chapter 12- resuscitation in special circumstances Flashcards
causes of hyperkalaemia?
renal failure
drugs - ACE-I, ARB, Kt sparing diuretics, saids, bb
tissue breakdown- rhabdomyolysis, tumour lysis, haemolysis
metabolic disorders
endocrine disorders e.g. addisons
diet
ECG changes associated with hyperkalaemia?
tall tented T waves first degree heart block flat or absent P waves ST depression ST merging widened QRS VT bradycardia
Management of hyperkalaemia principles?
1) cardiac protection
2) shift K into the cells
3) remove K from the body
4) monitor K and glucose
5) prevent from reoccurring
Risks associated with treatment of hyperkalaemia?
hypoglycaemia following insulin administration
Tissue necrosis
rebound hyperkalaemia
management of hyperkalaemia in patient not in cardiac arrest?
10 ml calcium gluconate 10% IV
10 units of insulin in 25g glucose
management of hyperkalaemia in patient in cardiac arrest?
10 ml calcium gluconate 10% IV
10 units of insulin in 25g glucose
50mmol sodium bicarbonate (50ml of 8.4%) IV if severe renal failure
consider dialysis
causes of hypokalaemia?
diarrhoea drugs - diuretics, laxatives, steroids renal losses - diabetes insipidus endocrine disorders - cushings metabolic alkalosis
ECG changes hypokalaemia?
U waves
T wave flattening
ST segment changes
sepsis 6?
HIGH FLOW O2
IV ABX
IVF
URINE OUTPUT
BLOOD CULTURES
LACTATE
Doses of IM, IV, SC and IN naloxone?
400 mcg IV
800mcg IM
800mcg SVC
2mg IN
what is the duration of naloxone?
45-70 mins
ECG changes in TCA overdose?
widening of QRS
RAD
tachycardia
first line management of stimulant overdose?
small doses of benzodiazepines
GTN to relieve coronary vasoconstriction
symptoms of stimulant overdose?
agitation, symptomatic tachycardia, hypertensive crisis, hyperthermia, MI
what is the definition of anaphylaxis?
serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death. It is characterised any potentially life threatening compromise in airway, breathing and/or circulation.
Criteria for anaphylaxis?
1) sudden onset and rapidly progressing symptoms
2) life threatening airway and/or breathing and/or circulation problems
3) skin and/or mucosal changes (flushing, urticaria, angioedema)
what are some of the airway, breathing and circulation features of anaphylaxis?
A: airway swelling, hoarse voice, stridor
B: SOB, wheeze, patient becoming tired, cyanosis, respiratory arret
C: pale, clammy, tachycardia, hypotension, decreased consciousness, MI/cardiac arrest
D:
what is the algorithm for management of anaphylaxis?
1) AE
2) diagnosis - look out for sudden onset of airway, breathing and/or circulatory problems and usually skin changes
3) call for HELP
4) remove trigger + lie patient flat (if pregnant - lie of left side)
5) give IM ADRENALINE (0.5mg, i.e 0.5ml of 1:1000 adrenaline)
6) establish airway, give high flow O2, apply monitoring
7) if no response - repeat IM adrenaline after 5 mins + IV fluid bolus
8) if no improvement despite 2x doses - follow refractory anaphylaxis algorithm
where should IM adrenaline be given in anaphylaxis?
anterolateral aspect middle third of thigh
what is the refractory anaphylaxis algorithm?
1) establish IV/IO access + seek critical care
2) give rapid fluid bolus + start adrenaline infusion - 1mg adrenaline in 100ml of NaCL - ON A SEPARATE LINE and start at 0.5ml/kg/hr and titter according to response
3) give IM adrenaline every 5 mins until adrenaline infusion has been started
if there is partial airway obstruction - nebuliser adrenaline (5mg of 1mg/ml)
if severe/persistent bronchospasm - nebulised salbutamol and ipratropium with O2, and consider infusion of aminophylline or salbutamol
what are the timings of mast cell tryptase measuring?
initial sample ASAP
second sample 1-2h (but no later than 4h)
third sample 24h - to provide baseline
what are the features of life threatening asthma?
altered consciousness exhaustion arrhythmia hypotension cyanosis silent chest poor expiratory effort PEF < 33% SpO2 < 92% PaO2 < 8 normal PaCO2
what are the features of near fatal asthma?
raised PaCO2
Mechanical ventilation with raised inflation pressures
what are the features of severe asthma?
PEF 33-55% of best predicted
RR > 25
HR >110
inability to complete sentences
what are the causes of cardiorespiratory arrest in asthma?
severe bronchospasm and mucous plugging
cardiac arrhythmias caused by hypoxia
dynamic hyperinflation can occur in mechanically vented patients (auto-PEEP is caused by air trapping and breath stacking causing gradual build up of pressure and reduced venous return)
tension pnuemothorax
Management of severe asthma attack?
O2 to achieve 94-98% SpO2
salbutamol 5mg NEB back to back
ipratropium bromide 500mcg NEB back to back
Hydrocortisone 100mg IV
MgSo4 2g (8mmol) IV 20 mins
consider aminophylline (5mg/kg loading dose)
IVF
criteria for considering tracheal intubation in asthma?
deteriorating peak flow decreasing conscioussness worsening hypoxaemia deteriorating resp acidosis severe agitation, confusion, fighting against the mask progressive exhaustion resp or cardiac arrest
what position should a pregnant woman be placed in during emergency situation to prevent cardiac arrest?
left lateral position OR manually displace the uterus to the left
where should IV access be ideally placed in a pregnant woman during cardiac arrest?
above the diaphragm, as after 20 weeks gestation the uterus can press down on the IVC impeding venous return and cardiac output.
what position should a pregnant woman be in during chest compressions?
left lateral tilt if possible
manually displace the uterus to the left
when should a peri-mortem c section be performed?
Foetus older than 20 weeks gestation and no ROSC within 5 mins
signs of tension pneumothorax?
respiratory distress prior to cardiac arrest haemodynamic compromise absent breath sounds on auscultation chest crepitations subcutaneous emphysema tracheal deviation jugular vein distension
management of tension pneumothorax?
needle decompression- needle is inserted into the 2nd intercostal space (just above third rib), or the 4th/5th intercostal space at the mid axillary line
