Life support Flashcards
If patients temp <30 degrees and in arrest/arrythmia/SBP <90 what should we do?
Transfer to ECMO centre
If temp <30 degrees what change should we make to the ALS algorithm? (2)
- Don’t give adrenaline
2 If 3 shocks unsuccessful don’t shock again until >30 degrees
When temp is 30-34 degrees what should we do with adrenaline?
Increase interval to 6-10min
How should heat syncope be managed?
Cool and oral fluids
How should heat exhaustion be managed? (3)
- Cool enviroment
- Lie flat
- IV isotonic/hypertonic fluid
How should we manage heat stroke? (4)
- Actively cool
- IVI - hypertonic if Na+ <130 (up to 3 x 100ml 3% saline)
- Benzos if seizing but will also help with cooling, no anti-pyretics
- Aim temp 38.5, not normothermia
- May need RRT/I+V/peritoneal or chest lavage
May need IVI ++
What is the treatment for malignant hyperthermia? (4)
- Stop triggering agent
- Target normocapnia
- Active cooling
- Dantrolene
How long should patients be observed following malignant hyperthermia?
72 hours - 25% relapse
How long should we perform CPR if we thrombolyse PE?
60-90 mins
What dose ALSG state is managment of tension PTX in arrest?
Thoracostomy
Can use needle decompression if quicker but needs to be followed up by thoracostomy and chest drain
What is the difference between laryngectomy and tracheostomy in relations to resus?
Laryngectomy patients do not have a patent airway and therefore oral measures will not work at all
If suspecting an issue with a tracheostomy what is the very first step to assess?
Look/listen/feel mouth and trachy
ETC02 and Mapleson C can help
If you have assessed a trachy and suspect an occlusion what is the first step in the algorithm following the initial look/listen/feel?
Remove any speaking valve or cap and inner tubs and place a suction catheter down
If is passes then it is at least partially patent
If you have removed a tracheostomy inner tube but cannot pass a suction catheter down if, what is the next step in the algorithm?
Deflate the cuff
If improves then either partial tube obstruction or diplaced
You have removed the inner tube of a trachy and deflated it with no effect. What is the next step?
Remove trachy tube
What are the primary emergency oxygenation maneuvers once a tracheostomy has been removed because it wasn’t working? (2)
- Standard oral oxygenation measure (facemask/adjuncts)
- Tracheostomy stoma ventilation (paeds face mask/LMA to stoma)
What are the secondary emergency oxygenation measures once a tracheostomy has been removed? (2)
- Oral intubation (uncut tube and advance beyond stoma)
- Stoma intubation - small trachy tube/size 6 ETT cuffed, consider fibre-optic or bougie
What are the 5 types of heat illness?
What are the 3 cardinal signs of heat stroke?
- Temp >40 degrees
- Encephalopathy
- Anhydrosis
What is the underlying mechanism that makes heat stroke different from heat exhuastion?
SIRS response leading to multi-organ failure with encephalopathy predominating
What biochemical abnormalities can be seen in heat stroke? (6)
What are the two types of decompression injury?
Decompression sickness - evolved gas being release
Arterial gas embolism (AGE) - escaped gas bubble in arterial system (either via PFO for overwhelming the lungs).
In neonatal resus what are the fist steps to take when the baby is born? (4)
- Delay cord clamping if possible
- Start clock
- Wrap + stimulate
- Head neutral
If a baby has been stimulate and is not breathing what is the next steps (3)
- 5 inflation breaths (30cmH20)
- 5-6cmH20 PEEP
- Oximetry +/- ECG
Following 5 inflations breaths the baby is still not breathing - what are the next steps? (5)
- Check position
- 2 person technique
- Suction
- Repeat 5 inflation breaths
- Consider increasing pressure
You have delivered 5 inflation breaths to a neonate and the chest is now moving - now what?
30 secs ventilation breaths once confirmed still no pulse/HR <60bpm
Following 30 secs ventilation breaths there is no pulse or HR <60bpm - what are your next steps? (5)
- 3:1 breaths:compressions
- 100% Fi02
- Reassess every 30 secs
- Consider I+V with size 3 ETT
- IV access and drugs
With regards to neonatal resusitation what should be done if a baby is < 32 weeks in terms of heating?
- Place undried in plastic wrap
- Under radiant heat
What Fi02 should be used in the first stages of neonatal resus based on gestational age? (3)
- > 32 weeks - 21%
- 28-31 weeks 21-30%
- < 28 weeks 30%
What are appropriate pre-ductal SATs (right hand) in terms of term after birth (3)
- 2 mins = 65%
- 5 mins = 85%
- 10mins = 90%
What should we aim to do with cord clamping in neonatal resus? (3)
- Aim to delay at least 60 secs until after lungs aerated
- If practical can keep unclamped
- If < 28/40 ‘cord milking’ - milk mothers blood to baby
When should drugs be used in neonatal resus?
If no CO despite good ventilation and chest compressions
What dose of adrenaline should be used in neonatal resus? (2)
20mcg/kg (0.2mk/kg 1 in 10,000)
No response consider increasing to 30 mcg/kg
When should sodium bicarbonate be used in neonatal resus and what dose?
- No CO and low HR
- 1-2mmol/kg (2-4ml 4.2 bicarbonate)
What dose of atropine and calcium should be used in neonatal resus?
No role in neonatal resus
When should stopping neonatal resusitation be considered?
After 20 mins if all reversible causes have been considered
What ratio compressions should be used in paeds resus?
15:2
What size BVM should be used in paeds resus?
< 1 year = 500ml bag
> 1 year = 1600ml bag
What long should IV access take place for before switching to IO?
2 attempts or 90 secs then IO
What is the dose of atropine in paeds resus?
20mcg/kg (minumum 100mcg)
What is the dose of amioderone in paeds resus?
5mg/kg
What is the dose of lidocaine (can be used instead of amioderone) in paeds resus?
1mg/kg
What is the dose of magnesium in paeds resus?
25-50mg over several minutes (polymorphic VT)
What dose of calcium chloride should be used in paeds resus?
0.2ml/kg of 10%
What dose of sodium bicarbonate should be used in paeds resus?
1-2ml/kg 8.4%
(dont mix with adrenaline as it inactivates adrenaline)
What is the dose of glucose in paeds resus?
2ml/kg 10% dextrose
What is the dose of adrenaline in paeds resus?
10mcg/kg IV 1:10,000
What is the dose of lorazepam in paeds resus?
0.1mg/kg
What is the dose of PR diazepam in paeds resus?
0.5mg/kg
What is the dose of buccal midazolam in paeds resus?
0.5mg/kg
What is the estimated weight calculation in paeds resus?
Weight = (age(yrs) + 4) x 2
Only 1-10 years
What is the ETT size calculation in paeds
(age/4) + 4
What is the ETT length calculation in paeds?
(age/2) + 12
How can sinus tachy vs SVT be determined in paeds?
- SR HR <200bpm
- p waves upright 1 in SR
- Hx of shock if sinus
- Beat to beat variation in SR
What is the SVT algorithm in paeds? (5)
- Valsalva (cold water in neonates/babies, hand stand in kids)
- Atropine:
Up to 1 year: 150 mcg kg-1, increase 50–100 mcg kg-1
every 1–2 min. Maximum single dose: Neonates 300
mcg kg-1, Infants 500 mcg kg-1)
1–11 years: 100 mcg kg-1 increase 50–100 mcg kg-1
every 1–2 min. Maximum single dose: 500 mcg kg-1
(max. 12 mg)
12–17 years: 3 mg IV, if required increase to 6 mg
after 1–2 min, then 12 mg after 1–2 min
- Consider cardioversion or amioderone
DV cardioversion in paeds VT what is the voltage? (2)
- 2J/kg
- If fails 4J/kg
What is the dose of magneisum in torsades des pointes in paeds?
25-50mg/kg
In the paeds choking algorithm what should be done for a conscious infant (<1) who has a poor cough?
5 back blows (head downward and prone) followed by 5 thrusts (supine and chest position as CPR) continually until resolution or reduced GCS
In the paeds choking algorithm what should be done for a conscious child > 1 who has a poor cough?
5 back blows (head down, forward leaning) followed by 5 thrusts (abdominal thrust) continually until resolution or reduced GCS
What is the paeds choking algorithm for unconscious patients? (7)
- Lie flat and open mouth - look for FB
- If seen - 1 x finger sweep
- McGills/direct laryngoscopy
- Attempt x 5 rescue breaths
- No chest rise - reposition head
- CPR 15:2 checking for FB every time airway opened
- No improvement and hypoxic - surgical airway
What are the adrenaline dose for paeds anaphx? (3)
- > 12 = 500mcg (0.5ml 1:1000)
- 6-12 = 300mcg (0.3ml)
- < 6 year = 150mcg (0.15ml)
What is the IV dose of adrenaline for paeds anaphx?
1mcg/kg 1:10,000
adult dose = 50mcg
What are the paediatric chlorphenamine doses? (4)
- > 12 year = 10mg
- 6-12 years = 5mg
- < 6 year = 2.5mg
4 < 6 months = 250mcg/kg
What are the paediatric hydrocortisone doses? (4)
- > 12 years = 200mg
- 6-12year = 100mg
- < 6 years = 50mg
4 < 6 months = 25mg
When should tryptase measurements be taken?
Immediately and then another sample < 4 hours
What is refractory anaph and how should it be treated?
- 2 or more doses of adrenaline with no improvement
- Adrenaline infusion
= 1mg (1ml of 1mg/ml 1:000) in 100ml normal saline
Start at 0.5/1.0 ml/kg/hr
What are the contraindications to Penthrox?
C - linically significant cardiac or resp disease
H - hypersensitivity to methoxyflurane (or any flurinated gas)
E - stablished hx of malignant hyperthermia
C - onsciousness altered
K - kidneys (eGFR <45) or liver disease
What is the gauge and flow rate of an orange cannula?
14G and 240ml/hr
What is the gauge and flow rate of a grey cannula?
16 G and 180ml/min
What is the gauge and flow rate of a green cannula?
18G and 90ml/min
What is the gauge and flow rate of a pink cannula?
20G and 60ml/min
What is the gauge and flow of a blue cannula?
22G and 36ml/min
What is the gauge and flow rate of a yellow cannula?
24G and 20ml/min
What do the resus council recommend for DC shock J in AF/SVT?
70-120 J
What does resus council recommend for initial shock J in pulses VT?
120-150 J
How many attempts does DASS say is maximum for tracheal intubation?
3 - change something each time
Following failed intubation what does DASS recommend moving onto as second line?
Igel
After what TBSA burns do 1. paeds and 2. adults need fluid/
- 10%
- 15%
What is the Parkland formula
2-4ml x weight(kg) x TBSA burns
Usually use 3 ml
Over what period should fluid calculated by the Parkland formula be given?
First half in 8 hours, then second half over 16 hours
When should an escharotomy be perfored?
With deep burns skin can become stiff. In chest this can impair ventilation and in the limbs circulation
How is an escharotomy performed?
1.The limb should be kept in the anatomical position.
2. The area is cleaned and incised along the anatomical lines with a scalpel down to the fat
3. The incision should not go down to the muscle or fascia
4.For the limbs the incisions need to release both medial and lateral aspects
5. For the chest the incision needs to release the whole breast plate
What biochemical marker suggests a likely poor outcome in hypothermic arrests?
K+ >10
What are the recommended methods for measuring temperature in severe hypothermia? (3)
- Tympanic (accurate to 20degrees C)
- Oesophageal
- Intravascular
Not rectal
At what voltage should you start at to defibrillate AF or SVT?
70-120 J
At what voltage should you start at to defibrillate VT?
120-150J
What are the escalating doses of adenosine in adults who are in SVT but stable?
6mg
12mg
18mg
Describe the anaesthetic intubation grades
How do we convert L/min to Fi02?
(L/min x 4) + 20
e.g. (5L/min x 4) = 40
What is the landmark for anterior humerous IO access?
1cm above the surgical neck
What is the landmark for proximal tibia IO access?
2 finger breadths below the patella and 1-2cm medial to the tibial tuberosity in adults
What is the landmark for distal tibia IO access?
3 cm proximal to the most prominent aspect of the medial malleolus
Describe the Mallampati scoring system
Class I: Soft palate, uvula, fauces, pillars visible.
Class II: Soft palate, major part of uvula, fauces visible.
Class III: Soft palate, base of uvula visible.
Class IV: Only hard palate visible.
What are the ranges for mild/moderate and severe hypothermia?
Mild = 32-35 degrees
Moderate = 28-32 degrees
Severe = 24-28 degrees
Describe the APGAR scoring system
A-ppearance
0 - pale/blue
1 - pink body, blue extremities
2 - pink
Pulse
0 - absent
1 - < 100
2. > 100
G-rimace
0 - nil
1 - some movement
2 - cry
A-ctivity
0 - limp
1 - some flexion of extremities
2 - well flexed
R - espirations
0 - absent
1 - weak cry or hypoventilation
2 - good
Describe the Swiss staging system for hypothermia? (5)
- Mild (Stage I) – conscious with shivering. 32 to 35°C.
- Moderate (Stage II) – Altered mental status without shivering. 28 to 32°C.
- Severe (Stage III) – Unconscious. 24 to 28°C
- Very Severe (Stage IV) – Apparent death. Core temperature 13.7 to 24°C (resuscitation may be possible). Remember cold delays the brain death.
- Death (Stage V) – Death due to irreversible hypothermia. Core temperature <9 to 13.7°C (resuscitation not possible).
How long should be check for signs of life in hypothermic arrest?
1 minute
What is HAPE and how is it managed?
High altitude pulmonary oedma
- descend
- 02
- decompression chamber (portable)
- nifedipine
What is HACE and how does it differ from Acute Mountain Sickness?
High Altitude Cerebral Oedema
AMS + confusion or ataxia
Describe the MPTT-24 Modified Physiology Triage Tool (6)
What are the 3 component parts of the current triage sieve used by MIMMS?
- GCS
- RR
- SBP
What does METHANE stand for?
M - ajor incident declared
E - xact location
T - type of incident
H - azards
A - Access/egress
N - Number and type of casualties
E - emergency services present/requried
What is the breakdown of the ‘rule of 9s’? (6)
- Head and neck - 9%
- Anterior trunk - 18%
- Posterior trunk - 18%
- Upper extremity - 9%
- Lower extremity - 18%
- Perineum - 1%
When is entonox c/i? (6)
- Head injury
- Chest injury
- Suspected bowel obstruction
- Middle ear disease
- Early pregnancy
- B12/folate deficiency
Describe the ASA grading
- normal
- mild systemic disease
- severe systemic disease -
- severe systemic disease, constant threat to life e.g. unstable angina, DKA
- moribund, will die without operation
Describe the LEMON anaesthetic assessment
- L-ook externally
- E - valuate using ‘3,3,2’
3 fingers mouth opening
3 fingers from mentum for hyoid
2 fingers between hyoid and throid gland
- Mallampati
- Obstruction/obesity
- Neck mobility
In post extubation hypoxia what does the mnemonic DOPES stand for?
D: Dislodgement of the tube – check depth of tube against recorded depth at intubation. Is
ETCO2 still connected and recording?
O: Obstruction – can a suction catheter be passed?
P: Pneumothorax
E: Equipment failure – disconnect ventilator and return to manual BVM.
S: Stacked breaths – especially auto-PEEP in COPD/asthma. Disconnect from ventilator.
