Management 2 Flashcards
1
Q
TBI
A
- Primary survey (A,B,C,D,E)
- Secondary survey (quick general comments, making emphasis in fluids resuscitation to avoid hypotension and adecuate oxygenation, the 2 more dangerous causes of secondary brain damage; keep normoventilation).
- Regarding TBI, Tier 0 standard measures
- HOB 30º,
- neutral head position,
- adecuate sedoanalgesia,
- correct hyponatremia and hyperthermia,
- keep CPP > 60-70 mm Hg).
2
Q
Increased ICP Tier 0
A
Tier 0 standard measures
- HOB 30º,
- neutral head position,
- adecuate sedoanalgesia,
- correct hyponatremia and hyperthermia,
- keep CPP > 60-70 mm Hg).
3
Q
Increased ICP Tier 1
A
- mannitol 0.5-1 gm/kg IV bolus every 4-6h, monitor serum Osm, no benefit >320 mOsm/kg;
- CSF 5-10 ml drainage;
- start 3% saline 10-20 cc/hour,
- consider repeating CT
4
Q
Increased ICP Tier 2
A
Review decompressive surgical options. If surgery not appropriate or not performed, move to Tier 2
- hypertonic saline bolus (23.4%), increasing the target, Na >160 doesn´t add benefit;
- sedative bolus and infusion, propofol up to 200 mcrg/kg/min;
- consider decompressive craniotomy again.
5
Q
Increased ICP Tier 3
A
- Pentobarbital infusion 1-4 mg/kg/h and
- hypothermia 32-34ºC.
- Hyperventilation (pC02 towards 30, not useful for more than 6 hours, high risk of ischemia without additional neuromonitoring, including jugular venous oximetry, brain tissue oxygenation, and cerebral microdialysis),
- increase the MAP target starting inotropes if not done before.
6
Q
Apnea test
A
- Patient is hemodynamically stable (even with the use of vasopressors)
- Ventilator adjusted to provide normocarbia (PaCO2 35-45 mm Hg)
- Patient preoxygenated-100% FIO2 for ≥10 minutes to PaO2 ≥200 mm hg
- Patient well oxygenated with a positive end-expiratory pressure (PEEP) of 5cm of water
- Provide oxygen via suction catheter to the level of carina at 6L/min or attach T-piece with continuous positive airway pressure (CPAP) at 10 cm water
- Disconnect ventilator
- Spontaneous respirations absent
- Arterial blood gas drawn at 8-10 minutes, patient reconnected to the ventilator
- Pco2 ≥60 mm Hg, or 20 mm Hg rise from normal baseline value OR Apnea test aborted.
7
Q
Apnea Test with ECMO
A
- Ensure patient stability on ECMO.
- Decrease ECMO sweep rate to allow pCO2 rise, targeting 20 mmHg above baseline.
- Monitor for respiratory effort, vital signs, and oxygen saturation.
- Check ABG after about 10 minutes for pCO2 elevation.
- No respiratory effort with pCO2 ≥ 20 mmHg above baseline or ≥ 60 mmHg suggests brain death.
- Resume previous ECMO settings post-test.
8
Q
Organs donation
A
- Rule of 100 (SBP >100, HR<100, UOP>100 ml/h, PaO2>100 mmHg, Hb>100 g/l.
- Optimize CO and O2 delivery with fluids and vasopressors (CVP>10,CI>2.5).
- Temp>35ºC.
- Adequate oxygenation: PEEP 5 (to prevent atelectasis), PIP<35, TV<10 ml/kg, FiO2<40%
- Recruitment manoeuvres after apnea test and after suctioning, close circuit suction preferable.
- ETCO2 normal.
- Hormonal replacement: methylprednisolone 15 mg/kg bolus,
- 1 amp D50% and 20 IU Insuline and cont. infusion minimum 1 IU/h for glucemia 120-180 mg/dl,
- 20 mcrg levothyroxine and 10 mcg / h cont. infusion,
- Vassopresine 1 IU bolus and 1-4 IU/h infusion.
- Desmopresin iv if DI to maintain UOP<200 ml/h.
9
Q
Brain death clinical exam
A
- Pupils are fixed and unresponsive to light – 2nd and 3rd cranial nerves.
- There is no corneal reflex – 5th and 7th cranial nerves.
- There is no oculo vestibular reflex: no eye movement to 50 mL ice-cold saline in each ear over 1 minute with clear tympanic membranes – 3rd , 6th and 8th cranial nerves.
- There is no motor response to pain within cranial nerve distribution – 5th and 7th cranial nerves.
- There are no gag or cough reflexes to stimulation – 9th and 10th cranial nerves.
10
Q
Ancillary testing
A
- Cerebral angiogram
- Electroencephalogram (EEG)
- Transcranial Doppler (TCD)
- Cerebral scintigraphy Tc-99m Exametazime (HMPAO)
11
Q
Organ donation
A
- Keep map >65
- Uo 1ml/kg/h
- LV Ef >45%.
- Dopamine or dobutamine requirement around 10 max.
- Hormonal Therapy :
- Methylprednisolone 15mg/kg stat thenn15mg/kg next day.
- Thyroxine 20mic stat and 10mic/h infusion.
- Vasopressin 1U stat then 0.5 to 4units/h infusion.
- Insulin 10 units+50%dextrose then maintain RBS 80-150mg/dl . Minimum insulin 1unit/h infusion.
12
Q
Diagnosed aortic aneurysm (initial)
A
ABC
- Take full precautions as I am dealing during pandemic period
- A (check airway, can talk and protect his airway)
- B (SpO2, supply O2 if SpO2<94%, RR, chest movement , chest auscultation)
- C (connect to monitor, continuous BP monitoring, insert 2 P-lines, start Fluids as boluses, consider Vasopressors if still hypotensive, send CBC, ABG and full Chemistry, Cardiac Panel, Blood Cross match and Grouping, ECG, POCUS, bedside ECHO and assess for Volume responsiveness)
- D (assess for LOC, check Blood Glucose)
- E (Expose skin and avoid Hypothermia
Medical
- Pain Control (IV Opiates)
- Rapid reduce SBP, HR and LV contraction to reduce shear stress and prevent extension by IV B-blocker (Labetalol, Esmolol), SBP <120 mmHg, MAP <80 mmHg, HR <60 bpm
- Cocaine Toxicity: AVOID Selective B-blocker, because of alpha activity; Verapamil is preferred
- AVOID Hydralazine because it increases aortic wall distress
13
Q
Aortic aneurysm indications of surgery
A
- Type A
- Complicated Type B
- Rupture
- Branch vessel compromise/ organ ischemia
- Refractory Hypertension
- Aneurysmal Dilatation
- Refractory Pain
14
Q
Septic Shock
A
ABCDE then septic shock protocol the hour-1 bundle - includes five key elements:
- Measure lactate level (Remeasure if initially > 2 mmol/L)
- Obtain blood cultures prior to administration of antibiotics, but don’t delay appropriate antibiotic
therapy If obtaining blood cultures is difficult. - Administer broad-spectrum antibiotics
- Begin rapid administration of 30 mL/kg crystalloid fluids for hypotension or lactate ≥ 4 mmol/L
Give 500 – 1000 mL bolus of crystalloid, then titrate boluses up to 20-30 ml/kg against monitored
Parameters (dynamic indices , fluid responsiveness) - Apply vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain
MAP ≥ 65 mmHg
15
Q
Septic shock vasopressors
A
- Norepinephrine is a good initial vasopressor choice
- Add vasopressin if norepinephrine dose gets high or epinephrine (especially if patient is demonstrating insufficient cardiac output)
- Avoid dopamine in most patients (can be used as an alternative to norepinephrine in patients with low risk of Tachyarrhythmia or with Bradycardia)
- Inotropic therapy Dobutamine can be considered if the patient has evidence of significant myocardial dysfunction and ongoing signs of hypo perfusion, (echo, low ScvO2 and low Hb) despite achieving adequate intravascular volume and MAP.
