Resuscitation and Shock Flashcards
What are the ABCDEs?
establishing airway, controlling the work of breathing, optimizing the circulation, ensuring adequate oxygen delivery, and achieving end points of resuscitation
how to approach a HoTN pt?
ABCDEs
how to assess/manage circulation
- Water in the pipes
- Obtain access: peripheral vs central
- Crystalloid fluids - 30 ml/kg
- Vasopressors - Need water in the pipes to use
how to assess/manage delivery of O2
- Pain further suppresses myocardial function, impairing oxygen delivery and increasing consumption - Providing analgesia, muscle relaxation, warm covering, anxiolytics, and even paralytic agents, when appropriate, decreases this inappropriate systemic oxygen consumption.
- Arterial O2 >91%
- Consider PRBC transfusion
mean arterial pressure ___ mm Hg, central venous pressure of ___ to ___ mm Hg, ScvO2 ___%, and urine output ____ mL/kg/h during ED resuscitation of septic shock
End points of ABCDE
- > 65
- 8-12
- > 70%
- > 0.5
State of circulatory insufficiency that creates an imbalance between tissue oxygen supply (delivery) and demand (consumption) → end-organ dysfunction.
shock
types of shock
Cardiogenic, distributive, hypovolemic, obstructive
how does cardiogenic shock happen
- Left ventricle fails to deliver oxygenated blood to peripheral tissues due to variances in contractility, as well as preload, afterload, and right ventricular function.
- “pump failure,” resulting in diminished cardiac output, hypotension, systemic vasoconstriction, and increasing cardiac ischemia.
MCC of cardiogenic shock
MI
another common cause of cardiogenic shock because they can lead to a decreased CO?
dysrhythmias
which type of dysrhythmia causes low CO vs decreased preload stroke volume?
- Bradyarrhythmias →low cardiac output
- Tachyarrhythmias → decreased preload and stroke volume
The most important definitive intervention for acute ischemia-related cardiogenic shock is ?
emergent revascularization
management/tx for cardiogenic shock
- Initial management focuses on airway stability and improving myocardial pump function to maintain end-organ perfusion while arranging definitive care such as revascularization and early mechanical circulatory support
- Airway; Continuous cardiac monitor/IV access; Fluid bolus vs vasopressors
- Definitive: revascularization by PCI, CABG
- Survival is highest with emergency coronary intervention, then intra-aortic balloon pump + thrombolytic therapy
____ therapy alone is least effective in reducing mortality in cardiogenic shock
thrombolytic
Thrombolytic therapy is not as effective in establishing reperfusion in AMI with cardiogenic shock as it is in uncomplicated AMI.
septic shock syndrome is characterized by:
- widespread inflammation
- organ distress initiated by any type of microorganism
sepsis requiring vasopressors after adequate resuscitation and with an elevated lactate.
what is this term
septic shock
presentation of septic shock
Abnml VS with possible source of infection
In those with signs or symptoms of infection, look for ___ shock: check vital signs and consider lactate early and repeat if in doubt.
occult
management/tx for septic shock
- Vanc + Zosyn w/in 3hrs of presentation
- Look for infection source (blood cx, medical devices)
- 1-2 L bolus of IV crystalloid (LR) if HoTN or elevated lactate
- 1st line vasopressor: NOR (for refractory HoTN despite adequate fluid resuscitation)
- consider central venous pressure and central venous oxygen monitoring to titrate dobutamine and PRBC, and consider corticosteroids in those
how does neurogenic shock happen
Loss of peripheral sympathetic innervation —> extreme vasodilatation secondary to loss of sympathetic arterial tone → blood pooling in the distal circulation with resultant hypotension → bradycardia or absence of reflex tachycardia
warm, peripherally vasodilated, and hypotensive with a relative bradycardia
what is this presentation?
Neurogenic Shock
tx for neurogenic shock
vasopressors
7 steps of CPR
- recognition
- activate emergency medical response system and get an AED
- assess circulation
- begin cucle of 30 closed chest compressions
- use defribillator when available and indicated
- continue high-quality CPR
- rescue breaths
Assess airway for obstruction, which can be ______ (e.g., unconscious patient) or ____ (e.g., foreign body).
functional
mechanical
what patient position is best to facilitate airway patency and subsequent airway management efforts?
- Extend neck with anterior displacement of mandible - moves hyoid bone anteriorly and lifts epiglottis away from laryngeal inlet
- Forward flex neck in + extension (“sniffing” position) - relieve upper airway obstructions and requires less neck extension - place a folded towel (not rolled) or foam rubber device underneath
- avoid cervical spine injury
benefit of Nasopharyngeal (Nasal) Airway
- displaces soft palate and posterior tongue.
- helpful in patients with an intact gag reflex absent any midface trauma
- a self-inflating insufflation device coupled with a facemask and a valve to prevent reinhalation of exhaled air.
- deliver approximately 75% oxygen with optimal use
Bag Valve Mask
technqiue for Airway-Bag Valve Mask Ventilation
- can be done using one- or two-person techniques - Two-person techniques deliver greater tidal volumes, preferred
- 1-person - one hand on mask, other squeezes bag
- mask-sealing technique - “C” shape while placing third, fourth, and fifth digits in an “E” shape to lift the mandible; Keep the fingers on mandible
- 2-operators - a two-handed technique, one seals the facemask with both hands, while the other person squeezes the bag.
- modified two-handed approach - placing thenar eminence and thumb of each hand on the mask, with the remaining digits grasping the mandible. Both methods yield comparable tidal volumes.
indications for Endotracheal Intubation
- rsp failure (hypoxic or hypercapnic),
- apnea
- reduced level of consciousness (GCS <8),
- rapid change of mental status
- airway injury or impending airway compromise
- high risk for aspiration
- trauma to the box (larynx)
Assess for difficulty of airway if time allows - what criteria?
Mallampati criteria
how to prepare for endotracheal intubation
- Preoxygenation ASAP - before intubation, even if no apparent hypoxia or hypoxemia; 100% O2 for 3 mins w/ non-rebreather mask supplied with at least 15 L/min of oxygen.
- Blade selection
- tube selection
types of blade selection for endotracheal intubation
-
MAC - less traumatic and stimulating; less view
- Indirectly lifts epiglottis = < tachycardia or arrhythmias
- “Less across the board” -
Miller - more traumatic and stimulating; better view
- Directly lifts epiglottis = >tachycardia or arrhythmias
- “More across the board”
tube sizing for endotracheal intubation
- 7.5 to 8.0mm tube for women
- 8.0 to 8.5mm tube for men
difference between tubes used for laryngoscope vs glidescope?
- Flexible stylet for traditional laryngoscope
- Hyperangulated, rigid stylet for Glidescope
Rapid Sequence Intubation process?
Simultaneous administration of an induction (sedative) followed by a neuromuscular blocking (paralytic) agent
- Prepare equipment and check its function, draw up meds, and assign personnel roles before RSI
- Administer Induction - Etomidate, propofol, ketamine
- administer paralytic - succinylocholine, rocuronium
- Apply cricoid pressure as needed
- bag mask ventilate if intubation fails or O2 < 90%
- 3 fails = failed airway and other techniques need to be considered
which inductoin agent to avoid in hypotensive pts?
what to use instead?
propofol
ketamine - also good for bronchospams
which paralytic do you avoid in pts with a neuromuscular disorder, denervation injury >7 d or severe burns >5 d d/t risk of hyperkalemia
Succinylcholine
which paralytic agent to avoid if history of Myasthenia Gravis
Rocuronium
what to avoid when doing IV Access-Peripheral
- Avoid access through or distal to areas of infection, injuries, or sites of potential vascular disruption
- Avoid using extremities with arteriovenous fistulas or grafts, previous lymph node dissections
- If using peripheral access for vasopressors→ ensure not distal and well secured
procedure of peripheral IV line insertion
- torniquet
- locate bein
- clean area w/ alc or iodine
- apple traction to anchor vein
- insert catheter needle into skin and vessel at 15-20 degree angle
- look for blood flash
- advance cetheter into vessel
- remove tourniquet, attach IV tubing and monitor, secure catheter
IV Access-Central indications
- Inability to obtain peripheral access
- Access to central circulation needed for procedures (pulmonary artery catheter placement, transvenous pacemaker placement, or urgent hemodialysis)
- Measurement of central venous pressure (sepsis, congestive heart failure, pericardial effusion)
- Administration of sclerosing medications, continuous vasopressors, concentrated ionic solutions, or cytotoxic chemotherapeutic agents]
Sites: Internal jugular, subclavian, and femoral veins
tx for Asystole/PEA
CPR, epinephrine, ABCD’s
tx for Ventricular Fibrillation
defibrillation, CPR
Defibrillation: 200 J biphasic
what is a non-shockable rhythm
asystole/PEA
mgmt for Sinus tachycardia and multifocal atrial tachycardia
treating the underlying cause rather than the dysrhythmia specifically
mgmt for SVT
- Vagal maneuvers
- Adenosine 6mg, then 12 mg, then another 12mg
- If converts - observe and monitor
- If does not convert - control rate
mgmt for afib/aflutter
- block the AV node to control ventricular response, initiating oral anticoagulants to prevent thromboembolism, and reevaluation after 3 to 4 weeks for elective cardioversion
- recent-onset afib and a rapid ventricular response that is producing hypotension, myocardial ischemia, or pulmonary edema → urgent electrical cardioversion
- Unstable, long-standing afib → hemodynamic resuscitation and ventricular rate control tx
- Stable low-risk, new-onset → rate-control or rhythm-conversion
mgmt for Ventricular Tachycardia
- Pulseless - Defibrillate (360 J mono, 200 J biphasic), CPR
- with pulse - Procainamide or Amiodarone
Emergent treatment of bradyarrhythmia is not required unless
- HR < 50-60 + hypotension or hypoperfusion - resuscitate while evaluating the cause
- d/t structural disease of infranodal conduction system - closely monitored, cardiac pacing while arranging definitive care (not immediate care like first one)
? is the most appropriate pacing method for the acutely symptomatic patient
Transcutaneous pacing
Mobitz type II, third degree heart block
more common causes of arrest among children and infants than adults
Respiratory failure and shock
difference in resuscitation in pediatric population?
- 15:2
- elevated shoulders or thorax to align airway
- IV access can be more difficult - Use IO
- airway - smaller and more anterior; larger tongue and epiglottis
- artificial ventilation is more pertinent to children than adults due to their lesser oxygen reserve
a broader term that may include prolonged events or those that are explained by an underlying disorder
term?
what term do we use now?
- Apparent life-threatening event (ALTE)
- BRUE - when episodes are brief, resolved, and unexplained
BRUE is not a specific diagnosis but a description of a sudden, brief, and now resolved episode in an infant that includes one or more of the following features
● Cyanosis or pallor
● Absent, decreased, or irregular breathing
● Marked change in tone (hyper- or hypotonia)
● Altered level of responsiveness
when is BRUE applied?
- infant is asx on presentation and when there is no explanation for episode after a focused H&P
- The estimated duration - < 1 minute (typically < 20-30 s).
RF for Apparent End of Life Event
- feeding difficulties
- recent upper respiratory symptoms
- < 2 months old
- history of previous episodes
warning signs of Apparent End of Life Event
● toxic appearance, lethargy, unexplained recurrent vomiting, or rsp distress.
● Significant physiologic compromise during the event - generalized sustained cyanosis or loss of consciousness, and/or need for resuscitation
● Bruising or any other evidence of trauma.
● H/o prior events esp < 24 h, or clusters of events.
● H/o significant events or unexpected death in a sibling.
● possibility of child maltreatment
● Dysmorphic features, congenital anomalies, and/or known syndrome.
Low risk BRUE indications:
- Age >60 days
- If premature, born at gestational age ≥ 32 wks and current postconceptional age is ≥ 45 wks
- Occurrence of only 1 BRUE (no prior BRUE, and BRUE did not occur in clusters)
- Duration < 1 min
- No CPR required
- No concerning H&P features
do you need work up for Apparent End of Life Event
no need for routine testing with a urinalysis, blood tests (glucose, bicarbonate, or lactic acid), or neuroimaging, or admission to the hospital solely for cardiorespiratory monitoring.
unexpected death of an infant under 1 year of age for which no pathologic cause can be determined by an examination of the death scene, an autopsy, and a review of the infant’s medical history.
leading cause of death for infants between 1 month and 1 year of age.
SIDS
RF for SIDS
Smoking
Sleeping position of baby
s/s of SIDS
- not amenable to resuscitation or potentially responsive to resuscitation measures
- rigor mortis, livedo reticularis, pH < 6, and reduced core temp with no h/o hypothermia should not be resuscitated
- warm infant with apnea and no pulse may benefit need resuscitation.
prevention of SIDS
Firm sleeping surface, no bed sharing, don’t overheat, use pacifier
