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H1. Emergency Flashcards

1
Q

In emergency, where to take pulses? (Infants/children)

A

Infants: Brachial artery
Children: Carotid/femoral artery

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2
Q

Capillary refill ranges (3)

A

Normal <2s
Delayed 2-5s
Suggested shock >5s

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3
Q

Formula to determine hypotension

A

Systolic BP < 70 + 2xage

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4
Q

Bradycardia HR, requiring chest compression?

A

HR < 60

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5
Q

End tidal CO2 indicating inadequate chest compression?

A

< 20mmHg

Normal range 35-45

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6
Q

In resuscitation, chest compression depth (Infant/Prepubertal/Adol•Adults)

A

*1/3 AP diameter of the chest

Infant: 1.5 inch (4 cm)
Prepubertal: 2 inch (5 cm)
Adol•Adult: 2 - 2.5 inch (6 cm)

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7
Q

In resuscitation, chest compression rate?

A

100 - 120 / minute

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8
Q

In resuscitation, chest compression/ventilation ratio, method for chest compression?
(Infant•prepubertal, 2 or 1 rescuers)

A

Infant•prepubertal:
when 2 rescuers, 15:2 with two thumbs
when 1 rescuers, 30:2 with two fingers

(Adults: 30:2 when 1 or 2 rescuers)

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9
Q

Location of chest compression? (Infant/prepubertal/adult)

A

Infant: 1 fingerbreadth below the intermammary line
Prepub: 2 fingerbreadths below the intermammary line
Adult: Lower half of the sternum

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10
Q

In resuscitation, what kind of fluid should be used?

A

Isotonic crystalloids (Normal saline or lactated Ringer’s solution)

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11
Q

In resuscitation, how much fluid should be given?

A

20 ml/kg boluses each within 5 min for a total of 60 ml/kg in the first 15 min
(Check for hepatomegaly after each bolus)

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12
Q

In resuscitation, when known or suspected cardiac insufficiency, how much fluid should be given?

A

5 - 10 ml/kg

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13
Q

Types of shock (4)

A

Hypovolemic
Cardiogenic
Distributive
Obstructive

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14
Q

Causes of cardiogenic shock? (4)

A

Congenital heart disease
Myocarditis
Cardiomyopathy
Arrhythmia

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15
Q

Causes of distributive shock? (3)

A

Sepsis
Anaphylaxis
Neurogenic

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16
Q

Causes of obstructive shock? (3)

A

Pulmonary embolus
Cardiac tamponade
Tension pneumothorax

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17
Q

Stridor vs wheezing, sound differences?

A

Stridor: single pitch
Wheezing: musical

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18
Q

Stridor vs wheezing, which respiratory cycle?

A

Stridor: inspiratory
Wheezing: expiratory

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19
Q

Stridor vs wheezing, which airway obstructed?

A

Stridor: large airway with severe obstruction
Wheezing: any size of airway

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20
Q

Single-pitched, inspiratory, severe large airway obstruction.

Stridor vs wheezing?

A

Stridor

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21
Q

Musical, expiratory, obstruction of airway of any size?

Stridor vs wheezing?

A

Wheezing

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22
Q

Sellick maneuver?

A

Cricoid pressure to minimize gastric inflation and aspiration
Excessive use could obstruct the trachea

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23
Q

Cricoid pressure to minimize gastric inflation and aspiration
Excessive use could obstruct the trachea

Name of the maneuver?

A

Sellick maneuver

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24
Q

In conscious patients, what airway is used?

Nasal vs oral airway?

A

Nasal airway

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25
In unconscious patients, what airway is used? | Nasal vs oral airway?
Oral airway
26
How to measure the length of oral airway?
From corner of mouth to mandibular angle
27
How to measure the length of nasal airway?
From tip of nose to tragus of ear
28
Laryngeal mask airway, pro(1) and con(1)?
Pro: simple (no laryngoscopy needed), especially in difficult airways Con: does NOT prevent aspiration
29
Formula to determine the size of endotracheal tube? (Cuffed/uncuffed)
Cuffed: age/4 + 3.5 Uncuffed: age/4 + 4
30
When cuffed endotracheal tube is preferred? (4)
Poor lung compliance High airway resistance Glottic air leak Between age 1-2
31
Formula to determine depth of endotracheal tube (ETT) insertion?
ETT size * 3 | ETT size; cuffed: age/4 + 3.5, uncuffed: age/4 + 4
32
How to measure nasogastric tube length?
From nose to angle of jaw to xiphoid
33
In rapid sequence intubation (RSI), | what’s the purpose?
To induce immediate unresponsiveness and muscular relaxation to reduce aspiration risk
34
Rapid sequence intubation (RSI) indications? (2)
High aspiration risk: Intact gag reflex ‘Full’ stomach ( <4-6 hours from last meal)
35
In rapid sequence intubation (RSI), | How long is pre-oxygenation recommended in children/adults?
Children: minimum 3 minutes Adults: 3 minutes
36
In rapid sequence intubation (RSI), | How is pre-oxygenation administered?
Non-rebreather mask at 100% oxygen without positive pressure ventilation unless patient’s effort is inadequate
37
In rapid sequence intubation (RSI), | Why is pre-oxygenation longer in children?
Less oxygen/respiratory reserve than adults Due to higher oxygen consumption lower functional residual capacity (Adults: 3min, children >3 min)
38
Steps for rapid sequence intubation (7)
1. Preparation (SOAP-ME; Suction, Oxygen, Airway supplies, Pharmacology, Monitoring Equipment) 2. Pre-oxygenation for minimum 3 minutes +/- 3. Atropine if at risk for bradycardia (e.g. using succinylcholine) +/- 4. Cricoid pressure (Sellick maneuver) 5. Adjunct (Atropine, lidocaine) 6. Sedative (Thiopental, ketamine, midazolam, fentanyl, etomidate, propofol) 7. Paralytic (Succinylcholine, vecuronium, rocuronium)
39
Atropine, mechanism of action? (2)
Anticholinergic (= vagolytic, inhibition of parasympathetic system) Competitive antagonist of the muscarinic receptors (M1,2,3,4,5)
40
In rapid sequence intubation, | Dosage of atropine?
0.02 mg/kg IV/IO | Adult 0.5-1.0 mg/kg, max 3 mg
41
In rapid sequence intubation, | Effects of atropine? (2)
Prevents bradycardia | Reduces oral secretion
42
In rapid sequence intubation, | Side effects of atropine? (2)
``` Tachycardia Pupil dilatation (eliminates the ability to examine neurologic responses i.e. pupil reflexes) ```
43
In rapid sequence intubation, | Indications of atropine?
High risk of bradycardia (e.g. using succinylcholine)
44
Lidocaine, mechanism of action?
Inactivates the fast voltage-gated Na+ channel in the neuronal cell membrane to prolong action potential of neurons
45
In rapid sequence intubation, | Dosage of lidocaine?
1 mg/kg IV/IO (max 100 mg/dose)
46
In rapid sequence intubation, | Effects of lidocaine? (3)
Blunts ICP spike, Reduces gag/cough reflexes Controls arrhythmia
47
In rapid sequence intubation, | Indications of lidocaine as adjunct? (4)
Shock Arrhythmia Increased ICP Status asthmaticus
48
In rapid sequence intubation, | Drug of choice for adjunct? (2)
Atropine | Lidocaine
49
In rapid sequence intubation, | Drug of choice for sedatives? (6)
``` Thiopental (Barbiturate) Ketamine (NMDA antagonist) Midazolam (Benzodiazepine) Fentanyl (Opiate) Etomidate (Imidazole, hypnotic) Propofol (Sedative, hypnotic) ```
50
Thiopental, class of drug?
Ultrashort-acting barbiturate | Sedatives
51
Brand names for thiopental? (2)
Pentothal | Trapanal
52
In rapid sequence intubation, | Dosages for normotensive / hypotensive patients?
For the normotensive, 3-5 mg/kg IV/IO | For the hypotensive, 1-2 mg/kg IV/IO
53
In rapid sequence intubation, | Effects of thiopental? (2)
Decrease O2 consumption Decrease cerebral blood flow
54
In rapid sequence intubation, | Side effects of thiopental? (4)
Vasodilatation Myocardial depression May increase oral secretion Cause bronchospasm/laryngospasm (not to be used for asthma)
55
In rapid sequence intubation, | Indications for thiopental?
Drug of choice for increased ICP
56
In rapid sequence intubation, | What’s DOC for IICP?
Thiopental
57
Thiopental, mechanism of action?
Ultrashort-acting barbiturate (GABA agonist; potentiate inhibitory neurons)
58
Ketamine, class of drug?
NMDA receptor antagonist
59
Ketamine, mechanism of action?
NMDA R antagonist in neurons; inhibits action potential of neurons (NMDA R = inotropic R = ligand gated ion channel)
60
In rapid sequence intubation, | Dosage of ketamine? IV/IM
1-2 mg/kg IV/IO | 4-10 mg/kg IM (only drug available for IM)
61
In rapid sequence intubation, which sedative drug is available for IM?
Ketamine
62
In rapid sequence intubation, | Effects of ketamine? (2)
Bronchodilation | Catecholamine release may benefit hemodynamically unstable patients
63
In rapid sequence intubation, | Side effects of ketamine?
May increase BP, HR May increase oral secretions May cause laryngo
64
In rapid sequence intubation, | Drug of choice for asthma?
Ketamine
65
In rapid sequence intubation, | Indication for ketamine?
Drug of choice for asthma
66
Midazolam, class of drug?
Short-acting bezodiazepine
67
Midazolam, mechanism of action?
Short-acting benzodiazepine (Increase GABA neurotransmitter)
68
Brand name for midazolam?
Versed
69
In rapid sequence intubation, | Dosage of midazolam and max total?
0.05 - 0.1 mg/kg IV/IO | Max total dose of 10 mg
70
In rapid sequence intubation, | Effects of midazolam? (2)
Amnestic | Anticonvulsant properties
71
In rapid sequence intubation, | Side effects of midazolam? (3)
Respiratory depression/apnea Hypotension Myocardial depression
72
In rapid sequence intubation, | Indication of midazolam?
Mild shock
73
Fentanyl, class of drug?
Opiate
74
Fentanyl, brand names for transdermal/oral transmucosal/injection?
Duragesic (Transdermal) Actiq (Oral transmucosal) Sublimaze (Injection)
75
In rapid sequence intubation, | Dosage of fentanyl?
1-3 mcg/kg IV/IO | Fentanyl dosage is in mcg/kg not mg/kg, mg = 1,000 mcg
76
In rapid sequence intubation, | Effects of fentanyl?
Fewest hemodynamic effects of all opiates
77
In rapid sequence intubation, | Side effects of fentanyl? (2)
Chest wall rigidity with high dose or rapid administration | Cannot use with MAOIs
78
In rapid sequence intubation, | Indication of fentanyl?
Shock
79
Etomidate, class of drug?
Imidazole/hypnotic
80
Brand names for etomidate? (2)
Amidate | Hypnomidate
81
Benefits of etomidate compared to propofol (2)
Minimal histamine release | Stable hemodynamic profile
82
Propofol benefits compared to etomidate
Rapid onset
83
In rapid sequence intubation, | Dosage of etomidate?
0.2-0.3 mg/kg IV/IO
84
In rapid sequence intubation, | Effects of etomidate? (2)
Cardiovascular neutral | Decrease ICP
85
In rapid sequence intubation, | Side effects of etomidate?
Exacerbates adrenal insufficiency by inhibiting 11-beta-hydroxylase
86
In rapid sequence intubation, | Indication of etomidate?
Patients with severe shock, especially cardiac patients | Do not use routinely in patients with septic shock
87
Propofol, mechanism of action? (3)
Potentiation of GABA R activity Na+ channel blocker Endocannabinoid system
88
Brand names of propofol? (2)
Diprivan | Propoven
89
In rapid sequence intubation, | Dosage of propofol?
2 mg/kg IV/IO
90
In rapid sequence intubation, | Effects of propofol? (4)
Extremely quick onset (15-30s) Short duration (5-10 min) Blood pressure lowering Good antiemetic
91
In rapid sequence intubation, | Side effects of propofol?
Hypotension Profound myocardial depression Contraindicated patients with egg allergy
92
In rapid sequence intubation, | Indication of propofol
Induction for general anesthesia
93
In rapid sequence intubation, | Drug of choice for paralytics? (3)
Succinylcholine Vecuronium Rocuronium
94
Neuromuscular blockers | Drugs for depolarizing vs nondepolarizing?
Depolarizing: succinylcholine Nondepolarizing: vecuronium, rocuronium
95
Neuromuscular blockers: depolarizing vs nondepolarizing | Initial excitatory response?
Depolarizing (succinylcholine): Transient fasciculation | Nondepolarizing (vecuronium, rocuronium): none
96
Neuromuscular blockers: depolarizing vs nondepolarizing | Reactions to cholinesterase?
Depolarizing (succinylcholine): not reversed | Nondepolarizing (vecuronium, rocuronium): reversed
97
In rapid sequence intubation, Dosage of succinylcholine? (IV/IO, IM)
1-2 mg/kg IV/IO | 2-4 mg/kg IM
98
In rapid sequence intubation, | Drug available for IM?
Succinylcholine
99
In rapid sequence intubation, | Advantages of succinylcholine? (2)
``` Quick onset (30-60s) Short duration (3-6min) Make it an ideal paralytic ```
100
In rapid sequence intubation, | Disadvantages of succinylcholine?
Irreversible (Non-competitive Ach R agonist) | 9077
101
Contraindications for succinylcholine (6)
1. Burns 2. Massive trauma/muscle injury 3. Neuromuscular disease 4. Myopathies 5. Eye injuries 6. Renal insufficiency
102
In rapid sequence intubation, | Dosage of vecuronium?
0.1 mg/kg IV/IO
103
Brand names of succinylcholine? (2)
Quelicine | Anectine
104
Brand name of vecuronium?
Norcuron
105
Brand names of rocuronium? (2)
Zemuron | Esmeron
106
In rapid sequence intubation, | Advantages of vecuronium? (2)
Onset 70-120s | Cardiovascular neutral
107
In rapid sequence intubation, | Disadvantages of vecuronium? (2)
Longer duration 30-90min | Must wait 30-45 min to reverse with glycopyrrolate and neostigmine
108
In rapid sequence intubation, | Indications for vecuronium? (2)
When succinylcholine contraindicated | When longer term paralysis desired
109
In rapid sequence intubation, | Dosages of rocuronium?
0.6 -1.2 mg/kg IV/IO
110
In rapid sequence intubation, | Advantages of rocuronium? (3)
Quicker onset (30-60s) Shorter acting than vecuronium (duration 30-60 min; may reverse in 30 min with glycopyrrolate and neostigmine) Cardiovascular neutral
111
What class of glycopyrrolate and neostigmine?
Anticholinergic drugs | Reverse nondepolarizing neuromuscular blockers
112
Brand name of glycopyrrolate?
Robinol
113
Brand name of neostigmine
Bloxiverz
114
Brand name of vecuronium?
Norcuron
115
Brand names of rocuronium? (2)
Zemuron | Esmeron
116
In rapid sequence intubation, | Advantages of vecuronium? (2)
Onset 70-120s | Cardiovascular neutral
117
In rapid sequence intubation, | Disadvantages of vecuronium? (2)
Longer duration 30-90min | Must wait 30-45 min to reverse with glycopyrrolate and neostigmine
118
In rapid sequence intubation, | Indications for vecuronium? (2)
When succinylcholine contraindicated | When longer term paralysis desired
119
In rapid sequence intubation, | Dosages of rocuronium?
0.6 -1.2 mg/kg IV/IO
120
In rapid sequence intubation, | Advantages of rocuronium? (3)
Quicker onset (30-60s) Shorter acting than vecuronium (duration 30-60 min; may reverse in 30 min with glycopyrrolate and neostigmine) Cardiovascular neutral
121
What class of glycopyrrolate and neostigmine?
Anticholinergic drugs | Reverse nondepolarizing neuromuscular blockers
122
Brand name of glycopyrrolate?
Robinol
123
After endotracheal tube intubation, | What can signify acute respiratory failure (4)
``` DOPE Displacement of the ETT Obstruction Pneumothorax Equipment failure ```
124
In resuscitation, | Mouth-to-mouth or mouth-to-nose breathing duration/volume per breath?
1 sec/breath | Adequate volume to cause chest rise
125
In resuscitation, | Mouth-to-mouth or mouth-to-nose breathing rate for newborns?
One breath for every three chest compression
126
In resuscitation, | Mouth-to-mouth or mouth-to-nose breathing for infants/children with one rescuer?
Two breaths after 30 compressions
127
In resuscitation, | Mouth-to-mouth or mouth-to-nose breathing for infants/children with two rescuer?
Two breaths after 15 compressions
128
In resuscitation, | Bag-mask ventilation rate in infants/children?
Infants: 30 breaths/min Children: 20 breaths/min
129
Definition of anaphylaxis (4)
1. A rapid onset 2. immunoglobulin (Ig) E-mediated 3. systemic allergic reaction 4. involving multiple organ systems, including two or more of the followings: A. Cutaneous/mucosal (flushing, urticaria, pruritus, angioedema) B. Respiratory (laryngeal edema, bronchospasm, dyspnea, wheezing, stridor, hypoxemia) C. Gastrointestinal (vomiting, diarrhea, nausea, abdominal pain) D. Circulatory (tachycardia, hypotension, syncope)
130
Organ systems and symptoms involved in anaphylaxis and its percentage(4)
A. Cutaneous/mucosal (flushing, urticaria, pruritus, angioedema) ~90% B. Respiratory (laryngeal edema, bronchospasm, dyspnea, wheezing, stridor, hypoxemia) ~ 70% C. Gastrointestinal (vomiting, diarrhea, nausea, abdominal pain) ~40-50% D. Circulatory (tachycardia, hypotension, syncope) ~30-40%
131
Anaphylaxis initial reaction onset and recurring time
Initial reaction may be delayed for several hours AND Symptoms may recur up to 72 hours after initial recovery
132
Anaphylaxis management steps (9)
1. Remove stop exposure to precipitating antigen 2. Epinephrine IM/SQ 3. Establish airway 4. Obtain IV access, fluid or cardiac inotropes 5. Histamine-1 receptor antagonist (dyphenhydramine) or histamine-2 receptor antagonist (ranitidine) 6. Corticosteroid 7. Albuterol (for bronchospasm or wheezing) 8. Racemic epinephrine (for upper respiratory obstruction) 9. Should be discharged with Epi-pen
133
In anaphylaxis, | Dosage of epinephrine
0.01 mg/kg IM/SQ
134
Sites of epinephrine IM/SQ in case of anaphylaxis
Lateral aspect of thigh, owing to its vascularity
135
Histamine receptor antagonists used for anaphylaxis and dosages
Histamine0
136
Brand name of diphenhydramine
Benadryl
137
Brand name of ranitidine
Zantac
138
Dosage of diphenhydramine (Benadryl) for anaphylaxis (max)
1-2 mg/kg IM/IV or PO | Max 50 mg
139
What phase of the allergic response that can be helped by corticosteroids?
Late phase
140
Corticosteroids dosages for anaphylaxis?
Methylprednisolone 2 mg/kg IV bolus -> 2 mg/kg/day IV/IM q6hr or Prednisone 2 mg/kg PO qD
141
Albuterol dosage for anaphylaxis? (> 30kg)
2.5 mg for <30 kg 5 mg for >30 mg Every 15 min as needed
142
How racemic epinephrine is used for anaphylaxis
Inhaled | 0.5 mL of 2.25% solution
143
When racemic epinephrine is used for anaphylaxis?
Upper airway obstruction
144
With what patient of anaphylaxis should be discharged?
Epi-Pen (>30 kg) Epi-Pen Junior (< 30kg) Anaphylaxis action plan
145
Common causes of respiratory emergencies? (4)
1. Asthma 2. Upper airway obstruction a) epiglottitis b) croup c) foreign body obstruction
146
The hallmarks of upper/lower airway obstruction?
Upper airway obstruction: stridor | Lower airway obstruction: cough, wheeze, prolonged expiratory phase
147
Asthma triad
Inflammation Bronchospasm Increased secretions
148
Asthma assessment (7)
1. Respiratory rate 2. Work of breathing 3. O2 saturation 4. Heart rate 5. Peak expiratory flow 6. Alertness 7. Color
149
Asthma initial management (5)
1. O2 to keep saturation >95% 2. Inhaled b-agonisits (albuterol) 3. Ipratropium bromide (atrovent) 4. Steroids 5. Consider epinephrine, terbutaline, magnesium sulfate
150
Ipratropium bromide, mechanism of action?
Muscarinic acetylcholine antagonist | Medium-large airway dilatation
151
Ipratropium bromide, brand name?
Atrovent
152
For asthma, how to use steroid?
Mild to moderate: prednisone/prednisolone 2mg/kg (max 60mg) PO qD for 5 days or dexamethasone 0.6 mg/kg (max 16 mg) qD for 2 days Severe: Methylprednisolone 2mg/kg IV/IM bolus, then 2 mg/kg/day divided q6h
153
Systemic steroids require a minimum of _____ (time) to take effect
2-4 hours
154
For asthma, drugs to consider if air movement still poor after initial treatment (3)
Epinephrine Terbutaline Magnesium sulfate
155
For asthma, dosage of epinephrine?
0.01 mg/kg of 1:1000 SQ/IM (maximum dose 0.5mg)
156
In asthma, effects of epinephrine? (3)
Bronchodilator Vasopressor Inotropic effects
157
Terbutaline, mechanism of action?
b2-adrenergic receptor agonist (“Reliever” inhaler for asthma, tocolytics for preterm labor)
158
Terbutaline, brand name?
Bricanyl
159
When to consider IV terbutaline?
If no response to second dose of SQ terbutaline
160
When using terbutaline for asthma, what to monitor? (4)
12-lead ECG Cardiac enzymes UA Electrolytes
161
For asthma, when to consider terbutaline? (2)
Severely ill patients | Patients who are uncooperative with inhaled beta agonists
162
For asthma, dosages of magnesium sulfate?
25 to 75 mg/kg/dose IV or IM (max 2g) infused over 20 min
163
For asthma, magnesium sulfate, mechanism of actions?
Smooth muscle relaxant; relieves bronchospasm
164
Precautions to take when giving magnesium sulfate?
Many give a saline bolus prior to administration, | because hypotension may result
165
For asthma, contraindications of magnesium sulfate? (2)
Significant hypotension | Renal insufficiency
165
Asthma management: | A normalizing PCO2 is often a sign of ________.
Impending respiratory failure During an asthma exacerbation there is air trapping and ventilation/perfusion mismatch, resulting in hypoxemia. Initially compensation occurs and hyperventilation causes the PCO2 to decrease. When further air trapping leads to decreased lung compliance and increased work of breathing, the PCO2 will begin to increase.

Pediatrics (24 decks)

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