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PGY1 Resuscitation Block > Resuscitation > Flashcards

Resuscitation Flashcards

1
Q

define rapid sequence intubation (RSI)

A

sequential administration of an induction agent and neuromuscular blocking agent to facilitate intubation

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2
Q

equipment needed for airway management in ED

A 
O2 source and tubing
Ambu bag
mask with valve, various sizes and shapes
oropharyngeal airways, NP airways
suction - catheter and source
pulse oximetry
CO2 detector
endotracheal tubes
laryngoscope blades and handles
syringes
magill forceps
stylets 
tongue blade
water soluble lubricant
alternative or rescue device: video laryngoscopy, LMA, etc.
surgical cric kit
medications for topical airway anesthesia, sedation, and RSI
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3
Q

how to preoxygenate

A

administer 100% O2 for 3 mins using a non-rebreather with 15L/min of O2

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4
Q

ways to improve preoxygenation

A

elevate HOB to 20-30 degrees
short period of non-invasive positive pressure ventilation
use high flow nasal cannula or optiflow during apneic period

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5
Q

patient positioning fo rintubation

A

lower the neck and extend the atlanta-occipital joint (sniffing position) to align the oropharyngeal-laryngeal axis
padding under the shoulders improves visualization
ear should be aligned with sternal notch

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6
Q

common causes/ situations associated with aspiration

A 
iatrogenic
BVM 
NG tube placement
neuromuscular paralysis
medical conditions
trauma
bowel obstruction
obesity
overdose
pregnancy
hiatus hernia
seizures`
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7
Q

conditions associated with false negative capnographic or colorimetric CO2 readings

A

low pulmonary perfusion - cardiac arrest, inadequate chest compressions duringg CPR, massive PE
massive obesity
tube obstruction- secretions, blood, foreign body

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8
Q

conditions associated with false positive capnographic or colorimetric CO2 readings

A

recent ingestion of carbonated beverage - will not persist beyond 6 breaths
heated humidifier, nebulizer or ETT epinephrine -transient

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9
Q

steps in RSI

A
  1. monitors, IV access, oximetry, capnography
  2. assess airway and physiologic status to plan procedure
  3. prepare equipment
  4. pre oxygenate
  5. pretreatment agents prn
  6. induce with sedative agent
  7. give NM blocking agent immediately after induction
  8. BVM only if hypoxic, otherwise apneic oxygenation
  9. intubate trachea
  10. confirme placement and secure tube
  11. postinubation sedation nd low tidal volume (6cc/kg) management
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10
Q

induction dose of etomidate

A

0.3-0.5 mg/kg IV

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11
Q

benefits of etomidate

A

decreases ICP
decreases IOP
neutral BP

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12
Q

caveats of using etomidate

A

myoclonic jerking and vomiting in awake patients

decreased cortisol

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13
Q

induction dose of propofol

A

0.5-1.5mg/kg IV

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14
Q

benefits of using propofol

A

anticonsulvinga
antiemetic
decreases ICP

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15
Q

caveats of using propofol

A

no analgesia
hypotension
apnea

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16
Q

induction dose of ketamine

A

-2mg/kg IV

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17
Q

benefits of using ketamine

A

dissociative amnesia
analgesia
bronchdilators

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18
Q

caveats of using ketamine

A

increased secretions
emergence phenomenon
increased BP

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19
Q

succinylcholine complications and contraindications

A

hyperkalemia in patients with: burns >5 days old, denervation injury > 5days old, significant crush injuries > 5 days old, severe infection > 5 days old, pre-existing myopathies, preexisting hyperkalemia
fasciculations
transient increpad intragastric, intraocular and ICP
masseter spasm alone or with MH
bradycardia
prolonged apnea with pseudocholinesterase deficiency or myasthenia

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20
Q

intubating dose of rocouronium

A

1mg/kg IV

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21
Q

succinylcholine intubating dose

A

1.5mg/kg IV

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22
Q

intubating dose of vecuronium

A

0.08-0.15 mg/kg IV

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23
Q

side effect of rocuronium

A

tachycardia

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24
Q

how much does succinylcholine make serum potassium rise

A

0.5

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25
Q

what to suspect if unexplained rapid fever with muscle rigidity, acidosis, or hyperkalemia occurs after succinylcholine

A

malignant hyperthermia

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26
Q

treatment of malignant hyperthermia

A

dantrolene 2.5mg/kg IV

temperature control

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27
Q

reversal agent for nondepolarizing agents

A

suggamadex- works by encapsulating circulating plasma roc, 2-4mg/kg
neostigmine- not effective unless some degree of spontaneous recovery, cholinergic effects

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28
Q

factors suggesting difficult bag valve mask ventilation

A 
MOANS
mask seal - ie. beard
obstruction/obesity
aged - older than 55
no teeth
stiffness (Resistance to ventilation)- ie. asthma, COPD, pulmonary edema, restrictive lung disease, term pregnancy
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29
Q

factors suggesting difficult airway

A 
obesity, 
a short neck, 
small or large chin, 
buckteeth, 
high arched palate
any airway deformity due to trauma, tumor, or inflammation.
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30
Q

airway assessment

A

LEMONS
Look externally
Evaluate- 3,3,2 rule- distance between incisors, distance of mandible from mentum to hyoid bone, thyromental distance
Mallampatti classification
Obstruction- airway edema, smoke inhalation, teeth ,trauma, etc.
Neck ROM
Sat - lower sat = less safe apnea time for intubation

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31
Q

Mallampatti classification

A

I: Faucial pillars, soft palate, and uvula can be visualized
II: Faucial pillars and soft palate can be visualized, but the uvula is masked by the base of the tongue
III: Only the base of the uvula can be visualized
IV: None of the three structures can be visualized.

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32
Q

initial ventilator settings in the ED

A 
mode: assist-control
FiO2: begin with 100% O2
tidal volume: 6mL/kg (ideal body weight)
RR: 12
inspiratory flow rate: 60L/min
insp:exp ratio 1:2 or 1:3
PEEP: 5cm H2O and titrate to 10
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33
Q

ventilation goals

A 
PaO2: 60-90mmHg
PaCO2: 40mmHg
pH: 7.35-7.45
FiO2: 40-60%
inspiratory peak pressure <35cm H2O
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34
Q

dose of fentanyl during mechanical ventilation - initial bolus and starting infusion

A

bolus - 1-2mcg/kg IV

infusion- 05.-1mg/kg/h

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35
Q

dose of remifentanyl during mechanical ventilation initial bolus and starting infusion

A

bolus- 1.5mcg/kg/IV

infusion 0.5-1mcg/kg/h

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36
Q

dose of midazolam during mechanical ventilation initial bolus and starting infusion

A
  1. 05mg/kg IV

0. 025 mg/kg/h

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37
Q

dose of propofol during mechanical ventilation initial bolus and starting infusion

A

0.5mg/kg IV

20-50mcg/kg/min

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38
Q

dose of ketamine during mechanical ventilation initial bolus and starting infusion

A
  1. 5-1mg/kg IV

0. 5mg/kg/h

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39
Q

decision to intubate based on

A
  1. failure to maintain or protect airway
  2. failure of ventilation or oxygenation
  3. patient’s anticipated clinical course and likelihood of deterioration
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40
Q

how to assess if pt can maintain patent airway

A

ability to swallow or handle secretions
pt LOC
ability to phonate

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41
Q

airway maneuvers to maintain patent airway

A

reposiion
chin lift
jaw thrust
insertion of oral or nasal airway

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42
Q

how to assess pt ability to ventilate/ oxygeation

A

pt general status
O2 saturation
ventilatory pattern

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43
Q

what is needed in preintubation assessment

A

evaluate pt for difficult intubation, difficult BMV , placement of and ventilation with an extraglottic device, cricothyrotomy

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44
Q

predictors of difficult extraglottic device use (ie. LMA)

A 
RODS
restricted mouth opening
obstruction/ obesity
distorted anatomy
stiffness (resistance to ventilation)
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45
Q

predictors of difficult cricothyrotomy

A 
SMART
surgery
mass (abscess, hematoma, scarring)
access/anatomy problems (obesity, deem)
radiation
tumor
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46
Q

how to confirm placement of ETT

A

EtCO2 - presence of CO2 after six manual breaths indicates tube is in airway (although not necessarily trachea)

if EtCO2 not available - can use POCUS over cricothyroid membrane or upper trachea

aspiration of air through the ETT cuff down - soft walls of esophagus will collapse and occlude ETT, whereas aspiration after tracheal placement is easy

put bougie down ETT- should stop once hits right main stem bronchus- if goes down too far in the stomach

secondary means: physical exam, oximetry, XRAY

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47
Q

define crash airway

A

intubation done in patient agonal, near death or in circulatory collapse = immediate intubation, no drugs

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48
Q

if airway is not crash, what is next step

A

determine difficulty of airway

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49
Q

if airway is not crash, not difficult airway what is next step

A

RSI and attempt intubation

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50
Q

what to do if more than one intubation attempt is required

A

monitor SpO2 continuously and if saturation falls below 90%, BMV performed until SpO2 recovered for another attempt

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51
Q

define failed airway

A

can’t intubate, can’t ventilate situation (ie. intubation fails and can’t BMV)
OR
three unsuccessful attempts at laryngoscopy

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52
Q

what to do with failed airway

A

can try EGD while setting up for cricothyrotomy as long as it doesn’t delay cric

FAILED AIRWAY = CRIC

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53
Q

potential pretreatments for RSI

A

reactive airways: salbutamol 2.5mg by neb, or lidocaine 1.5mg/kg IV
CV disease: fentanyl 3mcg/kg to mitigate SNS
elevated ICP: fentanyl ^^^

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54
Q

steps of RSI (seven Ps)

A 
seven Ps
preparation
preoxygenation
pretreatment
paralysis with induction
positioning
placement of tube
postintubation mgmt
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55
Q

whats done during preparation step of RSI

A

pt assessed for difficult airway
intubation planned: drug dosages, sequence of drugs, tube size and laryngoscopic type, blade and size
all equipment assembled
pt on monitors, 2 IVs
rescue plan for intubating failure made known to team

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56
Q

whats done during preoxygenation step of RSI

A

adminster 100% O2 for 3 mins of normal tidal volume or if time does not allow –> eight vital capacity breaths with high flow O2

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57
Q

how to improve preoxygenaiton in obese; what is desaturation time with improvements

A

head-up position and continuing O2 after apnea (via nasal cannula 5-15mL/min) after motor paralysis and during laryngoscopy until ETT placed; 5.3 mins from 3.5 min

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58
Q

how long to wait after neuromuscular blockade given to intubate

A

45 sec after succinylcholine 1.5mg/kg
60 sec after roc 1mg/kg

equal intubating conditions as long as roc dose between 1-1.2mg/kg

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59
Q

positiong for intubation

A

sniffing position, head elevation

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60
Q

whats involved in postintubation management

A

confirm tube placement with EtCO2
CXR
opioid + sedative (ie. fentanyl 3-5mcg/kg IV, and midazolam 0.1-0.2mg/kg IV )
OR
propofol infusion (5-50mcg/kg/min IV) with supplemental analgesia

only add long acting NMBA if sedation and analgesia fail to control pt adequately or when ventilation is challenging because of muscular activity

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61
Q

what is delayed sequence intubation

A

technique proposed to maximize pre oxygenation in preparation for intubation
ie. useful in agitation/delirium when preoxygenation challenging

uses dissociative doses of ketamine 1mg/kg IV

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62
Q

when to do awake oral intubation

A

difficult airway

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63
Q

how to do awake oral intubation

A

sedative and topic anesthestics administered to permit management of a difficult airway

can use ketamine 0.5mg/kg IV titrated to desired level of sedation and procedural tolerance
can use dexmedetomidine (central acting alpha receptor blocker) alone or with bentos 1mg/kg IV infused over 5-10mins

once pt sedated, topical anesthesia given, gentle direct VL or flexible endoscopic laryngoscopy performed

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64
Q

how to treat massetter spasm after succinylcholine

A

give competitive NMBA- i.e.. roc

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65
Q

what is recomnede intubation technique for pt with status asthmaticus

A

RSI

may be more challenging to bag due to airway resistnace

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66
Q

recommended ventilation parameters for pt with status asthma

A

low tidal volume and RR
high inspiratory flow rate

reducing resp rate important to give adequate exhalation to prevent auto-PEEP and breath stacking

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67
Q

hemodynamic consequences of intubation

A

laryngoscopy and intubating cause release of catecholamines leading to increased BP and HR
relevant in setting of increased ICP, CV diseases( ICH, SAH, aortic dissection or aneurysm, ischemic heart disease)

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68
Q

considerations in induction/intubatino in pt with elevated ICP

A

maintain MAP at 100mmHg or higher to support CPP and prevent secondary injury
RSI agents should dosed to minimize hypotension
etomidate recommended agent, propofol if not hemodynamically compromised

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69
Q

considerations in induciton/ intubation of pt with hypotension nd shocks

A

volume resuscitation prior to induction (isotonic fluid bolus or PRBCs)
reduced dose induction agent administration - etomidate or ketamine only - dose reduced by 50%
pretreatment with per-intubation pressor agents (phenylephrine 50-100mcg IV push)

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70
Q

considerations for C Spine precautions in intubation

A

videolaryngoscopy should be used and if not available ,DL can be used -provides better larygneal views with less neck manipulation

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71
Q

effects of positive pressure ventilation on CV system

A

venous return is diminished, cardiac output falls and there is a decreased pressure gradient between LV and aorta

relative hypotension can occur -exaggerated in patients with hypovolemic or vasodilatory states

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72
Q

how does PCV - pressure-controlled ventilation work

A

set amount of pressure is applied to the airway to expand the lungs for a specified amount of time
target pressure and inspiratory time set by provier
tidal volume and inspiratory flow rate variable based on lung compliance and airway resistance

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73
Q

how does volume controlled ventilation work

A

breath is defined by delivery of a set tidal volume
inspiratory volume and flow rate are set by provider and inhalation ends once a preset tidal volume has been delivered

lung pressure - peak inspiratory pressures and end-inspiratory alveolar pressures vary based on compliance and set tidal volume

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74
Q

benefit of PCV

A

controls pressure delivered so prevents barotrauma, especially important in asthma/COPD to prevent autoPEEP
improved ventilator synchrony in intubated patients with high respiratory drive

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75
Q

disadvantage of PCV

A

tidal volume changes with a cute changes in lung compliance

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76
Q

benefit of VCV

A

ability to control tidal volume and minute ventilation

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77
Q

disadvantage of VCV

A

cannot set pressure, so may cause spikes in peak pressures when lung compliance poor

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78
Q

when to use VCV

A

when need guaranteed delivery of tidal volume
used in ARDS - low tidal volume strategies = decreased mortality
obesity, severe burns

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79
Q

when to use PCV

A

severe asthma, COPD, salicylate tox

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80
Q

what is PRVC

A

pressure regulated volume control - set to deliver specific tidal volume while simultaneously minimizing airway pressure

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81
Q

how does ventilatory mode continuous mechanical ventilation (CMV) work, aka assist-control

A

provides full ventilatory support for patients with little or no spontaneous respiratory activity - will provide continuous delivery of preset breaths (ie. rate of 12 = 1 breath q 5 secs) but if pt makes inspiratory effort will be assisted by ventilator (after this breath timer resets another 5 secs)

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82
Q

what is the main challenge with assist control ventilation

A

patient initiated breaths are not proportional to patient effort, can result in hyperventilatino, air trapping, hypotension, and poor ventilator synchrony

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83
Q

how does intermittent mandatory ventilation work

A

delivers mandatory and spontaneous breaths- mandatory breath at preset rate but breath is synchronized to pt effort - useful for its who are sedated but have weak resp efforts

extra breaths above set rate are proportional to pt effort

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84
Q

what are examples of continuous spontaneous ventilation (CSV) and how do they work

A

PSV- pressure support ventilation - delivers pressure on airway after patient triggered breath - when inhalation stops, pressure support ceases and exhalation proceeds spontaneously - good for spontaneously breathing patients with good resp effort requiring minimal support

CPAP- constant airwpressure throughout resp cycle

BiPAP- alternates between higher pressure during inspiration and lower pressure during exhalation

both CPAP and BiPAP need alert, spontaneously breathing patients with immediately reversible causes of respiratory distress

85
Q

what is PEEP

A

maintenance of positive airway pressure after passive exhalation

86
Q

benefits of PEEP

A

increases functional residual capacity, improves oxygenation and decreased intrapulmonary shunting
reduces portions of non aerated lung that my contribute to ventilator induced lung injury

87
Q

adverse effects of PEEP

A

decreased cardiac output
lung overdistension
pneumothorax

88
Q

contraindications to noninvasive positiv epressure ventilation

A 
decreased LOC
lack of respiratory drive
increased secretions
hemodynamic instability
facial trauma/other conditions that prevent mask seal
89
Q

what factors predict failure of NPPV at 1 hour of therapy

A

increased hr

decreased PaO2/FiO2 ratio

90
Q

if BiPAP applied and no improvement of work of breathing, what adjustments can be made

A

increased IPAP can reduce hypercarbia by increasing tidal volume and minute ventilation
increased EPAP can improve oxygenation by combating atelectasis and promoting alveolar recruitment

91
Q

initial settings for ventilator in intubated patient

A 
tidal volume - 6-8ml/kg of IBW
rate: 12-14 breaths/min
initial pressures: should not exceed 30 cm H2O
FiO2: 1.0 -can titrate down 
PEEP: 5cm H2O
92
Q

what is the PIP (peak inspiratory pressure)

A

max pressure in ventilator circuit during a breath cycle

in PCV, PIP = target pressure + PEEP

93
Q

what is Pplat

A

pressure measured at the end of inspiration as flow in circuit stops, in VCV

94
Q

approach to mechanically ventilated patient whose condition suddenly deteriorates and they are acutely unstable

A

remove from ventilator and manually bag with 100% O2, examine pt (listen for breath sounds), confirm ETT placement

causes: tension pneumo, auto-PEEP (breath stacking)

if improves after disconnect from ventilator, likely autoPEEP

if doesn’t improve, needle decompression for presumed tension pneumothorax
if after this remains unstable, consider PE

95
Q

approach to mechanically ventilated patient whose condition suddenly deteriorates and they are not acutely unstable

A

confirm ETT placement, evaluate airway pressures

if elevated PIP and Pplat- indicates decreased resp system compliance ie. worsening lung compliance from underlying pathology, pneumothorax, abdominal distension, inadequate sedation/vent dyssynchorny

if elevated PIP only - indicates increased airway or circuit resistance, ie. worsening airway obstruction from underlying pathology, new bronchospasm (eg. allergic rxn), ETT obstructed, ventilator circuit obstruction

96
Q

considerations when ventilating pt with AECOPD

A

aim to minimize autoPEEP by decreasing airway resistance with bronchodilators and corticosteroids
adequate oxygenation achieved while minimizing barotrauma by reducing minute ventilation - permissive hypercapnia
I:E ratio 1:4
PEEP -5

97
Q

considerations when ventilating status asthmaticus

A

low resp rate, maximize expiratory time

VCV with tidal volume 6-8cc/kg, RR of 10-15, and little or no PEEP

98
Q

consdierations when ventilating patient with ARDS

A

tidal volume below 7cc/kg of IBW and Pplat of less than 31 confer mortality benefit

99
Q

what is gold standard for BP and when to use it

A

arterial line
used for persistent/recurrent hemodynamic instability, monitoring of conditions or treatments that result in large fluid or bp shifts, frequent arterial blood sampling and expected inaccuracies in noninvasive bp mgmt (eg. obesity/ dysrhythmias)

100
Q

when does pulse oximetry fail

A

methemoglobinemia and carboxyhemoglobinemia

can only detect oxy and deoxyHb, reads others as oxyHb

101
Q

how does colorimetric EtCO2 work

A

purple < 4mmHg CO2
tan 4-15
yellow > 20

102
Q

phases of EtCO2 monitor
3 ______4
/ \
_1__2/ \ 5___

A

1-2: CO2 free portion, inspiratory phase
2-3: transition from inspiratory to expiratory, mixing of dead space and alveolar gas
3-4: alveolar plateau - CO2 rich alveolar fas in breath system and tends to slope gently upward toward uneven emptying of alveoli
4- max CO2 concentration in each breath - # on the monitor
4-5 : inspiratory downstroke - nearly vertical drop to baseline

103
Q

EtCO2 - what does elevation of baseline from 1-2 represent

      3 \_\_\_\_\_\_4
        /              \ _1\_\_2/                 \ 5\_\_\_
A

rebreathing of CO2 - as in increased dead space in the circuit or contamination of the sensor

104
Q

EtCO2- what does prolongation of 2-3 represent

      3 \_\_\_\_\_\_4
        /              \ _1\_\_2/                 \ 5\_\_\_
A

obstruction to expiratory gas flow, ie. obstructive lung disease, bronchospasm, kinked ETT or leaks in the breathing system

105
Q

EtCO2 what does an increased 3-4 mean
3 ______4
/ \
_1__2/ \ 5___

A

obstruction to expiratory gas flow, ie. obstructive lung disease, bronchospasm, kinked ETT or leaks in the breathing system

normal physiologic variant in pregnancy

106
Q

EtCO2 what does a dip in the 3-4 alveolar plateau mean

      3 \_\_\_\_\_\_4
        /              \ _1\_\_2/                 \ 5\_\_\_
A

spontaneous respiratory effort during mechanical ventilation as in hypoxia, hypercarbia, or inadequate anesthesia

107
Q

EtCO2 what does a prolongation of Phase 4-5 represent

      3 \_\_\_\_\_\_4
        /              \ _1\_\_2/                 \ 5\_\_\_
A

endotracheal cuff leaks

108
Q

what is gold standard to confirm intubation of trachea

A

EtCO2 or direct visualization of tracheal rings on bronchoscopy

109
Q

how does EtCO2 detect difference between patients with and without DKA

A

with DKA, HCO3 < 15, therefore increased compensatory minute ventilation and EtCO2 is lower

without DKA, HCO3 > 15, EtCO2 normal

110
Q

DDX for flat EtCO2 trace

A 
Ventilator disconnection
Airway misplaced – extubation, oesophageal intubation
Capnograph not connected to circuit
Respiratory/Cardiac arrest
Apnoea test in brain death dead patient
Capnongraphy obstruction
111
Q

DDX for increased EtCO2

A 
CO2 Production:
Fever
Sodium bicarbonate
Tourniquet release
Venous CO2 embolism
Overfeeding
Increased metabolism - NMS 
Release of tourniquet

Pulmonary perfusion:
Increased cardiac output
Increased blood pressure

Alveolar ventilation:
Hypoventilation
Bronchial intubation
Partial airway obstruction
Rebreathing
Apparatus malfunctioning:
Exhausted CO2 absorber
Inadequate fresh gas flows
Leaks in ventilator tubing
Ventilator malfunctioning
112
Q

DDX for decreased EtCO2

A

CO2 production:
Hypothermia
Acidosis

Pulmonary perfusion:
Reduced cardiac output
Hypotension
Hypovolemia
Pulmonary embolism
Cardiac arrest
Alveolar ventilation:
Hyperventilation
Apnea
Total airway obstruction (note high airway pressures)
Extubation
Apparatus malfunctioning:
Circuit disconnection (note low airway pressures)
Leaks in sampling tube
Ventilator malfunctioning
113
Q

DDX for sudden flatline of EtCO2 to zero

A

Kinked ET tube
CO2 analyzer defective
Total disconnection
Ventilator defective

114
Q

DDX for sudden change in baseline of EtCO2 - not to zero though

A

Calibration error
CO2 absorber saturated (check capnograph with room air)
Water drops in analyzer or condensation in airway adapter

115
Q

DDX for sudden increased in baseline of EtCO2

A

ROSC

correct ETT placement

116
Q

DDX for elevated inspiratory baseline

A 
CO2 rebreathing (e.g. soda lime exhaustion)
Contamination of CO2 monitor (sudden elevation of base line and top line)
 Inspiratory valve malfunction (elevation of the base line, prolongation of down stroke, prolongation of phase III)
117
Q

clinical manifestations associated with acute airway obstruction

A

vascular: hematoma, external hemorrhage, hypotension, hemoptysis
laryngotracheal: stridor, subQair, hoarseness, dysphonia, hemoptysis
pharyngeal: subQ air, hematemesis, dysphagia, sucking wound

118
Q

what to do in trauma if suspected disruption of trachea or larynx in terms of airway mgmt

A

do NOT attempt cricothyrotomy

an emergency tracheostomy is needed

119
Q

what size of tube to use in cricothyrotomy

A

a 6-mm tracheostomy or 6- to 7-mm endotracheal tube. Do not choose a larger (≥7 mm) tube or one smaller than 4 mm

120
Q

equipment needed to prepare for cricothyrotomy

A

Personal protective equipment
Scalpel with a #10 (preferable because of its greater width) or #11 blade
A 6-mm endotracheal tube or tracheostomy tube (latter preferred), plus a smaller one available
Tape to secure the tube in place
Cloth ribbon and sutures to secure tracheostomy tube in place
Bag-valve mask device and oxygen source
Gum elastic bougie for guiding tube
Suction devices

121
Q

what is survival rate in paediatric cardiac arrest

A

infants -2-3%

older children 9%

122
Q

what is the breakdown in percentages of aetiologies of cardiac arrest in pediatrics

A

33% - cardiac causes
21%- trauma
remainder = mostly respiratory

123
Q

what is the most common presenting rhythm in peds cardiac arrest

A

systole - 66%
PEA and bradycardia next most common
VF and VT in less than 10% of kids

124
Q

where is ideal spot for pulse check in kids

A

unclear –

infants -brachial, femoral
adolescent- carotid

125
Q

worrisome vital sign findings in children

A

SBP < 70 + (2 x age) is hypotension

RR > 60 breaths per min; declining RR in previously tachypneic patient can represent improvement OR fatigue and imminent respiratory failure

each 1 degree of fever increases HR by only 10bpm and RR by 2-5 breaths per min

EtCO2
progressive increase or decrease precede desaturation and respiratory failure

126
Q

differences in infant CPR

A

two thumbs or hands encircle chest
depth 1.5inches
ratio 15:2

127
Q

differences in children CPR

A

two hands
2 inches
15:2

128
Q

dose of epinephrine in paediatric cardiac arrest

A

0.01mg/kg IV/IO (0.1mL/kg of 1: 10,000) q 4 min

OR
0.1mg/kg (0.1mg/kg of 1:1000) via ETT

129
Q

what antiarrhythmics can be used during pediatric refractory VF/Vt

A

amiodarone 5mg/kg bolus , may repeat up to 2 times

lidocaine 1mg/kg loading doses, maintenance 20-50mcg/kg per minute infusion (repeat bolus dose if inufosn initiated > 5 mins after initial bolus)

130
Q

reversible causes in cardiac arrest

A

Hs and Ts

hypovolemia
hypoxemia
hypothermia
H+ - acidosis
hypoglycaemia
hypo/hyperK
tension pnuemothorax
tamponade
toxins
thrombosis, pulmonary
thrombosis, coronary
131
Q

when can you use compression only CPR in kids

A

cardiac etiology for arrest - kids had same outcome with conventional vs. comopression only

132
Q

defibrillation dose in kids in cardiac arrest with shockable rhythm

A

2-4 J/ kg

133
Q

what are the indications for epinephrine in paediatric cardiac arrest

A

asystole, PEA, bradycadia, VF, pulseless VT

134
Q

what is the indication for atropine in paediatric cardiac arrest, and what dose

A

bradycardia

0.02mg/kg, usually second line after epinephrine

135
Q

what is the indication for vasopressin in paediatric cardiac arrest

A

refractory cardiac arrest, mixed evidence -last resort option

136
Q

what are the indications for amiodarone in pediatric cardiac arrest

A

VF, VT, SVT - unclear if superior to lidocaine for VF/VT

137
Q

what are the indicaitons for lidocaine in paediatric cardiac arrest

A

VF, VT - avoid din WPW

138
Q

what are the indications for procainamide in paediatric cardiac arrest

A

SVT refractory to adenosine, stable VT

first line for SVT in WPW

139
Q

what are indication for adenosine in paediatric arrest

A

SVT first line

avoid in WPW, wide complex tachycardia, long QT

140
Q

what is indication for glucose in paediatric cardiac arrest and how to give

A

hypoglycaemia
D10W: 5ml/kg, D25W: 2ml/kg, D50W: 1ml/kg
do not use empirically

141
Q

what is indication for calcium chloride in paediatric arrest

A

hyperkalemia, hypocalcemia, CCB overdose

142
Q

what is indication for sodium bicarb in paediatric arrest

A

hyperkalemia, TCA overdose

143
Q

what is indication for magnesium in paediatric arrest

A

torsades de pointes, hypomagnesemia

144
Q

goals of post cardiac arrest care in pediatrics (6)

A
  1. oxygenation: avoid hypoxemia and hyperopia SpO2 94-98, avoid PaO2 >300 mmHg
  2. ventilation: avoid hypercapnia and hypocapnia, maintain PCO2 of 35-50
  3. CV support: avoid hypotension - maintain euvolemia with fluids, supplement norepinephrine if needed, monitor lactate
  4. temp: avoid hyperthermia, TTM 32-36
  5. glucose: maintain modest euglycemia - monitor glucose levels, supplement glucose for hypoglycaemia
  6. ECMO: potentially beneficial if initiated rapidly, underlying cardiac etiology, arrest with environmental hypothermia, hospital with high volume of ECMO patients
145
Q

how does time of resusciation in peds arrest relate to survival

A

every minute of CPR = 2.1% decrease in survival and 1.2% decrease in favourable neurological outcome

146
Q

when to consider termination of resuscitation in peds arrest

A

30 minutes of unsuccessful resuscitation in traumatic arrests

prolonged rests may be beneficial for hypothermia with growing or electrocution, in hospital arrest or prompt access to ECMO)

in atraumatic TOR should be considered after 30 minutes

147
Q

what is appropriate fluid resuscitation in paediatric sepsis

A

20ml/kg boluses over 5 to 15 minutes followed by reassessment and potentially additional boluses

148
Q

if peadiatric sepsis continues to be in shock after 60ml/kg of isotonic fluid boluses, or signs of fluid overload develop, what is treatment OR hypotension lasting more than 1 hour ?

A

vasoactive agetns
kids often had depressed CO with septic shock, so dopamine or epinephrine preferred first line, epi>top in terms of increased risk of death with dopamine in adults
NE also technically first line, better for “warm shock”

149
Q

when to use steroid sin sepsis

A

in patients with shock despite epinephrine or NE, testing serum cortisol level and giving hydrocortisone to those at risk of adrenal insufficiency (HPA axis abnormalities, chronic illness, chronic steroid use, purport fulminant)

150
Q

how to control glucose during sepsis

A

correct hypoglycaemia when present

cautious use of insulin and frequent glucose monitoring for blood glucose levels more than 10mmol/L

151
Q

define ALTE / BRUE

A

episode that is frightening to observer and characterzired by apnea, color change, change in tone, choking or gagging

age typically 2-4months

152
Q

risk factors for serious etiology following ALTE/BRUE

A

PMHX: prematuriy, comorbities, <1mo old, prior ALTE

hx: color change to blue, >1 event in 24 h, absence of choking absence of URI symptoms,fever
physical: abnormal findings in ED, ill-appearing, fever

153
Q

potential workup as guided by hx in ALTE/BRUE

A 
CBC - anemia
viral and bacterial cultures, including RSV and pertussis
UA
lytes- dehydration
liver enzymes- metablic disorder
toxicology screen - poisoning
CXR - infection, cardiomegaly
brain CT- mass, hemorrhage
skeletal survey - nonaccidental trauma
ECG - arrhythmia, congenital cardiac abnormalitiy
154
Q

dispositiona fter ALTE/BRUE

A

observe in ED fo 3-4 hours to watch for progression

high risk, ill-appearing and those with more ethan one epsideo or requiring resusuction should be admitted

healthy infants with first episode, particularly when associated with feeding and a normal physical exam may be discharged assuming close follow up can be guaranteed

155
Q

when is antiseizure prophylaxis indicated

A

traumatic brain injury

do not use in ICH -associated with worse neuro outcomes

in post arrest patients, dont prophylaxis but treat seizures prompty

156
Q

what medicationt o use in seizure prophylaxis

A

phenytoin, leviteracetam, or valproic 20mg/kg loading dose

levetiracetom 500mg BID preferred option in TBI patients (better tolerateD)

157
Q

what is blood glucose target in brain injury/ICH/stroke etc

A

under 10mmol/L

158
Q

targets for adequate brain resuscitation

A

bp: keep MAP > 65 and CPP of 50-70mmHg
PaCO2: target 35-40, don’t hyperventilate except as rescue for coning to bridge to OR
glucose: below 10mmol/L
treat seizures, prophylaxis in appropriate cases

159
Q

3 major cardioresp changes from intrauterine to extrauterine life of neonate

A

removal of fluid from unexpanded alveoli to allow ventilation
lung expansion and establishment of functional residual capacity
redistribution of CO to provide lung perfusion

160
Q

what is a major indicator of hypoxia in neonate

A

bradycardia

161
Q

neonatal conditions suggesting need for resuscitation

A 
hypoxia
hypothermia
hypoglycemia
hypovolemia
prematurity
meconium stained amniotic fluid
162
Q

what other effects does hypothermia have on neonate

A

accelerates metabolic acidosis, O2 consumption, hypogylcemia and apnea

163
Q

what neonates at risk for hypoglycemia

A

SGA
premature
diabetic mothers

164
Q

what may be some underlying causes of hypoglycaemia inneonate

A 
respiratory illness
hypothermia
polycythemia
asphxyia
sepsis
165
Q

what symptoms suggest hypoglycemia in neonate

A 
apnea
color change
respiratory disress
lethargy
jitteriness
seizures
acidosis
poor myocardial contractility
166
Q

cutoff of glucose for neonatal hypoglycaemia

A

< 2.2mmol/L

167
Q

risk factors for neonate hypovolemia

A

maternal hemorrhage during delivery, prematurity, newborns with overt shock, and initiation of CPR

168
Q

what should newborn MAP be

A

diastolic pressure + (pulse pressure/3) = GA in weeks

169
Q

when is tracheal suctioning in meconium aspiration indicated

A

signs of airway obstruction secondary to meconium that do not improve with resuscitation including warming, drying, initiation of PPV

170
Q

how to perform tracheal suctioning in meconium aspiration

A

meconium aspirator placed on ETT, place ETT with direct laryngoscopy, then withdraw with suction applied x 2
if bradycardia or apnea persist beyond2 passes, ongoing resuscitations with BMV and endotracheal intubation to secure airway

171
Q

when is is approrpiate to withhold neonatal resus

A

GA < 23 weeks, weight less than 400g, those with confirmed anencephaly, trisomy 13 or 18

parental requests - age 22-25 weeks

more than 25 weeks = must resus

neonates with no signs of life (asystole, apnea), after 10 mins of resuscitation have high mortality or severe lifelong developmental delay and resuscitations can be terminated; however therapeutic hypothermia has shown some improvement in outcomes even with APGAR of 0 at 10 mins

172
Q

exam findings suggestive of congenital diaphgramatic hernia

A

barel chest, ipsilateral absence of breath sounds, tracheal or PMI discoid ,scaphoid abdomen

173
Q

how to manage congenital diaphragmatic hernia

A

intubate

dont BMV will distend stomach and worsen respiratory status

174
Q

special considerations for neonate with myelomeningocele

A

never place supine ! put prone or on side
wrap defect with sterile gauze pads soaked in warm sterile saline and enclosed with plastic wrap
elevated risk of latex allergy so avoid latex

175
Q

special considerations for neonate with omphalocele

A

cover defects with occlusive plastic wrapping to decrease water and heat loss

often require IV fluids, OG tube for gastric decompression, and abx prophylaxis

176
Q

special considerations for neonate with choanal atresia

A

can diagnose by inability to pass cather through either saris into posterior oropharynx

use oral airway device to bypass obstruction

look for other congenital anomalies

177
Q

what is Pierre Robin sequence

A

profound micrognathia resulting in glossoptosis (retraction or downward displacement of tongue) and cleft palate

178
Q

special considerations in neonate with Pierre Robin sequece

A

high risk of upper airway obstruction - nasal or oral airway should be able to bypass, if not intubate using fiberoptic intubation

can attempt prone position and LMA
may need to consult ENT/anesthesia

179
Q

exam findings suggestive of congenital heart disease

A 
bp difference between upper and lower extremities
weak femoral pulses
central cyanosis
pathologic murmur
hepatomegaly
180
Q

lab findings in congenital heart dsiease

A

polycythemia

uneplained acidosis

181
Q

what congenital cardiac lesions are ductal-dependent

A 
ductal dependent pulmonary blood flow: 
 -critical pulmonary stenosis, atresia
 -severe tricuspid stenosis, atresia
 -severe tetralogy of Fallot
ductal dependent systemic blood flow:
 -hypoplastic left heart
 -crtiical aortic stenosis
-interrupted aortic arch
182
Q

equipment checklist for neonatal resuscitation

A
  1. gown, gloves, eye protection
  2. timing device
  3. blankets (to warm and dry infant)
  4. plastic wrap
  5. radiant warmer
  6. bulb syringe
  7. suction and suction catheters
  8. bag / masks
  9. larygoscope - miller- 00, 0, and 1
  10. ETT with stylets (2.5, 3.0, 3.5 and 4.0mm)
  11. scissors and tape to stabilize ETT
  12. ped CO2 detector
  13. meconium aspiratory
  14. umbilical catheters (3.5 and 5 Fr)
  15. hemostat, sterile drapes and gloves, iodine, scalpel, umbilical tape, suture and 2 way stopcock for umbilical vessel catheterization
183
Q

what med for kids with ductal dependent cardiac lesion

A

prostaglandin E1 - PGE1 with dose titration to max of 0.1ug/min

184
Q

maternal hx questions for neonatal resus

A 
GA? 
multiple gestation?
meconium present?
hx of vag bleeding?
meds given or drugs taken
documented maternal fever?
prenatal care ? any abnormalities on US?
185
Q

recommended ETT size and depth for infant <1 kg or <28 weeks GA

A

ETT- 2.5 mm uncuffed

depth- 7cm

186
Q

recommended ETT size and depth for infant 1-2kg or 28-34 weeks GA

A

ETT- 3.0 uncuffed

depth- 8cm

187
Q

recommended ETT size and depth for infant 2-3kg or 34-38 weeks GA

A

ETT- 3.5 uncuffed

depth - 9cm

188
Q

recommended ETT size and depth for infant 3+ kg or 38+ weeks

A

ETT- 3.5-4 uncuffed

depth- 10cm

189
Q

targeted pre ductal SpO2 after birth by time

A 
1 min- 60-65%
2min - 65-70%
3 min- 70-75%
4 min- 75-80%
5 min- 80-85%
10 min- 85-95%
190
Q

APGAR Score

A

0 1 2
HR absent <100 >100
resp- absent slow, irreg good, crying
tone- limp some flexion active, good flexion
grimace none grimace cough,sneeze
color blue, pale pink w. blue hands all pink

191
Q

intubation corrective action in NRP

A

MRSOPA

Mask adjustment
Reposiiton airway
Suction mouth and nose
Open Mouth
Pressur increase
Airway alternative
192
Q

possible cause of deterioration while intubated

A 
DOPE
displacement of ETT
obstruction of ETT
pneumothorax
Equipment failure
193
Q

airway differences in pediatrics

A

larynx more anterior and cephalic
epiglottis composed of more flexible cartilage
larger occipital = neck flexion when supine and potential airway obstruction - -may need roll under shoulders for intubation
large tongue- obstructs airway easier - can us NP airway
smaller airways more easily obstructed
preferential nose breathers= suction the nose to improve WOB

194
Q

CV differences in pediatrics

A

tachycardia is earliest sign of CV collapse, hypotension LATE
tachycardia in calm or sleeping child is concerning
bradycardia is ominous may signal impending cardio or respiratory arrest

195
Q

MSK differences in children

A

ligaments strongly than immature bone, more likely to # bones, if tender on growth plate, physeal injury should be considered in children with normal Xray

196
Q

normal behaviour in infants younger than 2 months

A

sleeping, crying, quiet alert time, feeding and stooling

197
Q

normal behaviour in infants under 12 months

A

social smile, track close objects by 2 months

after 6 months- stranger anxiety

198
Q

what do look for under appearance in paediatric assessment triangle

A 
TICLS
tone
irritable, interactive
consolable
look, gaze
speech, cry
199
Q

what to look for under work of breathing in paediatric assessment triangle

A

abnormal sounds - stridor, grunting, snoring, wheezing
abnormal positing - sniffing, tripoding, refusal to lie down
retractions
head bobbing
nasal flaring

200
Q

what to look for under circulation in paediatric assessment triangle

A 
pallor
delayed cap refill >2s
cyanosis
mottling
petechiae
201
Q

child with norml appearence, abnormal WOB, normal circulation has

A

respiratory distress

202
Q

chid with abnormal appearance, abnormal WOB, normal to abnormal circulation has

A

respiratory failure

203
Q

child with normal appearnce, normal WOB, abnormal circiaultino has

A

compensated shock

204
Q

child with abnormal appearnce, normal-abnormal WOB, abnormal circulation has

A

decompensated shock

205
Q

child with abnormal appearance, normal WOB, normal circulation has

A

brain injury or dysfunction

206
Q

child with abnormal appearance, abnormal WOB, abnormal circulation has

A

cardiopulmonary failure

207
Q

what breathing styles indicate impending respiratory failure in kids

A

head bobbing - use of neck muscles to assist respiration

seesaw breathing - ineffective breathing pattern where abdomen moves outward while chest moves inward during inspiration

208
Q

physical exam and radiologic findings concerning for abuse

A

any bruises in young pre cruising infants
patterned ecchymosis, burns or skin marks
bruises on ears, trunk, inner thighs, neck or groin
posterior oropharynx bruising or laceration
posterior rib fractures
classic metaphyseal fractures
any fracture in nonambulatory child
fractures in different stages of healing

PGY1 Resuscitation Block (1 decks)

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