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Emergency Medicine > Lecture 9: Resuscitation and Shock > Flashcards

Lecture 9: Resuscitation and Shock Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is often the first clinical sign of shock?

A

Hypotension

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2
Q

When we first suspect shock, what protocol do we begin with first? (5)

A
  • Airway
  • Breathing
  • Circulation
  • Deliver of O2
  • End Points
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3
Q

What MAP do we typically aim for in a hypotensive patient?

A

> 65 mmHg

also Central Venous Pressure 8-12 mmHg

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4
Q

What are the 4 primary end goals during ED resuscitation of septic shock?

A
  1. MAP > 65 mmHg
  2. CVP of 8-12
  3. ScvO2 > 70% (Venous O2 Sat)
  4. Urine output > 0.5mL/kg/hr
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5
Q

Define shock

A

A state of circulatory insufficiency between tissue oxygen supply and demand, leading to end-organ dysfunction.

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6
Q

What characterizes distributive shock hemodynamically? (3)

A
  • Decreased preload
  • Decreased SVR
  • Mixed CO

Sepsis, neurogenic shock, anaphylaxis

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7
Q

What characterizes Hypovolemic shock hemodynamically? (3)

A
  • Decreased preload
  • Increased SVR
  • Decreased CO

Hemorrhage, capillary leak, GI losses, burns

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8
Q

What characterizes cardiogenic shock hemodynamically? (4)

A
  • Increased preload
  • Increased afterload
  • Increased SVR
  • Decreased CO

MI, dysrhythmias, HF, valvular disease

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9
Q

What characterizes obstructive shock hemodynamically? (3)

A
  • Decreased preload
  • Increased SVR
  • Decreased CO

PE, pericardial tamponade, tension PTX

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10
Q

What is the MC type of shock?

A

Distributive

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11
Q

What is the MCC of cardiogenic shock?

A

AMI

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12
Q

What is the primary intervention in acute ischemia-related cardiogenic shock?

A

Emergent revascularization

Ideally: PCI or CABG.

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13
Q

What kind of bacteria is MC in sepsis?

A

Gram positive (+)

Staph, strep, enterococcus, clostridium, listeria

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14
Q

What qualifies as septic shock?

A

Sepsis that also requires vasopressors after adequate resuscitation and elevated lactate

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15
Q

What are the primary management steps in Septic Shock management? (4)

A
  1. Empiric ABX ASAP
  2. 1-2L bolus of LR/IV crystalloid (may need more)
  3. Administer NE as first-line vasopressor if refractory hypotension is present.
  4. Consider dobutamine and CVP monitoring

May need more fluids

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16
Q

What almost always precipitates neurogenic shock?

A

Spinal cord injury!

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17
Q

Why is neurogenic shock unique in terms of presentation and initial assessment? (2)

A
  1. Warm to touch
  2. Bradycardiac
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18
Q

What is the primary management for neurogenic shock?

A

Vasopressors

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19
Q

What kind of position may help relieve upper airway obstructions and require minimal neck extension?

A

Sniffing position

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20
Q

What must you ensure prior to using an OPA for airway adjunct?

A

No gag reflex can be present

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21
Q

When would you use an NPA as an airway adjunct? (2)

A
  • Intact gag reflex
  • Absent any Facial trauma
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22
Q

How much O2 is delivered with optimal BVM technique?

A

75%

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23
Q

What is the E-C technique for BVM? (2)

A
  1. C shape with thumb and index finger on mask
  2. 3-5th fingers in an E to lift mandible
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24
Q

What are the 7 indications for ETT?

A
  • Respiratory failure
  • Apnea
  • Reduced LOC (think GCS < 8)
  • Rapid change in mental status
  • Airway injury or impending airway compromise
  • High risk for aspiration
  • Trauma to the larynx
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25
Q

What criteria is used to evaluate ease of intubation?

A

Mallampati criteria

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26
Q

Why do we preoxygenate prior to intubation and how? (3)

A
  • Displacing nitrogen from alveoli to create a reservoir
  • Increases safe apnea time from 1 min to 8 mins
  • Done via 100% O2 for 3 mins using NRB @ 15LPM ideally.
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27
Q

What are the 2 blades used for ETT?

FYI

A
  • MAC is less traumatic but less across the board
  • Miller is more traumatic but more across the board

Mac Miller (maC is Curved) or MiLLer is like an LINE

28
Q

Which ETT blade is more associated with tachycardia and trauma?

A

Miller

29
Q

Image of ETT tubing

FYI

A
30
Q

What are the 5 factors that predict difficulty with mask ventilation?

A
  • Facial hair
  • Obesity
  • No teeth
  • Advanced age
  • Snoring

Any 2 of the 5!

31
Q

What is administered first in RSI: paralytic or sedative?

A

Sedative.

Date before you Succ

You don’t want to be paralyzed but awake.

32
Q

What 5 factors predict difficulty with intubation?

A
  • Facial hair
  • Obesity
  • Short neck
  • Short/long chin
  • Airway deformity
33
Q

Which RSI sedative should be avoided in hypotensive patients?

A

Propofol

Propofol makes your Pressure Fol

34
Q

Which RSI sedative is a good option for bronchospasm or hypotension?

A

Ketamine

35
Q

Why is Succinylcholine preferred among the paralytics?

A

Quick on/off

36
Q

When is succinylcholine not used in RSI? (3)

A
  • Neuromuscular disorder
  • Burns
  • Hyperkalemia

Succ is the only depolarizing NM blocker

37
Q

When is rocuronium CId?

A

Hx of myasthenia gravis

38
Q

How many attempts constitute a failed airway?

A

3 failed attempts

39
Q

What two things must be ensured if infusing vasopressors via a peripheral IV?

A
  1. Cannot be a distal IV
  2. Must be well-secured
40
Q

What are the primary sites to insert central lines? (3)

A
  1. IJ
  2. Subclavian
  3. Femoral

Needs US

41
Q

What is the easiest site to insert a central line?

A

Femoral vein

Easy to palpate, but dirtiest area

42
Q

Tx for VF (2)

A
  1. Defibrillate @ 200J (biphasic)
  2. CPR
43
Q

When can epi be given during CPR and how often?

A
  • Epi can be given after the 2nd shock attempt
  • Epi can be administered every 3-5 minutes

1mg IV

44
Q

What is the tx for Asystole/PEA?

A
  • CPR
  • Epi
  • ABCDs
45
Q

What are the reversible Hs for cardiac arrest? (5)

A
  • Hypoxia
  • Hypovolemia
  • Hydrogen ion (acidosis)
  • Hypo/hyperkalemia
  • Hypothermia
46
Q

What are the reversible Ts for cardiac arrest? (5)

A
  • Tension PTX
  • Tamponade (cardiac)
  • Toxins
  • Thrombosis: pulmonary
  • Thrombosis: coronary
47
Q

What rhythms fall under supraventricular arrhythmias?

A
  • AF/Aflutter
  • AVNRT
  • AVRT (narrow/orthodromic)
48
Q

What is the tx for SVT? (2)

A
  1. Vagal maneuvers
  2. Adenosine 6mg, then 12mg, then 12mg.
49
Q

What is the pharm tx for AF/Aflutter? (2)

A
  1. BB
  2. CCB
50
Q

When would we convert AF urgently? (4)

A
  1. Recent onset and RVR
  2. Hypotension
  3. MI
  4. Pulmonary Edema
51
Q

How do we manage stable, low-risk AF pts? (3)

A
  1. Rate control
  2. Oral anticoagulants
  3. Reevaluate in 3-4 weeks
52
Q

What is the tx for VT without a pulse? With?

A
  • Without a pulse: Defib at 200J
  • Pulse present: Procainamide/amiodarone
53
Q

What are the 2 indications to emergently treat a bradyarrhythmia?

A
  • HR < 50-60 + hypotension/hypoperfusion
  • Structural disease of the infranodal conduction system (close monitoring)
54
Q

What heart blocks are most associated with needing emergent tx? (2)

A
  • Mobitz type II 2nd degree HB
  • 3rd degree HB

Immune to atropine injection usually

55
Q

What is the ratio of compressions:ventilations for a 2 person rescue for a pediatric pt?

A

15:2

Adult is 30:2

56
Q

What is the primary etiology of pediatric arrest?

A

Respiratory

57
Q

What are the 4 clinical features of a BRUE (Brief, resolved, and unexplained event)?

A
  1. Cyanosis or pallor
  2. Absent/decreased/irregular breathing
  3. Marked change in tone
  4. Altered level of responsiveness

Any of the 4

58
Q

What are the 4 RFs for BRUEs in pediatric patients?

A
  1. Feeding difficulties
  2. Recent URI symptoms
  3. < 2 months old
  4. Hx of previous episodes
59
Q

What is the criteria to be considered low-risk for recurrence after BRUE for a pediatric patient? (7)

A
  1. > 60 days old
  2. If a preemie, must have been GA >= 32wk and postconceptional age older than 45 wks
  3. 1 BRUE only
  4. BRUE < 1 min
  5. No CPR needed
  6. No concerning historical features
  7. No concerning PE findings

Not advised to do routine testing

60
Q

Top 2 RFs for SIDS

A
  1. Smoking
  2. Sleeping position of baby
61
Q

Define SIDS

A

Unexpected death of infant < 1 yr old with no pathologic cause identifiable.

Leading cause of infant death between 1mo-1y.

62
Q

When is resuscitation of SIDS NOT indicated?

A
  • Rigor mortis
  • Livedo reticularis
  • pH < 6
  • Significantly reduced core temperature without environmental hypothermia.
63
Q

Prevention of SIDS (4)

A
  1. Firm sleeping surface
  2. No bed sharing/cosleeping
  3. Don’t overheat
  4. Use pacifier
64
Q

After what amount of time is pediatric resuscitation associated with a poor outcome?

A

> 20 minutes

65
Q

In what situation might we continue CPR longer for a pedatric arrest? (2)

A
  • Presence of cardiac electrical activity PLUS
  • Hypothermia is underlying cause

Can continue resuscitation while attempting core rewarming to 30C

Emergency Medicine (29 decks)

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