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PHM BSc - Resus Science > ERC - special circumstances > Flashcards

ERC - special circumstances Flashcards

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1
Q

Is hypoxia due to apnoea or due to airway obstruction likely lead to arrest first and why?

A

airway obstruction
Patient trying to breathe against the obstruction which increases oxygen demand therefore leading to hypoxic cardiac arrest quicker

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2
Q

Name some causes of asphyxial cardiac arrest

A

laryngospasm, asthma, spinal cord injury, drowning, pneumonia, tension pneumothorax

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3
Q

What K level is considered hyperkalaemia

A

> 5.5 mmol/L

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4
Q

State some cause of hyperkalaemia

A

metabolic acidosis (inc diabetic keto)
ACEi, ARB, Bblocker, NSAIDs
rhabdomyolysis
AKI

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5
Q

What ECG changes are you looking for in hyperkalaemia

A 
Rate: Bradycardia, VT
flat P
wide QRS
Peaked T
Sine wave - S and T merge
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6
Q

A long transit time would lead to hyper or hypo kalaemia

A

hyper - K released in the clotting process

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7
Q

Management of a mild hyperkalaemia (5.5-5.9mmol/L)

A

Calcium resonium 15g 4x/day oral -

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8
Q

Management of moderate (6-6.4) and severe (>6.5) hyperkalaemia without ECG changes

A 
25g glucose (50ml 50%) + 10 unit soluble short acting insulin IV over 10 minutes
\+ calcium resonium or dialysis
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9
Q

Management of moderate (6-6.4) and severe (>6.5) hyperkalaemia with ECG changes

A

10ml 10% calcium chloride IV over 2-5 minutes
repeat dose after 5 minutes if needed
+ 25g (50ml 50% glucose) and 10 units insulin
+ calcium resonium or dialysis
+ salbutamol nebulisers 10-20mg

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10
Q

In which patients hyperkalaemic would you consider dialysis

A

end stage renal failure
oliguric AKI
rhabdomyolysis

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11
Q

Define mild, moderate and severe hyperkalaemia

A

mild 5.5-5.9
moderate 6-6.5
severe >6.5

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12
Q

What monitoring is needed during hyperkalaemia management

A

pottasium
ECG
glucose (risk of hypo due to treatment)

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13
Q

A hyperkalaemic patient has severe acidosis or renal failure, what additional drug would you consider

A

sodium bicarbonate

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14
Q

signs of hyperkalaemia

A

parasthesia
loss of deep tendon reflex
flaccid paralysis

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15
Q

signs of hypokalaemia

A

fatigue
weakness
cramps
constipation

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16
Q

K level defining hypokalaemia

A

<3.5mmol/L

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17
Q

causes of hypokalaemia

A 
diarrhoea 
K losing diuretics 
metabolic alkalosis
hypomagnesaemia 
steroids
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18
Q

ECG signs of hypokalaemia

A

Flat T

U wave

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19
Q

Management of hypokalaemia

A

replace K slowly unless emergency in which case you can give 20mmol/hr

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20
Q

Management of a tension pneumothorax

A

intubate, PPV and decompress the chest

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21
Q

Why is a needle decompression not often used

A

Chest wall thickness often too thick for it to work

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22
Q

Describe a thoracostomy in tension pneumothorax management

A

PPV
cut and then dissect to reach the pleural cavity
a chest tube can then be inserted

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23
Q

Describe some general management options to decontaminate and enhance elimination of poisons

A

50-100g activated charcoal
whole bowel irrigation
haemodyalysis

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24
Q

benzodiazepine toxicity management

A

flumazenil

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25
Q

opioid toxicity management

A

400 micorgrams naloxone

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26
Q

TCA toxicity presentation

A

VT
hypotension
seizures

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27
Q

TCA toxicity management

A

sodium bicarbonate 1-2mmol/kg

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28
Q

B blocker toxicity management

A

limited evidence but can try glucagon or insulin and glucose

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29
Q

CCB toxicity management

A

20ml 10% calcium chloride

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30
Q

Digoxin toxicity management

A

Digoxin-FAB antidote

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31
Q

cyanide toxicity management

A

hydroxycobalabamin

sodium thiosulfate

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32
Q

Which benzo toxicity patients would you not give flumazenil to

A

if they coingested TCAs

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33
Q

aspirin toxicity management

A

urinary alkalinisation with IV sodium bicarbonate

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34
Q

Brief overview of traumatic CA management

A

treat the reversible causes. These take priority over compressions

  1. hypovolaemia - control catastrophic haemorrhage
  2. hypoxia - control airway
  3. tension pneumothorax - bilateral chest decompression
  4. tamponade
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35
Q

how is external haemorrhage controlled

A

direct pressure, torniquet, pelvic binder
blood products
TXA 1g over 10 minutes
further 1g infused over 8 hours

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36
Q

how is airway managed in traumatic CA

A

immediate intubation if possible but if not SGA

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37
Q

how should a traumatic CA patient be ventilated and why

A

Low tidal volume and rate as aggressive ventilation and PPV leads to increased intrathoracic pressure and therefore reduced diastolic filling and reduced CO
aim for normocapnoea

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38
Q

You are with a traumatic CA patient, they arrested <10 minutes ago, you have the expertise, equipment and right environment, what do you do

A

consider a resuscitative thoracotomy

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39
Q

when is a resuscitative thoracotomy considered

A

cardiac arrest <10 minutes ago + penetrating chest/epigastrium injury + expertise, equipment and environment suitable

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40
Q

when in CPR stopped in traumatic CA

A

all reversible causes addressed
15 minutes downtime
obvious mortal injury
no cardiac activity on USS

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41
Q

a traumatic CA patient reaches hospital, what happens now

A

damage control resuscitation:

permissive hypotension + haemostatic resuscitation + damage control surgery

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42
Q

describe permissive hypotension

A

Fluids given to maintain:
systolic pressure at 80-90
radial pulse

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43
Q

describe haemostatic resuscitation

A

ratio of packed red cells: platelets: FFP is 1:1:1

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44
Q

What should you look for when diagnosis anaphylaxis

A

acute onset
life threatening problems with airway, breathing, circulation
skin or mucosal changes

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45
Q

Initial steps (before drugs) in anaphylaxis management

A

remove trigger
call for help
lie patient flat with legs raised (unless their breathing is easier sat up)

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46
Q

Anaphylaxis drug management

A

IM Adrenaline 500 micrograms (0.5ml 1:1000)
IM or slow IV Chlorphenamine 10mg
IM or slow IV Hydrocortisone 200mg
IV fluid challenge 500-1000ml crystalloid

47
Q

how does adrenaline work in anaphylaxis

A

alpha agonist: reverse peripheral vasodilation
B agonist: airway dilation, increased cardiac force of contraction, inhibits activation of mast cells so stops them releasing histamine

48
Q

A patient in anaphylaxis goes into arrest: how are they managed

A

Standard ALS adrenaline doses

49
Q

your anaphylaxis patient doesn’t improve after the first dose of adrenaline, what do you do

A

repeat the dose every 5 minutes

50
Q

MOA of chlorphenamine

A

H1 antihistamine which counters vasodilation and bronchoconstriction

51
Q

You arrive at the scene of an avalanche: in what situations would you not start CPR

A

can’t safely get to the victim
obvious mortal injury
whole body frozen

52
Q

You find a patient at the scene of an avalanche, what 2 factors determine using the standard ALS algorithm or not

A

duration of burial <60 minutes

temperature >30 degrees

53
Q

Your avalanche burial victim has been there for >60 minutes or is <30 degrees, what do you assess next

A

signs of life - spontaneous breathing or palpable pulse

check for 1 minute

54
Q

Your avalanche burial victim has been there for >60 minutes or is <30 degrees and has signs of life, now what

A

transport them to a hospital that can provide ECLS

55
Q

Your avalanche burial victim has been there for >60 minutes or is <30 degrees and has no signs of life. Compare your management strategy in regards to the different arrest rhythms

A

VF/pVT/PEA - transport them to a hospital that can provide ECLS
asystole with patent airway - test potassium
asystole with no patent airway - termination of CPR

56
Q

your avalanche burial victim is in asystole with a patent airway and you have measured their potassium, describe what results would lead to what management decision

A

> 8mmol/L: consider termination of CPR

<8mmol/L: transport to hospital that can provide ECLS

57
Q

What do you need to consider as a cause for a raised potassium in an avalanche burial victim

A

crush injuries

if any depolarizing neuromuscular blocking agents have been used

58
Q

What is commotio cordis

A

disruption of the cardiac rhythm due to a blow to the precordium

59
Q

what is the ETCO2 goal signifying effective CPR

A

> 2.7Kpa (20mmHg)

60
Q

define submersion vs immersion

A

submersion - the patients face is underwater

immersion - the patients head remains above water

61
Q

What reflex occurs on being submersed in water and what does this lead to

A

breath holding reflex - lead to hypoxia (and therefore bradycardia) and hypercapnia
eventually the laryngospasm relaxes and the patient aspirates water

62
Q

what leads to collapse on being rescued from water

A

The loss of hydrostatic pressure that the water has been providing leads to hypovolaemia

63
Q

Principles of managing a drowning victim

A

keep them horizontal
open airway
5 rescue breaths + O2 if possible

64
Q

drowning victims often have increased airway resistance. What does this mean for your management

A

SGA may not provide adequate inflation pressures so intubate asap
increased risk of gastric inflation and aspiration

65
Q

What causes later complications in drowning victims

A

surfactant has been washed out

66
Q

What are some altitude related illnesses

A

acute mountain sickness - headaches, nausea, dizzy
high altitude pulmonary oedema - cyanosis, SOB
high altitude cerebral oedema - confused, disorientated, odd gait

67
Q

treatment of a patient suffering from altitude related illnesses

A 
get them down
O2
hyperbaric chamber
dexamethasone for cerebral oedema
nifedipine for pulmonary oedema
68
Q

What injuries/illnesses should be examined for in a patient that has been electrocuted

A

fractures - from sustained tetanic muscle contraction
respiratory muscle paralysis
VF from the electrical current
ischaemia - from coronary vasospasm

69
Q

A patient survives the initial electrocution, what can then happen to lead them to being unstable

A

catecholaminergic surge - raised BP, long QT, T inversion

70
Q

management strategies for an electrocution patient

A

intubate if facial burns
c-spine if fall
ventilation for respiratory muscle paralysis
fluids for tissue destruction

71
Q

You are at a major incident and come across a patient that isn’t breathing, what do you do

A

Look listen feel for 10 seconds
nothing = dead
something = recovery position and move on

72
Q

what is auto-peep in asthmatics and what does it lead to cardiovascularly

A

air flow does not return to zero at the end of exhalation. Air enters and cannot escape meaning that intrathoracic pressure rises and venous return falls

73
Q

you give an asthmatic a B-agonist and there sats go down, why could this be

A

vasodilation and bronchodilation leads to increased shunting

74
Q

asthma emergency management

A 
5mg nebulised salbutamol every 15 minutes
0.5mg ipatropium bromide every 4 hours
\+/- I00mg hydrocortisone
\+/- IV magnesium sulphate 
\+/- IV salbutamol
\+/- aminophylline
75
Q

An asthmatic patient goes into arrest, what alterations need to be made to standard ALS

A

early intubation
ventilate at a rate of 8-10/minute
may need to increase defibrilation energy to overcome increased impedance from air trapping

76
Q

What is a ventricular assist device

A

pump that assists in moving blood from ventricles to great vessels (most common type is LVAD so LV to aorta)

77
Q

how can cardiac arrest be diagnosed in someone with a ventricular assist device

A

The device pump will tell you
arterial line and CVP give the same readings
echo

78
Q

Describe the management of VF,pVT, asystole and PEA in someone with a ventricular assist device

A

VF/pVT - defib as normal
asystole - pacing
PEA - turn pacing off and check for underlying VF

79
Q

ipatropium bromide MOA

A

anticholinergic so increases bronchodilation

80
Q

causes of cardiac arrest in pregnancy

A

haemorrhage, PE, eclampsia, genital tract sepsis

81
Q

At what week gestation does aortocaval compression begin to effect venous return and BP

A

> 20 weeks

82
Q

Changes to emergency management when the patient is pregnant

A

left lateral title to 15 degrees or manually displace the uterus
hand position for compressions higher
smaller tracheal tube due to the airway oedema associated with pregnancy
shock as normal

83
Q

methods to control haemorrhage in a pregnant patient

A

cell salvage
oxytocin and prostoglandin analogues
massage uterus
balloon tamponade

84
Q

at what week gestation would you start to consider resuscitative hysterectomy

A

> 20 weeks

until 24 weeks this is just for mothers sake

85
Q

management of eclampsia

A

magnesium sulphate

86
Q

why is early intubation needed in pregnancy arrest

A

increased abdominal pressure = harder to ventilate lungs

relaxed oesophageal sphincter = aspiration risk higher

87
Q

What would make you think someone was having an acute severe asthma attack

A

HR >110
RR >25
can’t complete sentence in one breath

88
Q

What would make you think someone was having a life threatening asthma attack

A 
sats <92%
PaO2 <8
normal PaCO2 (4.6-6)
hypotensive
cyanotic
silent chest
altered conscious
89
Q

What would make you think someone was having a near-fatal asthma attack

A

hypercapnia

90
Q

Normal range of calcium

A

2.1-2.6mmol/L

91
Q

causes of hypercalcaemia

A

primary hyperparathyroidism

malignancy

92
Q

symptoms of hypercalcaemia

A

moans, groans and stones

93
Q

ECG of hypercalcaemia

A

short QT
flat T
AV block
osborn waves (mimic hypothermia)

94
Q

management of hypercalcaemia

A

fluids

furosemide, hydrocortisone, pamidronate

95
Q

causes of hypocalcaemia

A

CCB OD
chronic renal failure
rhabdomyolysis

96
Q

symptoms of hypocalcaemia

A

tetany
parasthesias
seizures

97
Q

management of hypocalcaemia

A

20ml 10% calcium chloride

4-8mmol MgSO4

98
Q

ECG changes of hypocalcaemia

A

prolonged QT
T inversion
AV block

99
Q

normal range of Mg

A

0.6-1.1mmol/L

100
Q

causes of hypermagnesaemia

A

renal failure

101
Q

symptoms of hypermangnesaemia

A

weak
confused
respiratory depression

102
Q

ECG changes in hypermagnesaemia

A

Prolonged PR and AV block
Prolonged QT
peaked T waves

103
Q

management of hypermagnesaemia

A

only required when Mg >1.75mmol/L
10ml 10% calcium chloride
saline
furosemide

104
Q

symptoms of hypomagnesaemia

A

tremor
ataxia
nystagmus
seizures

105
Q

ECG changes of hypomagnesaemia

A 
Prolonged PR
Prolonged QT - TdP
Wide QRS
ST depression
T inversion
106
Q

management of hypomagneseaemia

A

2g 50% MgSO4 IV

107
Q

causes of hypomagnesaemia

A

GI loss
starvation and malabsorption
alcoholism

108
Q

A patient has an arrest with a shockable rhythm whilst in the cath lab, how are they managed

A

3 stacked shocks

CPR with a mechanical device (high quality and reduced radiation to CPR provider)

109
Q

A patient was fitted with a VAD less than 10 days ago and has an arrest that doesn’t respond to defibrillation, what do you do

A

emergency resternotomy

110
Q

Name a differential for ECG features suggestive of ACS

A

subarachnoid haemorrhage

111
Q

a patient has an arrest following major cardiac surgery - how should they be managed

A

if adequate airway and ventilation control and 3 stacked shocks (if VF/pVT) have not worked then undertake emergency resternotomy

112
Q

a patient goes into arrest whilst undergoing haemodyalysis, what is the most likely cause and rhythm

A

hyperkalaemia

shockable

113
Q

you suspect dynamic hyperinflation of the lungs whilst resuscitating an asthmatic patient, what can you do to relieve air trapping

A

compress the chest whilst disconnecting the tracheal tube

PHM BSc - Resus Science (29 decks)

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