Exam 5

Question 0

Cerebrospinal fluid in bacterial meningitis:
Appearance
Opening pressure
Cell content
Protein
Glucose
Culture

Answer 0

Appearance: cloudy
Cell content: increased WBC (polymorphonuclear)
Protein: increased (100-500 mg/dL, normal 15-45)
Glucose: decreased ( < 40%, normal 60-80)
Culture: + on Gram’s stain & culture

Question 1

What are the steps in the APPROACH acronym for intubation?

Answer 1

A: Assess (HAND: History, Anatomy, Neck Mobility, Difficult Airway)
P: Preoxygenation
P: Prepare
R: Review
O: Oxygen cutoff
A: Administer medications
C:Confirm tube placement
H: Hold tube until secure

Question 3

Describe cerebrospinal fluid in viral meningitis:
Appearance
Opening pressure
Cellular content
Total Protein
Glucose
Culture

Answer 3

Appearance: Sometimes cloudy, often clear
Opening pressure: normal (< 30 mm)
Cellular content: increased WBC (monomorphic)
Total protein: Normal or slightly increased
Glucose: Normal
Culture: - on Gram’s stain & culture. Different technique to show viral presence.

Question 4

Four Reliable Signs of CHF (Chest x-ray)

Answer 4

1) Kerley B lines
2) Fluid in the fissures
3) Peribronchial cuffing
4) Pleural effusion

Question 5

What is the beta-blocker that can be used to prevent the sympathetic response to intubation?

Answer 5

Esmolol; extremely short acting & beta-1 selective.

Question 6

Fentanyl for intubation
Dosage/Onset/Duration
Pros vs. Cons

Answer 6

1-2 mcg/kg over 1-2 minutes
Onset immediate, duration 0.5-1 hour
Pros: Primary pretreatment drug to provide sedation and analgesia; decreases hypertensive response to intubation [though at this time, no conclusive evidence supports the use of opioids in routine RSI]
Cons: Hypotension; chest wall rigidity at high doses (ie, >15 mcg/kg)

Question 7

Lidocaine (xylocaine) for intubation
Dosage/Onset/Duration
Pros vs. Cons

Answer 7

1.5 mg/kg IVP
Onset 1-2 min, Duration 10-20 min
Pros: Useful in patients with asthma/COPD to decrease hypertensive response
Cons: hypotension

Question 8

Atropine for intubation
Dosage/Onset/Duration
Pros vs. Cons

Answer 8

0.02 mg/kg (usually about 0.4 mg) IV push
[Typically administered for pediatric patients ≤1 y]
Onset 2-4 minutes, duration up to 4 hour
Pros: Antisialagogue
Cons: Tachycardia

Question 9

Vecuronium (Norcuron) for intubation
Dosage/Onset/Duration
Pros vs. Cons

Answer 9

Defasciculating dose: 0.01 mg/kg IV push (typically about 1 mg, or 10% of intubation dose)
Pro: Decreases fasciculation and potassium release from cells; particularly useful if intend to use succinylcholine
Con: Higher doses cause paralysis

Question 10

Rocuronium (Zemuron) for intubation
Dosage/Onset/Duration
Pros vs. Cons

Answer 10

Defasciculating dose: 0.06 mg/kg IV push (typically about 10% of intubation dose)
Pro: Decreases fasciculation and potassium release from cells; particularly useful if intend to use succinylcholine
Con: Higher doses cause paralysis

Question 11

The ideal drug for the induction phase of intubation should be…

Answer 11

The ideal drug produces rapid unconsciousness, has a short duration of action, and causes minimal alterations in hemodynamics, respirations, and intracranial pressure (ICP). It should also have the ability to be easily stored and readily available for use.

Question 12

What is the gold standard drug for RSI induction?

Answer 12

Etomidate:

An ultrashort-acting nonbarbiturate hypnotic agent.

Question 13

Ketamine in RSI
Dosage/Onset/Duration
Pros vs. Cons

Answer 13

1-2 mg/kg slow IV push (not to exceed 0.5 mg/kg/min)
Onset: 0.5-1minute, Duration: 5-10 minute
Pros: #Bronchodilatory effects advantageous if hypotension or lung disease present (leaves airway and other protective reflexes intact) #rarely used in adults #may possess neuroprotective affects and increase CPP
Cons: May increase ICP (though lacking evidence showing clinical significance) #hallucinations #increases sympathetic tone #potent cerebral vasodilation #cardiovascular stimulation (do not use with ischemic heart disease) #emergence delirium common, but more of a concern when used for conscious sedation with painful procedures (approximately 12%) in adults < 65 y

Question 14

Etomidate in RSI
Dosage/Onset/Duration
Pros vs. Cons

Answer 14

0.3 mg/kg IV push (normal adult dose about 20 mg)
Onset: 0.5-1 minute, Duration: 3-5 minute
Pros: #Rapidity of onset #short duration of action, #lack of cardiodepressant effects #marked safety in patients with head injury #minimal adverse effects. Etomidate is available as a solution of 20 mg/mL and may be stored at room temperature with a long shelf life.
Cons: # commonly causes myoclonus #pain upon injection; adrenal suppression (typically no clinical significance with one bolus) #does not suppress sympathetic response to laryngoscopy #nausea/vomiting #lowers seizure threshold #does not provide analgesia

Question 15

Propofol in RSI
Dosage/Onset/Duration
Pros vs. Cons

Answer 15

2-3 mg/kg IV push [Decrease dose if patient unstable]
Onset: < 1 min Duration: 3-10 min
Pros: #Provides rapid onset and brief duration #cerebroprotective (decreases ICP) #amnestic properties #extremely potent
Cons: #Causes cardiovascular depression and hypotension #respiratory depression is dose-dependent

Question 16

What effect do paralytics have on emergent intubation?

Answer 16

Previous studies have shown that emergent intubations without the use of paralytic agents lead to an increase in adverse events. More recently, Walls et al have looked at 8,937 emergency department intubations and found that the likelihood of any associated event was 1.7 times higher with sedation without paralytics compared with RSI.

Question 17

When should a paralytic be administered without an induction agent?

Answer 17

NEVER. Administering a paralytic agent without a potent and effective induction agent is inhumane. It is of utmost importance that this induction agent have an onset of action faster than or at least the same as that of the paralytic agent.

Question 18

What is the paralytic of choice in almost all RSI?

Answer 18

Succinylcholine (Sux)

Question 19

What are some contraindications to succinylcholine?

Answer 19

#Burns over a large surface area
#Multisystem trauma with crush injury
 #Spinal cord and other denervating injuries
 #Extensive muscle necrosis (eg, those due to large crush injuries)
 #Certain myopathies
  #Any preexisting hyperkalemia

Question 20

Succinylcholine in RSI
Dosage/Onset/Duration
Pros vs. Cons

Answer 20

0.3-2 mg/kg IV push (average dose 1.5 mg/kg)
Onset: 1 min Duration: 4-6 minute
Pros: #Depolarizing NMB #drug of choice for emergency pediatric intubation #rapid onset (< 60 s) and brief duration of action #enhances nondepolarizing neuromuscular blocking effects
Cons: #Increased serum potassium #muscle fasciculation #malignant hyperthermia #cardiac arrest in children with muscular dystrophy #dysrhythmia with multiple doses

Question 21

Rocuronium (Zemuron) in RSI
Dosage/Onset/Duration
Pros vs. Cons

Answer 21

0.6-1 mg/kg IV push
Onset: < 1 min Duration: 30-60 MINUTES
Pros: #Nondepolarizing NMBA #minimal effect on hemodynamics #low incidence of histamine release (0.8%)
Cons: #long duration #Duration prolonged with hepatic impairment

Question 22

Use of OLDCART acronym in HPI

Answer 22

O: Onset
L: Location (radiate?)
D: Duration
C: Character
A: Aggravating factors
R: Relieving factors
T: Timing (intermittent/constant?)

Question 23

HPI for Preceptor

Answer 23

1) Chief complaint including duration
2) OLDCART
3) Positive findings on ROS that haven’t been previously addressed
4) Review medical history & medications
5) Physical exam findings (include ALL positive findings)
6) Relevant diagnostic study results

Question 24

HPI Tips

Answer 24

1) Never omit details that might affect care or safety
2) Include pertinent NEGATIVES in both subjective & objective info
3) Do not include negative findings not relevant to chief complaint