Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

FACEM Written > Resuscitation > Flashcards

Resuscitation Flashcards

1
Q

Post Resuscitation Care (11)

A
  • O2 Sats 94-98%
  • TTM
  • ECG
  • ABG
  • ETT check / Lung protective ventilation
  • Inotropes for hypotension
  • Sedation
  • Complications of CPR
    • Fractures
    • Aspiration
    • PTx
  • Need for CT head

Goals:

Maintain normal vital signs

Prevent further organ dysfunction

Organise any interventions

Treat/Mx complications of CPR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Hypertonic Saline

A

Indications

  • Raised ICP
  • Hyponatraemia (Na<120)
  • Hypotension - small volume needed
  • Sputum expectoration

Preparations

  • 3% 150ml, 7.5% 75ml, 23.4% 30ml

Aims

  • Keep BP >90
  • ICP <20mmHg
  • Osmolality 300-320 mOsm/L
  • Na 145-155 mmHg

+ve EFFECTs

  • rapid effect (peak @ 10 min, lasts 1 hour)
  • VBG to monitor Na
  • Less hypovolaemia cf mannitol
  • Rapid restoration of intravascular volume, BP and decreases ICP
  • May have a better effect on CBF for a given reduction in ICP
  • May prevent cerebral oedema
  • cheap, available
  • Easy to transport (small volume)
  • Anti-inflammatory effect may decrease incidence of MODS

-ve EFFECTS

  • Hypernatraemia / hypokalaemia
  • Hyperchloraemic acidaemia
  • Renal failure
  • CVC required
  • Phlebitis, tissue necrosis if extravasates
  • Central pontine myelinosis if Na+ corrected too quickly in hyponatraemia
  • Increase in circulating volume -> risk of CHF (theoretical – not recorded)
  • Coagulopathy: can affect APTT, INR and platelet aggregation (no evidence for changes in outcome)
  • Rapid changes in Na+ may result in seizures and encephalopathy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Tracheoinnominate fistula

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Capnography

A

Noninvasive measurement of the concentration (partial pressure) of expired carbon dioxide over time

Clinical Uses

  • Rapid assessment critically ill / severely ill pt
  • Assess Response to treatment for acute respiratory distress
  • Monitoring during procedural sedation
  • Rapid assessment of ubtunded or unconscious pt
  • Sedated patients (Opioid Abuse, EtOH intoxication, procedural sedation, etc.)
  • Monitoring Airway Ventilation
    • Unlike pulse-oximetry, not prone to motion artifact
    • Earlier recognition of respiratory depression when compared to pulse-oximetry (Deitch 2010)
    • Median time to difference in detection = 60 seconds
    • May also detect other adverse effects, such as bronchospasm, laryngospasm, or upper airway obstruction
  • Metabolic Acidosis (Taghizadieh 2016)
    • Metabolic acidosis → decreased HCO3 → compensatory hyperventilation → increased minute ventilation and decreased ETCO2
  • Obstructive Lung Disease
    • Upsloping of alveolar plateau due to alveolar leak of CO2
    • Pattern also seen in leaks in breathing system (endotracheal tube leaks)
  • Ventilated Patients/Apneic Patients
    • ET Tube Placement - GOld Standard
    • CPR Effectiveness/ROSC
      • Quantitative measure of chest compression effectiveness
      • Prognostic factor of ROSC if <10 mmHg at 20 min of CPR (Levin 1997)
      • An early indicator of reperfusion from ROSC is sudden rise in EtCO2 and thereby may help to decrease deleterious pauses in chest compressions for pulse checks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Resuscitative Thoracotomy

A

Indications

  • Traumatic cardiac arrest <15 mins PLUS
    • Penetrating injury
    • Blunt injury + cardiac tamponade
    • Bleeding from ICC >1.5L or 200mls/hr for 3 hrs

Goals

  • Relieve cardiac tamponade
  • Perform open cardiac massage
  • Occlude aorta to increase blood flow to heart and brain
  • Control life threatening thoracic bleeding
  • Control bronchovenous air embolism

https://www.aci.health.nsw.gov.au/networks/eci/clinical/procedures/procedures/554100

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Capnography in CPR

A

Normal 35-45mmHg

During cardiac arrest:

  • Gradual fall in ETCO2 suggests compressionist fatigue during CPR
  • Abrupt increase in ETCO2 suggests ROSC during CPR (detectable before pulse check)
  • ETCO2 at 20 minutes of CPR is prognostically useful

Prognosis

  • >20 mmHg at 20 minutes CPR -> higher chance of ROSC
  • <10 mmHg at 20 minutes CPR -> almost no chance of ROSC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

FFP / ELP

vs

Cryoprecipitate

A

Prep time for both approx 30 mins

FFP

  • All clotting factors
  • Fibrinogen 700-800mg
  • 250-300ml

Cryo

  • Factors VIII, XIII and vWF
  • Fibrinogen 150-252mg
  • 10-20ml
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Hypothermic Arrest

A

Correct electrolyte abnormalities

  • May see relative hypokalaemia - fluid shift resolves with rewarming

Defib

  • Try up to 3 times
  • No success - no further attempts until T >30C
  • Pacing not successful

Int+Vent

  • Low risk ppte VF
  • Aim normocapnoea

Drugs

  • <30C - withold
  • 30-35 - twice time interval i.e every 8-10mins

Rewarming

  • Passive - remove wet clothes, warm blanket, warm drinks
  • Active
    • Ex - bare hugger, immersion hot watert
    • Int - warm air, IVF, lavage, haemofiltration, ECMO or CPB
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Arterial line uses

A
  1. Persistent or recurrent hemodynamic instability
  2. Monitoring of conditions or treatments that result in large fluid or blood pressure shifts
  3. Frequent arterial blood sampling
  4. Expected inaccuracies in noninvasive blood pressure management (e.g. because of obesity or dysrhythmias)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Pulse Oximetry

A

Measures arterial hemoglobin that is in the oxyhemoglobin state

Pulse oximetry is limited by:

  • Artifact
  • Low perfusion states
  • Increased ambient light
  • Deep skin pigmentation
  • Nail polish
  • Methylene blue
  • CarboxyHb
  • MetHb
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

ETCO2 uses

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Considerations for resuscitation

A
  • Pt wishes
  • Presence or absence of advanced care directive
  • Presence of enduring guardianship
  • Duty of care - identify and treat reversible pathology
  • Pre-morbid QOL
  • Co-morbidities
  • Limits of Mx, Rx goals and disposition destination
  • Other stake holders i.e. NOK, ED nurses, ICU
  • Personal biases
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Organ donation

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

ECMO criteria

A

Acute, severe REVERSIBLE respiratory or cardiac failure with a high risk of death that is refractory to conventional management

  • poor gas exchange
  • compliance < 0.5mL/cmH2O/kg
  • P:F ratio < 100
  • shunt fraction > 30%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

ECMO complications

A
  • Clot formation
  • Haemolysis
  • Air embolism
  • Bleeding
  • Pump failure
  • Decannulation
  • Circuit rupture
  • Cardiac arrest
  • Oxygenator failure
  • VA: left ventricular overdistension -> APO, cardiac damage, pulmonary haemorrhage, pulmonary infarction, aortic thrombosis, cardiac or cerebral hypoxia, CVA 15%
  • VV: cardiac arrest -> perform CPR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

ECMO contraindications

A

Absolute
* progressive non-recoverable cardiac or respiratory disease
* Severe PHTN
* Advanced malignancy
* GVHD
* >120kg
* Unwitnessed cardiac arrest

Relative
* age > 75
* multi-trauma with multiple bleeding sites
* CPR > 60 minutes
* multiple organ failure
* CNS injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Intubation of Obese

A
  • Cardiovascular
    • HTN
    • LV dysfunction
  • Respiratory
    • O2 consumption increased
    • CO2 production increased
    • Reduced FRC - abN elevated diaphragm, dec chest wall compliance
  • Airway
    • Difficult in all aspects i.e BVM, SGA, ETT, surgical
    • Time to desaturation decreased due to resp factors
    • Ramping, Head-up
    • Pre-oxygenation and Apnoeic oxygenation
  • Drugs
    • LBW for hypnotics
    • TBW for NMB
  • Ventilation

NEEDS FINISHING

18
Q

Clamshell vs anterolateral ED thoracotomy

A

Clamshell

ADV - Better access to heart and lower mediastinum

ADV - Access to both pleural cavities

ADV - Better performance for non-surgeons

CONS - Difficult wound closure

CONS - Post-op pain

AL approach

ADV - Direct / fast access to heart /pericardium

ADV - Easy to close

ADV - less morbidity assoc

CON - Limited access

CON - Limited interventions due to space restriction

CON - If bleeding source on right - unable to reach

19
Q

High pressure alarm - Ventilator

A
20
Q

Low pressure alarm - Ventilator

A

Think Air Leak

Ventilator can’t generate the peak or plateau pressure necessary to oxygenate or ventilate the patient.

Most likely disconnection of circuit or patient from ventilator

ETT Position Too High:

  • Check ETT depth
  • Dislodged during transport

ETT Cuff Leak:

  • Cuff pressure - inc or replace
  • Leak at ETT/ventilator interface
  • Check tubing

Check ICC - may be a leak through ICC

21
Q

NIV Complications

A
  • Inc WOB
    • w/ asynchrony
    • Improperly set triggers
    • Increase in intrathoracic pressure
    • Resp alkalsosis
  • Decreased venous return
    • Dec CO
    • Dec renal blood flow and GFR → inc fluid retention
  • Inc ventilation/perfusion ratio
  • Air trapping
  • Intrinsic positive end-expiratory
    pressure,
  • Barotrauma
  • Nosocomial infections of the
    lungs and sinuses
22
Q

Analgesics - adverse rxns

A
  • Fentanyl - chest wall rigidity
  • Oxycodone - serotonin syndrome
  • Hydromorphone - inactive metabolites
23
Q

Sedative adverse rxns

A
  • Etomidate - myoclonus
  • Ketamine - laryngospasm
  • Propofol - venous irritation
  • Pentobarbitol - 30min sedation duration
24
Q

Local Anaesthesia Toxicity Treatment

A
25
Q

Local Anaesthesia Tox Symptoms / Diagnosis

A
26
Q

Thoracotomy Interventions

A
  1. Pericardotomy & release of tamponade
  2. Identification and closure of cardiac laceration
  3. Compression/cross-clamping of descending thoracic aorta
  4. Internal cardiac compressions
  5. Management of pulmonary haemorrhage (hilar twist or tie off vessels)
  6. Control of bronchovenous air embolism
  7. Right atrial catheterisation facilitating IV fluids/blood products administration
27
Q

Emergency Thoracotomy Indicatons

A
  1. Cardiac tamponade
  2. Penetrating chest trauma + cardiac arrest < 10mins
  3. Vascular injury at thoracic outlet
  4. Traumatic loss of chest wall
  5. Massive air leak form chest tube
  6. Massive or continuing haemothorax
    a. Stable > 200ml/hr for 3 hours or > 1500mls
    b. Unstable > 100mls/hr or > 1000mls
  7. Mediastinal traversing penetrating injury
  8. Oesophageal injury - OGD or CT
  9. Tracheo-brachial injury - endoscopy of CT
  10. Great vessel injury
  11. Thoracic penetration with industrial liquids esp coal tar
28
Q

Thoracotomy CI

A
  1. Blunt injury + TCA w/o evidence of tamponade
  2. Non-survivable injuries
  3. Alternative option with non-surgical resuscitation
29
Q

Indications for ICC

A
  1. Tension PTx
  2. Traumatic PTx
  3. Moderate to large PTx
  4. Bilateral PTx (regardless of size)
  5. Assoc haemothorax
  6. Respiratory distress
  7. Failed conservative Mx
  8. Recurrence after ICC removal
  9. Pt requires PPV or GA
30
Q

6 most common causes oesophageal peforation

A
  1. Iatrogenic
  2. FB
  3. Caustic burns
  4. Blunt or penetrating trauma
  5. Spont rupture (Boerhaave’s)
  6. Post-op breakdown of an anastamosis
31
Q

Oesophageal Perforation Mimics

A
  1. Spont pneumomediastinum
  2. Aortic aneurysm (thoracic)
  3. PE
  4. Perforated peptic ulcer
  5. MI
  6. Pneumonia
  7. Pancreatitis
  8. Cholecystitis
  9. Mesenteric thrombosis
32
Q

Re-expansion pulmonary oedema folowing ICC insertion

A

More likely with:
Younger pt <30yrs
> 3L pleuralfluid aspiration
Large PTx
> 7 days duration of pl effusion

Prevention
<1.5L pleural fluid drained at a time or slow to 500ml/hr
Avoid suction

33
Q

NIV indications

A
34
Q

Anaphylaxis

A

Severe allergic reaction w/ skin + A/B/C/GI symptoms

Preciptants
Foods: Nuts, cow milk, egg, soy, shellfish, wheat
Bites/Stings: bee, wasp, jack jumper ants, ticks
Meds: B-Lactams, NSAIDs
Other: Exercise, Rubber/Latex (gloves, bottle nipples, dummies)

RF for fatal anaphylaxis
* Delay in treatment
* Poorly controlled asthma
* Allergy to nuts / shellfish / drugs/ insect stings
* Adolescence
* Preexisting cardiac and resp disease

Rx
* Remove allergen
* Adrenaline
* 10mcg/kg IM x 2
* Infusion of 1mg in 100mls Saline at 60-120mls/hr (10-20mcg/min)
* Neb 5mg 1:1000
* HF O2 + nebulised adrenaline 5mg
* Call for help - ICU / anaesthetics
* ETT early w/ difficult airway set up + surgical airway
* IV access +/- IVF bolus 10-20mg/kg
* IV hydrocortisone 4mg/kg QID
* Loratidine 2.5-10mg PO

Discharge Instructions:
Home when vitals normal
Asymptomatic or observation period 6 hours
Epipen and instructions
Referral to Immunologist / Allergen specialist
- Anyone discharged home with Epipen
- Food/drug/exercise induced
- Severe reaction with no trigger

35
Q

Inotrope / Infusion Doses

A

Adrenaline – 0.1-1 microgs/kg/min
Dexmedetomidine – 0.2-0.7 microgs/kg/h
Dobutamine – 1-20 microgs/kg/min
Dopamine – 1-20 microgs/kg/min
GTN – 0.1-0.8 microgs/kg/min
Ketamine – analgesia: 0.05-0.1 mg/kg/h, sedation: 0.2 mg/kg/h
Lignocaine – 1.5 mg/kg/h
Noradrenaline – 0.1-1 microgs/kg/min
Phenylephrine – 0.1-2 microgs/kg/min
Propofol – 4-12 mg/kg/h or 75-175 microgs/kg/min

36
Q

Inotropes - Adverse Rxns

A
  1. Adrenaline - lactic acidosis, low K, low PO4
  2. NA - reflex bradycardia, HTN, peripheral ischaemia
  3. Dobutamine - tachyarrhytmia, tachyphylaxis, AMI
  4. Dopamine - arrhythmia, pulmonary vasoconstriction, N+V, immune dysregulation, TSH and Prolactin release
  5. Vasopression - PHTN, splanchnic ischaemia, uterine contraction
37
Q

Extubation in the ED

A

Determine disease resolution
Airway / ETT not difficult else best in ICU

Readiness
1. Drug reversal
a. Turn off sedative / muscle relaxants
b. Absent inotrope requirement
2. Stable Resp physiology
a. FiO2 <30%
b. No resp acidosis
c. Spontaneous breathing trial - minimise ventilatory support
i. Good TV, sats, RR
3. Stable cardiac physiology
a. Stable rate and rhythm
b. Low dose or absent inotropic support
4. Stable CNS
a. Strength - lift head off pillow, raise arms for 15 seconds
b. Mentation - eyes open to voice, obeying commands

Preparation
Sit up 45 degrees
High flow O2 100%
Equipment to re-intubate
Apply positive pressure - ask pt to inhale
Remove ETT as pt coughs / exhales
Suction orpharynx

Post ETT care
High flow O2 Hudson
Reassess adequacy of ventilation
- HFNP or NIV for respiratory distress
- ETT if above fails
Close observation for 60mins

38
Q

LVAD

A

Indications
* Bridge to recovery - unable to wean cardiac bypass
* Bridge to cardiac transplant
* Bridge to decision
* Destination therpay - not eligible for cardiac Tx

CI
Metastatic cancer
Cerebral accident
Irreversible hepatic or renal disease

Relative CI
Active coagulopathy
Active infection
Mechanical cardiac valves
Severe AR

Components
1. Inflow cannula (from left ventricle)
2. Blood pump
3. Outflow conduit (anastomosed to ascending aorta)
4. Percutaneous lead (drive line)
5. External system components (controller, monitor, power source and battery)

How it works
Blood flows from heart to VAD which pumps blood back to body
Provides partial or total circulatory assistance
LVAD, RVAD or BiVAD

39
Q

LVAD hypotension

A

VAD-related
suckdown
malposition
pump failure/ obstruction (thrombosis, kinking, etc)
excessive pump speed

Non-VAD-related
hypovolemia (dehydration or haemorrhage)
cardiac tamponade
aortic regurgitation
dysrhythmias
vasodilation

40
Q

LVAD Complications

A

Initial - RHF, bleeding/clotting/suckdown

Device related - suckdown, failure, malposition, migration

CVS - RH dysfunction, AR, dysrrhytmias, CVA

Haem - bleeding, thromboemolbism, haemolysis, VAD thrombosis, acquired VWF dysfunction

Infection

Anti-coagualtion complications - GIH, ICH

41
Q

Assessment of LVAD pt

A

CALL VAD CENTRE EARLY

All anticoagulated and can presnet with GIH or ICH
Can dvp acquired Von Willebrand’s PLT dysfunction
Dysrrhythmias frequent so pts have AICD

LVAD
* Sats may be unreliable due to low pulse pressure
* Some - No palpable pulse or BP
* MAP with art line
* BP cuff - constant flow indicates MAP
* Assess other vitals for perfuson status
* Shock may be RVF - deviced does not support RV - consider dobutamine, dopamine
* Compressions NOT HELPFUL - confirm absence of pump function and fix malfunction
* Some have backup hand pump

TAH
* ECG asytole as no native cardiac activity
* Defib / pacing and chest compressions NOT HELPFUL

42
Q

IABP

A

Actions
Increases cornoary perfusion, diastolic flow
Reduces afterload, LV stroke work, myocardial O2 demand, R-> L shunt in VSD, degree of MR

Indications
Cardiogenic shock and myocardial ischaemia
- Post MI
- Cardioomyopathy
- Severe iHD awaiting curgery
- Severe acute MR waiting surgery
- Prophylactic in high risk pt
Unable to wean of cardiopulmonary bypass

CI
Severe AR
Aortic dissection
Severe PVD, AAA, AAA repair
Sepsis
Severe coagulopathy
CI < 1.2
Tachyarrhytmias

Components
Large bore catheter w/ long sausage shaped balloon at distal tip
Console w/ pump that inflates balloon

Complications
Insertion
Insertion failure, malposition
Aortic dissection or arterial puncture, accidental femoral vein puncture
Use
Infection
Thrombosis - Limb ischaemia
Embolisation - end-organ ischaemia
Bleeding at insertion site
Gas embolism
Balloon rupture
Haemolysis and thrombocytopaenia
Anti-coagulation issues

FACEM Written (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions