medical emergencies, stroke (non acls/pals) Flashcards
anaphylaxis soundbite and symptoms, tx
1) a life threatening condition due to a class I allergic reaction mediated by ige molecules that bind to mast cells that cause degranulation leading to release of histamine, leukotrienes and prostaglandins which causes cardiovascular collapse, interstitial edema, and bronchospasm.
2) symptoms - warmth, tingling, pruritus (itching), flushing, urticaria (rash), angioedema (swelling, often of face),
swelling can lead to airway compromise
3) check A,B,Cs if fall into an acls category, also treat that (ie circulatory collapse, no pulse = chest compressions) simultaneously.
call 911
1. fluid bolus 1L adults, 20 ml/kg lactated ringers
2. epi -
IM - 1:1000, 0.15 mg if 10-25 kg (under 50 lb kid) or 0.3 mg for over 25 kg. repeat every 5-15 minutes based on response
IV - 10 mcg to 1 mg bolus q2 min in adults
- 1-10 mcg/kg bolus q 1-2 minutes for children
- epi for cardiac arrest is 1 mg every 3-5 min for comparison
3. beta agonist - 2-3 puffs
4. diphenhydramine
- 50 mg for adults
- 25 mg for children (or 1mg/kg)
5. steroids: hydrocortisone 1-2.5 mg/kg IV or 100 mg IV over 1 minute, methylprednisolone - 1 mg
dexamethasone 4-12 IV over 1 minute
mild allergy tx
50 mg IV or PO, 100 mg IM
Histamine may circulate for 3 days or more so they should take diphenhydramine every 4 hours for the first 2 days
malignant hyperthermia soundbite, signs and symptoms, tx
1) hypermetabolic state that occurs with exposure to volatile anesthetics (not nitrous) and succinylcholine, specifically the lower threshold of calcium release channel activation leads to elevated calcium and sustained muscle contraction.
2) (after volatile or sux) signs are sinus tachycardia, hypercarbia, master spasm
later signs - peaked T waves (due to hyperkalemia), increase in core temp, dark blood in surgical site, whole-body spasm
3) treatment - discontinue offending agent, call 911 and 1-800-MHHYPER
- ET tube and hyperventilate (deepen sedation with intubating dose of prop and using rocuronium (0.6-1 mg/kg)
- dantrolene 2.5 mg/kg q5-10 mins, up to 10 mg/kg
- IV fluids to maintain 2ml/kg/h UOP
- surface ice packs and inbtracavity lavage goal core 38 degrees celsius (100.4)
- correct metabolic acidosis with sodium bicarb
- tx hyperkalemia with calcium, insulin, dextrose solution
-ICU
what is the mechanism of dantrolene
post-synaptic muscle relaxant
laryngospasm soundbite ddx and tx
laryngospasm is where the muscles of the glottis spasm (both false and true vocal cords) as a protective mechanism to irritation of fluids or foreign body.
ddx: upper airway obstruction vs laryngospasm
tx:
stop surgery/pack off surgical sites
2) jaw thrust with extreme pressure behind the jaw (pain can sometimes break laryngospasm) called Larsons maneuver/laryngospasm notch superior between angle of mandible and mastoid process. also may depress chest as another mechanical way to open the airway
3) mechanical ventilation with bag-mask, apply extreme positive pressure
4) give a large bolus of propofol (100 mg)
consider 20 mg of sux or 1 mg/kg of rocuronium
call 911 if to here.
1-2 mg of sux if 20 mg dose fails, consider 0.02 mg/kg of atropine (same as pediatric bradycardia algorithm dose) and support airway, either bag mask or intubate,
ICU for negative pressure pulmonary edema. (see when people bite the tube at the end of a case as well)
bronchospasm soundbite, sx,
spasm of bronchiole smooth muscle causing lower airway obstruction, often characterized by wheezing, often see in asthmatics or someone with a recent URI.
- symptoms: wheezing, cyanosis, etco2 with obstructive, shark fin pattern
tx:
1) stop surgery, pack of surgical sites
2) 100% oxygen with positive pressure
3) 6-10 puffs albuterol
4) epi - same as allergic reaction -
IM - 1:1000, 0.15 mg if 10-25 kg (under 50 lb kid) or 0.3 mg for over 25 kg. repeat every 5-15 minutes based on response
IV - 10 mcg to 1 mg bolus q2 min in adults
- 1-10 mcg/kg bolus q 1-2 minutes for children
- epi for cardiac arrest is 1 mg every 3-5 min for comparison
4. diphenhydramine
- 50 mg for adults
- 25 mg for children (or 1mg/kg)
5. 1-2 mg/kg succinylcholine and ETT
consider atropine 0.02 mg/kg for bradycardia (same as pediatric dose for PALS bradycardia algorithm.)
emesis soundbite, tx
oral expulsion of gastric contents
- get worried for aspiration leading to pneumonitis
Tx: turn to right and trendelenburg, suction, 100% o2, auscultate
- if not able to maintain pulse ox the transfer to ER, consider could get a spasm or wheezing, may need to assist ventilation
- in hospital would get serial X-ray and blood gas analysis as aspiration pneumonitis can present hours later.
intra-arterial injection tx
leave catheter - administer 10 cc of 1% lidocaine (vasodilation) may decrease arteriospasm
consider transfer to hospital for vascular surgery.
hypoglycemia soundbite, tx
a state of low blood sugar, usually below 60 mg/dL which can be caused by elevated glucagon and epinephrine and insufficient glucose
tx:
- POC blood glucose (below 60)
- is patient awake? if so give 15 g of simple carbohydrate, must be swallowed 6 oz of coke or 1 tbsp of honey
- if not awake obtain IV access, turn off anesthesia if sedating
- give D50W, 1 amp
or give glucagon SC or IM 1 mg adults
0.5 mg children
patient has a seizure, ddx, and tx?
history of seizure disorder, hypoglycemia, withdrawal from alcohol and vasovagal
how to treat -
1) trendelenburg (if this resolves less than 1 min and patient comes to without post ictal state then likely vasovagal
2) seizure continues:
take point of care blood glucose if low, tx hypoglycemia, if normal the give benzos
history of drug abuse?
3) obtain IV access
benzos will tx withdrawal and status epileptics
if believe status epilepticus (over 5 min) then tx
Status epileptics soundbite and tx
Status epileptics is a continuous episode of prolonged seizure activity or multiple without consciousness between the seizures
Tx: call 911
ABCs
supplemental 02
est venous access, give benzos
if in hospital draw labs for electrolytes, toxicology, and anticonvulsant drug levels, and hematology
- benzos - can give 10 mg of midazolam (versed) greater than 40 kg, less than 40 kg give 5 mg or lorazepam, diazepam (Ativan and valium)
- r/o hypoglycemia
- if hyperthermia cool patient
- if continues consider anesthetic dose of propofol, phenobarbital, phenytoin
stroke cincinnati prehospital stroke scale
what is an in hospital stroke scale
1) facial droop (with forehead sparring, Bell’s palsy includes forehead/frontalis),
2) pronator drift - eyes closed extend arms palms up for 10 seconds, sign of stroke will be that one arm drifts down compared with the other
3) abnormal speech - repeat “ you can’t teach and old dog new tricks”
- if any one of these signs, probability of stroke is 72%
- more in depth for providers is the NIH stroke scale
pearls of stroke management
1) get to hospital, eval, order stat non contrast CT
2) determine if ischemic or hemorrhagic
3) if ischemic consider tPA if patient able - 3 hours to 4.5 hours depending on patient eligibility
- can also do thrombectomy but not discussed on the acls stroke algorithm
4) hemorrhagic - consult neurosurgery for appropriate management
intraoperative/pre-operative hypertension what blood pressure do we get worried about?
180/110 mmHg without end organ disease is NOT a risk for peri-operative cardiac complications
pulse pressure (systolic - diastolic) greater than 80 mmHg is more sensitive for cardiovascular and cerebrovascular risk
if intraoperative hypertension how do we treat?
Hypertension
1) stop stimulus, confirm bp, make sure good Local anesthesia, sedation and oxygenation (hypoxia can lead to increased CO therefore htn)
2) if confirmed and above then can treat with medications
Labetolol - non selective beta blocker with selective alpha -1 blocker
- good for hypertension with tachycardia,
- dose 5-10 mg every 10 min for a max dose of 300, onset 5 min
hydralazine - direct arterial vasodilator, can cause sympathetic activation and tachycardia
- good for htn with bradycardia AVOID IN PTs with concern for MI, CAD etc
- 2.5 - 5 mg IV over 2 min redos every 10 min max dose 25 mg
nitroglycerin - ventilator and arterial dilator at high doses
MAKE SURE NOT ON ERECTILE DYSFUNCTION (phosphodiesterase inhibitors) MEDICATIONS - can lead to hypotension unresponsive to vasopressors if taken within last 48 hours
sublingual dose is 0.4 mg sublingual every 5 min for total of 3 doses.
- IV dose on page 479 in blue book
good for hypertension with bradycardia, or concerned for MI/angina
