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cardiac arrest and trauma Flashcards

1
Q

goal TTM and why

A

the goal is normothermia (36C)
- source: Nielsen TTM trial

no clear benefit to hypothermia (33C) in comparison

hypothermia

  • is more hemodynamically unstable (can induce bradycardia - dangerous if there’s underlying torsades)
  • can induce dangerous electrolyte shifts
  • suppresses immune fx (a/w increased rates of PNA)
  • delays accurate neuroprognostication
  • keeps us from focusing on why the pt arrested (THE MOST IMPORTANT QUESTION)
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2
Q

Who needs TTM?

A

reliable hx that indicates no anoxia (i.e. witnessed arrest, immediate CPR, ROSC < 5m)?
- if yes, no TTM

following verbal commands post-arrest?
- if yes, no TTM

if no to both, perform TTM
- basically, any unresponsive post-ROSC pt w/anoxic injury

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3
Q

how to induce TTM36

A

external cooling device + anti-shivering package: scheduled APAP (1000q6), hydrocortisone (50q6), buspirone (30q8), and mag repletions

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4
Q

post-arrest interventions: imaging, procedures, neuro, cards, resp, renal, GI, ID

A

imaging: RUSH, panCT
procedures: central line, a line, Foley

  • neuro: TTM36, vEEG, anti-shivering package
  • cards: EKG, cards cs for cath or antiarrhythmic recs if possible cardiac cause, MAP > 75 w/pressors PRN
  • resp: TV 6-8 mL/kg, normoxia, normocarbia
  • renal: repletions
  • GI: ppx
  • endo: hydrocortisone, normoglycemia
  • ID: abx (post-arrest SIRS ~ septic shock)
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5
Q

post-arrest vitals targets

A
  • MAP > 75 to optimize the anoxic brain’s perfusion
  • normocapnia: get the ETCO2 30-35, then get an ABG
  • normoxia: 92-96%
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6
Q

early-onset myoclonic status: definition and significance

A

myoclonic jerks that happen w/n 24h of arrest and last > 30m, w/burst suppression on EEG = a bad sign

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7
Q

post-arrest sedation

A

propofol w/pressors PRN (lets you get a neuro exam, decreases shivering)
- avoid Fentanyl and benzos

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8
Q

arrest: immediate actions

A
  • compressions
  • access (IV/IO)
  • LMA BVMs
  • monitor and pads > ID rhythm
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9
Q

VF/pulseless VT actions (rounds 1-3)

A
  1. shock 200J, compressions x 2m > epi if no ROSC
  2. amio 300 > 150 or lido 100 > 50 q5-10m + 2g mag > repeat
  3. esmolol
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10
Q

asystole/PEA actions

A
  • epi q3-5m
  • cardiac/lung US
  • ID rhythm and calcium if wide
  • consider: LR/blood, tox
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11
Q

3 major causes of PEA and what to do

A

3 & 3 rule:

  1. hypovolemia
  2. obstruction: PTX, tamponade, massive PE
  3. pump failure (MI w/myocardial rupture)
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12
Q

3 causes of wide-complex PEA

A

hyperK, TCA tox, MI w/pump failure

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13
Q

definition of refractory VF

A

after 3 shocks, 3 epis, amio, lido

don’t use this in resistant VF, i.e. if they shock, come back, go out, etc.

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14
Q

refractory VF: how to do dual sequential defib

A

while compressions are ongoing, place second set of pads and shock together @200J > 1, 2, 3, shock

don’t let any of the pads touch or you’ll destroy the machines

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15
Q

refractory VF: how to give esmolol for “electrical storm”

A

50 mg bolus (“normal bolus dose”), repeat x1 –> if it helps, 50 mcg/kg/min gtt

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16
Q

medication to avoid in refractory VF

A

epi - do not contribute to the catecholamine surge

17
Q

how to give lytics

A

weight-based tenecteplase (max 50 mg if > 90 kg)

18
Q

resistant VF: strategy

A

start w/esmolol sooner and consider cath lab/weight-based tenecteplase (max 50 mg if > 90 kg)
- delayed cath if ST elevations are improving, cath now if they’re persistent

19
Q

massive PE tx

A

3 arms: lytics decision, maintain perfusion, maintain oxygenation

  • lytics: if absolute contraindication, IR/surgical thrombectomy; if relative contraindication, 50 mg alteplase; if no contraindication, 100 mg alteplase
  • perfusion: norepi > inhaled NO if that fails
  • oxygenation: if hypoxic/dyspneic, HFNC; AVOID INTUBATION
20
Q

approach to the bradycardic neonate

A

30 sec BVM > if ineffective,

  1. pulse ox on R hand/wrist (preductal)
  2. HR monitoring w/3-lead EKG
  3. MR SOPA
M - mask adjustment
R - reposition airway
S - suction nares
O - open mouth (jaw thrust, OPA, NPA, shoulder roll)
P - PEEP to 5-8 and PPV >20 (max 40)
A - advanced airway (LMA, then ETT)
21
Q

goals of neonatal resus

A

warm, pink, and sweet

22
Q

neonatal temperature management

A

avoid hypothermia at all costs

  • > 32 wga w/good tone/respiration: towel, mom’s chest
  • younger, poor tone/respiration: infant warmer at 25C, wet infant in plastic bag up to neck, warm blankets

goal temp = 36.5-37.5

23
Q

neonatal stimulation

A

rubbing the back
flicking the soles
toweling the well >32 wga infant

24
Q

How long does it take a neonate to achieve a normal O2 sat?

A

can be up to 10m

25
Q

neonatal oxygenation

A

first of all, ventilation&raquo_space; oxygenation

term/late-preterm: 21% O2
preterm: 21-30% O2, then titrate to pulse ox

26
Q

neonatal ventilation

A

principle: recruitment

PEEP 5-8

27
Q

fat embolism definition and txx

A

post-traumatic (esp long bone fx) hypoxemia, neuro deficit, and nondependent petechiae

tx: supportive while sx resolve spontaneously

28
Q

What complication is typically the cause of death in fat embolism syndrome?

A

ARDS

29
Q

Jefferson fracture

A

C1 burst fracture
axial compression injury
rarely has neuro deficits
needs semi-permanent immobilization (i.e. Halo)

30
Q

atlanto-occipital dislocation

A

pure flexion injury that usually kills pt right away

31
Q

hangman fracture

A

C2 spondylolisthesis fracture

hyperextension fractures posterior elements of C2

32
Q

blast injury classes

A

1 - hollow organ injury
2 - projectiles
3 - thrown
4 - environmental hazard

33
Q

most common blast injury

A

TM rupture

34
Q

2 contraindications to IO placement

A

fracture, vascular disruption

35
Q

LeFort fractures

A 
1 = speak no evil (maxilla)
2 = see no evil (infraorbital)
3 = hear no evil (out to the sides)

2 and 3 can give you CSF rhinorrhea

36
Q

how to dose morphine in chronic pain pts

A

10% of daily morphine equivalents, then double, then double again

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