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EM quiz readings > Lecture 9: Resuscitation and Shock > Flashcards

Lecture 9: Resuscitation and Shock 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? What other end points do we want to meet?

A
  • MAP - > 65 mmHg
  • Central venous pressure of 8-12mmHg
  • ScvO2>70%
  • urine output >.5 mL/kg/hr
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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

increase d/t bodies attempt to make up for low volume
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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

dysrhythmias are also common!

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12
Q

how can cardiogenic shock vary with different arrhythmias

A

bradyarrhythmias - low CO
tachyarrhythmias - decreased preload and stroke volume

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13
Q

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

A

Emergent revascularization

Ideally: PCI or CABG.

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14
Q

What kind of bacteria is MC in sepsis?

A

Gram positive (+)

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15
Q

What qualifies as septic shock?

A

Sepsis that also requires vasopressors after adequate resuscitation and elevated lactate

sepsis + vasopressors + evelated lactate

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16
Q

How do you assess for occult shock in those with s/s of infection and what is occult shock?

A
  • Occult = normal vital signs w elevated lactate!!! (googled this but also says “vital signs and lactate” in slides)
  • look for infection source! culture everything and look for surgical/gyn/indwelling medical device infection.

google: Occult shock is the state of early hypoperfusion causing a. metabolic acidosis that occurs in trauma patients, prior to. changes in vital signs.

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17
Q

Is a central venous catheter mandatory to resuscitate most patients in septic shock?

A

No, central venous pressure trends are more important than absolute values.

no idea what this means but sounds important

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18
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, packed RBCs, corticosteroids and CVP monitoring

May need more fluids

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19
Q

what occurs in neurogenic shock?

A
  1. loss of peripheral sympathetic innervation
  2. extreme vasodilation 2/2 loss of sympathetic arterial tone
  3. blood pooling in distal circulation w resultant hypotension
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20
Q

What almost always precipitates neurogenic shock?

A

Spinal cord injury!

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21
Q

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

A
  1. Warm to touch
  2. Bradycardiac

even if this is present, neurogenic shock cant be dx until other causes of hypotension are excluded.

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22
Q

What is the primary management for neurogenic shock?

A

Vasopressors

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23
Q

just glance at this in case she cray

A
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24
Q

what 2 positionings would you use to facilitate airway patency in a patient?

A
  1. extension of the neck w anterior displacement of the mandible (moves hyoid bone anteriorly and lifts epiglottis)
  2. sniffing position (forward flexion of neck with extension of the head.)
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25
Q

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

A

Sniffing position

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26
Q

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

A

No gag reflex can be present

used to prevent tongue from occluding hypopharynx

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27
Q

How do you place an oropharyngeal airway?

A
  1. place in airway with concave portion cephalic
  2. rotate 180 degrees after passing tongue
    ORRRR
  • Orient concave portion horizontal
  • rotate 90 degrees following curve of tongue after insertion
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28
Q

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

A
  • Intact gag reflex
  • Facial trauma
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29
Q

How do you insert an NPA?

A
  1. properly size (corner of mouth to angle of mandible)
  2. lubricate and insert horizontal to the palate w bevel oriented towards septum

insert parallel to nasal floor, not cephalad.

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30
Q

How much O2 is delivered with optimal BVM technique?

A

75%

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31
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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32
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
33
Q

What criteria is used to evaluate ease of intubation?

A

Mallampati criteria

34
Q

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

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

O2 desat to <70% is assocaited w increased risk of ysrhythmias, decompensation, and cardiac arrest!

35
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

36
Q

Which ETT blade is more associated with tachycardia and trauma?

A

Miller

37
Q

Image of ETT tubing

FYI

A
38
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!

39
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.

40
Q

What 5 factors predict difficulty with intubation?

A
  • Facial hair
  • Obesity
  • Short neck
  • Short/long chin
  • Airway deformity
41
Q

what is the MC RSI Sedative?

A

IV Etomidate

42
Q

Which RSI sedative should be avoided in hypotensive patients?

A

Propofol

43
Q

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

A

Ketamine

44
Q

Why is Succinylcholine preferred among the paralytics?

A

Quick on/off

45
Q

When is succinylcholine not used in RSI? (3)

A
  • Neuromuscular disorder
  • denervation injury older than 7 days
  • burns older than 5 days

denervation and burn = risk of hyperkalemia

46
Q

When is rocuronium CId?

A

Hx of myasthenia gravis

paralytic (non-depolarizing agent)

47
Q

How many attempts constitute a failed airway?

A

3 failed attempts

48
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
49
Q

what are CI for peripheral IV access? what do you do instead?

A
  1. infusing sclerosing solutions
  2. concentrated electrolyte or glucose solutions
  3. cytotoxic chemotheraputic agents

instead insert IV central access for these!

50
Q

what are indications for central Access IV’s?

A
  1. inability to obtain peripheral IV or CI to peripheral IV
  2. access central circ needed for procedures
  3. measure central venous pressure.
51
Q

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

A
  1. IJ
  2. Subclavian
  3. Femoral

Need to use US

52
Q

What is the easiest site to insert a central line?

A

Femoral vein

Easy to palpate, but dirtiest area

53
Q

Tx for VF (2)

A
  1. Defibrillate @ 200J (biphasic)
  2. CPR
54
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
  • amiodarone or lidocaine may be used after epinephrine

1mg IV

55
Q

What is the tx for Asystole/PEA?

A
  • CPR
  • Epi every 1-3 min
  • ABCDs
  • correct reversible causes
  • DO NOT SHOCK THIS RHYTHM
56
Q

I thin kthis is the least confusing flow chart of all of them but thats just me

A
57
Q

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

A
  • Hypoxia
  • Hypovolemia
  • Hydrogen ion (acidosis)
  • Hypo/hyperkalemia
  • Hypothermia
58
Q

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

A
  • Tension PTX
  • Tamponade (cardiac)
  • Toxins
  • Thrombosis: pulmonary
  • Thrombosis: coronary
59
Q

What rhythms fall under supraventricular arrhythmias?

A
  • AF/Aflutter
  • AVNRT
  • AVRT (narrow/orthodromic AVRT)
60
Q

What is the tx for SVT? (4)

A
  1. Vagal maneuvers
  2. Adenosine 6mg, then 12mg, then 12mg.
  3. if converts, observe and monitor
  4. if not, control rate
61
Q

What is the tx for AF/Aflutter? (3)

A
  1. BB
  2. CCB
  3. cardiovert if resistant
62
Q

When would we convert AF urgently? (4)

A
  1. Recent onset and RVR
  2. Hypotension
  3. MI
  4. Pulmonary Edema
63
Q

How do we treat unstable patients with long-standing afib

A
  1. electro cardioversion is NOT likely to succeed
  2. initiate hemodynamic resuscitation and ventricular rate control
64
Q

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

A
  1. Rate control
  2. Oral anticoagulants
  3. Reevaluate in 3-4 weeks
65
Q

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

A
  • Without a pulse: Defib at 200J
  • Pulse present: Procainamide/amiodarone
66
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)

transcutaneous pacing

67
Q

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

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

transcutaneous pacing

68
Q

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

A

15:2

Adult is 30:2. if only 1 rescuer do 30:2.

69
Q

What is the primary etiology of pediatric arrest?

A

Respiratory

70
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

71
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
72
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

73
Q

Top 2 RFs for SIDS

A
  1. Smoking
  2. Sleeping position of baby
74
Q

Define SIDS

A

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

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

75
Q

When is resuscitation of SIDS NOT indicated?

A
  • Rigor mortis
  • Livedo reticularis
  • pH < 6
  • Significantly reduced core temperature without environmental hypothermia.
76
Q

Prevention of SIDS (4)

A
  1. Firm sleeping surface
  2. No bed sharing/cosleeping
  3. Don’t overheat
  4. Use pacifier
77
Q

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

A

> 20 minutes

78
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

EM quiz readings (43 decks)

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