Resus Flashcards
What is CVP waveform
CVP is the measured pressure in Right Atrium- represent right sided filling.
a=atrial contraction
c=closure tricuspid valve
X=atrial relaxation
V=passive filling atrium
y= open tricuspid valve
Normal =5-12cm <5 hypovol >12 RVF
Analysis
Dominant a wave- TS/PS or pulm HTN
Dominant V wave- TR
Absent x descent- cardiac tamponade
Increased CVP- RvF - PE/ tamponade/ TV incompetence.
What is atrial waveform
1- systolic upstroke ventricular ejection - increased slope =increased contractility
2- systolic decline - rapid decline atrial pressure when ventricle stop contracting
3- diacritic notch- closure aortic valve pressure- measured at aorta
4- diastolic delay- pressure decrease as ventricle stops contracting
What is targeted temp management
Target <37.5
Principle- thought to improve outcomes AlS to protect against cerebral oedema
Avoid hypothermia
Duration 24 hrs
Prevent fever
No good evidence to actively cool
Not pre hospital
Causes PEA arrest
B-road complex QRS- us- LV hypokinesis- if hyper K- ca gluconate 10%60ml cacl-10%30ml
Na channel blocker- sodibic 100ml 8.4%
Or
Narrow complex QRS- RV collapse or tampon are or PTx pneumothorax
RV full- PE
Indications stopping CPR
Injuries not compatible with life-100% TBSA burn
NFR order
k>12 ph <6.5
No sign life Temp >32 degrees or 2hrs CPR <15 degrees
20-30 mins CPR- no ROSC (if rosc restart timer)
Underlying Rhythm- PEA or Asystole
Traumatic arrest- give blood
Or newborn- no HR after 10min CPR
HYPOTHERMIA - CPR
Reward pt- passive- remove wet clothes/dry/blanket
Active-external 28-32 degrees bair hugger
-internal- severe + CPR- thoracic/abdo lavage. Haemofiltratiin
<20 deg- intermittent CPR 5 min on 10 min off
<28 deg intermittent CPR 5 min on 5 min off
<30 no drugs trial 3 stacked shocks (defib not good till > 30 deg)
30-34 deg- double normal AlS drug intervals
Prolonged CPR till at least 30 degrees
Greater survival if rapid onset hypothermia
Child accidental etoh or drugs
CPR with toxins
CO- supplemental O2
Lignocaine Tox- intralipid- 20% 1-5mg/kg bolus
Cyanide- hydroxycobalamin 5mg IV
Digoxin- digibind in CPR 20 amps
TCA- sodibic 2mmol/kg 2-3 min post rosc
Opioids- Bali one 100mcg pre arrest IV 30-60 sec
CPR in pregnancy
Get help- OBGYN peads
L- lateral position
IV mgSO4- 4g Eclampsia
Causes- Cardiac/ PE/ haemorrhage-txt MTP
Sepsis/ ivabx/ IVF/ inotropes
HTN- eclampsia HELLP
Toxins
Amniotic fluid embolism
Prepare perimortem ceaser
CPR- in Trauma
Compression not routine
1-stop bleed
2-airway ETT
3- decompress chest- 2 finger thoracotomy
4- open chest decompresspercarditis
5- plug ventricular lacs
6- compress aorta
7- twist hi Lyn
8- MTP
9- crush injury manage hyper K
CPR and pulmonary Embolism
If lysis- ateplase <60kh 10mg bolus and 1.5mg/kg 2-4 hrs
Ateplase- >60mg 10mg IV bolus 90mg 2 hours
Heparin infusion
Prolonged CPR- 2 hrs post thrombopysis
CPR and asthma
Disconnect - BVM cpr forced exp
Seek and treat PTX
Prolong CPR and IVF
Severe bronchospasm/ mucus plug- CPR can dislodge and early tube suction and take over ventilation
Bronchodilators if ROSC
Anaphylaxis - CPR
Adrenaline- IM 500mcg IV- push 1mg +++
Prolonged CPR
Urgent intubation - vent
Fluid 20ml/kg
Adrenaline adrenaline Aim Map>65
ALS drugs dose and indication
Sodibic- 1mmol/kg 2-3 mins indicated hyper K TCA OD or metabolic acidosis
Calcium- cacl- 10% 5-10ml 3x more Ca or ca gluconate- 15-30ml 10%- indicated ca channel OD/ high K and low Ca
Mag- 5-10months bolus 20ml 4 hr infusion or mg torsades- hypo K low mg and dig toxicity
Potassium- 10-40 mail k<2.5
ALS drug- lignocaine dose/ indication
Anti arrhythmic- class 1b
Dose- 1-1.5 mg/kg after 10 mins 0.5 mg/kg
Indicated- refractory VF or pulseless VT or VT storm
Adverse effect- hypotension/ bradycardia and heart block/ asystole or CNS toxicity
Resus drugs- ALS - Amiodarone dose/MOA or induction
Dose- arrest 300mg bolus with further 150mg IV if req
Indication- refactory or pulseless VF/VT - 3rd loop/ shock
Class 3 anti arrhythmic
Adverse effects- hypotension/ bradycardia/ heart block/ prolonged QT
ALS drugs- Adrenaline- dose/routes/ MOA
ALS- 1mg every 2nd Loop -VT/VF 2nd shock
- PEA/asystole- after 1st rhythm check
Stridor- nebulised 1mg in 10ml
IV/IO- cpr 10mcg/kg or pressor 10mcg
ACEM- 5mcg/min titrate up or down
Adverse effect- tachycardia/ severe HTN with ROSC
Tissue necrosis if extravate
MOA- alpha/ beta receptors - inotrope/ chronotrope raised SVR. Increased cerebral and coronary blood flow
Decreased splanchnic and peripheral
Tachycardia
What are the steps post ROCS
A- ETT/ LMA secure airway- NGT/ CXr
B- aim SaO2 >94% max rib # or PTx and lung protective vent
C- target- SBO>100 MAp>80 12 lead ECG - cath lab if ischarmia
Inotrop- adrenaline 6mg in 100ml5-20 ml/hr amiodarone 0.6mg/kg/ hr
D- cerebral protection- head 30 degrees map>80 normo- glycaemia/ thermia/ normal Na. My seizure
Sedate P and F or M and M
Update Fsmily
ICU- organ donation?
Document and debrief
4Hs and 4Ts management
Hypoxia- Fio2-100%
Hypovolemia- ivf 20ml\kg blood TEG
Hypo K- kcl 20min l peripheral 40 mmol CVC
Hyper K- cagluconate 10% 30ml. Insulin/ dextrose 10 units 50ml 50% dextrose and sodibic- 100ml 8.4%
Hypo/ hyperthermia- <35 >40 rewarm or cool.
Tension PTx- finger thoractomy ICC mid axillary line 4 ICS
Toxins- antidote/ charcoal/ dialysis
Tamponade- percardiocentesis/clam shell
Thrombosis/ thrombus- cardiac PCI or PE- thrombolysis
What are causes of polymorphic VT
Torsades long QT
AMI
Short QT syndrome
Bi directional VT- dig toxcicity
Catecholamnergic polymorphic VT
Cardiac arrest- when can you use 3 stacked shocks
In witnessed monitored arrest where defib attached
What is coached algorithm
C- compression continued
O- oxygen away if BVM
All others clear
Charging
Hands off
Evaluate rhythm
Defib or disarm
Cardiac arrest - when can u use precordial thump
Witnessed VT-VF arrest with no pulse and no defibrillator on sight
Cardiac arrest- what is the chain of survival
Early recognition of CA
Early continuous CPR
Early defib
Minimise interruptions to cx compressiins
Aim nor other is
Avoid hyper or hypo O2
Peadiatric intubation differences
Straight blade- anatomy large tongue/ loose teeth short upper airway/ floppy glottis/ soft collapsible and big head
ETT= age/4 + 4 depth ETTx3
Pre oxygenate rapid desat has low FRC
ROC/ fent and Midas
Ketamine 2-4mg/kg
Roc 1.2mg/kg
Ensure IV access or IO
Adrenaline 10mcg/ kg
Famil- consideration and communication
Airway- what changes need to be thought about for intubation obese pt
Buy time- NIV/ delayed SI
Indications- do in DEM or OT
Get help- ent/ anos
Ramp- tragus to eternal notch
Aponeic O2- 15L/Min
Minimal drugs- ketamine or ROC
Pre O2- PEEP/ BVM/ NIV
Plan for difficulty
Post- intubated care
What changes need to be thought about in septic pt intubation
Optimise the pt- pressors or IVF
Drug choice- ketamine 0.5mg/kg
ROC 1.6mg/kg
Reduce induction drug dose
Increased muscle relaxant dose
Maintain resp comp increased RR
Complications when intubating asthmatic patient
Pneumothorax
Dynamic hyperinflation
Hypotension- decreased venous return and increased auto prep
Think-
D- dislodged tube
O- obstructed tube
P- pneumothorax
E- quipment failure
S- stacking
What considerations need to be made in intubating asthmatic
Become hypotensive- give IVF prior
DelayedSI- NIV/ BVM/ PEEP
Drugs- ketamine 1-2 mg/kg - b agonist and bronchodilator
ROC- 1.2 mg/kg IV
Larger ETT size to reduce breath stacking
++ bronchodilators prior or post- IV salbutamol or IV adrenaline
What are ideal ventilator settings in asthma
Vent- VC and SIMV
TV 6ml/kg
RR 6-8
Prolonged I:E ratio 1:4 reduce breath stacking
What is different when intubate pregnant person
Similar concept difficulties for obese pt
Similar size ETT size
Intubate- in L lateral posturing wedge right hip
Laringoscope short handle Kessel blade
Muscle relaxant reversal agents- non depolarising
Neostigmine adult 2.5mg + atropine 1.2mg
Child 0.08mg/kg
Suggamedex- normal 16mg/kg
Muscle relaxants vecuronium dose and duration
Vec- non depolarising
10mg powder dilute 10mg in 10ml saline-1mg/ml
Dose 0.1mg/kg adult 10mg
Induction- 0.3mg/kg RSI
Duration 30 mins
Muscle relaxant- Rocuronium dose/ onset/ metabolised/ adverse event
Non depolarising
ROC- 50mg in 5ml dilute 10mg/ml
Induction 1-1.2 mg/kg adult 100mg
Maintence 0.6mg/kg
Onset duration 45-60 secs
Duration 20-35 mins
Metabolised liver
Adverse effects- hypersensitivity/ tachycardia/ pain on injection/ if anticonvulsant- increased dose ROSC
Suxamethonium- cI and side effects
Depolarising
CI- congenital myopathy
Neurology condition in last 6 months
Burns to 20% TBSA
Infection
Hyper K and Hypo k
Adverse K- hyper K in burn pt
Muscle fasiculations
Bradycardia esp in child
Decreased LOS tone- GORD/asp
Malignant hypothermia
Aponea
Increased intraoccular pressure
Suxamethonium- dose/ phases/ duration/ onset
Presentation 100mg in 2ml as 50mg/ml
Dose- 1.5mg-2mg/kg adult 1-2.5 ml adult 100-150mg
Duration- 10mins
Rapid onset- fasicukations 30secs relax 45-60sec
2 phases
1- depolarising fasiculations flaccid paralysis
2- de- sensitising membrane desensitised early depolarised again
Head injury- what do need to consider intubating pt
Minimise changed in BP- reduced induction dose- ketamine 1mgkg fentanyl 2-3mcg/kg
ROC 1.2mg/kg
Anticipate difficult if collar- inline stabilisation or BURP
Neuroprotective- head 30 degrees/ neck clear/ saO2 >90 PCO2 35-45
MAP>80 normothermia/ normoglycaemia Na 135-145
Suxamethonium order of sensitivity of neuromuscular blockade
Large limbs—> diaphragm —> small trunk —> Larangeal—> eye muscles
Surgical airway approach
Steps
1- stabilise thyroid cartridge
2- palpate cricoid membrane
3- 4cm vertical incision into CTM
4- wide horizontal incision CTM
5- dilate finger- confirm location
6- bougie—> size 6 ETT
7- connect and confirm
