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Emergency Medicine > Resuscitation > Flashcards

Resuscitation Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Adult basic life support (out of hospital):
Management steps?

A
  1. Assess danger
  2. Assess breathing and responsiveness
  3. Call 999 and ask for an ambulance
  4. Send someone to fetch AED if ambulance dispatch identify one nearby
  5. CPR 30:2
  6. Attach AED and follow instructions
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2
Q

Adult advanced life support:
Initial steps of cardiac arrest management?

A

Patient unresponsive and not breathing normally:

  1. Call resuscitation team (delegate/ring 2222)
  2. CPR 30:2
  3. Attach defibrillator/monitor
  4. Assess rhythm - shockable (VF/pulseless VT), non-shockable (PEA/asystole), return of spontaneous circulation (ROSC)

ALSO:

  • Gain IV or IO access
  • Administer oxygen
  • Identify and treat reversible causes of cardiac arrest
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3
Q

Adult advanced life support:
Specific management of VF/VT cardiac arrest?

A
  • Give 1 shock, followed by 2 minutes of CPR. Repeat.
  • After the 3rd shock, 1mg of adrenaline is given upon restarting compressions
  • 1mg of adrenaline then given after alternating cycles of CPR (every 3-5 minutes)
  • Give amiodarone after every 3 shocks
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4
Q

Adult advanced life support:
Specific management of PEA/asystole (non-shockable rhythms)?

A
  • Adrenaline 1mg ASAP
  • 2 minutes of CPR then reassess rhythm
  • Intubation & ventilation (once intubated perform continuous compressions at โˆผ100bpm)
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5
Q

Adult advanced life support:
What are the reversible causes of cardiac arrest?
How are they managed?

A

4 Hโ€™s:
- ๐—›๐˜†๐—ฝ๐—ผ๐˜…๐—ถ๐—ฎ โ†’ intubation and ventilation
- ๐—›๐˜†๐—ฝ๐—ผ๐˜ƒ๐—ผ๐—น๐—ฎ๐—ฒ๐—บ๐—ถ๐—ฎ โ†’ stop bleeding, IV fluid/blood products
- ๐—›๐˜†๐—ฝ๐—ผ-/๐—ต๐˜†๐—ฝ๐—ฒ๐—ฟ๐—ธ๐—ฎ๐—น๐—ฎ๐—ฒ๐—บ๐—ถ๐—ฎ, ๐—บ๐—ฒ๐˜๐—ฎ๐—ฏ๐—ผ๐—น๐—ถ๐—ฐ โ†’ mx varies
- ๐—›๐˜†๐—ฝ๐—ผ-/๐—ต๐˜†๐—ฝ๐—ฒ๐—ฟ๐˜๐—ต๐—ฒ๐—ฟ๐—บ๐—ถ๐—ฎ โ†’ warm if hypo-, cool if hyper-, dantrolene if malignant hyperthermia.
NB: avoid IV drugs in ALS algorithm in hypothermic patients as may have a drastic response

4 Tโ€™s

  • ๐—ง๐—ฒ๐—ป๐˜€๐—ถ๐—ผ๐—ป ๐—ฝ๐—ป๐—ฒ๐˜‚๐—บ๐—ผ๐˜๐—ต๐—ผ๐—ฟ๐—ฎ๐˜… โ†’ needle thoracostomy with a wide-bore cannula
  • ๐—ง๐—ฎ๐—บ๐—ฝ๐—ผ๐—ป๐—ฎ๐—ฑ๐—ฒ โ†’ pericardiocentesis โ†’ thoracotomy โ†’ birth heart and remove the clot
  • ๐—ง๐—ผ๐˜…๐—ถ๐—ป๐˜€ โ†’ minimise absorption, antidote if available
  • ๐—ง๐—ต๐—ฟ๐—ผ๐—บ๐—ฏ๐—ผ๐˜€๐—ถ๐˜€ (coronary or pulmonary) โ†’ thrombolysis ยฑ embolectomy
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6
Q

Adult advanced life support:
What is the management after ROSC?

A
  • ABCDE assessment
  • Aim for SpOโ‚‚ of 94-98% and normal PaCOโ‚‚
  • 12 lead ECG
  • Identify and manage cause if not yet done
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7
Q

Bradycardia:
Initial management?

A
  • ABCDE
  • IV access and Oโ‚‚ if appropriate
  • Monitor ECG, BP, SpOโ‚‚
  • Evidence of life-threatening signs: shock, syncope, myocardial ischaemia, heart failure
  • If non-life-threatening manage supportively and arrange for the patient to receive a pacemaker
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8
Q

Bradycardia:
Management of life-threatening bradycardia?

A
  • Atropine 500micrograms IV

If bradycardia is still life-threatening, then:

  • Repeat atropine doses up to a maximum of 3mg
  • Isoprenaline 5micrograms/min IV infusion
  • Adrenaline 2-10micrograms/min IV

If still life-threatening:

  • Seek expert help
  • Arrange for transvenous pacing
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9
Q

Tachycardia:
Initial management:

A
  • ABCDE
  • IV access and Oโ‚‚ if appropriate
  • Monitor ECG, BP, SpOโ‚‚
  • Assess evidence of life-threatening signs: shock, syncope, myocardial ischaemia, severe heart failure
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10
Q

Tachycardia:
Management of life-threatening tachycardia?

A
  • Synchronised DC shock, up to 3 attempts

If unsuccessful:

  • Amiodarone 300mg IV over 10-20 minutes
  • Repeat synchronised DC shock
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11
Q

Tachycardia:
Assessment of non-life-threatening tachycardia?

A
  • Is the QRS narrow/broad?
  • Is the QRS regular/irregular?
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12
Q

Tachycardia:
Causes and management of regular, narrow-complex tachycardia?

A

SVT:

  1. Vagal manoeuvres (carotid massage โ†’ valsalva)
  2. Adenosine 6mg IV bolus โ†’ 12mg bolus โ†’ 18mg bolus (avoid in asthmatics)
  3. Verapamil/beta-blocker
  4. Electrical cardioversion
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13
Q

Tachycardia:
Causes and management of irregular, narrow-complex tachycardia?

A

Probable AF:

  • Rate control with beta-blocker (verapamil/diltiazem if asthmatic)
  • Consider digoxin or amiodarone if evidence of HF
  • Anticoagulate if >48hrs
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14
Q

Tachycardia:
Causes and management of regular, broad-complex tachycardia?

A 
If VT (or uncertain): 
- Amiodarone 300mg IV

If certain diagnosis of SVT with BBB:
- Treat as for SVT

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15
Q

Tachycardia:
Causes and management of irregular, broad-complex tachycardia?

A

Torsades des Pointes:
- IV magnesium 2g

Possible AF with BBB:

  • Consider expert help for diagnosis
  • Treat as for fast AF
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16
Q

Anaphylaxis:
Assessment?

A
  • ABCDE
  • Look for sudden onset ABC problems
  • Usually also skin changes e.g. itchy rash
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17
Q

Anaphylaxis:
Management?

A
  1. Remove trigger if possible
  2. IM adrenaline (1:1000; 1mg/mL)
    - ๐—”๐—ฑ๐˜‚๐—น๐˜ ๐—ฎ๐—ป๐—ฑ ๐—ฐ๐—ต๐—ถ๐—น๐—ฑ >๐Ÿญ๐Ÿฎ: ๐Ÿฑ๐Ÿฌ๐Ÿฌ๐—บ๐—ฐ๐—ด (๐Ÿฌ.๐Ÿฑ๐—บ๐—Ÿ)
    - Child 6-12 yrs: 300mcg (0.3mL)
    - Child 6mo-6yrs: 150mcg (0.15mL)
    - Child <6mo: 100-150mcg (0.1-0.15mL)
  3. Establish airway โ†’ high-flow Oโ‚‚
  4. Repeat IM adrenaline after 5 mins if no response
  5. Seek expert help for refractory anaphylaxis
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18
Q

Paediatric advanced life support:
Management of cardiac arrest?

A
  • Call 2222 for help
  • Commence CPR (5 rescue breaths โ†’ 15:2)
  • Assess rhythm
  • Reassess rhythm every 2 minutes
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19
Q

Paediatric advanced life support:
Management of a shockable rhythm?

A
  • 1 shock โ†’ 2 mins CPR, repeat
  • After 3rd shock IV adrenaline AND amiodarone bolus
  • Repeat adrenaline every alternate cycle
  • Repeat amiodarone once after 5th shock
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20
Q

Paediatric advanced life support:
Management of a non-shockable rhythm?

A
  • Immediately resume CPR for 2 mins
  • Give adrenaline IV ASAP then every alternate cycle (3-5mins)
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21
Q

Newborn life support:
Management algorithm?

A
  1. Dry baby and maintain temperature
  2. Assess tone, respiratory rate, heart rate
  3. If gasping or not breathing give 5 inflation breaths
  4. Reassess (chest movements)
  5. If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
22
Q

Shock:
What is shock?

A

A life-threatening disorder of the circulatory system that results in inadequate organ perfusion and tissue hypoxia, leading to metabolic disturbances and, ultimately, irreversible organ damage

23
Q

Shock:
What is the shock index?

A
  • Calculated by pulse rate รท blood pressure
  • > 1 โ†’ shock
24
Q

Shock:
Types of shock?

A
  1. Hypovolaemic shock (inc. haemorrhagic shock)
  2. Cardiogenic shock
  3. Obstructive shock
  4. Distributive shock (inc. anaphylactic, neurogenic, and septic shock)
25
Q

Shock:
How do you identify cardiogenic shock? Why is this important?

A
  • Measure pulmonary capillary wedge pressure โ†’ proxy for preload
  • It is important as IV fluid should not be given in cardiogenic shock; it will cause rapid pulmonary oedema and will lead to the patient deteriorating
26
Q

Shock:
Routine investigations?

A
  • FBC
  • U&E
  • LFT
  • coagulation panel
  • ABG/VBG โ†’ raised lactate (type A lactic acidosis)
27
Q

Shock:
Immediate management of shock?

A

Fluid challenge:

  • 500ml of crystalloid in less than 15 minutes
  • Monitor BP and end-organ function to look for improvement, while auscultating and monitoring SpOโ‚‚ to look for pulmonary oedema
  • Repeat until BP normalised or until fluid is no longer tolerated
28
Q

Transfusion:
Red cell transfusion threshold in patients without ACS?

A
  • Hb โ‰ค 70g/L
  • Target after transfusion = 70-90g/L
29
Q

Transfusion:
Red cell transfusion threshold in patients with ACS?

A
  • Hb โ‰ค 80g/L (transfuse earlier as higher risk)
  • Target after transfusion = 80-100g/L
30
Q

Transfusion:
What is autologous blood transfusion?

A
  • When a patient has some of their own blood taken and stored, ready to be transfused back into them if needed
31
Q

Transfusion:
What steps can be taken to reduce the risk of infection from blood transfusion?

A
  • Removal of WBCs (reduces risk of CMV, EBV transmission)
  • Blood samples are tested for many transmissible diseases in the blood bank
  • Irradiation - this further depletes T-lymphocytes. Indications include immunodeficiency and Hodgkin lymphoma
32
Q

Transfusion:
Threshold for platelet transfusion if there is active bleeding?

A

< 30 x 10โน if clinically significant bleeding

33
Q

Transfusion:
Threshold for platelet transfusion if there is no/insignificant active bleeding?

A

< 10 x 10โน

34
Q

Transfusion:
Contraindications for platelet transfusion?

A
  • Chronic bone marrow failure
  • Autoimmune thrombocytopenia (e.g. ITP)
  • Heparin-induced thrombocytopenia
  • Thrombotic thrombocytopenic purpura
35
Q

Transfusion:
Indications for using fresh frozen plasma?

A
  • โ€˜Clinically significantโ€™ but not โ€˜majorโ€™ haemorrhage
  • PT ratio or APTT ratio > 1.5
36
Q

Transfusion:
Indications for cryoprecipitate?

A
  • Solution containing vWF, factor VIII:C, fibrinogen, fibronectin and factor XIII
  • Used to replace fibrinogen
  • Suited for patients with โ€˜clinically significantโ€™ but not โ€˜majorโ€™ haemorrhage with fibrinogen levels < 1.5g/L
37
Q

Transfusion:
Indications for prothrombin complex concentrate?

A

Reversal of anticoagulation in patients with severe haemorrhage (including any intracerebral bleeding)

38
Q

Transfusion:
What to transfuse if the patientโ€™s ABO and Rh status is unknown?

A

Use the universal donors:

  • Packed red cells: O (Rh negative if possible)
  • FFP: Blood type AB
  • Platelets: less important but AB Rh -ve if possible
39
Q

ABCDE:

Airways assessment?

A
  • Can the patient speak?
    • If yes, patent โ†’ move on to B
  • Inspect the airway for foreign bodies
  • Check for signs of partial/complete obstruction
    • Signs of partial obstruction = cough, hoarseness, stridor, snoring
    • Signs of complete obstruction = inability to speak or cry out, absent breath sounds, cyanosis & profound hypoxia
  • Aspirate the airway with a suction catheter (if appropriate)
    • If no reflex response (coughing/gagging) or the breathing rate is less than 8 per-minute โ†’ call anaesthetist to intubate
40
Q

ABCDE:

Airways - what are the basic airway management manoeuvres?

A
  • Head tilt chin lift (should be avoided if thereโ€™s concern for c-spine injury)
  • Jaw thrust (doesnโ€™t require c-spine to be cleared)
  • Bag-mask ventilation
    • Indicated to preoxygenate before intubation or as part of CPR
  • Insertion of a basic airway adjunct
    • Oropharyngeal airway if patient is unconscious
    • Nasopharyngeal if patient is conscious. Contraindicated in basal skull fractures (โ€˜panda eyesโ€™, haemotympanum, mastoid bruising
41
Q

ABCDE:

A - indications for intubation?

A
  • Inability to maintain the airway: general anaesthetic, airway obstruction, reduced GCS, absent protective reflexes (gag/cough)
  • Inability to maintain ventilation: severe acute COPD/asthma
  • Conditions with a high risk of deterioration: anaphylaxis, severe septic shock, multisystem shock
42
Q

ABCDE:

A - management of a CICV (cannot intubate, cannot ventilate) scenario?

A
  • Needle cricothyrotomy
    • A large-bore cannula is inserted through the cricoid membrane
    • Indicated in young children (canโ€™t have surgical cricothyrotomy)
    • Indicated in adults when the practitioner is not comfortable performing a surgical cricothyrotomy
  • Surgical cricothyrotomy
43
Q

ABCDE:

Assessment of breathing?

A

Examination

  • Inspection
    • Appearance
      • Apnoea
      • Signs of lethargy or distress
      • Speaking in full sentences?
    • Vital signs
      • Respiratory rate
      • SpO2
    • Specific signs
      • Tracheal deviation
      • Paradoxical chest wall movement
      • Increased respiratory effort
  • Auscultation
    • Air entry
    • Pathological breath sounds
  • Percussion
    • Hyperresonance/dullness

Rapid/bedside investigations

  • ABG
    • VBG is likely sufficient if no respiratory distress
  • Consider bedside CXR and/or lung ultrasound
44
Q

ABCDE:

Initial management of breathing?

A
  • Apnoea/fulminant respiratory failure:
    • Bag-mask ventilation
    • Basic airway adjuncts
    • Prepare for intubation and ventilation
  • High-flow oxygen for all critically ill patients (except MI if theyโ€™re maintaining saturations or known CO2-retaining COPD patients)
  • If detected, provide emergency treatment of:
    • Tension pneumothorax
      • Needle thoracotomy decompression โ†’ chest drain
    • Massive haemothorax/pleural effusion
      • Insert a chest drain
    • Bronchospasm
      • Administer bronchodilators (neb salbutamol & ipratropium, IV magnesium sulfate)
    • Acute severe pulmonary oedema
      • Administer diuretics
45
Q

ABCDE:

C - what are things to check when assessing a patientโ€™s circulation?

A
  1. Assess skin appearance (e.g. pallor, mottling, cyanosis, diaphoresis)
  2. Check pulses
  3. Check HR and BP
  4. If shocked:
    • Initiate sepsis six, record qSOFA score if Sepsis confirmed
    • Check for signs of end organ damage
    • Check for signs of active bleeding
      • Take clotting screen, G&S and crossmatch if bleeding significant
  5. Auscultate the heart
    • Muffled may indicate pneumothorax or tamponade
    • Murmurs
    • Friction rub suggests pericarditis
  6. Assess volume status
    • Mucous membranes
    • JVP
    • CRT
  7. Obtain 12 lead ECG
  8. Consider other bedside tests such as a FAST scan, cardiac echo or CXR
46
Q

ABCDE:

C - management of shock

A
  • Establish (preferably x2) large-bore IV access
  • Always give haemodynamic support*
    • Fluid challenge (500ml IV crystalloid in < 5 minutes, 250ml if small & frail)
    • Vasopressors if not responding to fluid
      • The threshold depends on cause e.g. HHS may benefit from many litres of fluid while an elderly lady with cardiogenic shock may respond more poorly to small amounts.
  • Haemorrhagic shock
    • Blood transfusion
    • Emergency haemostatic measures (e.g. pressure, packing wound)
  • Obstructive shock
    • Cardiac tamponade: pericardiocentesis/thoracostomy
    • Tension pneumothorax: needle decompression โ†’ chest drain
    • Massive PE: thrombolysis
  • Distributive shock
    • Anaphylactic: IM adrenaline
    • Septic shock: empiric IV antibiotics according to local policy
    • Adrenal crisis: IV hydrocortisone
47
Q

ABCDE:

C - other immediate management of C pathology (not shock)?

A

Very much depends on what was found during the assessment

  • Hypertensive crisis
    • Cautious use of IV antihypertensives
  • Identify and manage any arrhythmias
  • Identify and manage any cardiac ischaemia
  • Treat any electrolyte disturbances that may compromise circulation
  • Rapid vascular surgery transfer if ruptured AAA or aortic dissection
  • etc. etc.
48
Q

ABCDE:

D - what forms the components of a disability assessment?

A
  • Evaluate consciousness
    • GCS
    • AVPU
  • Identify readily-apparent possible underlying aetiology
    • Head and neck trauma
    • Hemiplegia
    • Seizure activity
    • Toxins on clothes/skin
  • Check blood glucose level
  • Examine pupils
  • Evaluate for:
    • Lateralising signs
    • Signs of raised ICP
    • Meningism
  • Identify any classic toxidromes
  • Consider:
    • 12 lead ECG
    • Toxicology screen
    • Neuroimaging (e.g. CT head)
49
Q

ABCDE:

D - what are some toxidromes?

A
50
Q

ABCDE:

Management of D?

A
  • โ€œIf GCS โ‰ค 8 then intubateโ€œโ€‹
  • Agitated or violent patients
    • De-escalate if possible
    • Consider the need to restrain and/or administer calming medication if the patient remains a risk to themself or others
  • Suspected brain injury โ†’ initiate protective measures
    • Maintain adequate perfusion
    • Optimise oxygenation & ensure normocapnia
  • Provide emergency treatment for:
    • Status epilepticus: IV lorazepam 5mg โ†’ lorazepam 5mg โ†’ phenytoin infusion
    • Hypoglycaemia: IV glucose
    • Intoxication/poisoning: administer antidote (search toxbase if unsure)
    • Meningitis: IV antibiotics according to local policy
    • Correct severe electrolyte abnormalities (beware overly rapid correction โ†’ cerebral oedema)
  • Consider need for escalation
51
Q

ABCDE:

E - assessment of exposure?

A
  • Fully undress patient
  • Safely examine patientโ€™s back (using c-spine precautions if necessary)
  • Check for clues that may indicate the underlying condition:
    • Triggers of anaphylaxis e.g. latex, insect stings
    • Signs of trauma e.g. stab wounds, burns
    • Rash e.g. petechiae
    • Sources of sepsis e.g. infected wounds, gangrene
    • Toxins and drugs - needle track marks, medication patches
    • Other small wounds or foreign bodies e.g. insect bites, ticks
  • Measure core body temperature
52
Q

ABCDE:

E - management?

A
  • Remove all potential causes for deterioration
    • Allergens
    • Transdermal medication patches
  • Provide clean, dry clothing e.g. hospital gown
  • Manage body temperature
    • Hypothermia
      • Warm IV fluid
      • Active warming e.g. โ€˜bear-huggerโ€™
    • Hyperthermia
      • Begin surface cooling
      • Consider cool IV fluids
      • Antipyretics (not for environmental or malignant hyperthermia)
      • Dantrolene for malignant hyperthermia
  • Treat underlying pathology e.g. infection, trauma, intoxication etc.

Emergency Medicine (20 decks)

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