Emergency Scenerios Flashcards
What do you do if a patient stop breathing or has paradoxical breathing effort (foreign body algorithm)
-Recognize the situation
-Leave patient alone if they can breathe/exchange air
-If conscious, remove materials from mouth and preform heimlich
What do you do with an unconscious patient with known or suspected foreign body?
-Place in supine
-Remove materials from mouth
-Attempt to remove foreign body with finger sweep
-Improve airway with head tilt/jaw thrust
-Attempt to visualize hypopharynx with laryngoscope, remove object with Magill’s
-If vocal cords visualized and in spasm, move to laryngospasm algorithm
-If fails to resolve, perform abdominal thrusts and ventilate with 100% oxygen
-If fails, consider succinylcholine (1-1.5 mg/kg IV or 4 mg/kg IM) or Rocuronium 0.6-1.2 mg/kg. Consider laryngoscopy and intubation. Consider EMS
Describe your laryngospasm algorithm (Cessation of respiratory sounds, breath holding, high pitched crowing)
-Remove materials from mouth, control bleeding
-Place pt in supine position, improve airway with chin lift/jaw thrust
-100% oxygen
-Positive pressure ventilation with 100% oxygen, possibly airway adjuncts/LMA
-0.1-2 mg/kg IV Succinycholine or 4 mg/kg IM or Rocuronium 0.6-1.2 mg/kg
-Consider laryngoscope/intubation
-Consider reversal (Neostigmine/glycopyrolate: 0.07 mg/kg/0.01 mg/kg) or Sugammadex (2-4 mg/kg up to 16 mg/kg)
-Consider propofol 0.5-0.8 mg/kg, consider cricothyroidotomy, consider EMS
Describe bronchospasm algorithm. (Development of inspiratory and/or expiratory wheezes, prolonged expiration, increased breathing efforts)
-Improve airway/ventilation (remove materials from mouth, 100% oxygen, chin lift/jaw thrust). Monitor vitals (q3-5 min)
-Albuterol inhaler 6-8 puffs (90 mcg each), use spacer
-Bag-valve-mask
-Deepen anesthetic (ketamine 20-30 mg IV)
-Administer parenteral bronchodilator (terbutaline 0.25 mg SC q 15 min x2)
-Administer Epi (1:1000) .01 mg/kg IM up to 0.5 mg q 15 min
-Consider laryngoscopy/intubation, consider LMA
-Consider reversal agents, termination of anesthesia
Describe Emesis-Aspiration Algorithm (evidence of active/passive regurgitation)
-If conscious sedation place in right lateral position
-If pt under GA, trendelenberg position (and right side if possible)
-Remove materials from mouth, 100% oxygen
-High speed suction
-Cricoid pressure (sellick’s maneuver)
-Auscultate lungs
-Consider termination of procedure, discharge after further monitoring
-Ensure chest x-ray, EMS
-Consider laryngoscopy/intubation with hospitalization
Describe Respiratory Depression Algorithm (Evidence of low pulse ox, low respiratory rate/volume, high end tidal pressure CO2)
-Optimize positioning, 100% oxygen, remove materials from mouth
-Improve airway (jaw thrust, head-tilt-chin lift)
-Positive pressure ventilation with 100% oxygen, adjunctive airway
-Consider reversal agents
Narcan- 0.4-2mg IV q 2-3 min no more than 10 mg. 4 mg/0.1 mL IN q2-3 min
Flumazenil- 0.2 mg IV over 15 sec, 2nd dose 0.3 mg (don’t exceed 3 mg). Child 0.01 mg/kg, max dose 0.05 mg/kg or 1 mg
-Consider laryngoscopy, intubation, EMS
Describe Hypertension Algorithm (BP> 220/120, crisis with evidence of MI, neurologic dysfunction, bradycardia, pulmonary edema or visual disturbance)
-Optimize position, remove material from mouth, 100% oxygen
-Monitor BP q3-5 min, continuously monitor pulse oximetry
-Treat causes (anxiety, CV disease, dug interaction, full bladder, hypoxia, pain). Provide additional LA, pain control
Esmolol 1 mg/kg bolus then 150 mcg/kg/min for immediate. 500 mcg/kg over 1 min then 50 mcg/kg/min gradual control
Labetalol 5-20 mg q2min (not for asthmatics) then 40-80 mg IV q10 min (don’t exceed 300 mg)
Hydralazine (alpha blocke): 5-10 mg q20 min if bradycardic
-EMS if hypertensive crisis, physician referral if urgency
Describe hypotension algorithm (BP below 2/3 normal for patient or symptoms: lightheadedness, chest pain, disorientation)
-Recognize emergency, position with legs elevated, remove materials from mouth, 100% oxygen, monitor BP q3-5 min
-Look for causes (CV disease, drugs, pain, postural changes, 5Hs hypercarbia, hypoxia, hypovolemia, hydrogen ion acidosis, hypo/hyperkalemia, hypothermia, 5Ts toxin, tamponade, tension pneumothorax, thrombosis)
-Treat causes (IV fluid challenge)
Medicate:
Atropine-0.01 mg/kg atropine IV up to 0.5 mg if bradycardic up to 3 mg
Ephedrine- 5-10 mg q 5 min
Phenylephrine 0.1 mg q5 min if tachycardic (double dilute)
-Consider reversal agents, watch patient for 2 hours, consider EMS
Describe Allergic Reaction algorithm (flushing, urticaria, nausea, angioedema, wheezing, hypotension, difficulty breathing)
-Recognize, optimize positioning (supine), remove materials from mouth, 100% oxygen, start IV, monitor vitals
-For anaphylaxis administer Epi 0.1 mcg/kg/min increase by 0.05 mcg/kg until BP stable. Or 0.01 mg/kg epi (up to 0.3-0.5 mg IM)
-Adminster Diphenhydramine 50 mg (0.5 mg/kg in children) IV or IM. For cutaneous reactions only do Benadryl
-Fluids 20 mL/kg if hypotensive
-Activate EMS
-Consider Ranitidine 1 mg/kg IV
-Consider hydrocortisone NA+succinate 100 mg (2mg/kg children)
-Consider albuterol for bronchospasm
-Consider intubation for potential loss of airway or refractory bronchospasm
Describe Angina/myocardial infarction algorithm (Evidence of MI, chest pain to left arm/jaw/back, nausea, dyspnea, diaphoresis, ST segment changes or arrythmia)
-Recognize, supine position, remove materials from mouth, 100% oxygen, monitors
-Administer nitroglycerin 0.4 mg SL if BP >90 mm Hg
-Signs its working: Burning under tongue, pt feels better, headache, dizzy.
-Repeat q5 minx2 if pain unresolved
-Caution patients using sildenafil/vardenafil or HR <50
-Activate EMS
-Administer ASA 162-325 chewed and swallowed with water
Describe Cardiac Arrest Algorithm (sudden LOC, loss of pulse or arrythmia)
-Recognize emergency
-Alert staff, call for defibrillator or AED/crash cart and help
-Position pt supine, remove materials from mouth
-Assess ventilation and pulse
-Check pulse less than 10s (try carotid pulse)
-Start CPR 100-120 compressions per minute, 30:2 respirations
-Evaluate ECG and defib as necessary
-Activate EMS
-ACLS if VF/VT, ACLS for asystole or PEA
-Attempt airway placement
-Administer 1 mg epi IV push (0.01 mg/kg in children) q3-5 min
-Defibrilate q2 min (Biphasic 200J, children 2J/kg then 4J/kg)
-Consider amiodarone 300 mg if VF/VT (then 150 mg)
-Use Magnesium for Torsades 1-2g or 5 mg/kg Child
Describe Stroke Algorithm (pt starts slurring words)
-Recognize, FAST rule (facial drooping, arm drift w/ eyes closed, slurred words, 911 to stroke center ASAP)
-Write down time of last normal
-Don’t use D5W, give 0.9% NaCl
-Determine BS (give 50% dextrose if hypoglycemic, insulin if hyperglycemic)
Describe syncope algorithm (sudden LOC)
-Recognize emergency
-Call for defibrillator if loss of pulse
-Supine position, remove materials, head tilt-chin lift, lift legs (trendelenberg)
-IF breathing, give 100% oxygen and monitor
-If not breathing, positive pressure ventilation, evaluate ECG
-Search for cause (hypotension, hypoxia, hypoglycemia, arrithmia, stroke)
-Treat underlying cause
Hypotensive: Fluid challenge
Bradycardic: Atropine 0.5 mg up to 3 mg or dopamine 2-20 mcg/kg/min or Epinephrine 2-10 mcg/min or Isuprel 2-10 mcg/min
-EMS if not treatable
Describe Convulsions Algorithm (Tonic-clonic or Clonic Seizure)
-Recognize, supine position, protect patient from physical injury
-Remove objects from mouth if safe
-100% oxygen, monitor vitals
-If self terminating: Reassure pt, assess for injuries, continue treatment based on med history/anesthetic/operative need vs monitor recovery
-If continuous or recurring seizure activate EMS
-Administer anticonvulsant:
Midazolam 0.05-0.2 mg/kg IV max 10 mg
0.1-0.2 mg/kg IM or 0.2 mg/kg IN total dose 10 mg
Ativan: 0.05-0.1 mg/kg IV 2 mg/min with 4-8 mg loading dose
Diazepam: 1 mg/min IV (.2 mg/kg up to .5 mg/kg in children)
-Consider intubation or LMA if airway compromised
Describe hypoglycemia algorithm (h/o insulin dependent diabetes, diaphoresis, confusion, LOC)
-Recognize, supine, remove materials from mouth 100% oxygen, monitor vitals
-Obtain blood glucose
-Administer fluids containing sugar if conscious
-If unconscious administer 50% dextrose 1 mL/kg IV up to 50 mL
or D5W 10 ml/kg up to 500 mL or glucagon 0.025-0.1 mg/kg up to 1 mg
-Monitor BG
-Activate EMS if consciousness not resolved
