min of 100% 02
- Once intubated the ETT will be placed at 8-9cm at the lips (Age/2 + 12 for older kids, not applicable here)
Approach to Angioedema?
Angioedema with Urticaria DDx
- Anaphlayxis 90%
- Infection, autoimmune disease, idiopathic, pseudoallergic
- Treat with Adrenaline 10mcg/kg IM +/- adrenaline infusion (mainly for allergic causes)
- Hydrocortisone IV 4mg/kg or Dexamethasone 0.6mg/kg IV
- Consider emergent airway control +/- FONA
Angioedema NO Urticaria DDx
- Hereditary angioedema (most commonly C1-inhibtor deficiency)
- Acquired C1 deficiency (malignancy, autoimmune)
- Drug induced (ACE-I and NSAID induced Angioedema)
- Upper airway trauma or infection (ie recent ENT surgery or dental procedures/infection)
- Idiopathic angioedema
- Upper airway contact dermatitis
- Malignancy (ie Superior vena cava syndrome)
History
- Rash vs no rash
- GIT/NV symptoms
- Wheeze and pre-syncopal Sx
- Recent exposure to allergen
- PHX of swelling or allergy
- FHx of C1-inhibitor deficiency
- New medications
- Liver/Kidney/Heart (generalised oedema)
Tests
- Mast cell Tryptase
- C1 inhibitor concentration and function
- Inflammatory markers
Angioedema NO rash Mx
- ADRENALINE does NOT HELP
- ICATIBANT subcut 30mg (bradykinin receptor antagonist, usually patient will take prior to coming in)
- TXA 15mg/kg PO TDS, home medication
- C1 inhibitor concentrate (BERINERT, 25U/Kg IV, hospital medication)
- Fresh frozen plasma (2 units of 15ml/kg IV every 2-4hrs, contains C1 inhibitor)
- Ecallantide 30mg Sub cut (Kallikrein inhibitor)
- If in a rural area without access to above treatments (excluding FFP) consider early prophylactic intubation if airway involvement (awake oral or fibreoptic, mark neck for FONA)
Approach to the seriously unwell Pregnant patient
General Resus
- Aortocaval decompression (uterus to the left)
- CTG and consideration of emergent cesarean section
- Early Saline and Noradrenaline
- Consider peripartum cardiomyopathy
- Early discussion with NICU, anaesthetics and ICU
- HF nasal cannula vs BiPAP
Cardiac arrest causes
- Underlying cardiac disease
- PE
- Amniotic fluid embolism
- Haemorrhage
- Sepsis
- Hypertensive disorders
- Poisoning/self harm
- Any normal cause
Cardiac arrest management
- Standard ACLS management
- Aortocaval decompression (manually displace urterus to left, left lateral tilt 15-30 degrees)
- Prepare for resuscitative hysterotomy
General approach to starting ECMO?
General Indications
- Pulmonary +/- Cardiac failure
- Condition ir reversible
- OR transplantation is an option
- All other options have been exhausted or are likely to be futile
Neonatal indications
- Severe Mec aspiration
- Persistent foetal circulation
- Large congenital diaphragmatic hernia
- Severe pulmonary HTN
- Bronchiolitis
- Selected congenital HD’s
Specific Pathologies VV
- Status asthmaticus
- Large PE
- Traumatic pulmonary contusion
- Pneumonia/ARDS
- Post drowning
Specific pathologies VA
- Myocarditis
- Hypothermia
- Beta blocker/CCB overdose
- VT storm/intractable dysrhythmia
- E-CPR
Differences VA and VV
- VV only provides Gas exchange (+ dialysis and heat exchange)
- VA adds on cardiovascular support
- VA higher risk of limb ischaemia and thromboembolism
Approach to the Critical Asthma?
- Escalation of therapies
- Identification of complications (tension pneumothorax, salbutamol toxicity, arrhythmias etc)
- Exclusion of alternate causes (APO, pneumonia, pneumothorax, PE etc)
Approach to intubation
- Try not to intubate!
- Recognise high likelihood to arrest on induction
- Adrenaline infusion and IV bolus 20ml/kg prior to induction
- Consider delayed sequence with NIV
- BVM 100% with NP15L/min underneath if/when apnoeic
- Induction with 1mg/kg IV Ketamine, 1.6mg/kg IV Rocuronium
Cardiac arrest causes
- Terminal hypoxia from bronchospams and mucous plugging
- Arrhythmias from eletrolyte disturbance, hypoxia and adrenergic agents
- Dynamic hyperinflation (Auto-PEEP)
- Tension pneumothorax
Cardiac arrest alterations
- Follow standard resus guidelines considering the above
- Consider co-existing anaphylaxis
- Consider early endotracheal intubation
- If dynamic hyperinflation suspected then consider disconnecting tube with pressure ant-post and lateral chest wall followed by period apnoea (ie no breaths every 30 compressions)
Ventilator Settings
- PEEP is controversial, concerns about worsening iPEEP but also splinting open airways with ePEEP can help lower iPEEP
- Start Fi02 1.0, but can titrate down later to sats >90%
- Use expiratory hold to measure end expiratory pressure and subtract the extrinsic PEEP from this to get the iPEEP (aim iPEEP <10cmH20)
- TV 6ml/kg
- Permissive hypercapnoea aiming pH >7.2 and CO2 <80
- in line MDI for bronchodilators
- RR 8-12, closer to 8 if critical
- Combined TV and RR to a minute volume (MV) <115ml/kg/min
- short inspiratory/long expiratory time with I:E ratio 1:4 or greater
- High inspiratory pressure limit, pressure might be high but accept plateau pressure to 30 (measure with inspiratory hold maneuver)
- Higher inspiratory flow rates approx 60 - 80L/min
- Paralysis bolus/infusions
- Deep sedation
- Ongoing IV therapies
Approach to the Tracheostomy or Laryngectomy patient with respiratory compromise?
Laryngectomy (Lx) differences
- Lx patients are obligate stoma breathers
- Tx patients still have at least partially patent upper airway
- Lx stomas are typically larger
- Lx stomas will have a blind ending superior tracheal inlet
- Lx often have a heat moisture exchanger (HME) on the outside that can be removed
- Sometimes a flexible tube is attached to the HME (Larytube) that is used to maintain patency early post surgery
- Lx often have a tracheo-esopheal prosthesis (TEP) inserted inside to allow for speech (one way valve that should not be removed)
- Capnography should be placed over the stoma, if placed over the mouth it will be 0 (confirming a laryngectomy)
Laryngectomy complications
- Pharyngocutaneous fistulas, dehiscence and local haematoma in 7-10 days post surgery
- Obstruction by FB (parts of the stoma care or the TEP dislodging)
- Excess secretions (try 5mls of N. saline to break it up, suction)
Carotid Blowout Syndrome
- More common than tracheo innominate fistula in Lx (TIF rare in Lx patients due to lack of inner cannula)
- When the carotid or its branches erode into the Lx
- Heralded by new haematoma, bruise or bleeding
- Secure with ETT, direct pressure, early surgical/IR and MTP
Laryngectomy Emergency
- Call ENT/Anaesthetics
- Arrange OT
- NRB 15L to stoma +/- face if unclear of Lx vs Tx
- Can place LMA or paediatric face mask with BVM over stoma
- Ideally Mapleson C circuit with T-piece, but BVM will do
- Capnography to stoma
- Difficult airway trolley, ideally fibreoptic scope, size 6 or smaller ETT, trahcoestomy kit, soft suction catheters and bougie
- Remove outer covering, HME, any inner cannula and suction
- If not working then remove outer cannula as well (only stoma left)
- Never remove the TEP
- If still not working then ideally fibreoptic guide size 6 ETT into stoma
Tracheostomy Emergency
Tracheoinnominate fistula
- Overinflate the Tx balloon
- If fails then remove cannula and place finger into Tx and put direct pressure over bleeding site
- Ideally intubate from above to maintain airway in this situation
Approach to the Geriatric Airway and peri-intubation?
Issues
- Increased likelihood to need to be intubated due to lack of reserve
- Increased difficulty with BVM (missing teeth, less facial tissue)
- Reduced cardiopulmonary reserve leading to faster hypoxia and hypotension
- Need for adjustment of drug doses
- More friable airway tissue and may bleed easier (ie on anticoagulants)
- At greater risk of C-spine injury from laryngoscopy
Physiologic changes
- Impaired gas exchange
- Increase V/Q mismatch
- Decreased lung elasticity/decreased compliance leading to increased WOB
- Less chest wall muscle
- Reduced cough and mucocilliary clearance (aspiration risk)
- Reduced brain responsiveness to hypoxaemia and hypercarbia
- Heightened sensitivity to negative inotropy/vasodilation from induction agents
- Greater number of co-morbidities
Modifications
- Inquire about patient wishes and advanced care directives prior to intubation
- Adequate pre-oxygenation and apnoeic 02/BVM through apnoeic period
- Adequate cardiovascular resuscitation prior to induction, consider bolus/infusion vasopressors
- Normal dose of paralytics, but decrease induction dosing by 30-50%
- Use of 2-hand technique and NPA/OPA for BVM
- Use of VL and adjuncts to aid intubation
- Consider awake intubation
Approach to the Obese airway and peri-intubation?
Issues
- Increased thoracic fat distorts airway position when on back
- Large breasts
- Reduced intraoral space
- Harder to palpate CTM
- Raised Intra-abdominal pressure increased the risk of aspiration
- Facial fat makes BVM harder
- Reduced FRC and atelectasis
- Higher metabolic demand leads to faster desaturation
- Difficult IV access
- less reliable NIBP readings
Modifications
- use ramping to get tragus in line with sternal notch
- Consider short handly laryngoscope for large breasts
- Vertical incision then dissect down to CTM before horizontal CTM cut
- 2-handed BVM technique with NPA and OPA
What is the predicted BVM difficulty mnemonic?
MOANS
Mask Seal
- Bushy beard, crusted blood, disruption to facial continuity in trauma
Obesity/Obstruction
- Obesity, pregnancy, angioedema, ludwigs angina, upper airway, abscess, epiglottis
Age
- >55
No Teeth
- Leave dentures in edentulous patients
Sleep Apnoea/Stiff lungs
- COPD, asthma, ARDS
What is the predicted intubation difficulty mnemonic?
LEMON
Look externally
- Lower facial disruption, bleeding, small mouth, agitated patient
Evaluate (3-3-2 rule)
- Mouth opening >3 fingers
- 3 finger breadths from tip of mandible to anterior neck
- 2 fingers from the base of the mandible to the thyroid neck
Mallampati Score
- I Complete visualisation of soft palate
- II Complete visualisation of the Uvula
- III base of the uvula only
- IV No soft palate seen
Obstruction/Obesity
- obesity
- stridor, muffled voice, not swallowing secretions, sniffing position/tripod
Neck Mobility
- Trauma C-spine precautions
- Arthritis, ank spondylitis
What is the mnemonic for difficult LMA insertion?
RODS
Restricted mouth opening
Obstruction
Disrupted/Distorted anatomy
Stiff lungs/cervical spine
What is the mnemonic for difficult front of neck access?
SHORT
Surgery
- ie previous laryngectomy etc
Haematoma
- also infection, abscess, any swelling
Obesity/Obstruction
Radiation
- To the neck, distorts tissue planes
Tumour
- Neck and mediastinal tumours
An approach to massive haemoptysis SCBD
Life Threats!
- Massive PE
- Eroded tumour (Lymphoma, mets, primary bronchial tumour)
- Severe pneumonia or abscess (staph, strep, legionella)
- AVM or aortobronchial fistula
- aortic aneurysm
- Tracheoinnominate fistula or Carotid blowout syndrome (laryngectomy and tracheostomy patients)
- Severe coagulopathy/DIC (including leukaemia)
- Severe congenital or acquired heart disease or pulmonary hypertension (RHD with MS as example)
- Trauma or iatrogenic ie post procedural
DDx
- Bronchitis or Bronchiectasis (chronic infection, cystic fibrosis)
- TB
- Foreign body
- Non-eroding tumour
- Vasculitis (Wegeners, Goodpastures, SLE)
- Cocaine
- Mimics (haematemesis, post tonsillectomy, epistaxis)
History
- Rate, amount, and appearance (more than 500mls highly concerning)
- Previous episodes
- Known PHx
- PE risk factors
- Recent trauma/surgery
- Bleeding diathesis
- Medications (ie anticoagulants)
Investigations
- FBE and film
- Group and hold + cross match
- VBG, BSL and electrolytes
- Coags, D-Dimer, troponin
- ECG
- Sputum culture
- CXR/CTPA
- Early bronchoscopy
Emergency Management
- Soiled airway algorithm, difficult airway trolley, low threshold for FONA
- ENT/Resp/ICU/Anaesthetics
- Massive transfusion protocol, TXA 15mg/kg bolus then infusion (+/- Vit K, prothrombinex)
- Bleeding lung down (if known)
- Large bore ETT (ideally 8.5 or 9)
- Consider specifically intubating the R) or L) mainstem with 90 degree rotation, then can consider bronchial blocker post
- Anaesthetics may consider a double lumen tube
- Ultimately needs IR and angioembolization +/- thoracic surgery
What strategies can be implemented to tackle the physiologic challenges of intubating a critically ill patient?
Pre-oxygenation
- NRB or NIV
- Sit up until last moment
Apnoeic 02
- Nasal prongs vs BVM
Avoid Acidosis
- Important if already very acidotic or acid sensitive ie aspirin/TCA OD
- NIV, BVM in apnoeic period for ventilation, sodi bic
Hypotension
- Adequate pressors/fluids
- Reduced dose induction agents
Hypertension
- Pre-induction ie 2mcg/kg Fentanyl
- Important for hypertensive crises and strokes/bleeds
Aspiration
- Suction, head up 30 degrees
- SALAD
Difficult airway
- Most senior operator, VL, hyperangulated blade, ETT adjuncts
Pulmonary oedema
- NIV, BVM with PEEP
- Suction, vasodilators
- Sit upright, avoid fluids
General Answer to Intubation Q
Equipment
- ETT, bougie/stylet, adjuncts, difficult airway trolley, suction and justify)
Drugs
- type, doses and justify
Peri-Induction/Intubation
- Positioning, pre-oxygenation, resuscitate before intubate
Ventilator Settings
- based on clinical scenario
Post Intubation
- capnography, CXR, equal chest rise, auscultation, fogging, sedation and paralysis, NGT and IDC
Disposition
- Theatre vs retrieval vs ICU
Spinal cord injured patient
High risk C-spine fractures
Jeffersons fracture
- C1 burst fracture
- Diving
Hangman’s Fracture
- C2 fracture
Bilateral facet joint dislocation
- Buckling or hyperflexion
- Anterolisthesis of the cephalad vertebra compared to the caudad vertebra
Flexion tear drop
- Hypeflexion
- Diving injuries
Chance fracture (thoracolumbar)
- T12/L1 hyperflexion
- Back seat car crash
Spinal Cord Injury complications ED
- Neurogenic shock
- Respiratory failure
- Expanding haematoma in the neck
- Urinary retention
- Aspiration
- Hypothermia from reduced autonomic regulation
- Pressure areas (if delay to transfer)
Spinal shock and Neurogenic shock
- not a true form of shock, it refers to the flaccid areflexia that occurs after spinal cord injury, and may last hours to weeks
- It may be thought of as ‘concussion’ of the spinal cord and resolves as soft tissue swelling improves. - Priapism may be present with complete transection (complete loss of sympathetics)
- Bulbocavernosus reflex is present in incomplete lesions with spinal shock but absent in cord transection/complete lesions (sacral sparing in incomplete lesions)
- Spinal shock at a level above T6 can lead to neurogenic shock
- Neurogenic shock is hypotension, bradycardia and peripheral vasodilation
SPINAL CORD SYNDROMES
Anterior Cord
- Complete paralysis below lesion + loss of pain and temp sensation
- Intact posterior columns including vibration and proprioception
- Poor prognosis
Central cord Syndrome
- Upper > Lower limb quadriparesis and loss of pain/temp sensation
- Good prognosis
Brown-Sequard Syndrome
- Ipsilateral loss paresis and loss of proprioception/vibration
- Contralateral loss of pain and temperature, these tracts cross the midline
General Management
- Assess and treat ABC’s (ETT, 02, fluids, inotropes)
- Spinal immobilisation/precuations!!
- Analgesia
- Early discussion with Neurosurgical or trauma service, organise retrieval if not on site
- Consider cause for injuries (intoxication, pathological fall, NAI or domestic violence, suicide attempt etc)
- Assess and manage associated injuries
- Attend to predicted complications (IDC, NGT, keep warm, fast, IV fluids, pressure ulcers etc)
General approach to severe burns?
Resuscitation
Initial
- Send for help, trauma call, consider anaesthetics and ENT, massive transfusion protocol
- Analgesia as needed (IN fent)
Airway
- Assess for airway burns, airway trauma and obstruction, intubate as required
- Consider awake fibreoptic intubation/laryngoscopy, ketamine with topicalisation
Breathing
- Assess for chest wall injuries
- Consider need for escharotomy for chest wall burns
- Lung protective ARDS strategy if intubated
Circulation
- IV Saline bolus +/- MTP for shock
- Modified Parklands (3 x kg x TBSA), 50% in 1st 8hrs and 50% next 16hrs
- Early urinary catheter for adequate fluid balance assessment (1ml/kg/hr)
- In children also give maintenance fluid (4:2:1 rule)
- If fluid given prior then take this off the full parklands formula amount
- Some centres may also adjust rate based on number of hours since burn and also halve the parklands formula calculated amount to account for increased vascular permeability
Disability
- Fentanyl and ketamine for analgesia
- Assess for concomitant head/spine injuries
- Seek and treat hypoglycaemia, add 5% dextrose to Hartmans/saline
Extra/Environment
- Burns first aid
- Temperatures management
- Clean, debride and assess burn % and depth (Lund and Browder chart)
- Transfer if not at tertiary centre
Approach to the critical trauma patient and traumatic cardiac arrest?
Permissive hypotension
- Minimal actual data
- Works best for penetrating thoracoabdominal trauma
- Contraindicated in head injured patients
- Relative contraindication in spinal cord injuries, small children, pregnant patients, pre-load dependent patients and those with baseline significant hypertension
- Usually 1L of crystalloid then blood products as needed, aiming SBP 80-90mmHg or palpable radial pulse and GCS 15
- Rationale is to reduce clot disruption and not contribute to the lethal triad of trauma
- Saline is acidic, cold and dilute the blood (clotting factors)
Massive Transfusion Protocol
Definition
- >10units of RBC’s or whole blood in 24hrs
- Others include use >4units in 1hr, >40ml/kg RBCs, >1 blood volume replacement in 24hr or >50% blood volume in 4hrs
Indications
- Severe thoracic, abdominal, pelvic or long bone trauma
- Anticipated ongoing haemorrhage
- Major obstetric, surgical/GI bleed
- TASH (trauma associated severe haemorrhage score) can be used to predict who will need it
Physiological Aims
- Temp >35, pH >7.2
- Lactate <4, BE <-6
- Ionised Calcium >1.1
- PT/APTT <1.5x normal
- INR <1.5, Fibrinogen >1.0
- Platelets >50
Hanging SCBD
History points
Prognostic indicators
- Down time, first aid/BLS, inital vital signs and GCS
- Cardiac arrest at scene
- Estimated height of fall if did fall
PAIDEM’s
- Co-morbidities
- Drug, alcohol and mental health issues
Other injuries/pathology
- Other trauma, co-ingestion, environmental exposure
Clinical Features
- External trauma to neck (ie ligature marks)
- Significant facial oedema and cyanosis
- Tardieu spots (petechiael haemorrhages in the conjunctiva and mucous membranes cephalad to ligature, associated with asphyxiation death
- Thyroid cartilage and hyoid bone fracture
- BCVI, particularly carotid injury
- Hypoxic ischaemic encephalopathy
Complications
- HIE
- Cardiac arrhythias/arrest from hypoxic ischaemia
- Negative pressure APO
- Neurogenic APO
- Hyoid, thyroid and C-spine fractures
Testing
- Head and neck CTA + CTB
Approach to Bradycardia
Stable vs Unstable
Symptomatic vs Asymptomatic
Reversible causes
Anatomic location
- Wide QRS vs narrow WRS
Approach to Ventricular Tachycardia
Classification
- Structurally normal vs structurally abnormal heart
- Monomorphic vs polymorphic
- Stable vs unstable vs pulseless
DDx for wide complex tachy
- Monomorphic VT
- Polymorphic VT
- SVT with aberrancy
- AF/flutter with aberrancy
- HyperK and TCA
- Pacemaker mediated tachycardia
-
Risk factors for VT
- Structural heart disease
- Channelopathies
- Acute ischaemia
- Ischaemic cardiomyopathy
- Electrolyte disturbance
- Hypothermia
- QT prolongation
- Age >35
Brugada Criteria
- See pic
- 98% sensitive and 96% specific
- Cannot reliably distinguish VT from Antidromic AVRT, no well validated algorithm can
Basel Criteria
- 93% sensitive, 90% specific, takes substantially shorter time to apply the criteria
- VT present if 2 or more of the 3 criteria are present
- 1: High risk clinical feature (History MI, history of ICD, history of HFrEF <35%)
- 2: Lead II time to first peak (ie when QRS changes direction) of >40ms
- 3: Lead AVR time to first peak >40ms
Antidromic AVRT vs VT
- Rule not validated but sometimes used, realistically need EP lab
- Rule about 70% sensitive, but 100% specific
- If yes to any then treat as VT
1- Predominantly -ve QRS in V4-6?
2- Presence of qR complex in any of V2-6?
3- AV dissociation?
Chemical Cardioversion
- Amiodarone 5mg/kg bolus followed by infusion
- Procainamide 15mg/kg IV
- Lignocaoine 1-1.5mg/kg bolus followed by infusion
Electrical cardioversion
Pulseless
- Unsynchronised 200J DC biphasic or 360J monophasic
-
Pulse
- 100-200J (1, 2, 4j/kg) synchronised
Electrical storm
Definition
- VT recurring within 5mins of cardioversion
- 3 or more episodes in 24hrs
- more PVC’s than sinus beats in 24hr
- Includes VT, pVT and VF
Triggers
- Drug toxicity or electrolytes
- Acute ischaemia
- Thyrotoxicosis
- QT prolongation
- New or worsened heart failure
Treatment
- Cardioversion
- Coronary revascularisation if ischaemia
- IV Amiodarone infusion
- IV/oral beta blocker (propranolol, sotalol or esmolol)
- Stellate ganglion block or thoracic epidural anaesthesia
- Intubation and ongoing sedation (reduces sympathetic tone)
Refractory VT
- As for electrical storm
- Overdrive pacing (above VT rate) followed by decremental pacing to slower rate (often done by AICD, but can be done with TV or TC pacing)
Polymorphic VT
- Congenital vs acquired (ischaemic vs non-ischaemic)
- Distinction based on differing treatment algorithms
- Long QT vs no long QT
Congenital
- Long QT, Catecholaminergic PVT and rarely Brugada syndrome
- General treatment is to slow down the rate with IV betablockers
Non-Ischaemic
- Almost invariably from long QT
- Antiemetics, psychotropics, antbiotics and antiarrhytmics
- Low K/Mg/Ca
- Hypothermia, RICP
- General treat with Mg+ and overdrive pacing, can consider Lignocaine
- Replace specific electroltyes and give specific antidotes if tox
- Amiodarone contraindicated
Ischaemic
- Causes both TdP from long QTc and PVT without long Qtc from myocardial irritability
- Thrombolysis/PCI, reduce ischaemia
- Overdrive pacing may worsen ischaemia and worsen situation
- Amiodarone contraindicated if QTc long, but not if PVT from with normal QTc
General approach to undifferentiated shock?
General
- Consider the 5 causes of shock
Cardiogenic
- Arrhyhtmia, heart failure, ischaemia, myocardial contusion
Distributive
- Sepsis, anaphylaxis, neurogenic
Hypovolaemic
- Haemorrhage, sepsis, dehydration
Obstructive
- PE, tamponade, pneumothorax
Dissociative
- Severe anaemia
- Aspirin, CO, cyanide
Tip
- List relevant differentials as above, demonstrates thinking broadly
- Say as part of HEI how you would rule in or rule out the above
RUSH Protocol
- See image
- Add on DVT and ectopic pregnancy screens as indicated
- Assess for cardiac causes, PE, tamponade, dissection, AAA, haemopneumothorax and intrabdominal bleeding
Stridor approach and intubation?
Critical DDx
- Epiglottis
- Anaphylaxis/Angioedema
- Trauma with expanding haematoma in the neck
- Ludwigs angina
- Retropharyngeal abscess
- Peritonsillar abscess
- Bacterial tracheitis/Laryngo tracheo bronchitis (more common in children, still possible in adults)
- Aspirated foreign body
- Caustic substance ingestion/inhalation
- Diptheria
Emergent DDx
- Trauma with non-expanding neck haematoma
- Tumour with mass lesion effect in the neck
- Laryngomalacia
- Subglottic stenosis
- Vocal cord dysfunction
Intubation approach
- Ideal is AFOI
- next is gas induction in theatre
- Next is laryngoscopic ketamine and lignocaine assisted awake intubation
- Next is double set up with RSI and FONA
- Alternatiely elective cricthyroidotomy or tracheostomy
- Dexamethasone 0.6mg/kg and nebulised adrenaline 5mg (5x 1:1000)
Intubation with C-spine injury
MILS
- remove collar and have an assistant keep the head in the neutral position
- Place hands on angles of mandible or on side of head
Different options
- See pic
Risk
- Very low, only small retrospective studies
- If unable to intubate during laryngoscopy, remove MILS (airway over c-spine)
Head injury intubation
Oxygenation
- PREVENT HYPOXIA
- Adequate pre-ox
- Apnoeic 02 or bag during the apnoeic period
CO2
- Prevent hypo/hypercarbia!
- Attach capnography to BVM
- Aim CO2 35-40 with BVM and post when ventilated
Blood pressure
- Avoid HYPER and HYPOtension
- If hypertensive them give 3-4mcg/kg of IV fentanyl
- Propofol for induction (low dose), ketamine not contraindicated and preferred if patient hypotensive
- Consider short acting hypotensive agents (ie esmolol)
- Reduce laryngeal stimulation and reflex hypertension, gentle laryngoscopy (video, optimise positioning, 1st pass, most senior operator)
- Consider lignocaine 1.5mg/kg IV
- Have short acting hypertensive ie metaraminol if BP drops
ICP
- Consider Mannitol 0.5gm/kg or 3ml/kg of 3% saline prior to intubation
- Head in neutral position, 30-45 degrees up, remove collar, dont use ETT tie
Paralysis
- Rocuronium preferred
- Sux may increase ICP
- Remain paralysed and well sedated post (prevent coughing, straining etc)
Post Intubation
- Aim CO2 35-40
- Sats 95% aim (avoid hypo and hyperoxia)
- Minimum PEEP necessary to avoid hypoxia
Drowning approach?
Assessment
- Immediate life threats
- Trauma including head/neck
- pulse present?
- Aspiration/lung injury
- Prognostic indicators
Exam
- Maintaining airway, signs of aspiration, adequacy of breathing (sats, RR)
- Signs of perfusion (Hr, BP)
- Temperature, at risk hypothermia
- Signs of head/neck trauma, neurological deficits, consider empiric spinal precuations
Good Prognostic factors
- Submersion time <5mins
- Time to effective BLS <10mins
- No CPR in progress on hospital arrival
- GCS >5
- Rectal temp >30C
- Arterial pH >7.1 on arrival
- 1st spont breath within 30mins
- Immersion in water <10 degrees C
Management
- Respiratory distress in semi conscious patient can escalate from NRB to NIV to intubation
- Decompress stomach with NG (often very distended)
- Support BP with judicious fluids and vasopressors
- No specific indication for antibiotics unless contaiminated water
Post intubation hypoxia and hypotension
Hypoxia
DOPES Mnemonic
- Displacement of ETT
- Obstruction of ETT
- Patient: pneumothorax, PE, aPO etc
- Equipment: Ventilator issue, tubing kinked, 02 disconnected etc
- Stacked breathes: Bronchospasm, incorrect ventilator settings
Management
- Disconnect tube and attached BVM
- Give 100% Fi02 with PEEp valve
- Determine patient vs Equpiment
- Check EtCo2, consider laryngoscopy to confirm position
- If BVM easy but no chest movmeent then likely dislodged ETT
- If BVM hard with slight chest movement consider R) mainstem, bronchospasm, hyperinflation and pneumothorax, block/kinked ETT
- If BVM easy, chest moves and patient improves then consider circuit/machine issue
Post Induction Hypotension
AAH SHITE Mnemonic
A- Acidosis
A- Anaphylaxis
H- Heart (tamponade, pHTN, arrhythmia)
S- Stacked breaths
H- Hypovolaemia
I- Induction agent
T- Tension PTX
E- Electrolytes
Management
- Assess for obvious cause based on 5 causes of shock
- CXR, bedside echo, ECG, examine
- judicious fluid bolus
- Early vasopressors including IM adrenaline for anaphylaxis
- As per DOPES disconnect and hand ventilate
- Decompress chest if needed
- Early discussion with ICU, consider IABP or ECMO
Heat stroke SCBD
DDx
- Sepsis (meningoencephalitis, Staph TSS etc)
- Toxidrome (SS, NMS, MH, anticholinergic)
- Intracranial bleed (SAH, thalamic bleed, head trauma)
- Metabolic (Hyperthyroid, hypoglycaemia, dehydration)
- Neurological (Post seizures, thalamic dysfunction)
Complications
-Rhabdomyolysis
- DIC
- Cerebral oedema
- AKI
- Multiorgan failure
Management
- Cooled IV fluids, usually hyperhydration due to concomitant rhabdo (1-2ml/kg/hr UO, IDC, early consideration of dialysis))
- Escalating cooling measures (remove clothes, tepid water, fans, ice packs, ECMO/DIalsysis, lavage)
- Intubation and paralysis (dont use Sux) for lung and neuroprotection but also prevent shivering
- Empiric broad spectrum antis if possibly sepsis
- Toxidrome antidotes if applicable
