Critical Care Transport CME Flashcards

Question

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

Answer 1

* 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.

Answer 2

* Every 30 - 60 minutes

Answer 3

8 cm H₂0 The normal ETT resistance is 8 cm H₂0

Answer 4

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.

Answer 5

Temperatures above 37.5 C

Answer 6

* 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)

Answer 7

Temperatures less than 35 C

Answer 8

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.

Answer 9

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

Answer 10

* 12 Lead ECG on every ROSC patient * Temperature on every ROSC patient * HR * Blood pressure * Oxygen Saturation * ETCO2

Answer 11

* Monitor temp continuously * Maintain temperature \< 36 degrees on ROSC patients

Answer 12

* Prevention of shivering and thermogenesis

Answer 13

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)

Answer 14

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

Answer 15

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

Answer 16

* 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%}

Answer 17

* Adjust flow rate between 5 - 15 LPM to obtain desired PEEP * Use the lowest flowrate to conserve gas source

Answer 18

* 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

Answer 19

* 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

Answer 20

M- mask adjustment R - reposition airway S - suction mouth and nose O - open mouth P - pressure increase A - airway alternative

Answer 21

* Begin resuscitation with 21% Oxygen

Answer 22

* Blended oxygen 21 - 30%

Answer 23

20 - 30 cm H₂O

Answer 24

* 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

Answer 25

* Upon initial inflation * At flying altitude * Upon landing * Anytime cuff volume requires adjustment

Answer 26

\< 20 cm H₂O

Answer 27

* 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

Answer 28

* 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

Answer 29

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

Answer 30

* Necrotising entercolitis * Peritonitis * Omphalocoele * Omphalitis * Gastroschisis

Answer 31

* 3.5 french for \< 1500 grams * 5 french for \> 1500 grams

Answer 32

* One week * Becomes the ligamentum Teres

Answer 33

* 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

Answer 34

* 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.

Answer 35

* 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

Answer 36

* 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**

Answer 37

* 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

Answer 38

* 40 mg of 2% Lidocaine in adult patients * Lidocaine preload comes 100 mg/5mL * Administer 2 mL

Answer 39

* 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)

Answer 40

* 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

Answer 41

* 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

Answer 42

* 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

Answer 43

* 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**

Answer 44

* 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

Answer 45

* 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)**

Answer 46

* 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.

Answer 47

* Epiglottitis * Laryngospasm * Facial trauma/burns * Laryngeal edema * Fracture larynx * Foreign body obstruction

Answer 48

* 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

Answer 49

* 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

Answer 50

* Urethral trauma * Blood at the urinary meatus

Answer 51

14 - 16 Fr

Answer 52

* 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

Answer 53

* 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.

Answer 54

* 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

Answer 55

* 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.

Answer 56

* 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.

Answer 57

* 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.

Answer 58

* Because pacemaker pulses may be falsely counted as breaths

Answer 59

120 Joules 150 Joules 200 Joules

Answer 60

50 Joules 70 Joules 85 Joules

Answer 61

* 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

Answer 62

* 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.

Answer 63

* 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.

Answer 64

* 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.

Answer 65

* 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

Answer 66

* 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

Answer 67

* 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.

Answer 68

* 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.

Answer 69

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

Answer 70

* 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.

Answer 71

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.

Answer 72

* Patients Age - BSA burned = projected survivability Example * 90 years old - 80% BSA burned = 10% chance of survivability

Answer 73

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

Answer 74

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)

Answer 75

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.

Answer 76

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

Answer 77

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

Answer 78

* 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

Answer 79

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

Answer 80

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

Answer 81

* Extend full-thickness and through subcutaneous fat to involve muscle or bone

Answer 82

% 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

Answer 83

* 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**

Answer 84

* Skin * Eyes * Lungs

Answer 85

**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.

Answer 86

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.*

Answer 87

* Low flows from ECLS machine * O2 supply disconnected * Oxygenator failure * Recirculation (on VV)

Answer 88

* Apply immediacte pressure to the site * Position the patient in trendelenberg * Call for help * Clamp the lines

Answer 89

Is the flow rate of oxygen supply.

Answer 90

120 minutes

Answer 91

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

Answer 92

0.1 - 0.2 mg/kg

Answer 93

Increase CO2 removal

Answer 94

* ARDS (non cardiogenic pulmonary edema) * Severe pneumonia * Status asthmaticus * Smoke inhalation * Pulmonary contusion

Answer 95

* Cardiac Arrest * ECMO/ECLS equipment failure * Failure to Oxygenate * Uncontrolled bleeding/volume loss/Exsangunation

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Critical Care Transport CME Flashcards

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