Clinical Practice Protocols Flashcards
What is the indication for IO access?
Emergent administration of medications when IV access cannot be obtained
What are the 5 contraindications for IO access?
Fracture in target bone
Previous significant orthopaedic procedure at the site i.e. prosthetic limb or joint
IO catheter insertion in previous 48 hours in target bone
Infection in area of insertion
Excessive soft tissue or absence of adequate anatomical landmarks
What are the 4 complications of IO access?
Local or systemic infection
Drug or fluid extravasation which can cause compartment syndrome
Fracture and/or epiphyseal plate damage
Air embolus
What is an epiphyseal plate (IO)?
Growth plate in paediatrics. Consists of a layer of cartilage.
What are the locations of IO access for adults (>12yo)?
Proximal humerus
Proximal tibia
Distal tibia
What are the locations of IO access for paediatrics? (<12yo)?
Proximal tibia only
How do you locate target site for IO insertion in the proximal humerus?
Place patient’s hand over abdomen to adduct the elbow and internally rotate humerus
Place one hand vertically over axilla
Place other hand over midline of the upper arm laterally
Place thumbs over the arm to identify vertical line of insertion
Palpate upwards over the surgical neck to find the greater tubercle.
The insertion site is the most prominent part of the greater tubercle approx. 1-2cm above the surgical neck.
How do you locate the site of IO insertion in the proximal tibia for an adult (<12yo)?
Locate the tibial tuberosity and the insertion site is approximately 2cm medial
Or approx. 3cm below the patella and 2cm medial from there
How do you locate the site of IO insertion in the proximal tibia for a paediatric (<12yo)?
Locate tibial tuberosity and insertion site is approximately 1cm medial from there.
How do you locate the site of IO insertion in the distal tibia?
Extend the patient’s leg
The insertion site is appro 3cm proximal to the most prominent aspect of the medial malleolus along the flat central aspect of the tibia
What are the sizes of IO catheters?
Red - 15mm
Blue - 25mm
Yellow - 45mm
Which size IO catheter is used for which site?
Red (15mm) for paediatrics
Blue (25mm) for adult tibia
Yellow (45mm) for proximal humerus or fat tibia
When inserting an IO, how much of the catheter should be out of the skin before drilling?
5mm which is indicated by black markers
What gauge of needle are the IO catheters?
15 gauge
What is the pad positioning for cardioversion?
Anterior and lateral pad placement
What is the indications for cardioversion?
Rapid ventricular rate with severely compromised cardiac output or haemodynamics
Pulsatile VT
SVT
AF
Atrial flutter
What are the 2 contraindications for cardioversion?
VF/Pulseless VT
Adequate perfusion despite dysrhythmia
What are the 2 complications for cardioversion?
Pain and discomfort
Paradoxical asystole or VF
What are the recommended joule settings for adult cardioversion?
100J
150J
200J
What are the recommended joule settings for paediatric cardioversion?
0.5J/kg
1J/kg
2J/kg
If synchronised cardioversion does not work what should you do?
Ensure the R wave is being sensed, consider alternative pad placement
Consider other causes of tachycardia such as hypovolaemia
Why is cardioversion synchronised and thus delivered during the R wave?
To avoid R on T phenomenon which can cause VF
What must the myocardium be able to do for TCP to be succesful?
Myocardium must be able to generate cardiac output with the muscular contractions
What are the two types of TCP and which does QAS use?
Demand and non-demand/asynchronous
How does demand pacing work?
Demand pacing senses the inherent QRS complex delivering electrical stimuli only when needed.
What are the indications for TCP?
Symptomatic bradycardia
What are the 2 contraindications for TCP?
Asystole/PEA
Overdrive pacing of dysrhythmia
What are the 4 complications of TCP?
Pain
Discomfort
Anxiety
Failure to achieve electrical capture
What position should pads be for TCP?
anterior-posterior position
What is the correct lcoation of the pads in anterior-posterior position?
Anterior pad - At the level of the bottom third of sternum between 4th and 5th ICS
Posterior pad - Left side of back beneath scapula and beside vertebral column
What is the most common error in TCP?
Not advancing the current high enough to achieve electrical capture
What current intensity should be used for conscious bs unconscious patients?
Conscious - start at 0 and increase until electrical and mechanical capture occur
Unconscious - Increased current to maximum and advance downwards
What are common causes of failure of TCP to improve cardiac output despite electrical capture?
hypoxia
acidosis
hypovolaemia
What is the phrenic nerve?
Phrenic most importantly innovates and has complete motor control of the diaphragm and sensation to the central tendon aspect of the diaphragm.
What nerve can be cut when doing a finger thoracostomy and what would that result in?
Long thoracic nerve which would result in winged scapulas
What needle decompression device is used for what ages/weight groups?
> 50kg = Pneumodart
15-50kg (4-14yo) = 14g cannula
<15kg (3yo) = 16g cannula
What length is a pneumodart, 14g cannula, and 16g cannula?
14g = 45mm
16g = 30mm
Pneumodart - 82.55mm
What is the rate, depth, and ratio of adult CPR?
30:2
Depth at least 5cm
Rate 100-120bpm
What rate do you continuously ventilate in CPR and when?
Continuously ventilate when SAD or ETT is placed
Ventilate at rate of 10brpm
How often do you defibrillate in CPR?
Every 2 minutes at 200j
How often do you replace the pads/change position in CPR?
After every 3 shocks
What is the correct position for anterior/lateral pad placement?
Anterior pad to the right of sternum below the clavicle
Lateral pad on mid-axilla line at level of V6 electrode
What is the correct position for anterior/lateral pad placement?
Anterior pad goes to left of sternum just below left nipple line (underneath breast tissue in females)
What is the stepwise approach to airway management in cardiac arrest?
Basic airway manoeuvres first followed by iGel if mouth is clear of vomitus or secretions.
ETT only if adequate ventilation cannot be achieved by SGA or basic airway.
What are the normal lung protective tidal volumes?
7L/kg
What are the potential benefits of IPPV with PEEP?
Improves oxygenation in ARDS and other forms of hypoxemic respiratory failure
Reduces gas trapping in people with expiratory flow limitation (COPD and asthma)
Minimises lung injury by preventing repetitive atelectasis
Reduces V/Q mismatch by recruiting alveoli
What are the 5 (actually 8) indications for PEEP?
APO (cardiogenic and non-cardiogenic
Asthma and COPD with SPO2 <90% on FiO2 >65%
Newborn resuscitation
Profound hypoxameia associated with:
Flail segments
Pulmonary contusions
Aspiration
What are the absolute (1) and relative (4) contraindications for PEEP?
Absolute = Hypotension (<90mmHg)
Relative = pneumothorax, uni-lateral lung disease, bronchopleural fistula, hypovolaemia
What are the complications/considerations of using PEEP?
Ensure PEEP is less than intrinsic PEEP (5cmhH2O) in asthma and COPD
Hypotension (Increased intrathoracic pressure)
What are the Indications for CPAP?
APO
Severe or life threatening asthma (unresponsive to 3 x salbutamol nebs)
What are the 7 contraindications for CPAP?
Patients <16yo
GCS<8
Inadequate ventilatory drive
Hypotension (<90sys)
pneumothorax
Epistaxis
Facial trauma
What are the complications of CPAP?
Aspiration
Gastric distension
Hypotension
Corneal drying
Barotrauma
What is the indication for OG tube insertion?
Gastric suctioning and/or decompression in the intubated patient
Are there any contraindications for OG tube insertion?
No
What are the 3 complications of OG tube insertion?
Passage of tube into the trachea
Coiling of the tube in the posterior pharynx
Localised trauma
What size OG tube is used for what ages?
> 16 years = 18fr OG tube
<16 years = 12fr OG tube
How do you measure length for OG tube?
Nose to earlobe to xiphisternum
