Emergency Med Flashcards
Chest compression rate for CPR
100/minute….provide at least 30 before giving rescue breaths. Allow Chest to recoil after each compression.
True or False: Compression-only CPR is superior to no CPR
True (exception drowning rescues and pediatric arrests should include rescue breaths if possible)
ACLS Shockable Rhythms
VF/VT
ACLS not-shockable rhythms
Asystole and PEA
ACLS Sequence for VF or VT
- Start CPR for 2 min immediately after Shock, then recheck rhythm
- Administer epi 1 mg IV/Intraosseously every 3-5 min
- vasopression 40 units can replace 1st or 2nd dose of epi
- If VF/VT persist after 3 shock consider amiodarone
- Amiodarone 300mg IV/IO
ACLS Sequence for PEA or Asystole
Use CPR with CAB sequence for 2 minutes, then recheck rhythm.
Administer epi 1 mg every 3-5 min
Vasopression 40 units IV/IO can replace 1st or 2nd dose of Epi
Treatmetn reversible causes.
Reversible Causes of Cardiac Arrest (H’s and T’s)
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyperkalemia/hypokalemia Hypothermia Toxins (and drug overdose) Tamponade Thrombosis (pulmonary or coronary) Tension pneumothorax)
Epinephrine
alpha-receptor agonist- increases cerebral and myocardial perfusion through vasoconstrictive effects.
B-receptor agonist- increases myocardial oxygen demand (considered a negative effect of epi)
Pulseless arrest dosing 1 mg every 3-5 min
Can be given by endotracheal route 2-2.5 mg diluted with 10ml of sterile water.
Vasopressin
Vasopresson 1 receptor agonist- causes vasoconstriction in the skin and skeletal muscles
Vasopression 2 receptor aonigsts- causes vasoconstriction in the mesenteric circulation
Vital organs recieve inreased perfusion secondary to stimulation of vasopressin 1 and 2 by shunting blood flow.
Half-life is 10-20 min, so repeat dosing is not indicated
Pulseless arrest dosing 40 units IV/IO to replace 1st or 2nd dose of epi
Absorbed by the tracheal route but a dose recommendation has not been established.
Amiodarone
First-line antiarrhythmic for VF/VT unresponsive to shock, CPR, and vasopressor administration
Antagonizes potassium, sodium, and calcium channels as well as blocks alpha and B receptors
Dosing for refractory VF/VT 300mg IV/IO push may repeat 150mg if needed.
If there is a ROSC, a maintenance iV infusion can be initiated at 1 mg/min for 6 hours, then 0.5mg/min for 18 hours.
Lidocaine
Inhibits sodium influx through ion channels, historically used for VF/VT
Second line agent b/c lidocaine us is associated with a higher rate of asystole and lower survival rates to hospital admission compared with amiodarone.
Dosing 1.5mg/kg Iv/IO up to a maximal dose of 3 mg/kg. Can be administered by endotracheal route.
Magnesium Sulfate
Effective for torsades depoints even in the absence of hypomagnesemia
Improves potassium transport and shortens the QT interval
Dose is 1-2 g diluted in 10ml of D5W
Medications absorbed by the trachea (NAVEL)
Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine
Type 1 Immunoglobulin E (IgE) mediated Reactio
Immediated hypersensitivity
Bronchospasm, laryngeal edema, anaphylaxis, urticaria, angioedemia.
Type II IgG or immunoglobulin M (IgM) mediated
Cytotoxic response occurs when the drug binds with immunoglobulins and leads to cell destruction.
Ex. Hemolytic anemia (Methyldopa, quinidine, pcn)
Thrombocytopenia (heparin, LMWH, quinidine, sulfonamide antibiotics)
Granulocytopenia
Type III: IgG or IgM
IgG or IgM complexes with drugs, which can then deposit in vessel walls and lead to inflammation and tissue damage.
Ex: Serum sickness (fever, rash, urticaria, arthalgia, lymphadenopathy) Drug ex. PCN, sulfonamide antibitocis, phenytoin, ASA, murine monoclonal antibodies.
Type IV T-cell mediated
Classically termed delayed hyper sensitivity
T-cells recognize antigens using receptors on the cell surface and release cytokines directly or in conjunction with effector cells such as eosinophils, monocytes or neutrophils.
Ex. Contact dermatitis
Maculopapular rash
Drug ex. ampicillin, amoxicillin, sulfonamide antibiotics, phenytoin, carbamazepine.
Bullous exanthema (Erthema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) least severe to most severe respectively.
Drug exm. Sulfonamide antibiotics, allopurinol, carbamazepine, phenytoin, sometimes associated with viral infections.
Other Type IV reactiosn
Fixed drug eruptiosn (well defined rash borders, red slightly elevated) Ex. sulfonamide, tetracycline, NSAID, carbamazepine, cirpo
Drug Rash with eosinophila and systemic symptoms. Hepatitius can occur in 60% of these casues (phenytoin, phenobarbital, carbamazepine, sulfonamide, allopurinol, dapsone.
Eosinophilia
If possitive test supports the diagnosis of drug-induced allergic reaction. If negative, does not rule out the drug-induced allergic causes.
Combs test
Antiglobulin test
Positive in drug-induced hemolytic anemia
Direct: antiglobulins are combined with the patient’s red blood cells. If the red blood cells are coated with antibodies, there is agglutination.
Cutaneous warning signs for severe reactions (SJS, TEN)
elevated temp, malaise, erythematous edema of the face, target lesions, confluent erythema covering much of the body surface, mucosal involvement, lesions that are hemorrhagic or palpable, painful skin on touch.
Management of Hypersensitivity Rxn
Symptomatic Tx (Antihistamines, NSAIDS, Glucocorticoids)
Severe (SJS, TEN)- consider burn center care, fluids, nutrition, support, skin care, avoid topical sulfonamide products. Opthalmoloist required, topical opthalmolgic corticosteriods are usually required. IV IG 2-3 g/kg over 3-5 days. Systemic Corticosterioids are controversial.
Patients with amoxicillin allergy should avoid cephalosporins that share a common side chain…
Cefadroxil, cefprozil
Patients with ampicillin allergy should avoid cephalosporins that share a common side chain….
cephalexin, cefaclor
True or False…There is conclusive evidence of cross-reactibity b/t the sulfonamide antibiotics and other sulfonamides such as carbonic anhydrase inhibitors, sulfonylureas, lopp diuretics, thiazide diuretics, Cox-2 inhibitors.
False…no conclusive evidence.
Pseudo-allergies
Direct release of mediators from mast cells and basophils
Rxn are immediate and do not require previous exposure
Common examples include opiates, radiocontrast media, colloid volume expanders, iron dextran, aspirin, and NSAIDs.
Anaphylaxis Clinical Features
Rapid onset, life-threatening respiratory or cardiobascular collapse.
Skin involvement in 90% of cases (ie urticaria, rash, swelling, pruritus)
Respiratory invovlement in up to 70% (Nasal sx, upper airway, lower respiratory (SOB, chest tightness))
GI tract in up to 45% (NVD, abdominal pain)
Cardiovascular in up to 45% (chest pain tachycardia, bradycardia, hypotension, shock) Up to 50% fluid shift from the intravascular compartment in 10 min
Central nervous system in up to 15% (headache, dizziness, confusion, tunnel vision)
Anaphylaxis Differential Dx
- Scrombroid poisoning (histamine poisoning caused by eating spoiled fish)
- Angioedema
- Severe asthma
- Vasovagal rxn
Epinephrine
Cornerstone of tx for anaphylaxis
Administer IM in the thigh
Adults 0.2-0.5 mg IM
Pediatric patients 0.01 mg/kg IM up to 0.3 mg
Home Kits- kids weighing less than 30 kg get 0.15 mg, more than 30kg get 0.3 mg
Administer every 5-15 min as needed.
If fails, could use IV but not generally recommended d/t arrhythmias, myocardial ischemia, and severe hypotension.
When epi fails to reverse hypotension
Isontonic crystalloids (eg. 0.9% NaCL)
Adults 500-1000 ml
Pediatric patients 20ml/kg
Colloid infusions should not be used because they can cause anaphylaxis.
Other Acute treatment for anaphylaxis
- Oxygen
- Antihistamine (diphenhydramine & also cimetidine and ranitidine if combined with diphenhyramine improved cutaneous sx and tachycardia)
- Glucocorticoids
- Glucagon
Angioedema
Edema of skin or mucous membranes, non-pitting, sudden onset, mild to severe.
causes: allergic
non-allergic
Aspirin and NSAIDS rxn develop within 4 hours
Radiocontrast media
ACE-Inhibitor
Can occur in 1 day to 5 years later.
Gastric Decontamination-Poisoning
Not routinely indicated
Syrup of ipecac no longer recommended
Single-dose activated charcoal, may be useful for toxins known to bind to activated charcoal when exposure is less than 1 hour.
Multi-dose activated charcoal-useful for selected life-threatening exposures to the following toxins, carbamazepine, dapsone, phenobarbital, quinine, theophylline. (b/c of enterohepatic circulation)
Whole bowel irrigation (useful to expel contents of the GI tract
Orogastric lavage, if exposure is less than 1 hour and life threatening.
Antidote for Benzodiazepine
Flumazenil
Antidote for digoxin
Digoxin immune Fab
Antidote for Acetaminophen
N-acetylcysteine
Antidote for b-blockers
Glucagon
Antidote for Isoniazide
Pyridoxine
