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A+E > ALS/ trauma > Flashcards

ALS/ trauma Flashcards

1
Q

why is it important to recognise the deteriorating patient?

A

to prevent cardiac arrest or be red for it - the quicker we act the better the outcome

majority of patients who arrest have clinical signs beforehand - they have slow and progressive deterioration (particularly hypoxia and hypotension) - if we notice and treat this we can prevent arrest, reduce morbidity and mortality

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2
Q

how can we recognise a deteriorating patient?

A

monitor vital signs regularly
use EWS to recognise when signs are abnormal - tells you weather the patient needs escalating to senior or how regularly their signs need monitoring (EWS of 5 then 1 hourly, EWS 2 then 4-6 hourly etc)

have them reviewed by clinician if necessary

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3
Q

what is the chain of prevention?

A

the process by which we aim to prevent a cardiac arrest e.g. by monitoring vital signs and allowing EWS to flag up any deteriorating patients

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4
Q

what is the main cause of cardiac arrest?

A

MI leading to VF (VF is the most common cardiac arrest rhythm seen)

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5
Q

what are the causes of sudden cardiac death?

A

Acute coronary syndrome - most common
non-ischaemic cardiomyopathy
valvular disease

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6
Q

briefly how are acutely unwell patients dealt with?

A

primary survey - A to E (treat any life threatening problems)
secondary survey - SAMPLE: signs and symptoms, allergies, medications, PMH/pregnancy, last meal, events leading up to illness. basically detailed history and examination and review notes and investigations

definitive treatment
consider non life threatening injuries e.g. broken hand.

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7
Q

what method do we use to call for help to keep the approach simple and thorough?

A

SBAR -

  • situation :introduce yourself, check who you are speaking to and where you are. identify patient and current problem
  • background: about patient, reason for admission, PHM
  • assessment: appearance, vitals, EWS
  • recommendation : what do you want from the person you are calling ..
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8
Q

when examining pupils, what could the following suggest..

a) one dilated
b) bilateral dilation
c) one constricted
d) bilateral constriction ?

A

a) brain injury, optic nerve injury
b) drugs (amphetamines), bilateral 3rd nerve palsy, brain hypoxia
c) sympathetic nerve injury
d) drugs, midbrain lesion, metabolic encephalopathy

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9
Q

what is agonal breathing?

A

occasional irregular gasps of air.

normal in early stages of cardiac arrest - should not be mistaken for life.

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10
Q

how deep should the bag in the bag valve mask ventilator be inflated to inflate the chest in cardiac arrest?

A

on 1/3 of the bag - sufficiently to expand chest but not over expand/ gastric dilation. if patient is smaller use even less of the bag.

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11
Q

how are chest compressions correctly given?

A

5-6cm deep or 1/3 of the depth of patient
rate 100-120 bpm
allow complete recoil after each compression

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12
Q

if cardiac arrest is witnessed and defibrillation pads are already on and ready, what can be done?

A

3 shock strategy
if rhythm is shockable you can give up to 3 successive shocks and look for regain of spontaneous circulation (ROSC).
continue with CPR if 3rd shock is unsuccessful

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13
Q

what energy is used for the first shock, second shock and 3rd shock?

A

200, 300, 360 joules

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14
Q

which rhythms are shockable? non-shockable?

A

shockable: VF and pulseless VT

non-shockable: asystole, pulseless electrical activity

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15
Q

how far should O2 devices be from patient when shocking?

A

1m away from patient chest.

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16
Q

what dose of adrenaline and amiodarone should be given in ALS and when are these given?

A

shockable rhythm:
- 300mg amiodarone and 1mg adrenaline after 3rd shock every 4 mins/ every other shock

non shockable

  • 1mg adrenaline straight away and repeat every 4 mins
  • no amiodarone given in non shockable

can give adrenaline as many times as CPR continues
can only give 5 doses of amiodarone.

(lidocaine can be given as an alternative to amiodarone but don’t give both)

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17
Q

list the 4 Hs and 4 T = reversible causes of cardiac arrest.

A

H: hypovolaemia, hyperkalaemia (hypoK, hypoglycaemia, acidaemia), hypoxia, hypothermia

T: thrombus, tamponade, tension pneumothorax, toxin

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18
Q

what should be done if circulation is regained after cardiac arrest?

A

A to E
ITU for recovery

Airway and breathing: maintain sats at 94-98% - usually require ventilation and waveform capnography recorded. If they regain consciousness consider extubating tracheal tube OR sedate the patient

circulation: 12 lead ECG, IV access, aim for SBP >100mmHg with fluids , intraarterial BP monitoring, consider vasopressor/ionotrope to maintain systolic. monitor lactate, urine output, ECHO
disability: keep temperature between 32 and 36 for >24 hours and prevent fever for atleast 72 hours. sedation can help reduce shivering. antipyretics and cooling can be used. monitor glucose (maintain below 10mM). treat any seizures. may require NGT and decompression of gastric air following bag valve mask ventilation.

diagnose cause of arrest and treat.
deal with aspects of post arrest syndrome
follow up and rehab 
document, communicate with relatives
hot breifing
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19
Q

what two parameters are known to be associated with bad outcome after arrest?

A

hyperthermia
high glucose - associated with poor neurological outcome.
The quicker ROSC after arrest the better recovery because less time for cerebral hypoxia

20
Q

why is it important to know a patients normal physiological reserve post arrest?

A

so that ITU know how long organs will need to be supported for.

21
Q

what is hot briefing?

A

all workers involved in arrest are briefed by team leader and an opportunity to raise concerns

22
Q

how do we work through 4Hs and 4Ts?

A

hypoxia - ensure oxygen is being correctly given e.g. endotracheal tube is correctly placed. O2 sats recorded
hypovolaemic - is blood loss suspected?
hyperK and other metabolic changes - blood tests and medical history should indicate this.
hypothermia - are they cold?

thrombus - are they likely to have MI/ P.E - depends how they presented?
tension pneumothorax - clinically made e.g. tracheal deviation, unequal chest expansion
tamponade - raised JVP, muffled heart sounds, likely reason for this?
toxins - known psych history, look at drug chart

23
Q

how are 4 Hs, 4Ts reversed?

A

hypoxia - oxygen
hypovolaemia - fluids/ blood
hypothermia- warm up
hypok/metabolic - IV CaCl can be used for hyperK, hypoCa, or Ca channel blocker overdose.

thrombus - thrombolysis/ PCI / stent
tamponade - pericardiocentesis
tension pneumothorax - decompression
toxin - antidote / dialysis

24
Q

how is death diagnosed after cardiac arrest?

A

absence of central pulse on palpation
absence of heart sounds on auscultation
one or more of:
- asystole on ECG
- absence of pulsatile flow using direct intra-arterial pressure monitoring
- absence of contractile activity using ECHO

should observe for 5 mins before confirming death.
after 5 mins, check:
- pupil responses
- corneal reflexes
- monitor response of supra-orbital pressure.

25
Q

what is a precordial thump?

A

whilst awaiting defib, a ‘thump’ with fist can be applied to patients chest to shock heart - rarely used now

26
Q

is survival after shockable or non shockable rhythms more likely?

A

more likely to survive with shockable rhythms

27
Q

what is waveform capnography? and what is its use?

A

measures end tidal CO2
shows you the effectiveness of ventilation and CPR

exhaled CO2 reflects metabolic activity and pulmonary blood flow and thus is a reflection of cardiac output and circulation effectiveness from CPR. in cardiac arrest patients we therefore expect CO2 to be low. by monitoring CO2 in real time we can assess the effectiveness of CPR.

this is most reliably measured via endotracheal tube.

therefore waveform capnography is useful for:

  • ensuring correct positioning of endotracheal tube
  • monitoring the ventilation rate of CPR
  • monitoring quality of chest compression
  • identification of ROSC - increase in tidal CO2 volume
  • prognostic - higher values are associated with better survival outcome
28
Q

what should be considered if IV access cannot be obtained in resuscitation?

A

intraosseous access - proximal humerus, proximal tibia and distal tibia

29
Q

when does cerebral hypoxia start after loosing a pulse and what does this mean?

A

3 mins after

earlier successful defib and ROSC, the better for neurological recovery.

30
Q

what are ionotropes and vasopressors and when are they used

A

ionotropes - for cardiogenic shock (adrenaline and dopamine)

vasopressors - for distributive shock (NA/vasopressin)

31
Q

how do defibrillators work?

A

passage of electrical current across myocardium to depolarise a critical mass of heart muscle simultaneously to try restart SAN

32
Q

what determines the chance of defib being successful?

A

transthoracic impedance - how well placed on chest e.g. made worse by hair and water
electrode position
shock energy is adequate

33
Q

what is difference between defibrillator and synchronised DC cardioversion?

A

defibrillator gives shock at any point in rhythm

synchronised DC cardioverter delivers shock at a specific point by synchronising with R waves of ECG. not used for arrest, used to treat arrhythmia.

34
Q

what does post cardiac arrest syndrome comprise of?

A

post cardiac arrest brain damage - coma, myoclonus, neurodysfunction, brain death. varying degree depending on duration of arrest

post cardiac arrest myocardial dysfunction - common but usually recovers in 2-3 days. hypotension, low CO and arrhythmias.

systemic ischaemic repurfusion response - activation of immunological and coagulation pathways resulting in multiorgan failure and increasing risk of infection.

persistent precipitating pathology - what caused the cardiac arrest in first place

35
Q

why is it important to maintain MAP after arrest?

A

brains normal regulatory mechanisms to maintain cerebral perfusion are lost.

36
Q

how is post cardiac arrest myocardial dysfunction treated?

A

early ECHO can determine degree of myocardial dysfunction.

treat with fluids, vasopressor/ ionotropes guided by HR, BP, urine output and lactate.

37
Q

what is the role of sedation post cardiac arrest?

A

reduces oxygen consumption
allows intubation for adequate ventilation
stops shivering so temperature can be controlled
short acting drugs such as Propofol allow neurological assessment when required.

38
Q

what is the prognosis after cardiac arrest?

A

not reliable until 72 hours later

based on neurological examination, biochemical markers and imaging of the brain

39
Q

what is DNA CPR

A

clinician decides if CPR is appropriate and discusses with family/ patient.
don’t stop CPR unless you see DNA CPR form and check identity matches

if someone is dying from an irreversible cause of death, the CPR is unlikely to work and even if it does, does not change anything and thus is most likely unpleasant and undignified.

40
Q

how are trauma patients managed?

A 
primary survery:
- catastrophic haemorrhage
- A to E:
secondary survery:
- SAMPLE 
- minor injuries dealt with
41
Q

what is blood on the floor and 4 more?

A

blood on floor
pelvis - blood in pelvis e.g. bruising
long bones - blood collected in long bones e.g.deformity of long bones/ swelling
blood collected in chest - tender
blood collected in abdomen - tender, tense, PR bleeding

42
Q

why should we be careful when administering fluids to trauma patients?

A

dilution of clotting factors

if systolic is too high it can promote further bleeding.

43
Q

what can priapism in a trauma patient suggest?

A

spinal cord injury

44
Q

why is hypothermia in trauma patients bad?

A

reduces clotting

peripheral shut down

45
Q

if IV access cant be gained in trauma patient what should be used instead?

A

intraosseous access

46
Q

what are the common reasons why breathing may be abnormal in trauma patients?

A

flail chest
tension pneumothorax
haemothorax

47
Q

what is the TWELVE FLAP acronym?

A

assessing breathing in trauma
TWELVE = trachea, wounds, emphysema, larynx crepitus, veins, expose (bleeding on chest, trauma etc)
FLAP = feel, look (expansion, symmetry, resp rate), auscultate, percuss

A+E (4 decks)

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