Resus Prox Pearls, part 2 Flashcards
If using peripheral access for vasopressors, make sure that _____
it is not distal and it is well secured
The first step in treating peripheral venous access complications is
catheter removal
Remarks on internal jugula vein catheterization
- For the first step, place the probe on the sternocleidomastoid muscle
- Identify the thrydoid gland and carotid artery in addition to the IJV. Do NOT attempt needle insertion before visualizing all 3 structures
most accessible central access site during critical illness, notably cardiac arrest or trauma
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
management of arterial access complications
- The first step is catheter removal
- Apply direct pressure for a minimum of 3 to 5 minutes after removal at all peripheral sites and 10 minutes for a femoral site
Estimate MAP using by
MAP = DBP + pulse pressure/3
remarks on lactic acidosis
All lactic acidosis is associated with poor outcome.
All lactate acidosis should be alarming to the emergency physician.
The primary sites of catheter insertion for transvenous pacing in the ED are
the right internal jugular vein (preferred)
and the left subclavian vein
If a patient who has a permanent pacemaker requires countershock, place the pads or paddles ________ from the pulse generator
at least 8 cm
Treatment of choice for sudden cardiac death
implantable cardioverter-defibrillators (ICD)
reducingmortality from approx 30% -45% per year to <2% per year
most common cause of death in patients with an ICD
congestive heart failure
Most common reason a patient with an ICD comes to the ED
evaluation after a delivered shock
Remarks on ICD evaluation
- Place each patient on a continuous ECG monitor.
- Obtain a 12-lead ECG
- any shock-related ST-segment elevations or depressions should resolve within 15 minutes
- ongoing changes suggest new ischemia
If the patient is receiving repeated inappropriate shocks for a non-lethal rhythm, temporarily deactivate the ICD by
*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
remarks on percardial effusion
If a pericardial effusion compromises hemodynamics, pericardiocentesis is lifesaving
Tamponade from trauma is best treated with a
subxiphoid window procedure, though a temporizing pericardioentesis can aid while preparing for this or definitive surgical repair
Pulsus paradoxus
SBP drops >10 mmHg during respiration.
Common in those with cardiac tamponade
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
50 mL
Largest group of patients with pericardial effusions leading to hemodynamic compromise
oncology patients
key symptoms of tamponade
dyspnea and chest pain
Beck’s triad
Hypotension
Jugular venous distention
Decreased/muffled heart sounds
Classic ECG finding for pericardial tamponade
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
When hemodynamic compromise is present, do this while preparing for emergency pericardiocentesis
infusion of a crystalloid fluid bolus
this will enhance right ventricular volume
Remarks on emergency pericardiocentesis
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
Absolute contraindication for pericardiocentesis
Some consider aortic dissection as an absolute contraindication
