Resus 2

Question 1

historical features on headache history that suggest SAH

Answer 1

maximal at onset - peaking in seconds to minutes

onset with exertion/sex

Question 2

headaches which can result with history of trauma

Answer 2

subdural, epidural, traumatic SAH, intraparenchymal hemorrhage, skull fracture and closed head injuries such as concussion and diffuse axonal injury

Question 3

etiology of headache when pt headache rapidly improve when removed from environment

Answer 3

carbon monoxide

Question 4

headaches which can occur in pregnant women (or postpartum)

Answer 4

pre-eclampsia, idiopathic intracranial hypertension and reversible cerebrovascular syndrome
venous sinus thrombosis, pituitary apoplexy, cervical artery dissection and stroke

Question 5

critical and emergent headache diagnoses

Answer 5

critical: 
CNS: SAH, carotid dissection, venous sinus thrombosis
tox: CO poisoning
rheum: temporal arteritis
ID: bacterial meningitis, encephalitis

emergent: 
CNS: shunt failure, traction headaches, tour or mass, subdural hematoma, reversible cerebral vasoconstriciotn syndrome
tox/enviro: mountain sickness
eye: glaucoma
ID: brain abscess
pulm: anemia, anoxic h/a
CV: hypertensive crisis
unspecified: preeclampsia, IIH

Question 6

nonemergent headache diagnoses

Answer 6

migraine
vascular headahce
trigeminal neuralgia
post-traumatic (concussion)
post LP headache

sinusitis
dental
TMJ dz.

tension headache
cervical strain

cluster or histamine headaches
febrile headaches

stn

effort-dependent or coital headachaes

Question 7

possible diagnoses to consider with sudden onset of pain in headache, with any decreased mentation, any positive focal finding, meningismus or intractable pain

Answer 7

SAH, cervical artery dissection, CVT

Question 8

possible diagnoses to consider with sudden onset of pain in headache, with recurrent thunder clap episodes, may be associated with stroke-like symptoms

Answer 8

reversible cerebral vasoconstriction syndrome

Question 9

possible diagnoses with sudden onset of headache with pre syncope or syncope

Answer 9

SAH, cervical artery dissection, CVT

Question 10

possible diagnoses of headache with periorbital or rtetroorbital pain, sudden onset with tearing

Answer 10

temporal arteritis, acute angle closure glaucoma

Question 11

risk factors consistent with headache caused by ____

breathing in enclosed space with engine exhaust or ventilation of heating equipment
multiple household members with same syptoms
wintertime and working around machinery or equipment ie. furnaces

Answer 11

carbon monoxide poisoning

Question 12

risk factors consistent with headache caused by ____

hx of sinus/ear infection or recent surgical procedure
immunocompromised
acute febrile illness
extremes of age
impacted living conditions (eg. military or college dorms)
lack of primary immunization

Answer 12

meningitis, encephalitis, abscess

Question 13

risk factors consistent with headache caused by ____
age > 50
females more than males (4:1)
hx of other collagen vascular diseases
previous chronic meningitis
previous chronic illness - tb, parasitic or fungal infection

Answer 13

temporal arteritis

Question 14

risk factors consistent with headache caused by ___
history of previous glaucoma
age > 30
history of pain increasing in a dark environment

Answer 14

acute angle closure glaucoma

Question 15

risk factors consistent with headache caused by ___

female
pregnancy, postpartum, hormone replacement therapy or oral contraceptive use
prothromotic conditions

Answer 15

cerebral venous sinus thrombosis

Question 16

risk factors consistent with headache caused by ____

episodic sudden severe pain with or without focal neuro deficits or seizure
recurrent episodes over a period of several weeks
exposure to adrenergic or serotonergic drugs
postpartum state

Answer 16

reversible cerebral vasoconstriction syndrome

Question 17

risk factors consistent with headache caused by ____

sudden and severe pain
post exertion or sex
hx of SAH or cerebral aneurysm
hx of polycystic kidney disease
famhx of SAH
hypertension -severe
previous vascular lesions in other areas of body
young and middle aged

Answer 17

SAH

Question 18

risk factors consistent with headache caused by ____

hx of EtOH defence with or withou trauma
use of anticoagulants

Answer 18

subdural hematoma

Question 19

risk factors consistent with headache caused by ____

traumatic injury
lucid interval followed by acute altered mentation or somnolence
anisocoria on exam

Answer 19

epidural hematoma

Question 20

headache red flags indicating higher risk for serious cause of headache

Answer 20

sudden onset
WHOML
altered mental status
meningismus
unexplained fever
focal neuro deficit on exam
symptoms refractory to torment or worsening despite
onset of headache during exertion
hx of immunosuppression
pregnancy or peripartum state

Question 21

patients with abdominal pain who are are higher risk for serious underlying disorders

Answer 21

age over 60
previous abdominal surgery
hx of IBD
recent instrumentation (eg. colonoscopy w. biopsy)
known abdominal/pelvic/retroperitoneal malignancy
active chemotherapy
immunocompromised, including low dose prednisone
fever, chills, systemic symptoms
women of childbearing age
recent immigrants
language or cognitive barrier

Question 22

what is mortality for all cuase shock

Answer 22

> 20%

Question 23

categories of schok

Answer 23

hypovolemic shock
distributive shock
cardiogenic shock
obstructive shock
dissociative shock

Question 24

types of hypovolemic shock

Answer 24

hemorrhagic: trauma, GI bleed, body cavity
hypovolemia: GI losses, dehydration from insensible losses, third-space sequestration from inflammation

Question 25

types of distributive shock

Answer 25

septic shokc anaphylactic shock central neurogenic shock drug overdose

Question 26

types of cardiogenic shock

Answer 26

MI cardiomyopathy arrhythmia: fib, VT, sVT overdose of negative inotropic drug - BB, CCB structural - ventriculoseptal rupture, papillary muscle rutpure

Question 27

types of obstructive shock

Answer 27

``` PE tamponade tension pneumothorax valvular dysfunction: critical AS, acute thrombosis of prosthetic valve congenital heart defects HOCM ```

Question 28

types of dissociative shock

Answer 28

CO methemoglobinemia HS CN

Question 29

lab changes that typically occur with traumatic hemorrhage

Answer 29

lactate > 4 PaCO2 < 35 mild hyperglycemia mild hypokalemia (3.5-3.7)

Question 30

empirical criteria for diagnosis of circulatory shock

Answer 30

``` ill appearance or altered mental status HR > 100 RR > 20 or PaCO2 < 32 base deficit < -4mEq or lactate >4 urine output < 0.5ml/hr arterial hypotension > 30 min duration, continous ```

Question 31

approach to undifferentiated shock

Answer 31

1. hx of trauma? - search for hemorrhage, tension pneumothorax, cardiac tamponade or cardiac injury 2. evidence of GI bleed, vomitng, diarrhea --> volume resuscitation 3. fever or hypothermia ? - treat sepsis, search for source, consider thyroid function tests 4. ECG evidence of ischemia or CP with risk factors -- treat for cariogenic shock from MI, consider massive PE with RV strain 5. unexplained bradycardia or hypotension? - evaluate for ingestion of negative inotropic drug 6. unexplained hypoxemia ? -rule out PE 7. abdo or low back pain - volume resuscitation, emergency CT abdominal or surg consult to evaluation for peritoneal inflammation or vascular rupture 8. wheezing with hives or skin flushing - tx for anaphylaxis

Question 32

what effect does prehospital hypotension have on in hospital mortality rate (shock patients)

Answer 32

fourfold higher in hospital mortality rate

Question 33

variables indicating tissue hypoperfusion

Answer 33

``` hypotension tachycardia low cardiac output dusky or mottled skin delayed cap refill altered mental state low urine output low CVO2 elevated lactate ```

Question 34

management of hemorrhagic shock

Answer 34

ensure adequate ventilaiton/ oxygenation control of hemorrhage (ie. traction for long bones, direct pressure) and obtain urgent consult prn IV crystalloid bolus 10-20cc/kg with evidence of poor organ perfusion and 30 min anticipated delay to hemorrhage control, being PRBC infusion 5-10ml/kg with suspected massive hemorrhage, immediate PRBC transfusion may be preferable treat coincident dysrhythmias (eg. fib with sync cardioversion)

Question 35

management of cardiogenic shock

Answer 35

``` ameliorate increased WOB, provide O2 and PEEP for pulmonary edema begin vasopressor or inotropic support (NE, E, and dobutamine) reverse insult (i.e. thrombolysis) consider intraaortic balloon pump for refractory shock ```

Question 36

management of septic shock

Answer 36

ensure adequate oxygenation, remove WOB administered 20cc/kg crystalloid and titrate infusion based on dynamics indices, volume responsiveness and/or urine output beging abx, attempt surg drainage or debridement begin PRBCs if Hb < 70 if volume restoration fails to improve perfusion, starts vasopressors, NE at 0.5ug/min

Question 37

what marker can be used instead of central venous oxygen saturation

Answer 37

lactate clearance if lactate has not dropped by 10-20% 2 hours after resist began, additional steps taken to improve systemic perfusion

Question 38

what to do if patients require more than 2 units of PRBCs

Answer 38

start giving 1:1:1 of PRBC, FFP, platelets - better hemostasis and lower death rate due to exsanguination at 24 hours

Question 39

what is starting dose of norepinephrine in septic shock

Answer 39

0.05ug/kg/min and titrated at 3-5 min intervals until MAP > 65 or SBP > 90

Question 40

what is the max dose of norepinephrine - beyond which no further effect seen

Answer 40

30ug/min

Question 41

what is next step if max dose of norepinephrine does not control bp

Answer 41

add vasopressin at a rate of 0.03-0.04 units/min and don't titrate it

Question 42

what percent of cardiac arrest patients have VF as initial presenting rhythm

Answer 42

20%

Question 43

what percent of cardiac arrest patients receive bystander CPR

Answer 43

45%

Question 44

what percent of cardiac arrests get bystander AED

Answer 44

8% in public settings, 1% home arrest

Question 45

what is survival rate of OOHCA EMS-treated

Answer 45

11% , ranges from 3-17% based on region

Question 46

what percentage of patients with ROSC survive to hospital DC and have good nerve function

Answer 46

survival 19-59% based on centre 78% of those has good neuro outcome

Question 47

if patient is comatose post cardiac arrest, and meets inclusion for TTM what is the survival rate with good neuro outcome

Answer 47

50%

Question 48

with primary respiratory failure cause of cardiac arrest what are vitals typically like

Answer 48

tachycardia and hypertensive, followed by hypotension and bradycardia progressing to PEA, VF or asystole

Question 49

what do primarily circulatory obstruction (eg. tension pneumothorax, pericardial tamponade) and hypovolemia vitals on presentation typically like

Answer 49

initial tachycardia and hypotension, progressing through bradycardia to PEA, but may also deteriorate to VF or asystole

Question 50

what do primary cardiac causes of arrest typically present like

Answer 50

VF or pVT

Question 51

causes of non traumatic cardiac arrest

Answer 51

cardiac: CAD, cardiomyopathies, structural abnormalities, valvular dysfunction respiratory: -hypoventilation: CNS, neuromuscular, tox/metabolic encephalopathies -upper airway obstruction: CNS dysfunction, fb, infection, trauma, neoplasma -pulmonary dysfunction: asthma, COPD, pulmonary edema, PE, pneumonia circulatory: -mechanical obstruction: tension pneumothorax, tamponade, PE -hypovolemai: hemorrhage -distributive: sepsis, neurogenic metabolic: hypo/hyperkalemia, hypo/hypermagnesemia, hypocalcemia toxic: -rx: antidysrhythmics, digoxin, CCB, BB, TCAs -rec drugs: cocaine, heroin -tox: CO, cyanide environmental: lightning, electrocution, hypothermia or hyperthermia, drowning or near-drowning

Question 52

which H & T to consider in drowning patient

Answer 52

HYPOTHERMIA

Question 53

important history to obtain from cardiac arrest patient

Answer 53

``` witnessed vs. not ? time of arrest what pt was doing (eating, exercising, trauma, etc). possibility of drug ingestion time of initial CPR initial ECG rhythm interventions by EMS ``` PMHX: baseline health, previous heart, lung, or renal disease, malignancy, hemorrhage and infection risk factors for CAD and PE medications & allergies

Question 54

overall goals of physical examination in cardiac arrest patient

Answer 54

ensuring adequacy of airway maintenance and ventilation confirm diagnosis of cardiac arrest find evidence of cause monitor for complications of therapeutic intervention

Question 55

approach to physical exam in cardiac arrest patient (detailed list)

Answer 55

general: pallor (hemorrhage), cold (hypothermia) airway: secretions, vomit or blood (aspiration, airway obstruction), resistance to PPV ( tension pneumothorax, airway obstruction, bronchospasm) neck: JVD (tension pneumo, tamponade, PE), tracheal deviation (tension pneumo) chest: median sternotomy scar (underlying cardiac dz) lungs: unilateral breath sounds (tension pneumothorax, R mainstream intubation, aspiration), distant or no breath sound or no chest expansion (esophageal intubation, airway obstruction, severe bronchospasm), wheezing (aspiration, bronchospasm, pulmonary edema), rales (aspiration, pulmonary deem, pneumonia) heart: diminished heart sounds: hypovolemia, tamponade, tension pneumothorax, PE abdomen: distended and dull (ruptured AAA or ectopic), distended, tympanic (esophageal intubation), gastric insufflation rectal: blood, melena (GIB) extremities: asymmetric pulses (dissection), AV shunt or fistula (hyperkalemia) skin: track marks or abscesses (IVDU), burns (smoke inhalation, electrocution)

Question 56

define cardiopulmonary arrest

Answer 56

unconsciousness, apnea and pulselessness

Question 57

indications of inadequate blood flow during CPR

Answer 57

``` carotid or femoral pulse -not palpable CPP < 15mmHg arterial relaxation (diastolic) pressure <20-25mmHg PETCO2 <10mmHg SCVO2- <40% ```

Question 58

what is SCVO2 representative of

Answer 58

during cardiac arrest SVO2 (O2 sat remaining in PA after systemic extraction) correlates well with SCVO2 - because O2 consumption and SaO2 remains constant any change in SCVO2 represents change in cardiac output

Question 59

what is normal range os SCVO2

Answer 59

60-80% | during cardiac arrest- 25-35% (greater oxygen extraction of tissues)

Question 60

difference between EMD and pseudo-EMD

Answer 60

electromechanical dissociation: primary disorder of electromechanical coupling in myocardial cells, usually brady/wide QRS, associated with global myocardial energy depletion, and acidosis resulting from ishcemia or hypoxia pseudo-EMD: myocardial contractions occurring but inadequate, usually transient before true EMD and has same causes, in addition can be causes by papillary muscle rupture and myocardial wall rupture; primary SVT can cause; extra cardiac causes: hypovoelmua, tension pneumothorax, pericardial tamponade, and massive PE

Question 61

what therapies are useful for pseudo-EMD

Answer 61

volume loading or continuous vasopressor infusion,

Question 62

what to do if see asystole on monitor

Answer 62

confirm with second lead

Question 63

when is ECMO most successful for use in cardiac arrest

Answer 63

timely access and initiation of ECPR within 60 mins of arrest

Question 64

complications of ECMO

Answer 64

coagulopathy, hemorrhage, limb ischemia, vascular injury, renal replacement therapy, and stroke

Question 65

relative contraindications to TTM

Answer 65

another obvious reason for coma (drug overdose, status epilepticus), known end stage terminal illness, preexstiing DNR

Question 66

complications to TTM

Answer 66

coagulopathy

Question 67

when to consider PCI post arrest

Answer 67

any pt with STEMI on ECG should have immediate PCI post ROSC | when high clinical suspicion of ACS without STEMI, rapidly post ROSC because improved survival to hospital DC

Question 68

relative contradincaitions to fibrinolytics post arrest if at centre without PCI

Answer 68

evidence of significant CPR trauma such as pneumothorax, flail chest or pulmonary contusion with hemorrhage