Resuscitation and Shock

Question 1

What are the ABCDEs?

Answer 1

establishing airway, controlling the work of breathing, optimizing the circulation, ensuring adequate oxygen delivery, and achieving end points of resuscitation

Question 2

how to approach a HoTN pt?

Answer 2

ABCDEs

Question 3

how to assess/manage circulation

Answer 3

• Water in the pipes
• Obtain access: peripheral vs central
• Crystalloid fluids - 30 ml/kg
• Vasopressors - Need water in the pipes to use

Question 4

how to assess/manage delivery of O2

Answer 4

• 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

Question 5

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

Answer 5

• > 65
• 8-12
• > 70%
• > 0.5

Question 6

State of circulatory insufficiency that creates an imbalance between tissue oxygen supply (delivery) and demand (consumption) → end-organ dysfunction.

Answer 6

shock

Question 7

types of shock

Answer 7

Cardiogenic, distributive, hypovolemic, obstructive

Question 8

how does cardiogenic shock happen

Answer 8

1. Left ventricle fails to deliver oxygenated blood to peripheral tissues due to variances in contractility, as well as preload, afterload, and right ventricular function.
2. “pump failure,” resulting in diminished cardiac output, hypotension, systemic vasoconstriction, and increasing cardiac ischemia.

Question 9

MCC of cardiogenic shock

Answer 9

MI

Question 10

another common cause of cardiogenic shock because they can lead to a decreased CO?

Answer 10

dysrhythmias

Question 11

which type of dysrhythmia causes low CO vs decreased preload stroke volume?

Answer 11

• Bradyarrhythmias →low cardiac output
• Tachyarrhythmias → decreased preload and stroke volume

Question 12

The most important definitive intervention for acute ischemia-related cardiogenic shock is ?

Answer 12

emergent revascularization

Question 13

management/tx for cardiogenic shock

Answer 13

• 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

Question 14

____ therapy alone is least effective in reducing mortality in cardiogenic shock

Answer 14

thrombolytic

Thrombolytic therapy is not as effective in establishing reperfusion in AMI with cardiogenic shock as it is in uncomplicated AMI.

Question 15

septic shock syndrome is characterized by:

Answer 15

1. widespread inflammation
2. organ distress initiated by any type of microorganism

Question 16

sepsis requiring vasopressors after adequate resuscitation and with an elevated lactate.

what is this term

Answer 16

septic shock

Question 17

presentation of septic shock

Answer 17

Abnml VS with possible source of infection

Question 18

In those with signs or symptoms of infection, look for ___ shock: check vital signs and consider lactate early and repeat if in doubt.

Answer 18

occult

Question 19

management/tx for septic shock

Answer 19

• 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

Question 20

how does neurogenic shock happen

Answer 20

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

Question 21

warm, peripherally vasodilated, and hypotensive with a relative bradycardia

what is this presentation?

Answer 21

Neurogenic Shock

Question 22

tx for neurogenic shock

Answer 22

vasopressors

Question 23

7 steps of CPR

Answer 23

1. recognition
2. activate emergency medical response system and get an AED
3. assess circulation
4. begin cucle of 30 closed chest compressions
5. use defribillator when available and indicated
6. continue high-quality CPR
7. rescue breaths

Question 24

Assess airway for obstruction, which can be ______ (e.g., unconscious patient) or ____ (e.g., foreign body).

Answer 24

functional
mechanical

Question 25

what patient position is best to facilitate airway patency and subsequent airway management efforts?

Answer 25

• 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

Question 26

benefit of Nasopharyngeal (Nasal) Airway

Answer 26

• displaces soft palate and posterior tongue.
• helpful in patients with an intact gag reflex absent any midface trauma

Question 27

• 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

Answer 27

Bag Valve Mask

Question 28

technqiue for Airway-Bag Valve Mask Ventilation

Answer 28

• 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.

Question 29

indications for Endotracheal Intubation

Answer 29

• 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)

Question 30

Assess for difficulty of airway if time allows - what criteria?

Answer 30

Mallampati criteria

Question 31

how to prepare for endotracheal intubation

Answer 31

1. 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.
2. Blade selection
3. tube selection

Question 32

types of blade selection for endotracheal intubation

Answer 32

1. MAC - less traumatic and stimulating; less view
   - Indirectly lifts epiglottis = < tachycardia or arrhythmias
   - “Less across the board”
2. Miller - more traumatic and stimulating; better view
   - Directly lifts epiglottis = >tachycardia or arrhythmias
   - “More across the board”

Question 33

tube sizing for endotracheal intubation

Answer 33

• 7.5 to 8.0mm tube for women ​
• 8.0 to 8.5mm tube for men ​

Question 34

difference between tubes used for laryngoscope vs glidescope?

Answer 34

• Flexible stylet for traditional laryngoscope
• Hyperangulated, rigid stylet for Glidescope

Question 35

Rapid Sequence Intubation process?

Answer 35

Simultaneous administration of an induction (sedative) followed by a neuromuscular blocking (paralytic) agent

1. Prepare equipment and check its function, draw up meds, and assign personnel roles before RSI
2. Administer Induction - Etomidate, propofol, ketamine
3. administer paralytic - succinylocholine, rocuronium
4. Apply cricoid pressure as needed
5. bag mask ventilate if intubation fails or O2 < 90%
6. 3 fails = failed airway and other techniques need to be considered

Question 36

which inductoin agent to avoid in hypotensive pts?
what to use instead?

Answer 36

propofol
ketamine - also good for bronchospams

Question 37

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

Answer 37

Succinylcholine

Question 38

which paralytic agent to avoid if history of Myasthenia Gravis

Answer 38

Rocuronium

Question 39

what to avoid when doing IV Access-Peripheral

Answer 39

1. Avoid access through or distal to areas of infection, injuries, or sites of potential vascular disruption
2. Avoid using extremities with arteriovenous fistulas or grafts, previous lymph node dissections
3. If using peripheral access for vasopressors→ ensure not distal and well secured

Question 40

procedure of peripheral IV line insertion

Answer 40

1. torniquet
2. locate bein
3. clean area w/ alc or iodine
4. apple traction to anchor vein
5. insert catheter needle into skin and vessel at 15-20 degree angle
6. look for blood flash
7. advance cetheter into vessel
8. remove tourniquet, attach IV tubing and monitor, secure catheter

Question 41

IV Access-Central indications

Answer 41

1. Inability to obtain peripheral access
2. Access to central circulation needed for procedures (pulmonary artery catheter placement, transvenous pacemaker placement, or urgent hemodialysis)
3. Measurement of central venous pressure (sepsis, congestive heart failure, pericardial effusion)
4. Administration of sclerosing medications, continuous vasopressors, concentrated ionic solutions, or cytotoxic chemotherapeutic agents]

Sites: Internal jugular, subclavian, and femoral veins

Question 42

tx for Asystole/PEA

Answer 42

CPR, epinephrine, ABCD’s

Question 42

tx for Ventricular Fibrillation

Answer 42

defibrillation, CPR
Defibrillation: 200 J biphasic

Question 43

what is a non-shockable rhythm

Answer 43

asystole/PEA

Question 44

mgmt for Sinus tachycardia and multifocal atrial tachycardia

Answer 44

treating the underlying cause rather than the dysrhythmia specifically

Question 45

mgmt for SVT

Answer 45

• Vagal maneuvers
• Adenosine 6mg, then 12 mg, then another 12mg
• If converts - observe and monitor
• If does not convert - control rate

Question 46

mgmt for afib/aflutter

Answer 46

• 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

Question 47

mgmt for Ventricular Tachycardia

Answer 47

1. Pulseless - Defibrillate (360 J mono, 200 J biphasic), CPR
2. with pulse - Procainamide or Amiodarone

Question 48

Emergent treatment of bradyarrhythmia is not required unless

Answer 48

• 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)

Question 49

? is the most appropriate pacing method for the acutely symptomatic patient

Answer 49

Transcutaneous pacing
Mobitz type II, third degree heart block

Question 50

more common causes of arrest among children and infants than adults

Answer 50

Respiratory failure and shock

Question 51

difference in resuscitation in pediatric population?

Answer 51

• 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

Question 52

a broader term that may include prolonged events or those that are explained by an underlying disorder
term?
what term do we use now?

Answer 52

• Apparent life-threatening event (ALTE)
• BRUE - when episodes are brief, resolved, and unexplained

Question 53

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

Answer 53

● Cyanosis or pallor
● Absent, decreased, or irregular breathing
● Marked change in tone (hyper- or hypotonia)
● Altered level of responsiveness

Question 54

when is BRUE applied?

Answer 54

• 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).

Question 55

RF for Apparent End of Life Event

Answer 55

• feeding difficulties
• recent upper respiratory symptoms
• < 2 months old
• history of previous episodes

Question 56

warning signs of Apparent End of Life Event

Answer 56

● 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.

Question 57

Low risk BRUE indications:

Answer 57

• 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

Question 58

do you need work up for Apparent End of Life Event

Answer 58

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.

Question 59

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.

Answer 59

SIDS

Question 60

RF for SIDS

Answer 60

Smoking
Sleeping position of baby

Question 61

s/s of SIDS

Answer 61

1. not amenable to resuscitation or potentially responsive to resuscitation measures
2. 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.

Question 62

prevention of SIDS

Answer 62

Firm sleeping surface, no bed sharing, don’t overheat, use pacifier