General

Question 1

What does AMAX4 stand for?

Answer 1

Adrenaline (1mcg/kg), muscle relaxant (roc +/- sedative), airway ETT, xtreme ventilation/bronchodilators/vasopresors/PTX, 4 minutes until brain death

Question 2

What patients is AMAX4 protocol meant for?

Answer 2

Unresponsive/apnea/arrest anaphylaxis or asthma

Question 3

How long does IM and SQ epi take to work? When is it advised to switch to IV? What does?

Answer 3

IM: 5-8 mins
SQ: 20 mins

Switch to IV if crashing or given 2 epi pens. IV dose per anaphylaxis committees is 1mcg/kg. Easy and quick is NO dilution and just give 0.5 mL of code epi (50 mcg)

Question 4

Went putting asthma/anaphylaxis on vent, what should you change your pressure limit to?

Answer 4

100. Maximize PIP limit. Consider lateral chest squeeze (assisted exhalation). BVM as well but this can cause PTX

Question 5

What tertiary site intervention should be considered for crashing and then intubated and stabilized anaphylaxis/asthma/brinchoconstriction patients?

Answer 5

VV ECMO

Question 6

What vasopressin’s should be considered in asthma/anaphylaxis?

Answer 6

Epi, norepi, vasopressin, methylene blue

Question 8

What is the dose of tranexamic acid in angioedema?

Answer 8

1g over 10 mins, repeat q4h prn

-theoretically should be beneficial in any bradykinin-mediated angioedema, specifically ACEi and hereditary angioedema. Data is VERY limited, no controls, small studies <10 patients

Question 9

What are the two FDA approved uses of TXA?

Answer 9

Menstrual bleeding, tooth extraction hemorrhage.

Question 10

What is the dose of tpa for epistaxis?

Answer 10

500mg soaked gauze

Question 11

Did tpa work in GIB?

Answer 11

Most recent HALT-IT which was largest RCT did not show benefit

Question 12

Dose of tpa in menstrual bleeding?

Answer 12

10 mg/kg IV over 10 minutes then q8h max 600 mg

Question 13

TXA dose for hemoptysis?

Answer 13

500 mg nebulized TID for 5 days

Question 14

Can you use TXA for atraumatic SAH?

Answer 14

It appears so. 1g over 10 mins then q6h until aneurysm is occluded. Short term use does not show much increase risk of thromboembolic events. 2021 ULTRA trial showed no change in outcome however at 6 months. Ask NSGY

Question 15

TXA for post-tonsillectomy bleed?

Answer 15

Can do topical 500 mg soaked gauze, nebulized 500 mg, IV 1g

Question 16

TXA for tpa bleed?

Answer 16

1g over 10 mins

Question 17

TXA in trauma?

Answer 17

Greatest benefit in shock (SBP<70) but can be used for TBI or general trauma. Dose is 1g over 10 mins. GCS<13 >8. Need to be given within 3 hours for most benefit

Question 18

What is onset and duration of TXA?

Answer 18

Peak onset within minutes if IV, 2.5 hrs for oral. Duration 3 hours

Question 19

TXA adverse effects?

Answer 19

Headache, low incidence of seizures, abd pain nvd, HYPOTENSION IF GIVEN QUICKER THAN 10 MINS, VTE, back pain MSK pain, renal cortical necrosis

Question 20

TXA mechanism of action?

Answer 20

Tranexamic acid is a synthetic lysine derivative that binds at the lysine site on plasminogen, which reversibly prevents plasmin activation and inhibits fibrinolysis. It also inhibits the proteolytic activity of plasmin.※

Tranexamic acid inhibits the inflammatory effects of plasmin, resulting in reduced complement cascade (C1) activation, sparing the consumption of C1 inhibitor (C1-INH), thereby decreasing inflammation associated with hereditary angioedema. Tranexamic acid blocks the conversion of plasminogen to plasmin, which is a key step in the inhibition of kallikrein activation and bradykinin formation that occurs in ACE inhibitor-induced angioedema.

Question 21

What is mechanism of octreotide in variceal bleed?

Answer 21

Octreotide (somatostatin) inhibits secretion of gastric, VIP, glucagon. This may help with ulcers.

More importantly, it causes splanchnic vasoconstriction reducing inflow of blood to portal system thus reducing portal hypertension and reducing intravariceal pressure