ALS + ETLS Flashcards
Define Traumatic Brain Injury
Traumatic brain injury is an insult to brain tissue from an external force, leading to temporary or permanent impairment of cognitive, physical and psychosocial functions, with an associated diminished or altered state of consciousness
Pathophysiology of Brain Injury
Primary brain injury – skull #,IC hematoma, contusions,lacerations, DAI etc Acceleration and deceleration forces Secondary brain injury Prevent – Hypoxia - Hypovolemia - Hypo/hyperglycemia ? Prevent hyperthermia
Classification of shock
Stage 1 Shock - symptoms /signs
15:LOVE 15% Blood Loss Slight increase in respiratory rate Pulse up to 100 bpm Feeling nervous Capillary refill under 2 seconds Slightly pale Feeling thirsty BP normal
Classification of shock
Stage 2 Shock - symptoms /signs
30:LOVE 15%-30% Blood loss Raised respiratory rate Pulse over 100 bpm Starting to feel anxious Capillary refill at or over 2 seconds Pale/Cool Clammy Dry mouth Narrowing pulse pressure
Classification of shock
Stage 3 Shock - symptoms /signs
40:LOVE
30%-40% Blood Loss Increased Respiratory rate Pulse over 120 bpm Anxiety/agitation Pale/Cold Peripheral cyanosis Diaphoretic (profuse sweating) BP falling
Classification of shock
Stage 4 Shock - symptoms /signs
GAME OVER
>40% Blood Loss Respiratory distress Pulse over 140 bpm Confused/loss of consciousness Moribund appearance Central cyanosis Diaphoretic (profuse sweating) BP less than 70 mmHg systolic
45 yr old man burning rubbish in his back garden sustained burns to arms and chest. Bought in by ambulance (paramedic crew) 1 litre of 0.9% saline running i.v.
A: Clear, O2 mask in situ, screaming in pain
B: RR 28, chest clear, sats 99%. Obvious erythema and blistering/charring to anterior chest
C: HR 128, BP 136/85,
D: AVPU
E: Burns to both arms to elbows, anterior chest wall, under chin with singed hair on fringe/ eyebrows. Burns dressings in situ.
ABCDE History BSA Rule of 9’s Serial Halving Depth
Management
Fluids – 24 hours requirements
4ml x %BSA x kg
4 x 20 x 80 = 6,400mls
50% in first 8 hrs (3,200 ml)
Remainder over next 16 hrs
Does not include normal maintenance fluids
Urinary catheter is placed.
What is the aim for urine output?
Urine output - 0.5 – 1ml/kg/hr
Management of Burns
Management
Fluids – 24 hours requirements
4ml x %BSA x kg
4 x 20 x 80 = 6,400mls
50% in first 8 hrs (3,200 ml)
Remainder over next 16 hrs
Does not include normal maintenance fluids
Fluid regime in burns - what urine output should be aimed for?
Classification of shock Immediate management of burns Fluid regime 4mls x BSA x weight (kg) Urine output - 0.5 – 1ml/kg/hr
What is the Trimodal Death Distribution ?
1st peak: seconds to minutes
2nd peak: minutes to several hours
3rd peak: several days to weeks
True or False: ST-segment-elevation myocardial infarction (STEMI): Rarely causes VF.
False - During the acute phase, there is a substantial risk of VF.
True or False: ST-segment-elevation myocardial infarction (STEMI): A posterior STEMI will show ST depression in leads V1‒3.
True
True or False:ST-segment-elevation myocardial infarction (STEMI): May present with new left bundle branch block (LBBB) on the ECG.
True. New LBBB is diagnostic of STEMI.
True or False: When using transcutaneous pacing: Electrical capture typically occurs with a current of 5‒10 amps.
False Capture typically occurs with a current of 50‒100 mA (i.e. 100 times less).
True or False: When using transcutaneous pacing: May be unsuccessful in a patient with hyperkalaemia.
True. Hyperkalaemia may prevent successful pacing.
True or False: When using transcutaneous pacing: Movement artefact may inhibit the pacemaker.
True. If there is lot of movement artefact on the ECG this may be misinterpreted by the pacemaker and inhibit it.
True or False: When using transcutaneous pacing: Electrical capture and generation of a QRS complex ensures return of a pulse.
False. A QRS complex does not guarantee myocardial contractility. Absence of a pulse in the presence of good electrical capture constitutes PEA.
True or False: With regard to the ECG: Continuous monitoring via self-adhesive pads is preferable to using ECG electrodes.
False. Adhesive defibrillator pads should only be used in an emergency to assess the cardiac rhythm.
True or False: With regard to the ECG: If adhesive electrodes are used for 3-lead monitoring, they should be applied over bone rather than muscle.
True. Electrodes should be placed over bone rather than muscle to minimise interference from muscle artefact.
True or False: With regard to the ECG: The normal QRS complex has a duration < 0.12 s.
True. The normal QRS complex interval is < 0.12 s (< 3 small squares).
True or False: In drowning: There is immediate entry of water into the victim’s lungs.
False. There is initially laryngospasm and breath holding preventing entry of water into the victim’s lungs
True or False: In drowning: Resuscitation should be considered even if the patient has been submersed in water for 5 min.
True. Submersion durations of less than 10 min are associated with a very high chance of a good outcome and submersion durations of more than 25 min are associated with a low chance of good outcome.
True or False: In drowning: Q4c: Following submersion, respiratory arrest usually precedes cardiac arrest.
True. Cardiac arrest is usually a secondary event following a period of hypoxia.
True or False: In drowning: Prophylactic antibiotic therapy should be given routinely.
False. Prophylactic antibiotics have not been shown to be of benefit in preventing chest infection.
True or False: You arrive at the bedside 4 min after the cardiac arrest of a 70 kg woman. An IV line is in place, there is no pulse. The ECG confirms asystole. Two nurses are performing CPR competently. You would recommend: Delivery of a 150 J shock.
False. The treatment of asystole does not include defibrillation.
True or False: You arrive at the bedside 4 min after the cardiac arrest of a 70 kg woman. An IV line is in place, there is no pulse. The ECG confirms asystole. Two nurses are performing CPR competently. You would recommend: Sodium bicarbonate 500 mmol IV.
False. Routine use not recommended and is associated with a number of significant side-effects.
True or False: You arrive at the bedside 4 min after the cardiac arrest of a 70 kg woman. An IV line is in place, there is no pulse. The ECG confirms asystole. Two nurses are performing CPR competently. You would recommend: Calcium chloride 5 mL 10% solution IV.
False. Indicated only for PEA caused by hyperkalaemia, hypocalcaemia and overdose of calcium channel blocking drugs.
True or False: You arrive at the bedside 4 min after the cardiac arrest of a 70 kg woman. An IV line is in place, there is no pulse. The ECG confirms asystole. Two nurses are performing CPR competently. You would recommend: Adrenaline 1 mg IV.
True. Adrenaline 1 mg IV should be given as soon as intravascular access is achieved in patients in asystole.
True or False: A 55-year-old man on CCU has a witnessed, monitored VF cardiac arrest. After the 3rd shock he develops sinus rhythm with a pulse and starts to breathe spontaneously. He is given oxygen via a reservoir mask with a flow of 15 L-1. Analysis of blood gas shows: PaO2 22.6 kPa (FiO2 85%). These suggest that oxygenation is appropriate for the inspired concentration.
False. The PaO2 should be numerically about 10 less than the inspired concentration. In this case this would be > 60 kPa.
True or False: Pulseless electrical activity (PEA):
Is rarely the first monitored rhythm in a cardiac arrest.
False. The first monitored rhythm is VF/pVT in only 20% of cardiac arrests. Therefore, PEA and asystole are relatively more common.
True or False: Pulseless electrical activity (PEA): Is characterised by evidence of ventricular activity on the ECG that would normally be associated with a pulse.
True. This is the definition of PEA.
True or False: Pulseless electrical activity (PEA): Should be treated by giving 300 mg amiodarone IV.
False. Amiodarone is only indicated in the treatment of cardiac arrest due to VF/pVT.
True or False: Pulseless electrical activity (PEA): Is usually the cardiac arrest rhythm in patients with severe hypovolaemia.
True. Hypovolaemia, usually caused by severe haemorrhage, will cause PEA.
True or False: If a DNACPR decision is made with a person who has an implanted cardioverter-defibrillator (ICD) the shock function of the ICD should then be deactivated.
False. Some people with ICDs may not want to receive CPR, but would choose to receive treatment from their ICD which would be likely to restore their current clinical situation.
True or False: Adrenaline:
Has purely alpha-adrenergic effects.
False. Adrenaline has both alpha and beta-adrenergic effects.
True or False: Adrenaline: Is not associated with any long-term benefit to patients when given during a cardiac arrest.
True. Although there is no evidence of long-term benefit from the use of adrenaline, the improved short-term survival documented in some studies warrants its continued use.
True or False: Adrenaline: Increases systemic vasoconstriction.
True. This is due to the alpha-adrenergic effect of adrenaline.
True or False: Adrenaline: Improves coronary and cerebral perfusion pressures during CPR.
True. These are some of the alpha-adrenergic effects.
True or False: When monitoring the cardiac rhythm: Asystole presents as a completely straight line.
False. A completely straight line indicates usually that a monitoring lead has become disconnected.
True or False: When monitoring the cardiac rhythm: At a standard paper speed of 25 mm s-1 the ventricular rate is calculated by dividing the number of large squares between consecutive R waves by 60.
False. The best way of estimating the heart rate is to count the number of cardiac cycles (R wave to R wave, including fractions) that occur in 6 s (30 large squares) and multiply by 10. This provides an estimate of heart rate, even when the rhythm is irregular.
True or False: When monitoring the cardiac rhythm: A ventricular tachycardia will always require immediate cardioversion.
False. Cardioversion is required only if adverse features (e.g. shock, syncope, heart failure).
True or False: When monitoring the cardiac rhythm: A 55-year-old woman presents with a 1 h history of crushing central chest pain, nausea and sweating. Her pulse rate is 38 min-1, BP 75/45 mmHg. The ECG monitor shows sinus bradycardia. You would recommend that:
Atropine 500 mcg IV should be given.
True. Atropine is the first line treatment in a bradycardia with adverse features in an attempt to increase heart rate and cardiac output.
True or False: When monitoring the cardiac rhythm: When monitoring the cardiac rhythm: A 55-year-old woman presents with a 1 h history of crushing central chest pain, nausea and sweating. Her pulse rate is 38 min-1, BP 75/45 mmHg. The ECG monitor shows sinus bradycardia. You would recommend that: An adrenaline infusion, 20‒100 mcg min-1, may be required.
False. An adrenaline infusion may be required, but the correct rate is 2‒10 mcg min-1 IV.
