Module 1 - Shock, Geriatrics, RSI Flashcards
Describe the role of universal screening of ED patients for IPV and other social issues.
- opportunity to access resources
What is included in a comprehensive subjective history?
- ETOH
- Smoking
- Illicit druge use
- Interpersonal violence
What are the 7 P’s of rapid sequence intubation?
- Prepare
- Protection and position
- Preoxygenate
- Pretreat
- Paralysis and Induction (induction first!)
- Proof of placement
- Post-intubation care
What is involved in post-intubation care?
- Re-check ABCs and full vitals
- Secure ETT + document
- Tubes (OG, foley, CVCs, ART lines)
- Sedation & analgesia
- Mechanical ventilation (BVM vs. ventilator)
What are common presentations of ecotopic pregnancy?
- first trimester bleeding
- abdominal pain
- missed menstrual period
What are the clinical features of a ruptured ectopic pregnancy?
- hypotension
- tachycardia
- moderate to severe abdominal pain
- peritoneal signs (rebound tenderness)
What are the two treatments for ectopic pregnancies?
- Surgical management (for unstable patients)
- Medical management (stable patients)
What is the name of the medication used in the medical management of an ectopic pregnancy?
Methotrexate (MTX) - inhibits DNA synthesis and cell replication
What are the three stages of shock?
- Compensated
- Uncompensated
- Irreversivle
What are some signs and symptoms of shock?
- tachycardia
- hypotension
- tachypnea
- cool and clammy extremities
- oliguria
- dysglycemia
- delirium
What are the 4 types of shock?
- Hypovolemic
- Cardiogenic
- Distributive (sepsis, neurogenic, anaphylactic)
- Obstructive
True or False:
Vital signs may be normal in compensated shock
True
- Body is able to maintain cardiac output
- Cellular damage is STILL happening
What is the key to treating all types of shock?
Early recognition and intervention
What is the first line drug of choice in anaphlaxsis?
Epinephrine
What is the first line druge of choice in vasodilatory and septic shock?
Norepinephrine
When is dopamine used?
Vasodilatory shock associated with BRADYCARDIA
What does dobutamine do?
- Increases contractility of the heart
- Vasodilation (decreases SVR)
Can help improve CO by decreasing afterload, making it easier for the heart to eject blood with each contraction
What do colloid fluids contain?
Contain undissolved particles (protein, sugar, starch) that are too BIG to pass through capillary
What effect do colloids have? (Isotonic, Hypotonic, or Hypertonic)?
Hypertonic
- pull fluid from tissues into vasculature
What does fresh frozen plasma contain?
Albumin, Globulins, Antibodies, Plasma clotting factors
What are the components of the “Geriatric Giant”?
- Delirium
- Depression
- Dementia
- Drugs
- De-conditioning
- Falls
- Pain
- Incontinence
- Malnutrition / Dehydration
- Sleep disturbance
- Elder abuse
What are some cardiac changes that happen in older adults?
- cardiac muscles thicken
- arteries stiffen
- valves stiffen
- conductivity altered
What are some respiratory changes that happen in older adults?
- rigidity of chest wall
- enlargement of chest wall
- lung tissues diminish
What are some renal changes that happen in older adults?
- Less renin production
- Decrease in filtration
- Decrease ability to concentrate urine
- Decrease in renal blood flow
What are signs of multiple organ dysfunction in septic shock? *
- Altered mental status
- tachypnea
- poor cap refill
- hypotension
- tachycardia
- thrombocytopenia (increase d-dimer)
- metabolic acidosis (increase lactate)
- urine output < 0.5 mL/kg/hr)
What are the endothelia cell dysfunctions that leads to multiple organ dysfunction?*
- capillary leak
- microvascular thrombus
- cell adhesion
- tissue hypoxia
- apoptosis
- impaired vascular tone
- free radical damage
What can make for a difficult airway with RSI?
- Obesity
- Short or wide neck
- Obvious signs of deformity
What are the two paralytics that are commonly used in RSI?
- Roccuronium (non-depolarizing)
- Succinylcholine (depolarizing)
Which is longer acting, Roc or Succ?
Roccuronium
In what cases does Succinylcholine have to be used carefully?
- Hyperkalemia (K+)
- Renal Failure
- Burns
- Conditions that increase neuromuscular blockade (low Ca+, low K+, high Mg+, metabolic acidosis)
What is the name of the reversal agent for rocuronium?
Sugammadex
What are the drugs used for induction?
- Propofol
- Ketamine
- Etomidate
- Midazolam
What are the hazards of using Propofol?
- HYPOTENSION
- decreased HR
- allergy to eggs, soy, peanuts
- no analgesic effect
What is ketamine used for?
Induction for RSI
What is a potential side effect of ketamine?
May enhance pressor response
- increase HR
- increase BP
- decrease RR
What is fentanyl used for?
Analgesic
What is a potential hazard of using Fentanyl?
- Decrease RR
- Decrease HR
What is the antidote for too much fentanyl?
Naloxone
What is Phenylephrine used for?
Treatment of vasodilation and hypotension during anesthesia
- treatment of +++ low BP
What are some hazards of using phenylephrine?
- PVCs
- VT
- Increased BP
- Can’t use with sulfite allergy
- Causes severe peripheral vasoconstriction and reduced blood flow to organs
What is a side effect of Etomidate?
Can block the adrenal glands production of cortisol (stress hormone) that actually aids the body to deal with cardiovascular effects of sepsis, including hypotension
- can also decrease BP
- increase HR
What is a side effect of Midazolam?
Hypotension
Respiratory depression
What is considered in “Prepare & Plan” during RSI?
- gather the team
- vocalized plan and reason
- backup plan(s)
- prepare equipment and drugs (suction, oxygen, BVM, laryngoscope, ETT, OPA, bougie, RSI + pressers, EtCO2, SpO2, tele, NIBP)
What is considered in “Protection & Position” during RSI?
- consider c-spine
- adjust patient prior to or after induction and paralytics given to ensure adequate ergonomics
What is considered during “Pre-oxygenate” during RSI?
- 100% FiO2 for 3-5 minutes
- NRB, BVM, BiPap
- consider apneic oxygenation with nasal prongs
- advise physician when saturations reach a predetermined cutoff number to reduce potential harm (SpO2)
What is considered during “Pre-treatment” during RSI?
- Atropine - prevent bradycardia in children
- Lidocaine - neuroprotection in head injury, decrease airway reactivity in asthma
- Fentanyl - neuroprotection in head injury
- Rocuronium - prevent fasciculations from Succinylcholine
***These are not routinely seen in practice
What is the goal of the induction agent during RSI?
To provide rapid unconsciousness, unresponsiveness, amnesia, and analgesia
*Always give induction agent prior to paralytic
What is the goal of the paralytic agent during RSI?
Muscle paralysis to create an optimal environment for intubation
How is “Proof is Placement” verified during RSI?
- Visualization of tube through vocal cords
- Equal chest rise + fall
- Auscultation - no epigastric gurgling
- EtCO2 waveform capnography > 30
- Colourmetric - purple to gold if CO2 present (Gold is Good!)
- Portable chest xray
What is the expected capnography with CPR?
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