Resus Prox Pearls, part 2

Question 1

If using peripheral access for vasopressors, make sure that _____

Answer 1

it is not distal and it is well secured

Question 2

The first step in treating peripheral venous access complications is

Answer 2

catheter removal

Question 3

Remarks on internal jugula vein catheterization

Answer 3

1. For the first step, place the probe on the sternocleidomastoid muscle
2. Identify the thrydoid gland and carotid artery in addition to the IJV. Do NOT attempt needle insertion before visualizing all 3 structures

Question 4

most accessible central access site during critical illness, notably cardiac arrest or trauma

Answer 4

femoral vein
*Classically, the femoral vein is just medial to the femoral artery and 1 to 2 cm below the inguinal ligament

• *although US often demonstrates an anomalous position, which is one reason why landmark-based insertions are less successful

Question 5

management of arterial access complications

Answer 5

1. The first step is catheter removal
2. Apply direct pressure for a minimum of 3 to 5 minutes after removal at all peripheral sites and 10 minutes for a femoral site

Question 6

Estimate MAP using by

Answer 6

MAP = DBP + pulse pressure/3

Question 7

remarks on lactic acidosis

Answer 7

All lactic acidosis is associated with poor outcome.
All lactate acidosis should be alarming to the emergency physician.

Question 8

The primary sites of catheter insertion for transvenous pacing in the ED are

Answer 8

the right internal jugular vein (preferred)
and the left subclavian vein

Question 9

If a patient who has a permanent pacemaker requires countershock, place the pads or paddles ________ from the pulse generator

Answer 9

at least 8 cm

Question 10

Treatment of choice for sudden cardiac death

Answer 10

implantable cardioverter-defibrillators (ICD)

reducingmortality from approx 30% -45% per year to <2% per year

Question 11

most common cause of death in patients with an ICD

Answer 11

congestive heart failure

Question 12

Most common reason a patient with an ICD comes to the ED

Answer 12

evaluation after a delivered shock

Question 13

Remarks on ICD evaluation

Answer 13

1. Place each patient on a continuous ECG monitor.
2. Obtain a 12-lead ECG
   - any shock-related ST-segment elevations or depressions should resolve within 15 minutes
   - ongoing changes suggest new ischemia

Question 14

If the patient is receiving repeated inappropriate shocks for a non-lethal rhythm, temporarily deactivate the ICD by

Answer 14

*placing a magnet over the device
defibrillation can be reenabled by removing the magnet

• *have a cardiologist evaluate all patients with ICD after exposure to a magnet

Question 15

remarks on percardial effusion

Answer 15

If a pericardial effusion compromises hemodynamics, pericardiocentesis is lifesaving

Question 16

Tamponade from trauma is best treated with a

Answer 16

subxiphoid window procedure, though a temporizing pericardioentesis can aid while preparing for this or definitive surgical repair

Question 17

Pulsus paradoxus

Answer 17

SBP drops >10 mmHg during respiration.
Common in those with cardiac tamponade

Question 18

During an acute rapidly expanding pericardial effusion, stroke volume will increase with removal of even a small amount of fluid (as little as ______) from the pericardial sac

Answer 18

50 mL

Question 19

Largest group of patients with pericardial effusions leading to hemodynamic compromise

Answer 19

oncology patients

Question 20

key symptoms of tamponade

Answer 20

dyspnea and chest pain

Question 21

Beck’s triad

Answer 21

Hypotension
Jugular venous distention
Decreased/muffled heart sounds

Question 22

Classic ECG finding for pericardial tamponade

Answer 22

Electrical alternans
- alternating high- and low-voltage QRS complexes as the heart swings toward and then away from the ECG leads on the chest wall with each contractions

Question 23

When hemodynamic compromise is present, do this while preparing for emergency pericardiocentesis

Answer 23

infusion of a crystalloid fluid bolus
this will enhance right ventricular volume

Question 24

Remarks on emergency pericardiocentesis

Answer 24

If the patient is hemodynamically compromised or close or in cardiac arrest, perform emergency pericardiocentesis in the ED rather than delaying treatment by transporting to the operating room

Question 25

Absolute contraindication for pericardiocentesis

Answer 25

Some consider aortic dissection as an absolute contraindication