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Ornge CCP > Critical Care Transport CME > Flashcards

Critical Care Transport CME Flashcards

1
Q

What is Heated High Flow Nasal Cannula Therapy?

A

A respiratory care therapy that delivers humidified blended oxygen to patients using flow rates that are higher than those traditionally used with other oxygen therapies.

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2
Q

What is the effect of HFNC therapy on dead space?

A

HFNC floods the oral cavity and the pharynx with fresh gas, which creates a reservoir of fresh blended oxygen which provides a consistent breath to breath FIO2. The flushing effect reduces anatomical dead space resulting in improved carbon dioxide elimination.

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3
Q

What are the indications for HFNC therapy?

A

Refractory hypoxemia despite optimized conventional nasal cannula and/or non-rebreather mask O2 therapy in individuals with an intact respiratory drive. (Adults SP02 < 90%) COPD/CHF exacerbation requiring a minimal level of PEEP.

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4
Q

What are the contraindications of HFNC therapy?

A

A definitive airway is required. Nasal airway obstruction History of facial trauma

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5
Q

Explain the concept of dead space wash-out when using HFNC therapy in adults.

A

Flows in excess of 30 lpm flushes the dead space in the nasal and oral cavities at the same time creating an O2 reservoir.

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6
Q

In adults using HFNC therapy, a flow rate of 10 lpm will generate approximately what level of PEEP?

A

HFNC flow rate of 10 lpm = approximately 1.0 cmH20

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7
Q

How does HFNC therapy assists with the metabolic cost of gas conditioning in the adult?

A

A normal adult respiratory rate of 12 - 16 bpm and Vt of 500 ml requires 156 calories/min to condition the inspired gas.

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8
Q

What is the initial recommended flow for adults when initiating HFNC therapy.

A

30 - 40 lpm

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9
Q

What is the flow rate range of Junior mode when using the airvo2?

A

Junior 2 - 25 lpm

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10
Q

What is the flow rate range of adult mode when using the airvo2?

A

Adult 25 - 60 lpm

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11
Q

When using HFNC on infants at what level does the system provide positive pressure throughout the respiratory cycle. (CPAP)

A

> 2 lpm/kg

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12
Q

In Pediatric patients that are receiving HFNC therapy, initial flow rates can be started at:

A

1L/min/kg

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13
Q

When titrating HFNC therapy in the pediatric patient based on work of breathing; flow rates may be increased in increments of ____________ up to a maximum of ____________.

A

0.5 L/min/kg up to a maximum of 2 L/min/kg

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14
Q

What is the mechanism for Acetaminophen?

A

Similar to NSAIDS in affecting the arachadonic acid cycle but with lesser effect. Acetaminophen does not demonstrate the same anti-inflammatory properties as most NSAIDS. It does not cause bronchospasm It is a proven anti-pyretic.

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15
Q

When should the paramedic consider the use of acetaminophen?

A

Mild to moderate pain. Has a relatively short onset of 15 minutes when taken orally. Peak effect 30 minutes Duration 2 hours

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16
Q

What is the Personal Health Information Protection Act (PHIPA)

A

Patients privacy rights are primarily codified in Ontario’s Personal Health Information Protection Act 2004 (PHIPA) which describes how health custodians are permitted and required to collect, use, disclose and safeguard Personal Health Information (PHI)

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17
Q

What is Personal Health Information (PHI)?

A

Any information that could reasonably be expected to identify a patient and connect him or her to care. For example the name of the patient, OHIP numbers or other numbers that identify patients and information about the patients condition.

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18
Q

Lung Protective Strategy in Mechanical Ventilation

A

The lung protective strategy focuses on low-tidal volume ventilation to reduce ventilator-associated lung injury such as barotrauma and volutrauma.

It is appropriate for patients already demonstrating signs of acute lung injury.

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19
Q

What initial tidal volume setting should be used on intubated patients?

A

8 ml/kg

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20
Q

What is the role of inspiratory flow rate when mechanically ventilating a patient

A
  • Patient comfort
  • An initial setting of 60 L/minute usually leads to adequate flow for patient comfort
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21
Q

What is a good initial respiratory rate to start with on most mechanically ventilated patients?

A
  • An initial rate of 15 - 16 breaths/min should allow for normocapnia in most patients.
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22
Q

When should an arterial or venous blood gas be taken after placing a patient on a ventilator or doing a titration?

A

20 - 30 minutes

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23
Q

How is the combination of PEEP and FiO2 used?

A

Once the Fi02 reaches greater than 50%, any continuing hypoxemia is due to physiologic shunt. The solution to this shunt is to increase mean airway pressure through Positive-End Expiratory Pressure (PEEP).

The ARDSnet strategy guides clinicians to increase Fi02 and PEEP in tandem to allow for alveolar recruitment.

Immediately after intubation decrease Fi02 to 30 - 40% and assign the patient a PEEP of 5

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24
Q

How do you titrate PEEP-FiO2 using the Ardsnet chart?

A
  • Rapidly titrate to PEEP-Fi02 combinations that result in an Sp02 of 88% to 95%.
  • Allowing patients to achieve a saturation of 100% exposes them to excess pressure and hyperoxia.
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25
Q

How should you check for alveolar safety on a mechanically ventilated patient?

A
  • Every 30 to 60 minutes, a plateau pressure should be checked.
  • If the plateau pressure is greater or equal to 30 cm H20 there is potential for alveolar injury.
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26
Q

How often should you take a plateau pressure?

A
  • Every 30 - 60 minutes
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27
Q

What should the initial tidal volume be for patients with a Pa02/Fi02 ratio of < 200 mmHg?

A

6 mL/kg

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28
Q

What is the minium level of pressure support you should use?

A

8 cm H20

The normal ETT resistance is 8 cm H20

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29
Q

Why should temperature be monitored in Stroke or other brain injuries?

A

In patiens with stroke or other brain injuries, fever is associated with worse outcomes, including higher mortality rates, disability, lossl of function, and longer hopsital stays.

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30
Q

At what temperature should stroke and brain injures be managed?

A

Temperatures above 37.5 C

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31
Q

Why should hypothermia be prevented and treated aggressively in Trauma Patients?

A
  • Patients with admission temperatues less than 35 C had significiantly greater mortality (25% vs 3.0%, P<0.001)
  • Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71)
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32
Q

At what temperature in Trauma patients does mortality signficantly increase?

A

Temperatures less than 35 C

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33
Q

ROSC

Why should core body temperature be monitored?

A

Core body temperature should be monitored, as hyperthemia in the post cardiac arrest setting is associated with increased mortality and shoudl be avoided.

  • Targeted temperature management to maintain core body temperature at a minimum below 36 degrees Celsius is assoiciated with improved neurologic outcome and should be maintained during inter-facility transport.
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34
Q

When should temperature be measured on a patient?

A

Every patient requires a temperature to be measured as it is part of the vital signs. Temperature at a minimum should be monitored every 30 minutes.

Temperature Monitoring where Temperature has a direct Impact

  • These are patients where their direct outcome is related to temperature (i.e. Stroke, Trauma and ROSC patients)
  • Continuous temperature monitoring is preferred utilizing the one of the surface probes.
  • Temporal artery temperature should be matched to the continuous sufarce temperature probe to make sure the surface probe is accurate.
  • Intubated patients should have esophageal temperature monitoring
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35
Q
A
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36
Q

What are the essential Vital Signs to be documented on ROSC Patients?

A
  • 12 Lead ECG on every ROSC patient
  • Temperature on every ROSC patient
  • HR
  • Blood pressure
  • Oxygen Saturation
  • ETCO2
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37
Q

Targeted Temperature Management (TTM)

ROSC patients

A
  • Monitor temp continuously
  • Maintain temperature < 36 degrees on ROSC patients
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38
Q

What is the role of Neuromuscular blockade in Targeted Temperature Management in ROSC patients?

A
  • Prevention of shivering and thermogenesis
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39
Q

What is the Neo-Tee?

A

Single patient use infant T-Piece Resuscitator. The device is flow controlled and pressure limited and provides consistent, targeted Peak Inspiratory Pressure (PIP) and Positive End-Expiratory Pressure (PEEP)

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40
Q

What are the relief pressures of the Neo-Tee?

A

Integrated adjustable pressure relief valve that limits adjustment of ventilating pressures to either a peak of 40 cm H2O or activation of the overide button at 60 cm H2O

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41
Q

What are the indications for the Neo-Tee T-Piece Resuscitator?

A
  • Provide positive pressure ventilation for:
    • Apnea
    • Gasping respirations
    • Heart rate less 100 bpm following delivery
    • Oxygen saturations below target range
  • Provide CPAP
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42
Q

What is the recommended compressed gas source for the Neo-Tee?

A
  • When available use an oxygen/air blender to titrate oxygen concentrations as required to achieve targeted SpO2
  • Blender or flowmeter should be set to 21%
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43
Q

What is the recomendation for adjusting gas supply for the Neo-Tee?

A
  • Adjust flow rate between 5 - 15 LPM to obtain desired PEEP
  • Use the lowest flowrate to conserve gas source
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44
Q

How do you adjust the PEEP level on the Neo-Tee?

A
  • Set the PEEP using variable PEEP knob (Blue dial)
  • Flow rate 5 - 15 LPM to obtain desired PEEP
  • Patient connection must be occluded in order to adjust or determine PEEP set pressure
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45
Q

How do you ajust PIP on the Neo-Tee?

A
  • Adjust PIP using the colour coded adjustable PIP controller
  • PIP pressure relief valve limits operator PIP to 40 cm H2O
  • Over ride button allows up to 60 cm H2O
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46
Q

To trouble shoot ineffective ventilation in a neonate corrective steps can be followed using MRSOPA

A

M- mask adjustment

R - reposition airway

S - suction mouth and nose

O - open mouth

P - pressure increase

A - airway alternative

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47
Q

What is the recommended FIO2 for newborns greater than or equal to 35 weeks gestation?

A
  • Begin resuscitation with 21% Oxygen
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48
Q

What is the initial recommended FIO2 for newborns less than 35 weeks gestation?

A
  • Blended oxygen 21 - 30%
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49
Q

Adult ETT cuff pressure range?

A

20 - 30 cm H2O

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50
Q

Why do we measure Adult ETT cuff pressures?

A
  • Cuff pressures in excess of 30 cm H2O can result in tracheal mucosal injury within two hours.
  • Maintaining adequate cuff pressures is associated with less micro-aspiration and reduction in Ventilator Associated Pneumonia (VAP)
  • ETT cuff pressures < 20 cm H2O have resultd in an increase in “silent aspiration” and VAP
51
Q

When are Adult ETT cuff pressures to be measured?

A
  • Upon initial inflation
  • At flying altitude
  • Upon landing
  • Anytime cuff volume requires adjustment
52
Q

What is the target Pediatric ETT cuff pressure?

A

< 20 cm H2O

53
Q

What are the complications of ETT cuffs?

A
  • ETT cuff pressures > 20 cm H2O can result in tracheomalacia
  • Cuff leaks are associated with an increased risk of micro-aspiration, inaccurate EtCO2 measurement and hypoventilation
54
Q

Describe the procedure for Pediatric ETT cuff inflation

A
  • Following tracheal intubation and prior to cuff inflation confirm that an air leak is present. This ensures the selected ETT is not too big. Do not inflate the ETT cuff if you cannot confirm a leak.
  • Attach the manometer to ETT Pilot balloon valve and slowly inflate cuff. As cuff is inflated auscultate the trachea and inflate until no leak is detected at Peak inspiratory pressure (PIP)
  • Maintain Cuff pressure < 20 cm H2O
55
Q

Indications for UVC Inserton

A
  • Emergency Vascular Access
  • Central venous access for IV fluids and medications
  • Hyperosmolar solutions such as dextrose concentrations greater than D12.5W
56
Q

What are the contraindications for UVC insertion?

A
  • Necrotising entercolitis
  • Peritonitis
  • Omphalocoele
  • Omphalitis
  • Gastroschisis
57
Q

What sizes of umbilical vein catheters are to be used for the specificed weights?

A
  • 3.5 french for < 1500 grams
  • 5 french for > 1500 grams
58
Q

How long does the umbilical vein remain patent after birth?

A
  • One week
  • Becomes the ligamentum Teres
59
Q

What equipment is required for a UVC insertion?

A
  • Sterile gloves
  • Umbilical lines: 3.5 Fr for infants < 1500 grams & 5.0 Fr for infants > 1500 grams
  • Chlorhexidine swabs
  • Umbilical ties
  • 4.0 Silk Sutures
  • # 11 Straight blade Scalpel
  • Suture removal kit
  • Tegaderm
  • 10 cc syringe with NS
  • Stopcock
60
Q

Describe the cleansing procedure prior to inserting a UVC line

A
  • Cleanse umbilical cord downward from the base of the umbilicus in a circular motion around the base of the cord moving outwards.
  • Use chlorhexidine swabs or sterile water
  • Sterile water should be used in infants < 27 weeks gestation and < 48 hours old to prevent burns from antiseptic.
61
Q

What is the concern with using antiseptic solution in low birth weight infants when preparing for UVC insertion?

A
  • Antiseptic solutions such as chlorhexidine swabs can cause skin burns in low birth weight infants.
  • It is recommended to use sterile water in infants < 27 weeks and < 48 hours old
62
Q

How far are low lying UVC lines placed?

A
  • 2 - 4 cm below the skin (plus stump depth)
  • Max depth of insertion for term infants 4 - 5 cm
  • Max depth of insertion for preterm infants 2 - 3 cm
63
Q

EZ IO Humerus Site Identification

A
  • Place the patients hand over the umbilicus which causes medial rotation of the elbow and humerus
  • Locate the surgical neck of the humerus by palpating up the length of the humerus until you feel a “notch” or “groove”
  • The insertion site is 1 cm above the surgical neck on most adults
  • The 45 mm Needle set is used on patients greater than 40 kg
64
Q

What is the dose of lidocain to infuse after IO insertion in a conscious patient?

A
  • 40 mg of 2% Lidocaine in adult patients
  • Lidocaine preload comes 100 mg/5mL
  • Administer 2 mL
65
Q

How is the appropriate EZ IO needle set length determined?

A
  • Based on the weight of the patient
  • 15 mm (3 - 39 kg)
  • 25 mm ( > 3 kg)
  • 45 mm ( 40 kg or over and/or excessive tissue depth)
66
Q

EZ IO Insertion depth

A
  • The EZ IO needle is marked by black lines starting at 5 mm from the hub
  • With every insertion the needle should be used as a depth gauge
67
Q

What are the inications that the EZ IO needle set is not long enough?

A
  • The needle set does not reach the bone
  • No black lines are visible above the skin with the tip of the needle touching the bone
  • If these conditions occur you should select a larger needle or re-evaluate the insertion site
68
Q

How do you measure the landmark for the Adult Esophageal Temperature Probe?

A
  • Landmark probe from the opening of the patient’s mouth to the earlobe and the earlobe to the upper portion of the sternum (manubrium), approximately 2 finger widths below the sternal notch
  • Mark the measurement on esophageal temperature probe with tape or steri strip
69
Q

Confrimation of Adult Esophageal Temperature Probe

A
  • Due to the length of the esophagus, the placement of the probe is critical. If the probe is too high in the esophagus the reading will be affected by tracheal air
  • Monitor patient’s breathing pattern and oxygen saturation during insertion at the 20 – 25 cm mark. Coughing or choking may indicate passage of the tube into the trachea. If this is suspected remove esophageal temperature probe immediately
  • Placement of the probe is in the lower third of the esophagus will allow the sensor to be closer to the heart and aorta, where it will accurately reflect the patient’s core temperature
  • Proper placement of the probe on CXR is in the distal portion of the esophagus, (distal to the tracheal bifurcation and close to the left ventricle and aorta); at T5-T6 vertebral level – the esophagus is posterior to the left atrium and stays in close proximity until just above T8
70
Q

How do you measure the landmark for the Pediatric Esophageal Temperature Probe

A
  • Landmark probe from the opening of the patient’s mouth to the earlobe and from the earlobe to the xyphoid process; subtract 2 cm from the measured length of the probe to approximate the distance to lower esophagus
  • Mark the measurement on esophageal temperature probe with tape or steri strip
71
Q

Confirmation of Pediatric Esophageal Temperature Probe

A
  • Proper placement of the probe is in the lower third of the esophagus which will allow the sensor to be closer to the heart and aorta, where it will accurately reflect the patient’s core temperature
  • If a CXR is required post intubation or for changing clinical status, attempts should be made to insert the esophageal temperature probe prior to obtaining x-ray to confirm placement when possible (T6-T8)
72
Q

Indications for Cricothyrotomy

A
  • 12 years of age or greater
  • Inability to secure an airway by endotracheal intubation or supraglottic airway (LMA or King- LT)
  • Failed airway (unable to maintain SpO2 > 90% with two person bagging and 2 nasopharyngeal and 1 oropharyngeal airway in place.
73
Q

What are examples of acute upper airway obstruction that might require Cricothyrotomy?

A
  • Epiglottitis
  • Laryngospasm
  • Facial trauma/burns
  • Laryngeal edema
  • Fracture larynx
  • Foreign body obstruction
74
Q

Describe the procedure for using the Quicktrach.

A
  • Secure the larynx laterally between the thumb and forefinger. Find the cricothyroid ligament (in the midline between the thyroid cartilage and the cricoid cartilage) this is the puncture site.
  • Firmly hold device and puncture ligament at a 90 degree angle
  • After puncturing the cricothryroid membrane check entry into the trachea by aspirating air into the syringe.
  • Change angle to 60 degrees towards the feet and advance the device forward into the trachea to the level of the stopper. The stopper reduces the risk of inserting the needle too deeply and causing damage to the rear wall of the trachea.
  • Remove the stopper and advance the catheter
75
Q

Indications for Urinary Catheterization

A
  • To monitor urine output duirng low flow states
  • To relieve bladder distention
  • To obtain urine from the conconsious patient
  • To obtain an uncontaminated urine specimen for urinalysis and culture
76
Q

Contraindications to Urinary Catheterization

A
  • Urethral trauma
  • Blood at the urinary meatus
77
Q

What is the urinary catheter size for a a patient > 12 years?

A

14 - 16 Fr

78
Q

What equipment is required for Urinary Catheterization?

A
  • Sterile gloves
  • Sterile drapes
  • Cleansing solution (i.e. Savlon)
  • Cotton swabs
  • Forceps
  • Sterile water (10 cc)
  • Foley catheter ( 14 - 18 Fr)
  • Syringe ( 10 cc)
  • Lubricant (water based jelly or xylocaine jelly)
  • Collection bag and tubing
79
Q

Urinary Catheterization Procedure

Female

A
  • Place patient in frog leg position.
  • Lubricate catheter tip with water soluble lubricant.
  • Labia are separated with thumb and index finger of the non-dominant hand. This hand is now considered contaminated.
  • Prepare the urethral meatus and perineal area thoroughly by scrubbing with a providone-iondine solution. Three separte Benadine soaked gazes swiped anterior to posterior x 1 and then discard.
  • Grasp catheter with the dominant hand and gently pass through the meatus into the bladder. The catheter is advanced 5 - 6 cm in females as the female urethra is shorter.
  • Inflate the balloon.
  • Withdraw catheter after inflation of balloon. When the balloon strikes the internal urethral sphincter, reistance will be encountered and proper placement confirmed.
80
Q

Urinary Catheterization Procedure

Male

A
  • Put male in supine position
  • The catheter tip should be well lubricated with a water soluble lubricant
  • Prepare the urethral meatus and penis thouroughly be scrubbing with provi
81
Q

Perfusion Index (PI)

A
  • is the ratio of the pulsatile blood flow to the non-pulsatile static blood flow in a patient’s peripheral tissue, such as finger tip, toe, or ear lobe.
  • Perfusion index is an indication of the pulse strength at the sensor site. The PI’s values range from 0.02% for very weak pulse to 20% for extremely strong pulse.
  • PI has a high correlation with capillary refill time and central-to-toe temperature difference. In neonatal acute care, a low PI is an objective and accurate measure of acute illness. It is superior to qualitative approach such as foot warmth.
82
Q

SPO2 Averaging Time

A
  • Three different time periods on Zoll X-series 4 seconds, 8 seconds (default) and 16 seconds
  • For high risk patients with rapidly changing SpO2 conditions, ust the 4 second setting.
  • Use the 16 second setting only when the 8 second setting is inadequate due to extremely high artifact conditions.
  • Longer averaging times may reduce the signal artefact (from motion) but also reduce the ability to detect the rapid change in saturation.
83
Q

SPO2 Sensitivity

Zoll X-Series

A
  • You can select either normal or high sensitivity for SpO2 monitoring.
  • The high sensitivity allows you to monitor patients under low perfusion conditions such as severe hypotension and shock.
  • With high sensitivity setting, however, SpO2 results are more contaminated by artifact.
84
Q

Why is impedance pneumography not recomended for use on paced patients?

A
  • Because pacemaker pulses may be falsely counted as breaths
85
Q

What are the default enery settings for adult defibrillation on the Zoll

A

120 Joules

150 Joules

200 Joules

86
Q

What are the default settings for pediatric defibrillation on the Zoll?

A

50 Joules

70 Joules

85 Joules

87
Q

What is the CO2Sweep Speed?

A
  • The EtCO2 sweep speed determines the X-axis of the capnogram. For patients with slower respiration rates, a slower sweep speed will make the capnogram easier to view.
  • You can specify speeds of 3.13, 6.25 and 12.5 mm/second.
  • The default is 6.25 mm/second
88
Q

What is the clinical presentation for DVT?

A
  • Mild cramping or sense of fullness in calf.
  • Some patients use the term charley horse to describe pain.
  • Upper extremity DVT refers to a thrombosis in the Axillary vein which can cause arm swelling and pain.
89
Q

What is D-dimer?

A
  • The D-dimer is a protein from enzymatic breakdown of cross-linked fibrin, and an elevated plasma concentration indicates the presence of a clot formed somewhere in the bodyu within the previous 72 hours.
  • D-dimer concentration may be elevated with any condition that causes fibrin deposition such as pregnancy, prolonged bed rest, stroke, MI and inflammation.
90
Q

What is Deep Vein Thrombosis?

A
  • A disease process where you get formation of clot that results in excess fibrin formation.
  • Bunch of factors that enhance your fibrin sythesis such as systemic inflammation and vascular trauma.
  • Endotheial injury, slow blood flow and hypercoagulability are the cause of DVT and PE.
91
Q

How is a proximal lower limb DVT managed?

A
  • Start appropriate LMWH (Enoxaparin 1 mg/kg SC q 12 hrs) OR
  • Alternatives such as
    • Fondaparinux
    • Apixaban
    • Rivaroxaban
  • OR heparin infusion after a loding bolus
92
Q

What is the ECG criteria for Pulmonary Embolism?

A
  • Tachycardia
  • Right Ventricular Strain pattern - Symmetrical T-wave inversion in the right precordial leads (V1 - V4) and the inferior leads
  • Incomplete or complete RBBB
  • S1Q3T3 - Deep S wave in lead 1, Q wave in lead III and inverted T wave in lead III. Found in only 20% of Patients with PE
93
Q

Westermark sign

A
  • The Westermark sign referes to a region of pulmonary radiolucency representing oligemia (hypovolemia) distal to an occlusive pulmonary embolism.
  • It is an insensitive radiographic sign of pulmonary embolism.
94
Q

Hamptons Hump

A
  • The Hampton hump is a well-defined pulmonary pleural-based opacity representing hemorrhage and necrotic lung tissue in a region of pulmonary infarction caused by acute pulmonary embolism.
  • The medial margin of the opacity frequently demonstrates a medial curved hump directed towards the heart.
95
Q

What are the treatment issues with PE in pregnancy?

A
  • Manage with adjusted doses of LMWH for at least 3 - 6 months.
  • Heparin and Warfarin are not recommended.
  • Do not use Fondaparinux or DOACs
96
Q

What are burns?

A
  • Tissue destruction caused by contact with heat, electrical current, radiation or chemical agents.
  • Temperatures below 44 degree C are generally tolerated for long periods of time without injury.
  • Temperatures above 60 degree C cause protein denaturation in tissue
  • Burn progression is a result of both necrosis and apotosis of damaged cells.
97
Q

What is burn progression?

A

Mechanical Damage to Tissue

  • Tissue necrosis - passive process denaturing the lipid bilayer and ATP enzymes. Leading to cell swelling, loss of energy stores and massive release of immatory mediators.
  • Apoptosis of damaged cells - normal programmed cell death.
98
Q

Burn Survivability

Calculation

A
  • Patients Age - BSA burned = projected survivability

Example

  • 90 years old - 80% BSA burned = 10% chance of survivability
99
Q

List zones of burns

A

Listed from the center out they are:

  1. Irreversible coagulation and necrosis, formed immediately.
  2. Ischemia with impaired microcirculation. This tissue is at risk of subsequent necrosis – this is what we want to increase the perfusion to!
  3. Transient hyperemia
100
Q

List indications for intubation in a burn patient

A
  1. Upper airway obstruction
  2. Inability to handle secretions
  3. Hypoxemia despite 100% O2
  4. Patient obtundation
  5. Muscle fatigue suggested by high or low respiratory rate
  6. Hypoventilation (PCO2 > 50 mmHg and pH < 7.2)
101
Q

Burn Airway Pearls

A

Direct thermal injury – rarely happens below the vocal cords, but the smoke byproducts (chemical injury) lead to V/Q mismatch and pulmonary edema.

Both cause upper and lower airway edema

  • Shedding necrosis of the mucosa leading to a cascade of dysfunction in all parts of the pulmonary system leading to ARDS

Consider intubating early in patients who may look otherwise well but who are at high risk of developing complications of airway burns.

  • e., patients with oropharyngeal swelling and a hoarse voice

Remember that circumferential neck eschar can compress the neck, and hence neck vessels and trachea. Escharotomy may be necessary prior to intubation.

102
Q

Parkland Formula

A

Parkland formula – most commonly known, probably over-resuscitates patients

  • Lactated Ringers 4cc/kg/% TBSA burned
  • Give ½ of the fluid in the first 8 hours, remainder in the next 16 hours
  • Over the following 24 hours, 20-60% of patient’s plasma volume, titrating to maintain urine output of 0.5-1.0 cc/kg/hr (target 1.0 cc/kg/hr in children)
  • The modified parkland uses the same formula, but gives the fluid over a 24 hr period
  • Modified Brooke - LR 2 mL/kg% burn in adults over 24 hours
103
Q

Describe the classification of burn injuries

A
  1. First Degree
    • Limited to epidermis
  2. Second Degree
    • Invovles epidermis and extends into dermis
  3. Third Degree
    • Full thickness - extends through entire dermis
  4. Fourth Degree
    • Extend full-thickness and through subcutaneous fat to involve muscle and bone
104
Q

Describe First Degree Burns

A
  • Limited to epidermis
  • Painful, erythematous, dry surface
  • Heal in days
    • The skin’s ability to heal is limited to approx 1 cm from the uninjured epeidermis and the degree of damage to sebaceous glands/hair follicles
105
Q

Describe Second Degree Burns

A

Most painful Burns

  • Superficial Second Degree
    • Invovle only the papillary dermis
    • Painful, erthematous, blisters, blanches with pressure, moist surface
    • Heal in 2 - 3 weeks
  • Deep Second Degree
    • Extends into reticular dermis
    • Painful, white or only mild erythema, hemorhagic blisters, minimal blanching, dry or moist surface
    • Heal in 3 + weeks, or can progress to 3rd degree burns
106
Q

Describe 3rd Degree Burns

A
  • Full thickness - extend through entire dermis
  • Stiff, white or tan colour, dry, leathery and insensate
  • Require excision +/- grafting
107
Q

Describe 4th Degree Burn

A
  • Extend full-thickness and through subcutaneous fat to involve muscle or bone
108
Q

Rule of 9’s

Adult

A

% TBSA is allocated as:

  • 18% for fronto fo trunk (9% torso, 9% abdomen)
  • 18% for back of trunk (9% upper back, 9% lower back)
  • 18% for an entire lower extremity
  • 9% for the entire head
  • 9% for each upper extremity
  • 1% for the perineal area
109
Q

Describe Burn Dressing Management

A
  • Prevent hypothermia
  • Assume burns are contaminated: clean and debride gently
  • Tetanus toxoid booster if eligible (> 5 years since last)
  • Cover all 2nd degree burns estimated to involve > 15% BSA with dry sterile dressing or sheet
110
Q

What are the most susceptible organs to chemical injury?

A
  • Skin
  • Eyes
  • Lungs
111
Q

Describe the difference between Alkali and Acid Injuries?

A

Acidic compounds:

  • Cause protein denaturation and coagulative necrosis with the skin
  • The necrosis forms eschar → which LIMITS the depth of acid penetration
  • Their free hydrogen ions are easily neutralized on the skin by copious water irrigation

Alkali compounds:

  • Produce saponification and liquefactive necrosis of body fat – they produce soluble protein complexes which “permit the passage of hydroxyl ions deep into the tissue” and limiting the contact of the alkali complex on the surface of the skin.
  • Because there is no eschar formation they usually penetrate DEEPER into the tissue.
112
Q

What is the shock index?

A

SI = HR/SBP

>1

May indicate the presence of shock or occult shock, and is sensitive for predicting critical bleeding, the need for blood products, and incidence of postintubation hypotension.

113
Q

Chugging/swinging of the venous ECMO line could be the result of poor vascular volume.

A

True

114
Q

What can cause a low PaO2 on a patient receiving ECMO?

A
  • Low flows from ECLS machine
  • O2 supply disconnected
  • Oxygenator failure
  • Recirculation (on VV)
115
Q

If there is an accidental decannulation of a patient on ECMO one must

A
  • Apply immediacte pressure to the site
  • Position the patient in trendelenberg
  • Call for help
  • Clamp the lines
116
Q

What is Sweep on a patient receiving ECMO?

A

Is the flow rate of oxygen supply.

117
Q

What is the minimum internal battery life of the centimag ECMO machine?

A

120 minutes

118
Q

When transporting a patient on ECMO if air breaks through the post membrane oxygenator, what is the first thing you should do?

A
119
Q

The patient on ECMO 20 minutes into transport goes into cardiac arrest, in which ECMO mode would you not have to do CPR compressions?

A

V - A

In VA ECMO the circuit is providing cardiac support. Therefor no CPR is required.

120
Q

According to the ECMO Medical Directives the bolus dose for NIMBEX (Cisatracurium is?

A

0.1 - 0.2 mg/kg

121
Q

While transporting a patient on ECMO what will increasing the sweep speed do related to carbon dioxide?

A

Increase CO2 removal

122
Q

What are some pathological processes for which VV ECMO may be considered?

A
  • ARDS (non cardiogenic pulmonary edema)
  • Severe pneumonia
  • Status asthmaticus
  • Smoke inhalation
  • Pulmonary contusion
123
Q

According to the medical directive, ECMO failure consists of the following list which would require a patch to the TMP after appropriate action.

A
  • Cardiac Arrest
  • ECMO/ECLS equipment failure
  • Failure to Oxygenate
  • Uncontrolled bleeding/volume loss/Exsangunation
124
Q

What is the targeted Activating Clotting Time (ACT) for a patient on ECMO?

A

160 - 180

Ornge CCP (6 decks)

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