Resuscitation Flashcards
This deck covers Chapters 1-8 in Rosens, compromising all of resuscitation.
1
Q
Provide FIVE targets post-resuscitation of the cardiac arrest patient
A
-
Goal temperature
* 33-36°C for 24 hours -
Mechanical ventilation
* PaCO2 ~40 mmHg -
Avoid hypoxia
* SpO2 94-98% -
Maintain End Organ Perfusion
* MAP >65
* Ideally >80-100 for cerebral perfusion -
Glycemic control
* Glucose 7.8 to 10 mmol/L - Seizure Avoidance
-
Diagnose the cause
* ECG/Cath/Labs
2
Q
What did the ADRENAL and APROCCHSS trials tell us about steroid use in septic shock?
A
ADRENAL (3658 patients who had septic shock) found no statistically significant difference in 90-day mortality between the hydrocortisone and placebo groups.
APROCCHSS (1241 patients who had septic shock) found that hydrocortisone plus fludrocortisone reduced 90-day mortality.
3
Q
List a procedure for cooling the comatose patient post-arrest
A
Appropriate patient selection
Monitors
- Art line
- Central temperature monitoring
- Telemetry for arrhythmias
- CVC for CVP monitoring
Intubation & Sedation
- Benzos for shivering
- Paralysis only considered to prevent shivering
Cooling
- Ice packs around head/neck, axilla, and groin
- Cooling blankets + cold air Bair Hugger
- Cold saline
- Once temp is at target, ice packs are removed
- Maintained for 24h
Addressing underlying cause
- PCI
Supportive care
- Maintain CVP > 8
- MAP > 80 (unless AMI not treated)
- ScvO2 > 65%
- Raise head of bed
- Monitor K+
Rewarming
- Passive re-warming
- Maintain paralysis for shivering until 35ºC
- Monitor K+
4
Q
What are 8 relative contraindications for therapeutic hypothermia (there are no absolute)?
A
- Severe cardiogenic shock
- Life-threatening dysrhythmias
- Uncontrolled bleeding
- Pre-existing coagulopathy
- Pregnancy
- Other reason for coma other than cardiac arrest
- Terminal illness
- DNR
5
Q
Describe the 4 classes of hemorrhage based on an estimation of volume loss
A
Class 1
- <750 cc loss (<15%)
- HR< 100
Class 2
- 750-1500 cc (15-30%)
- HR >100
- Might need blood
Class 3
- 1500-2000 cc (30-40%)
- HR >120, low sBP
- Needs blood
Class 4
- >2000 cc (>40%)
- HR >120, low sBP, no U/O, altered
- Massive transfusion
6
Q
Describe 6 opioid receptors and their function
A
- Mu1: euphoria, supraspinal analgesia, nausea
- Mu2: Respiratory Depression, miosis, urinary retention
- Delta: Spinal Analgesia, CV depression
- Kappa: Spinal analgesia, dysphoria,
- Epsilon: hormone
- Gamma: dysphoria
7
Q
Provide an approach to high-pressure alarms on a vent
A
DOPES
- Displacement of tube
- Obstruction of tube
- Pneumothorax
- Equipment failure
- Stacked breath
Evaluate airway pressure
- If PIP and PPlat both elevated = decreased compliance
- DDx = PTX, Abdo distension, Dyssynchrony
- If only PIP elevated = obstruction
- DDx = Obstruction, bronchospasm or vent DC
8
Q
Define PEA and differentiate true EMD and pseudo-EMD
A
PEA (Pulseless Electrical Activity)
- Coordinated electrical activity without a palpable pulse
EMD (Electromechanical Dissociation)
- No myocardial contractions at all
- Often brady with wide QRS
- Issue with automaticity
- Ischemia, hypoxia, acidosis
Pseudo-EMD
- Myocardial contractions occur but no palpable pulse
- Transient state from hypotension to true EMD
- Same causes as EMD (Hs and Ts)
- Also consider SVTs, papillary or myocardial wall rupture
9
Q
What is SVO2? What are 4 reasons for it to be low?
A
SVO2 = Mixed Venous O2 Saturation
- Must be from the pulmonary artery
- SCVO2 - from a CVC as a surrogate since no Swan Ganz anymore
- Reflects amount of oxygen in central blood (extraction)
- Can be used in lieu of cardiac index
- SVO2 65% or CI 2.5-3.5
4 Reasons for Decrease
- Low cardiac output
- Low HgB
- Low SpO2
- High oxygen consumption
10
Q
List 6 situations that noninvasive BP monitoring may not be accurate
A
- Obese arms
- Moving patient (uncooperative or agitated)
- Extremely high BP
- Extremely low BP
- Dysrhythmias
- Extremes of age
11
Q
What is Litmann et al.’s simplified and structured teaching tool for the evaluation and management of PEA?
A
Narrow complex PEA (Mechanical obstruction)
- Tamponade (muffled heart, JVD)
- Tension pneumo (trauma, rib #, PPV)
- Hyperinflation (COPD, asthma, PPV)
- PE
Wide complex PEA (Metabolic problem)
- Hyperkalemia (sepsis, renal, older)
- Sodium channel (young/overdose)
- Acidosis
12
Q
What is the LEMON mnemonic for airways?
A
LEMON
- Look
- Evaluate : 3: 3: 2
- Mallmapati
- Opening
- Neck Mobility
13
Q
Compare and contrast acute vs. chronic pain with regards to inciting factor, relation to healing, psychosocial effects, treatment
A
Acute Pain
Pathology presented and expected to improve, pain improves as you heal, acutely stressful, analgesic and mobilization
Chronic Pain
Pathology not identifiable, not expected to improve, negative effects of psychosocial, analgesia plays a lesser role
14
Q
List 4 conditions that limit the usefulness of pulse oximetry for measuring O2 saturation
A
- Severe vasoconstriction (shock, hypothermia)
- Excessive movement
- Synthetic fingernails or nail polish
- Presence of abnormal hemoglobin
15
Q
How is difficult bag-mask ventilation determined?
A
MOANS
- Mask Seal
- Obesity
- Age
- No teeth
- Stiffness to ventilation
16
Q
What conditions are associated with hyperkalemia after succinylcholine administration?
A
- Burns >10 % TBSA >5 days until healed
- Crush Injuries >5 days until healed
- Stroke/Spinal Cord >5 days up to 6 months
- Neuromuscular disease (ALS/MS/MD): Indefinitely
- Intrabdominal sepsis: >5 days until healed
Just be aware that for all these periods of concern starting after 5 days, UptoDate and other sources quote 3 days.
17
Q
What are the recommended breath: compression ratios in neonates and children?
A
NRP
- 3:1 (90 compression; 30 breaths; 120 events/min)
- If cardiac cause, may do 15:2
PALS
- 1-rescuer: 30:2
- 2-rescuer (health care providers): 15:2
18
Q
What does the Surviving Sepsis Guidelines say re: steroid use?
A
- Against if fluids/vasopressors maintain MAP
- For if still low MAP
- Hydrocortisone 200 mg IV per day
- Weak recommendation, low quality of evidence
19
Q
List six clinical/biochemical indicators of tissue hypoperfusion
A
- Hypotension
- Tachycardia
- Decreased cardiac output
- Mottled
- Delayed cap refill
- Altered mental status
- High lactate
- Low SVO2
- Low SCVO2
20
Q
List 10 common causes of PEA arrest
A
H’s
- Hypoxia
- Hypovolemia
- Hypothermia
- Hyperacidosis
- Hyperkalemia
T’s
- Tension pneumothorax
- Tamponade
- Thrombus (PE)
- Thrombus (ACS)
- Toxin
21
Q
Outline the ASA scale used in procedural sedation. Give two diseases that would fall into each.
A
Class I
- Healthy
Class II
- Mild systemic disease
- Asthma, Type 1 DM, HTN
Class III
- Severe disease with functional limitations
- Seizure disorder, pneumonia, COPD
Class IV
- Disease with constant threat to life
- Advanced cardiac, dialysis
Class V
- Moribund
- Septic shock, trauma
22
Q
List 8 uses of ETCO2 monitoring
A
- Confirming ETT placement
- Estimate the PaCO2
- Monitor effectiveness of CPR
- Determine prognosis in CPR and trauma
* No survival if <10 mm Hg + 20 min CPR - Assess ROSC
- Adequacy of mechanical ventilation
- Adequacy of ventilation in altered patients
- Adequacy of ventilation in seizing patients
- Detect apnea during procedural sedation
- Help identify bronchospasm
23
Q
List vent settings for:
- Healthy patient
- Asthmatic
- COPD
- Pulmonary edema
- ARDS
- Hypovolemic shock
- Acute lung injury
A
24
Q
What pre-treatment options are available in:
- Reactive airways disease
- Cardiovascular disease
- Elevated ICP
A
Reactive Airways
- Ketamine 1 mg/kg
Cardiovascular
- Lidocaine 1 mg/kg
- Fentanyl 3-5 mcg/kg
Elevated ICP
- Lidocaine 1 mg/kg
- Fentanyl 3-5 mcg/kg
25
You’ve dried, warmed, suctioned, and stimulated baby for 30s. He still has a HR \<100 and respiratory difficulties. Now what?
**Positive pressure ventilation**
* Continuous pulse oximetry
* O2 at room air (21%) – titrate up as needed
* Only turn up to 100% if HR \<60 x90s
26
What do you do in the first 30 seconds of NRP?
**Warm**
* Place under a radiant warmer
**Dry**
* Blankets
**Stimulate**
* Flick the soles of feet and rub the back
**Position**
* Maximize air entry (neck in slight extension)
* Can place a small towel under the shoulders
**Suction**
* Immediately if meconium
27
List FOUR disadvantages of IM opioids
1. Slow
2. Painful injection
3. Diurnal variation
4. Unpredictable
5. Hard to titrate
6. Disease state may effect
28
Give THREE definitions of massive transfusion
1. ≥4U pRBCs within 1 hour with ongoing losses
2. \>6U pRBCs with 1 bleeding episode with ongoing losses
3. \>50% total blood volume within 3 hours
4. Entire blood volume within 24 hours
29
List clinically available modes of PPV
**Continuous mechanical ventilation (CMV)**
1. Assist-control (A/C)
* Ventilator will detect breathing and give whatever pressure/volume you've set.
* Gives 100% of a breath when it senses + backup rate
* For patients in total respiratory failure
* Bad if patient is extremely tachypneic (DKA/ASA)
**Intermittent mandatory ventilation (IMV)**
1. Synchronized intermittent mandatory ventilation (SIMV)
* Gives a breath with support every time patient triggers, but doesn't add if they take extra
**Continuous Spontaneous Ventilation**
1. Pressure-support
2. CPAP
3. BiPAP
30
List the 7 P’s of RSI
1. Prepare
2. Pre-oxygenate
3. Pre-treat
4. Paralysis
5. Position
6. Placement of tube
7. Post-intubation sedation/management
31
List 6 ways to reduce the pain of an IM/SC injection
1. Warmup solution
2. Use buffered Solution
3. Slow the rate
4. Topical
5. Distraction
6. Smaller needle
**Topical Anesthetic Options**
_Intact Skin_
* EMLA (Lidocaine + Prilocaine) - apply 30-60m before
* Ethyl chloride spray
_Open Skin_
* LET (Lidocaine, Epi, Tetracaine) - apply 20m before
_Mucosal Surface_
* Cocaine 4% (40 mg/mL) – max dose 200 mg (5 cc)
* Lidocaine 4% (40 mg/mL) – max dose 200 mg (5 cc)
32
Draw out a normal ETCO2 capnogram in a healthy patient
**Phase 1 – 2**
* CO2-free portion of the respiratory cycle
* Inspiratory phase
* Can also mean: apnea or device disconnection
**Phase 2 – 3**
* Rapid upstroke of curve
* Transition from inspiration to expiration
**Phase 3 – 4**
* Alveolar gas rich in CO2
* Gentle slope upwards due to uneven emptying of alveoli
**Phase 4 – 5**
* Inspiratory downstroke
* Should be almost vertical
33
List FOUR “storage lesions” experienced by blood products
1. Low pH (buffered by citrate preservative)
2. Low 2,3-DPG (L shift on OxyHb curve)
3. RBCs become spherical, rigid, less deformable
4. Na-K-ATPase pump becomes less efficient (hyperK)
5. Hypothermia (with 100 cc/min over 30 min)
34
When would you consider intubating a neonate during NRP?
* For tracheal suction of meconium in non-vigorous baby
* BVM ineffective or prolonged
* When CPR going on
* For medication administration (narcan, Epi)
* Low birth-weight
* Anatomic anomalies
35
List 4 indications for intra-arterial BP monitoring in the ED
1. Hemodynamic instability
2. Monitoring of conditions/treatments with large BP shifts
3. Frequent arterial blood sampling is required
4. Non-invasive methods expected to be inaccurate
36
What is CVP? What is normal? What is it influenced by?
**Central Venous Pressure**
* Pressure in right atrium/SVC
* Surrogate for preload
* Normal is 0-6 mmHg in non-vented patient
* Influenced by:
* Right atrial pressure
* Fluid volume
* Venous tone
* Ventricular function
* SVR
* PVR
* Intra-thoracic/pleural pressure
* Intra-abdominal pressure
37
What's happening here?
**Someone trying to take a breath**
DDx:
1. Hypoxia
2. Hypercarbia
3. Inadequate anesthesia
38
What are contraindications to an intra-aortic balloon pump?
**Contraindications**
1. Severe aortic insufficiency
2. Aortic dissection
3. Severe aortoiliac occlusive disease
**Note:**
* IABP Shock-II Trial (Lancet 2013) showed no benefit
* Still useful in:
* Acute MR
* VSD
* CCB/BB Overdose
39
List six immune-related complications of blood transfusion and state whether they occur acutely or chronically.
**Acute**
1. ABO incompatibility
2. Hemolysis
3. Febrile
4. Allergic
5. Anaphylaxis (usually IgA deficient)
6. TRALI
**Chronic**
1. GVHD
2. Extravascular hemolysis
* Delayed response from previous exposure
40
How is septic shock defined?
Patients with septic shock can be clinically identified by:
1. Vasopressor requirement to maintain MAP \>65 mmHg
2. Serum lactate \>2 mmol/L in the absence of hypovolemia
41
What are the SIRS criteria?
1. HR \>90
2. WBC \<4 or \>12
3. Temp \<36 or \>38
4. RR \>20 or PaCO2 \<32
42
How does graft vs. host disease occur with blood transfusions What are the symptoms? How is it prevented?
A donor who is homozygous for an HLA type (haploidentical), whose blood product is transfused to a recipient who is heterozygous for the same HLA type AND a different HLA type places the recipient at risk. The donor’s lymphocytes mount a reaction against the non-matching HLA determinants on the recipient’s cells.
**Symptoms**
* High fever
* Erythematous, maculopapular rash
* Anorexia, n/v/d
* Hepatomegaly, elevated LFTs
* Pancytopenia
**Pathophysiology**
* Lymphocytes transfused into an immunocomp host
* Donated WBCs multiply + attack the host
* Mortality = 90% (from coagulopathy or severe infection)
* Treatment = bone marrow transplant
**Prevention**
* Gamma irradiation of blood products so donor lymphocytes are incapable of multiplying
43
What is the Mallampati score?
**Mallampati I**
* Soft palate, uvula, fauces pillars
**Mallampati II**
* Soft palate, uvula, fauces
**Mallampati III**
* Soft palate, base of uvula
**Mallampati IV**
* Only hard palate
44
What are the symptoms/treatment of a febrile transfusion reaction?
**Pathophysiology**
* Common (1:200 pRBC) and (1:20 PLT)
* Anti-WBC and/or anti-PLT antibodies (or cytokines) are transfused into the patient
**Symptoms**
* Fever (increase of at least 1°C from baseline)
* Chills, malaise
**Treatment**
* Treat as an acute hemolytic reaction
* Analgesics, antipyretics, antihistamine
45
Which peripheral nerve fibers transmit pain? What tract(s) in the spinal cord are involved?
**A-delta and C**
* A-delta
* Sharp pain
* Contralateral lateral spinothalamic tract
* C Fiber
* Long-lasting burning pain
* Ipsi- and contralateral anterior spinothalamic tract
46
How is the evaluation of a difficult extraglottic device placement evaluated?
**RODS**
* **R**estricted mouth opening
* **O**bstruction or obese
* **D**istorted anatomy
* **S**tiffness to ventilation
47
List 5 adverse effects of ketamine
1. N/V
2. Emergence reaction
3. Laryngospasm
4. Stimulates endogenous catecholamines
5. Bronchorrhea
48
What are 7 things to avoid to prevent secondary injury during brain resuscitation?
1. Hypotension (sBP\<90)
2. Hypoxia (PaO2 \<60, SpO2 \<90)
3. Anemia
4. Hyperpyrexia (Temp \>38.5)
5. Hypercarbia
6. Coagulopathy
7. Seizures
8. Hypoglycemia
49
Desaturation time for an apneic, fully pre-oxygenated:
* Healthy adult?
* Moderately ill adult?
* Obese adult?
* Child?
**Desaturation Times**
* Healthy: 8 min
* Moderate Illness: 5 min
* Child: 3 min
* Obese: 2.5 min
50
List 7 ways to confirm ETT placement following intubation
1. ETCO2 (capnography)
2. ETCO2 (colorimetric)
3. Aspiration with an esophageal detector device
4. Physical exam
5. Pulse oximetry
6. CXR
7. Condensation in ETT
8. Ultrasound
9. Direct visualization
51
What are FIVE components of high-quality CPR?
1. Rate 100-120 bpm
2. Depth 5-6 cm
3. Allow chest recoil
4. Avoid excessive ventilation
5. Minimize interruptions
6. Switch providers q2min or earlier if tired
52
What is the MOA of NSAIDs?
**Mechanism of Action**
* COX-Inhibitor
* Prevents creation of leukotrienes and prostaglandins
* Most NSAIDs block COX-1 and COX-2
* Celecoxib is a selective COX-2 inhibitor
**COX-1**
* Stomach
* Platelets
* Synovium
* Endothelial cells
* Kidney
* Arteries
* Arterioles
* Glomeruli
* Collecting ducts
**COX-2**
* CNS
* Synovium
* Female reproductive tract
* Kidney
* Ascending limb of Henle
* Papillae
53
Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?
**CAEP Position Statement**
* Norepinephrine as the first-line vasopressor
* Dobutamine if an inotrope is deemed necessary
54
List 5 indicators of inadequate blood flow during CPR
1. Arterial diastolic \<20 mmHg
2. CPP \<15
3. SCVO2 \<30
4. **Rosen's:** ETCO2 \< 10
5. **Rosen's:** No palpable pulse
## Footnote
* Femoral pulse and SPO2 not helpful
55
What is the toxic dose of lidocaine, ropivacaine, and bupivacaine, both with and without epinephrine?
**Lidocaine**
* Without epinephrine: 5 mg/kg
* With epinephrine: 7 mg/kg
**Ropivacaine**
* Without epinephrine: 3 mg/kg
* With epinephrine: 3 mg/kg
**Bupivacaine**
* Without epinephrine: 2 mg/kg
* With epinephrine: 3 mg/kg
56
List SIX non-immune blood transfusion reactions and state whether they are acute or chronic
**Acute**
1. TACO
2. Sepsis
3. Coagulopathy
4. Hyperkalemia
5. Hypocalcemia
6. Hypermagnesemia
**Chronic**
1. HIV
2. Hep B
3. Hep C
4. CMV
5. TCLV
57
What is your definition of sepsis?
Life-threatening organ dysfunction caused by a dysregulated host response to infection (2016).
58
What are the features and management of acute ABO incompatibility?
**Clinical Presentation**
* Fever
* Nausea
* Hypotension
* Chest pain
* Joint pain
* Shock
**Pathophysiology**
* Ab-Ag interaction
* Immune-mediated intravascular destruction of RBCs
**Treatment**
* Stop the infusion
* Notify the lab
* Bloodwork
* T&S
* Urine HgB
* DAT
* DIC workup
* Hemolytic workup
59
What is the shock index? What value is bad?
Shock Index = HR/sBP
* \<0.8 = Normal
* \>0.8 = Shock
60
What are the symptoms of LAST (Lidocaine-Associated Systemic Toxicity) and how do you treat it?
**Symptoms**
* Initial
* Circumoral paresthesias
* Dysarthria
* Tinnitus
* Late
* Decreased LOC
* Confusion
* Seizures
* Wide QRS
* Dysrhythmia
**Treatment**
* Intralipid 1.5 mL/kg bolus over 2 min
* Intralipid 3 mL/kg infusion over 20 min
* Can double bolus amount if unstable
* Max dose 12 mL/kg (~850 mL in 70 kg patient)
61
The high-pressure alarms are going off on a patient you intubated in the ED 2 hours ago. List 8 possible causes.
**DOPES**
1. Dislodged ETT
2. Obstructed ETT
3. Pneumothorax
4. Equipment failure
5. Stacked breaths
6. Bronchospasm
7. PE
8. CHF
9. Abdominal distention
10. Dysynchrony
62
List common pediatric ACLS drug doses
**Adenosine**
* 0.1 mg/kg (max 6 mg) IV/IO then
* 0.2 mg/kg (max 12 mg) IV/IO
**Amiodarone**
* 5 mg/kg IV/IO over 20 mins
**Atropine**
* 0.02 mg/kg IV/IO
* Max 0.5 mg
**Calcium Chloride**
* 20 mg/kg (max 2g) IV
**Hypertonic Saline**
* 3 cc/kg of 3% bolus
**Lidocaine**
* 1 mg/kg IV/IO over 2 mins
**Magnesium Sulfate**
* 25-50 mg/kg IV/IO over 10 mins
**Naloxone**
* \<20 kg = 0.1 mg/kg IV/IO
* \>20 kg = 2 mg IV/IO
**Procainamide**
* 15 mg/kg IV/IO over 30 mins
**Sodium Bicarbonate**
* 1 mEq/kg/dose IV/IO
63
Walk though what you do if the vent pressure alarms are going off and the patient is unstable
1. Remove patient from vent
2. BVM on 100% FiO2
3. Rule out breath-stacking, auto-PEEP, and PTX
* Patient gets better: Decrease RR to avoid auto-PEEP
* Patient still bad: B/L needle decompression
* Still bad: Probably a PE
64
When should you initiate chest compressions during NRP?
* After 60s
* HR \<60
* Adequately ventilated
**CPR**
* 3:1 compression to ventilation
* 30 breaths/min
* 90 compressions/min
* Depth of compressions = 1/3 AP diameter of chest
* Wrap-around method preferred
* Reassess vitals q30 seconds
65
List SIX conditions or medications that result in prolonged paralysis after succinylcholine administration
**Normal Metabolism**
* Plasma Pseudocholinesterase (PCHE)
**Conditions**
1. PCHE deficiency
2. Liver disease
3. Cancer
4. Pregnancy
5. Cytotoxic drugs
6. Metoclopramide
7. Phenelzine
8. Cocaine
9. Myasthenia gravis
10. Organophosphate poisoning
66
What are THREE indications to give plasma? What is the dose?
**Contents**
* Factor 8 (hemophilia A)
* All clotting factors (Warfarin)
* Fibrinogen (DIC)
**Dose**
* FFP 4 units in adults
* 10cc/kg in children
**Indications**
* INR \>1.5 and massive transfusion
* Need to do a procedure and INR \>1.5
* DIC and PT/APTT \>1.5 x normal
* Hemophilia without Factor access
* Angioedema
* Plasma exchange
67
What are the usual initial BiPAP settings?
**Initial BiPAP Settings**
* IPAP = 10 cm H2O
* EPAP = 5 cm H2O
* FiO2 = 1.0
**If hypercarbia**
* Increase IPAP by 2s
* Increase EPAP at a ratio of 1:2.5
**If hypoxia**
* Increase FiO2
* Consider Intubation
68
What are the AHA chains of survival for IHCA and OOHCA?
**IHCA**
1. Surveillance and Prevention
2. Recognition and Activation
3. Early CPR
4. Early defibrillation
5. ACLS/Post-arrest care
6. Recovery
**OOHCA**
1. Recognition and Activation
2. Early CPR
3. Early Defibrillation
4. EMS transport
5. ACLS/Post-arrest care
6. Recovery
69
What is the risk of HIV, HBV, and HCV in blood or blood products in Canada?
* HIV: 1 in 21 million
* HCV: 1 in 14 million
* HBV: 1 in 7 million
* Bacteria
* 1 in 105,000 (pRBC)
* 1 in 47,000 (Platelets)
70
What are the EIGHT contraindications to NIPPV? What are the benefits? Risks?
1. Impaired LOC
2. Facial trauma
3. Inability to protect airway
4. Apnea
5. Upper airway obstruction
6. Copious secretions
7. Uncontrolled vomiting
8. Acute MI
9. Cardiac arrest
10. Recent gastric or esophageal surgery
**Benefits**
* Preserve speech, swallowing
* Less airway injury
* Decreased nosocomial infection
* Decreased LOS and ICU
**Risks**
* Pressure sores
* Barotrauma
* Not tolerating
* Aspiration
71
What is happening here?
**Obstructive Pattern**
* Prolonged phase 2-3
* DDx:
1. Obstructive lung disease (asthma, COPD)
2. Bronchospasm
3. Kinked ETT
4. Leaks in system
72
List SIX false-positive and SIX false-negative findings on colorimetric ETCO2 devices
**False Positives (eg. in esophagus but don't realize)**
1. Not allowing 6 breaths
2. Carbonated beverages
3. Air in stomach (from BMV)
4. Bicarbonate administration
5. Contact with gastric contents
6. Contact with acidic meds (e.g. lido, epi)
**False Negatives (it's in, but you're not getting feedback)**
1. Not allowing 6 breaths
2. Cardiac arrest
3. Device or ETT clogged by secretions
4. Severe airway obstruction
5. Pulmonary edema
6. Severe hypocarbia
73
List 6 adverse effects of succinylcholine
1. Fasciculations
2. Hyperkalemia
3. Bradycardia
4. MH
5. Trismus/masseter spasm
6. Prolonged paralysis (PCHE deficiency)
74
List 8 potentially negative physiologic outcomes of pain
1. Increased SVR
2. Increased BP
3. Increased metabolic demand on heart
4. Decreased gastric emptying
5. Urinary retention
6. Increased Cortisol
7. Increased ADH
8. Increased Glucagon
9. Increased Catecholamines
10. Anxiety /Fear
75
What is the Cormack and Lehane grading scheme of a laryngoscopic view?
**Grade I**
* Entire glottic aperture is seen
**Grade II**
* Portion of the glottis is seen
* IIa: arytenoids + part of cords
* IIb: arytenoids alone
**Grade III**
* Epiglottis only
**Grade IV**
* Not even epiglottis visible
76
Ok, so during NRP you just initiated step 2 and have provided PPV for 30 sec with no improvement. HR still \< 100 + resp distress. Now what?
**MR SOPA**
* **M**ask is tightly applied to the face
* **R**e-position the head into the “sniffing” orientation
* **S**uction the nares and the pharynx
* **O**pen the mouth
* **P**ressure of PPV increased to a max of 40 cmH2O
* **A**lternate airway
77
List equipotent opioid doses
78
What does APGAR stand for?
**APGAR**
* **A**ctivity
* **P**ulse
* **G**rimace
* **A**ppearance
* **R**espirations
79
What's this?
Endotracheal cuff leak
80
List 8 side effects of massive transfusion
1. Decreased pH
2. L-shift of oxyHb curve (low 2,3-DPG)
3. Less deformable RBCs (spherical + rigid)
4. Hyperkalemia (inefficient Na-K-ATPase)
5. Hypothermia
6. Decreased iCa (citrate)
7. Coagulopathy
8. Thrombocytopenia
81
What is the pathway from the periphery to the brain for pain?
**Pain Pathway**
1. Nociceptor
2. Dorsal root ganglion
3. Dorsal horn
4. Contralateral spinothalamic tract
5. Thalamus
6. Cortex
**Tracts Involved in Pain Perception**
* Spinothalamic tract
* Spinoreticular tract
* Spinomesencephalic tract
82
What is qSOFA?
**qSOFA**
* Altered mental status (GCS \<13)
* RR \>22
* Systolic BP \<100
If 2 or more, predicts mortality or long ICU stay
83
How is the evaluation of a difficult cricothyrotomy determined?
**SMART**
* **S**urgery
* **M**ass
* **A**natomy (obese)
* **R**adiation
* **T**umor
84
Define the failed airway
1. SPO2 \<90% despite good 2-person BVM
2. 3+ failed intubation attempts
3. Skilled operator concludes intubation would be impossible after even a single attempt
85
What is lactate clearance and what is it used for?
**Lactate Clearance**
* Equivalent to SCVO2
* Aim for 10-20% decrease in lactate q2h until \<2 mmol/L
Lactate (initial) = Lactate (delayed) / Lactate (initial)
