Emergencies

Question 1

Energy in Joules for Defibrillation? Monophasic and Biphasic

Answer 1

Should do biphasic with 200 J. 360 J if monophasic

Question 2

Evaluate Swan Ganz Catheter data?

Answer 2

If the filling pressures and CO were low, it suggests possible hypovolemia. If the filling pressures were high and the CO were low, it suggests myocardial dysfunction, PTX, or even severe bronchospasm. Myocardial dysfunction is likely due to the history of CAD. PTX or severe bronchospasm are possible given the prior elevated peak airway pressure. If the CO were high, it suggests a possible low SVR state, as with anaphylaxis.

Question 3

Normal Capillary Refill time?

Answer 3

2 seconds.

Question 4

Initial Bolus for hypovolemia? What kind of fluid and why?

Answer 4

10-20 cc/kg bolus. Start with Crystalloid as I don’t know of a benefit for colloid. LR > NS as NS may result in hyperchloremic metabolic acidosis.

Question 5

Why No colloids in first 48 hrs. after burn?

Answer 5

Increased capillary permeability leads to the accumulation of proteins in the interstitial tissue and cause edema by increasing the interstitial oncotic pressure. If we give colloid fluid, it might worsen the edema.

Question 6

At what pressure does there need to be an air leak for extubation?

Answer 6

Ideally less than 15-20 cm H2O

Question 7

Treatment for stridor?

Answer 7

If mild racemic epi and dexamethasone. If severe then reintubate.

Question 8

What can be done for Jehovah’s Witness that refuses blood?

Answer 8

• pre-op erythropoietin or iron
  
  • Positioning to prevent venous congestion
  • Keep patient awake so they can change their mind
  • Hypotensive anesthesia
  • Tourniquets
  • Meticulous surgical technique/experienced surgeon
  • Vasoconstrictor use Use of drugs that affect coagulation, e.g. tranexamic acid, aprotinin and desmopressin
  • Cell-saver use will need to be discussed with the individual patient Balloon occlusion/ligation of arteries that supply the bleeding area
  • Minimize Blood draws
    Ask about allowing albumin administration or intraoperative blood salvage with blood remaining in continuity with her circulatory system.

Question 9

Where to place the intraosseous line?

Complications?

Answer 9

Tibia at 10-15 degrees caudal angulation to avoid epiphyseal plate 1-2 cm below and 1 cm medial to the tibial tuberosity

Compartment syndrome, muscle necrosis, osteomyelitis, bacteremia, cellulitis, growth plate injury

Question 10

Do diuretics or steroids help with TRALI?

Answer 10

Neither have been proven beneficial.

Question 11

Pathophysiology of Trali?

Answer 11

Donor leukocyte antibodies during transfusion lead to the activation of neutrophils on the pulmonary vascular endothelium.