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Anaesthesia and resuscitation > Resuscitation > Flashcards

Resuscitation Flashcards

1
Q

Typical ventilator settings in a child with asthma?

A

RR 8-12
IE 1: 3-5
inspiratory time 0.75-1 second
PEEP 5cmH20 and <80% of iPEEP
TV 4-8ml/kg
PIP >40cmH20
- plateau pressure correlates kore with barotrauma than PIP
Inspiratory flow 4 - 10L/kg/min
minute ventilation <115ml/kg/min

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2
Q

Typical ventilator settings in adults for status asthmaticus?

A
  • RR 8-12
  • IE 1:3.5/4
  • Inspiratory time fast (0.75-1sec)
  • TV 6-8ml/kg (anatomic dead space higher in asthma (3ml/kg or so), thus TV’s any lower than 6 run the risk of only ventilating the dead space
  • PEEP 5-8cmH20 (<80% iPEEP)
  • Flow rate 80L/min (high)
  • Fi02 1.0 then titrate to sats approx 88% (ie 0.60 Fi02)
  • Increase peak pressure alarm to at least 40cmH20 (pressures will be high)
  • pH ideally >7.15
  • CO2 ideally <80-100
  • Aim plateau pressure <35cmH20
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3
Q

What is the law around withdrawing care when patients/family wish to continue futile treatment?

A
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4
Q

How should intubation be performed in someone with massive haemoptysis?

A
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5
Q

What are the indications for NIV?

A

Hypercapnoea
Hypoxaemia
Respiratory muscle fatigue/weakness
Bridge to intubation (delayed sequence intbation)

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6
Q

What are the contraindications to NIV?

A

Cardiorespiratory arrest
Unable to protect airway
Intractable vomiting
Inability to clear secretions
Upper airway obstruction
Untreated pneumothorax
Marked haemodynamic instability
Maxillofacial surgery
Base of skull fracture or surgery (risk of pneumocephalus)
Patient refusal/non-compliance (relative, can use sedatives)
Staff inexperience

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7
Q

What is a good mnemonic for post induction hypotension?

A

AAH SHITE

A- Acidosis
A- Anaphylaxis
H- Heart (tamponade, pHTN)
S- Stacked breaths
H- Hypovolaemia
I- Induction agent
T- Tension PTX
E- Electrolytes

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8
Q

How does obesity affect an RSI?

A

Airway/Resp
- Upper airway resistance makes BVM more difficult
- Soft tissue overcrowding
- Reduced FRC, TV and TLC
- Decreased chest wall compliance
- Difficult FONA
- Increased diaphragm pressure from the abdomen
- Higher CO2 levels if OHS or OSA
- Higher risk of atelectasis

Cardiac
- Underlying CVS disease
- Increased myocardial 02 demand
- Cor pulmonale
- Reduced venous return from raised intrabdominal pressures

Gastro
- Increased gastric volume
- GORD/aspiration

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9
Q

How should an RSI in the obese be done?

A
  • Optimise patient positioning
  • Apnoeic 02
  • Adequate pre-02 ie NIV
  • Bagging through apnoeic period
  • Video laryngoscopy
  • use of airway adjuncts
  • Tape breast down or use a stubby hand laryngoscope
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10
Q

What is a basic recruitment maneouvre?

A
  • Increase PEEP to 40cm in a graded fashion
  • ie increase to 20 then 30 then 40 with 30-40sec breaks in between
  • Then reduce PEEP back down in a graded fashion to absolute minimum of 15cm
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11
Q

What are the indications for intubation in the context of neurological compromise?

A

Also neuro protection in head injury

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12
Q

What factors should be considered when terminating a resuscitation?

A
  • Downtime prior to commencing (ie frank rigor mortis)
  • Have all reversible causes been identified and treated
  • Underlying comorbidities and the current disease (ie continuous asystole)
  • Severe biochemical derangement ie pH <6.8 or K+ >10
  • Has there been any response to treatment during resuscitation
  • Persistently low end tidal CO2 <10-15mmHg
  • Is the team in agreement that further resuscitation is futile
  • Has a senior clinician been involved, even if by phone
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13
Q

What is the dosing of Alteplase (rTPA) in pulmonary embolism? When should heparin infusion be resumed?

A

0.5mg/kg Alteplase IV
- Max 100mg in massive PE
- Max 50mg in submassive PE

Heparin resumed when PTT is below 1.5 - 2 times normal

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14
Q

When is surgical thrombectomy indicated for PE?

A
  • Clot in transit located on a PFO (risk of immediate stroke with thrombolysis)
  • Massive PE but absolute contraindications to thrombolysis
  • Massive PE with failure of other therapies
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15
Q

What are the potential medications for the treatment of refractory angioedema?

A
  • Adrenaline IM/Neb/IV
  • Prednisolone 50mg PO
  • Icatibant 30mg sub cut
  • Fresh Frozen plasma
  • Cetrizine 10mg PO
  • Diphenhydramine 50mg
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16
Q

What is the significance of the black line on an EZ-IO needle?

A
  • Gives confirmation that the needle length is long enough to reach the medullary space
  • The black line should still be visible when the needle touches bone, if not then the needle is not long enough
  • It is 5mm from the hub
17
Q

Which patients have the best prospect of neurologically intact long term survival post cardiac arrest?

A
  • Witnessed collapse of victim
  • CPR commenced immediately
  • Cardia rhythm VF/VT
  • Defibrillation within 2-3mins
18
Q

What are the main indications for ECMO CPR? What are the biochemical parameters for starting ECPR?

A

Indications
- Refractory VF
- Cardiogenic shock post AMI with arrest
- Hypo/hyperthermic arrest
- Massive Tox OD ie TCA
- Myocarditis
- Cardiomyopathy as bridge to transplant

Parameters
- Lactate >18
- Pa02 <50 on maximal 02
- p/etCO2 <10

19
Q

What are the exclusion criteria for ECPR?

A
  • Asystole
  • Arrest to ED arrival >45mins
  • Age + arrest time >100
  • Terminal illness
  • Chronic organ failure
  • Traumatic arrest/haemorrhage
  • Unwitnessed arrest with unknown length of downtime
  • Age >65 (relative)
20
Q

How should an unwell but cerebrally irritated patient be chemically and physically restrained to facilitate care?

A
21
Q

How is the Suction Assisted Laryngoscopic Airway Decontamination (SALAD) intubation performed?

A
  1. Oral decontamination followed by laryngoscope blade insertion hugging the surface of the tongue (anteriorly) so as to avoid submerging the illumination/optics module in vomitus
  2. Use of the rigid suction catheter as a tongue depressor/lifter to permit the laryngoscope blade perfect position on the first attempt
  3. Further decontamination of the hypopharynx, followed by insertion of the rigid suction catheter into the proximal esophagus to serve as a continued drain of emesis
  4. Repositioning of the suction catheter to the left corner of the patient’s mouth facilitated by a slight withdrawal and reinsertion of the laryngoscope blade to permit this transit. The laryngoscope blade will now effectively pin the suction catheter in place with this maneuver, as the left portion of the blade contacts the right portion of the suction catheter, securing it in place and holding it out of the path of endotracheal intubation
  5. Slight rotation of the laryngoscope blade leftward 30 degrees to further open a channel for endotracheal tube passage through the pharynx and into the larynx. Inflation of the endotracheal tube cuff and suctioning of the tracheal tube and trachea prior to ventilation to avoid spreading any aspirated material
22
Q

What measure can be done to improve ventilation and oxygenation post intubation?

A
  • Increased MV (ie RR and TV)
  • Sit up to 30 degrees
  • Decompress the stomach (NG)
  • Seek and treat pneumothorax
  • Ensure adequate sedation and muscle relaxation
  • Remove excess ventilator dead space (tubes, filters), particularly important in paediatrics
  • Ensure ETT correctly placed ie not 1 lung ventilation
23
Q

What are the different potential treatments for Anaphylaxis?

A
  • Adrenaline IM/IV/IO/Neb
  • IV fluids
  • Intubation/Cric for angioedema
  • Salbutamol/Mg+/Ketamine for bronchospasm
  • IV steroids (minimal evidence)
  • Other vasopressors and inotropes
  • ? Glucagon
  • Last line is ECMO
24
Q

What are the aims for neuroprotection post intubation in children?

A
25
Q

How should a neuroprotective RSI be performed in children?

A
26
Q

What strategies can be implemented to help with NIV tolerance?

A

Non-Pharm
- Start low and titrate up
- Coaching, reassurance
- Patient holds own mask at first

Pharm
- Ketamine 10mg (0.1mg/kg) aliquots
- Midazolam 1mg aliquots
- Fentanyl 10-20mcg aliquots
- Dexmetetomidine infusion if available
- Full IV sedation with Ketamine

27
Q

What is the correlation between IO aspirate and peripheral blood on testing?

A

Good correlation
- Hb
- BSL
- Urea/Creatinine
- Na+ but 5% variance from blood

Poor correlation
- WBC’s
- platelets
- Ca+ and K+
- CO2

IO samples can generally be used on IStat point of care analysers, although there is a risk of clogging the machine

28
Q

What factors influence the decision regarding timing (immediate, delayed, not at all) of intubation for critically ill patients?

A
  • Presence of immediate airway threats (angioedema, expanding haematoma etc)
  • Agitation inhibiting care
  • Dropping GCS
  • Fatiguing ventilatory drive (ie asthma, GBS etc)
  • Therapies given to date, the response to them and further ability to optimize
  • Significantly haemodynamic instability and need to optimize before induction
  • Team readiness (availability of backup, airway plan, difficult airway adjuncts, ventilator set up)
29
Q

What strategies can be implemented to tackle the physiologic challenges of intubating a critically ill patient?

A

Pre-oxygenation
- NRB or NIV
- Sit up until last moment

Apnoeic 02
- Nasal prongs vs BVM

Avoid Acidosis
- Important if already very acidotic or acid sensitive ie aspirin/TCA OD
- NIV, BVM in apnoeic period for ventilation, sodi bic

Hypotension
- Adequate pressors/fluids
- Reduced dose induction agents

Hypertension
- Pre-induction ie 2mcg/kg Fentanyl
- Important for hypertensive crises and strokes/bleeds

Aspiration
- Suction, head up 30 degrees
- SALAD

Difficult airway
- Most senior operator, VL, hyperangulated blade, ETT adjuncts

Pulmonary oedema
- NIV, BVM with PEEP
- Suction, vasodilators
- Sit upright, avoid fluids

30
Q

What is the utility of POCUS cardiac ultrasound in cardiac arrest?

A
  • Aid diagnosis of 4H’s and 4T’s
  • Differentiate rhythms ie asystole vs fine VF, PEA types (Electromechanical dissociation vs cardiac activity with low flow state)
  • Guide and assist management ie pericardiocentesis
  • Can help with prognosis (ie asystole with frank clot in ventricle forming)
  • Intra-arrest TOE can help guide CPR quality
31
Q

What is the general management of acute pulmonary oedema?

A
  • Sit patient up
  • High flow 02/NIV
  • IV GTN starting 5mcg/min if normotensive but starting 50mcg/min and titrating up if having SCAPE
  • Frusemide IV 20-80mg if thought to be fluid overloaded
  • Inotropy if cardiogenic shock
  • Dialysis/CVVHF if anuric/CKD
  • Intubation if not successful with control as above
  • Final is ECMO
32
Q

What are the advantages and disadvantages of the cannula cricothyrotomy technique compared to surgical technique?

A

Advantages
- Less mentally confronting
- Easier in skinny patients with obvious anatomy
- Faster and less messy to perform
- Can be done in small children

Disadvantages
- Can oxygenate but not ventilate
- not a definitive airway unlike the surgical technique
- High failure rates (60% failure in the NAP4 study)
- Clinicians may be unfamiliar with jet insufflation devices and technique
- Not feasible in obese patients

Anaesthesia and resuscitation (4 decks)

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