Resuscitation Flashcards
Define Shock
A state where oxygen demand is greater than supply
Types of Shock
Hypovolemic
Obstructive
Cardiogenic
Distributive
Causes of cardiogenic shock
Ischemia
Arrhythmia
Valvular dysfunction
B-Blocker / CCB overdose
Causes of obstructive shock
Tamponade
Tension pneumo
PE
Causes of distributive shock
Sepsis
Anaphylaxis
Pancreatitis
Neurogenic / spinal
Addison’s / Adrenal insufficiency
Toxins
Predictors of difficult to BVM
Beard
Obese
Older (neck mobility)
Teeth (edentulous)
Sounds (snoring / obstruction)
- STOPBANG > 3
- Snores
- Tired
- Observed Apnea
- Pressure (BP)
- BMI > 35
- Age > 50
- Neck > 17”
- Gender (M)
Predictors of difficult to Intubate / airway assessment
Look
Evaluate 3-3-2
Mallampatti
Obstruction / obesity
Neck Mobility
Predictors of difficult to Supraglottic device
Restricted mouth opening
Obese/obstruction
Distorted anatomy
Stiff neck or lungs
Etomidate Risk
Adrenal suppression
Myoclonus
Regional cerebral excitation
Dose 0.3 mg/kg (20 mg in average size)
Propofol Risk
Decreased cardiac output
Peripheral vasodilation
Dose 1.5-3 mg/kg (150 mg in average size - less if old or sick)
Ketamine Risks
Theoretical ICP increase (no evdience)
Bronchorrhea
Laryngospasm
Cardiac depression in patients with adrenal supression / catecholamine exhausted
Dose 1-2 mg/kg (1oo mg in average size)
Succinylcholine Contraindications
known hypersensitivity
family hx of malignant hyperthermia
recent burn. trauma, crush injury, neuromuscular disease, denervation (stroke, spinal cord)
Initial NPPV setting
iPAP = 10 cm
ePAP = 5 cm
Initial vent setting for ARDS
SIMV @ 6 cc/kg, RR 12, FiO2 = 1, PEEP = 10, I:E = 1:2
Vent setting in Asthma intubation
Volume - A/C or SIMV +PS
- 6-8 ml/kg
- RR 8-10 BPM
- I:E = 1:3-4
- FiO2 = 100%
- PEEP = 2-5 cmH2O
Vent Settings in Neuro ICH
Have to avoid hypotension, hypercarbia and hypoxemia
- Prevent sympathetic response with large dose fentanyl and topicalization or IV lidocaine
- Fentanyl 2-3 mg/kg
- Esmolol 1.5 - 2 mg/kg
- Ketamine or Etomidate for induction
Vent settings: Aim for PCO2 ~ 35
- Low PEEP 5-10 cm H2O
Vent and airway management in Metabolic Acidosis
Avoid intubation if possible - Minute ventilation needs HIGH
Settings: Assist Control 8ml/kg IBW
RR: 30 / min
(Require 120 ml/kg/min of minute ventilation, if attempting to reduce PCO2 may need 240 ,l/kg/min)
at 8 ml/kg - 30 BPM)
Normal Electrolyte Lab Values
Osm - 287
Na - 135-145
Cl - 98-106
K - 3.5-5.0
Lactate < 2
pH 7.35-7.45
IVC Measurements
1.3 - 2.5 cm normal.
1st and 2nd line vasopressors in septic shock
norepinephrine
2nd - vasopressin or epi
1st line vasopressors in neurogenic shoclk
Norepinephrine
1st line pressors in Cardiogenic shock
Norepinephrine as 1st line
- Low dose Epi (0-5 mcg) may act as pure inotrope without effects on vasodilation
- Vasopressin helpful in patients with pulmonary HTN or tachycardia
1st line inotrope - Dobutamine
Management of extravasation of pressors into peripheral tissues
Phentolamine injected into the site
SIRS Definition
2+ of
T < 36 or >38
RR > 22 or pCO2 < 32
HR > 90
WBC < 4 or > 10 or> 10% bands
Surviving sepsis guidelines in 2021 - First 3 hours
Measure a lactate
Draw Blood Cx
Give broad spectrum Abx
Fluid bolus of 30 ml/kg of Ringers/Plasmalyte if lactate > 4 or hypotensive
Early vasopressors if hypotensive despite fluid resuscitation.
Redraw lactate if initially elevated
ACLS Cardiac Arrest
Activate Emergency Response System
Pulse check - if absent, immediate HQ CPR
- 120 BPM
- At least 5 cm with complete recoil
If Shockable:
- Shock as soon as advised
- Continue CPR
- Shock Q2 mins if remains shockable
- Obtain airway and IV/IO Access
- Epinephrine Q4 mins
- Consider advanced capnography
- If after 2 shocks still in VF or pulseless VT then Amiodarone (300 mg IV)
If not shockable:
- CPR
- Epi Q4 mins
- Think of reversible causes: Hypoxia, hypovolemia, hypothermia, acidosis, hypo/hyper K. Thrombosis (pulm or cardiac), tamponade, tension pneumo, toxins
ACLS Brady with a pulse algorithm
HR < 50
1) Treat underlying cause. Give oxygen, cardiac monitor for rhythm, BP, IV/IO access, 12 lead ECG
2) Unstable: altered LOC, ischemic chest pain, acute heart failure, shock?
- Yes: Atropine (0.5 mg bolus up to 3 mg). If ineffective - transcutaneous pacing or epi infusion (2-10 mcg/min)
- No: monitor and observe
3) Expert consultation
ACLS Tachy with a pulse Narrow Algorithm
HR > 150
Unstable: Acute HF, ischemic CP, hypotension, altered LOC
Yes: Synchronized cardioversion
No: ECG, IV access, Vagal maneuvers, Adenosine (6 mg IV push), B-blocker or CCB.
ACLS Tachy with a pulse wide algorithm
HR > 150
Unstable: Acute HF, ischemic CP, hypotension, altered LOC
Yes: Synchronized cardioversion
No: ECG, IV access, Consider antiarrhythmic infusion:
- Procainamide 20-50 mg/min to 15 mg/kg. Stop if hypotension or QT increases by 50%
- Amiodarone: 150 mg over 10 mins, repeat if recurs.
Vent Modes
Assist / Support - Patient triggered
Control - Set times / RR
Volume Control Variables and significance
Safest in ED Setting
- Tidal Volume
- Resp Rate
(TV x RR = min vent)
- FiO2
- PEEP
(FiO2 PEEP, Oxygenation)
- I:E ratio or flow rate
(for Obstructive issues)
Peak Flow Rate Standard Settings
60-100 L/min (100 is high end)
(For RR 12 - I:E 1:4)
1 sec inspiration ~ 1 L
Winter’s Formula
HCO3 x 1.5 +8 +/- 2
- Optimized minute vent for metabolic acidosis.
