Resuscitation / Critical Illness Flashcards
Variceal Bleeding
Pantoprazole 80mg stat then 8mg/hr
Ceftriaxone 1g or ciprofloxacin 400mg IV
TXA 1g
Octreotide 50microg IV bolus then 50microg/hr for 48hrs
Terlipressin 2mg IV every 4 hours
Massive PE Thrombolysis
Tenectaplase
Wt < 60kg: 6000u = 30mg
Wt 60 – 70kg: 7000u = 35mg
Wt 70 – 80kg: 8000u = 40mg
Wt 80 – 90kg: 9000u = 45mg
Wt > 90kg: 10000u = 50mg
Alteplase
Wt > 65kg 10mg IV bolus then 90mg infusion over 2 hours
Wt < 65kg 10mg IV bolus then 1.5mg/kg (max 90mg) over 2 hours
Local Anaesthetic Toxicity
IV Fluids +/- inotropes for hypotension
Midazolam for seizures
Sodium Bicarbonate 1-2mmol/kg every 1-2 minutes for cardiac arrythmia (Na channel blockade) ……… buvipicaine
Intralipid 20% 1.5ml/kg over 1 minute then infusion 0.25 ml/kg/hr
Methylene Blue 1-2 mg/kg IV over 5 minutes for methemoglobinemia……….Prilocaine
Contraindications to NIV
- patient wishes
- patient compliance
- adequate respiratory effort
- vomiting
- pneumothorax
- bowel obstruction
- unable to fit mask due to anatomy or trauma
- decreased GCS
Lung Protective Ventilation - ARDS
ALWAYS VT of 4-8 ML/KG
ARDS – high RR 20-26, HIGH PEEP 10-15, I:E 1:1
Asthma Ventilation
ALWAYS VT of 4-8 ML/KG
ASTHMA – low RR 6-8, LOW PEEP 0-5, I:E 1:5
ensure plateau pressure < 30
expect high airway (peak) pressures
expect high pCO2 (prioritise oxygenation)
Predictors of difficult airway
Short thyromental distance / anterior larynx
Small / recessed mandible
Mouth opening < 2cm
Poor neck ROM – e.g. RA, Ankylosing Spondylysis
Pregnancy
Obesity
History of difficult intubation
Mallamnpatti Score >3
Triggers for laryngospasm
- intraoral injury or procedure
- stimulation of the posterior pharynx
- vomiting/aspiration
- ketamine
- anaphylaxis
steps to manage laryngospasm
- Apply O2 15lm BVM
- Apply painful stimulus to angle of mandibe + jaw thrust
- Attempt BVM ventilation – PPV with peep valve
- Give deeper sedation – use propofol
- Give sux IV 0.5mg/kg continue BVM
- Give sux 1 mg/kg IV and intubate
Biers Block drug + dose
Prilocaine 0.5%, 3mg/kg IV
duration = 20-30mins
toxic effects = seizure, decreased GCS, metHb
– quite safe cardiotoxicity profile – unlikely hypotension or arrythmia
contraindications to Biers Block
Uncooperative patient – must be able to tolerate cuff
Allergy to prilocaine
Unable to gain 2x IV access
Sickle cell disease
Raynauds
Open fracture
Vascular complication from the fracture
HTN, SBP > 200
Biers Block - complications
Seizure management
Abandon the procedure
Apply 15lmin O2 via NRBM, place on side, manage airway Midazolam 5mg IV alloquot – repeat q5mins
Check cuff still inflated – increase to max pressure
IV fluid 10ml/kg bolus
Monitor on cardiac monitor for arrythmias
Move the patient to resus if not there already
Check and correct hypoglycaemia
Intralipid not really for prilocaine – more bupivacaine
consider methaemoglobinaemia - administer methylene blue
Sore Throat + Fever + airway obstruction, causes?
Epiglottitis
Anaphylaxis
Peritonsillar abscess
Ludwigs angina – less likely
Retropharyngeal abscess
angiooedema
Adrenalin routes + doses for anaphylaxis
IM 10microg/kg of 1:1000 up to 500microg = 0.5ml
IV 1mcg/kg of 1:10000 bolus if peri-arrest, i
nfusion = 0.05 – 0.1 mcg/kg/min
Neb 5mg = 5ml of 1:1000
ET route 100mcg/kg in cardiac arrest
IO same as IV Cardiac arrest = 10mcg/kg IV every second round
Indications for intubation in Trauma
- GCS < 9
- restless patient needing procedure e.g. CT scan
- combative patient
- elective hypocapnia required (“controlled” PCO2 – low-normal range)
- hypoxaemia
ASA Class
- Healthy patient, no medical problems
- Mild systemic disease e.g. hypertension
- Severe systemic disease, but not incapacitating
- Severe systemic disease that is a constant threat to life
- Moribund, expected to live less than 24 hours irrespective of operation
- E operation is an emergency
Anaesthetic risk in pregnancy
- 10% incidence of spontaneous miscarriage if surgery performed in first trimester -6% overall
- significantly increased in later pregnancy
- difficult intubation -larger breasts -oedema may be present (especially in pre-eclampsia)
- higher risk of aspiration -abdominal distension -relaxation of the lower oesophageal sphincter
- higher gastric acidity
- higher rates of oxygen desaturation -higher baseline oxygen consumption -lower FRC and oxygen reserve capacity -impaired diagphramatic movement
Complications of NIV
- facial skin necrosis -pressure sores
- conjunctivitis
- gastric dilatation
- aspiration
- pneumothorax
RSI : HEAD INJURY
•fentanyl 0.5 – 1 µg/kg or lignocaine (lidocaine) 1 mg/kg IV
- may blunt the increase in ICP that occurs with instrumentation of the larynx
- usually given 1 - 2 minutes prior to other agents
- lignocaine (lidocaine) rarely used in Australasia for this purpose
•thiopentone 1.5 -3 mg/kg
- reduce dose or use fentanyl if hypotensive
- may also lower ICP
•rocuronium 1.2 - 1.5 mg/kg or suxamethonium 1 - 1.5 mg/kg (atropine handy in case of bradycardia)
- rocuronium does not cause an increase in ICP, however paralysis will be prolonged making subsequent neurological assessment difficult
- advantages of rapid paralysis outweigh the potential disadvantage of a brief increase in ICP with suxamethonium
DUNN
RSI: HYPOTENSION / SHOCK
Induction agent
•induction with ketamine 1.5-2 mg/kg, or fentanyl 3µg/kg may prevent further deterioration in cardiovascular status
•etomidate 0.2-0.3 mg/kg is another alternative, if available
•thiopentone
- best avoided if possible
- or reduce dose to 1.5 mg/kg or less
•propofol
- intermediate risk of worsening hypotension
- reduce dose to 1 mg/kg, if possible
DUNN
RSI: C-SPINE INJURY
Cervical spine injury
Indications for intubation
- concurrent head injury
- respiratory failure
- cord injury > C6 (phrenic nerve)
- 40% of patients with lesions at C3 will require longer term mechanical ventilation
- 15% of patients with lesions at C4 or C5 need longer term ventilatory support
- associated chest injury
- aspiration
Options
- get skilled assistance if assessed as potential difficult intubation
- orotracheal intubation with manual in line stabilisation (as described above)
- the method of choice – high success rate
- safe if performed properly
- causes more movement in the upper Cx spine than the lower spine
•video assisted intubation
- use whenever possible
- associated with less neck movement than traditional orotracheal intubation
•use an ETT over a bougie technique
- may result in less Cx spine movement
- only the posterior cords need to be visualised to pass the bougie, whereas most of the cords need to be seen to pass the ETT under vision
- fibreoptic assisted nasal intubation
- cricothyroidotomy
- not required routinely
- does not cause significant movement in the unstable spine
- movement greater at lower spine than upper
- tracheostomy
- retrograde intubation
- blind nasal intubation
-contra-indicated as very difficult to perform without head movement
RSI: Maxillofacial trauma
Maxillofacial trauma
- may be uncooperative
- may obstruct when sedated or following analgesia
- hypoxic
- bleeding
Techniques
- get skilled help!
- fibre-optic intubation may be safest (oral route after topical LA)
- consider option of intubation in theatre with surgeon nearby
- RSI
- adequate suction vital
- good laryngoscopes x 3
-may fail if covered with blood
•prepare for a surgical airway
Deformed facial anatomy
- large mask size
- assistant to compress cheek or seal defect if open wound
- laryngeal mask
- rapid sequence induction
- surgical airway if not successful
Facial burns
- intubate early as severe oedema may develop
- nasotracheal intubation - using fibreoptic laryngoscope is the method of choice if airway compromise already present
Lateral canthotomy
Lateral canthotomy
- surgical procedure used to compress the orbit
- if intraocular pressure > retinal artery pressure for more than 2 hours, the retina will start to be permanently damaged
- rarely required
- most common situations are post-traumatic
- other situations
- infection
- tumour
- spontaneous haemorrhage
INDICATIONS:
-increased intraorbital pressure causing compromise of the retinal blood supply
-visual loss
-afferent pupillary defect
-proptosis
-hard globe on palpation (IOP > 40 mmHg)
•anatomy
- medial and lateral canthal ligaments prevent globe from extrusion from the orbit
- originate medially and laterally from bony wall
- Y shaped and divide on the surface of the globe into inferior and superior ligaments
•procedure
- local anaesthetic infiltration of lateral canthus
- incise skin over lateral canthus towards bony orbit
- retract lower lid
- divide inferior lateral canthal ligament
- divide superior lateral canthal ligament if pressure does not drop sufficiently
DROWNING - Pathophysiology
Phases
- voluntary breath holding
- involuntary laryngospasm secondary to liquid in oropharynx / larynx
- hypoxia, hypercarbia, acidosis
- may swallow large amounts water
- active respiratory movements but no gas exchange because of laryngospasm
- worsening hypoxia results in laryngospasm abating
- subsequent active breathing of liquid (volume very variable)
- changes in lungs, body fluids, acid-base and electrolyte balance
- washout of surfactant, pulmonary hypertension and shunting contribute to hypoxia
- additional changes if immersion is in cold water
- tissue hypoxia leads to multi-organ dysfunction and death
Pathophysiology
- abnormal gas exchange induced by pulmonary injury
- results in
- severe hypoxia
- cerebral oedema
•previously estimated that 10% of human drowning victims die without aspirating liquid
-this has now been challenged as water was found in 99% of cases in a large study of drowned victims
•absence of water aspiration at autopsy probably means the death was not due to drowning
-water does not passively seep into lungs after death
•aspiration of other material may occur
- vomit
- sand
- mud
- algae
•arterial oxygenation is profoundly affected when as little as 1 to 2.2 mL/kg of water are aspirated
-aspiration of water results in persistent hypoxia even if ventilation and circulation is restored
•the end result of drowning in both fresh or sea water is
- pulmonary oedema
- decreased pulmonary compliance
- increased V/Q mismatch
- most drowning victims do not aspirate enough fluid to cause life-threatening changes in blood volume
- life-threatening changes in serum electrolyte concentrations seldom seen, regardless of the type of water
-except in the Dead Sea!
- significant changes in Hb / Ht and renal function are rarely seen
- most drowning victims suffer a period of unconsciousness due to cerebral hypoxia
- patients who are awake and oriented on arrival in ED survive neurologically intact if management of pulmonary complications are successful
- patients who present in coma have a worse prognosis
- effectiveness of cerebral resuscitation measures need further evaluation in drowning
DROWNING Prognosis
Prognosis
- no clinical score 100% accurately predicts which patients will survive the drowning event
- submersion time correlates with survival in some studies
- may be difficult to determine accurately
- 85% of survivors with good neurological recovery are submerged < 6 minutes
- 7.5% for 6–10 minutes
- 5% for 11–59 minutes
- <1% greater than 60 minutes
- > 10 minutes is considered a possible cut-off point for non-survival
- efficiency of initial resuscitation influences outcome
- water temperature no longer believed to influence outcome
- non-reactive pupils and a GCS of 5 on arrival in ICU are the best independent predictors of a poor neurological outcome
- 75% of survivors have good neurological outcome
Orlowski scale
- age < 3 years
- estimated submersion > 5 minutes
- no attempted resuscitation in the first 10 minutes after rescue
- coma on arrival at the ED
- metabolic acidosis on arrival with pH < 7.10
- outcome
- 90% chance of good recovery if < 3 of the above present
- 5% recovery if > 3 present
Glasgow coma scale
- patients with decorticate / decerebrate / flaccid response at 2 - 6 hours after rescue rarely survive or survive only with significant neurological impairment
- GCS of 5 = 80% risk of death / severe deficit
- patients with neurological improvement within 2 - 6 hours following rescue often recover with little or no neurological deficit
- 34% of comatose patients on arrival in ED die after presentation
- children comatose on arrival in ED
- 45% survive with normal brain function
- 15% survive with incapacitating brain damage
- 40% die
- patients with neurological improvement within 2 - 6 hours following rescue often recover with little or no neurological deficit
- time of first spontaneous respiratory effort
- if < 15 - 30 minutes after rescue, < 10% have significant neurological deficit
- if 60 - 120 minutes after rescue, 50 - 80% chance of sustaining serious neurological damage
Other prognostic factors
- on arrival in ED
- good prognosis
-spontaneous respiration and heart beat
•poor prognosis
- resuscitation duration > 25 minutes
- VT or VF on initial ECG
- fixed dilated pupils
- cardio or respiratory arrest
Prognosis in drowning and hypothermia
- patients with a core temperature > 33o C who have not ingested alcohol or other drugs and who do not make any respiratory effort < 40 minutes of rescue are unlikely to survive without significant brain damage
- in a study of 98 children with open water immersion and body temperature of < 34C, no child survived with good neurological outcome after > 25 min. of CPR
- chance of survival is related to rapidity of onset of hypothermia
-the more rapidly cooled = better chance of resuscitation
•water temperature rarely cold enough in Australia to provide protective effect from immersion
When CPR is likely to be futile
- water temperature > 6C and immersion time > 30 min
- water temperature < 6C and immersion time > 90 min
- submersion > 10 min without hypothermia (nearly all cases in Australia)
- persistent apnoea and asystole after 1 hour of post-rescue CPR provided not hypothermic
- serum K+ > 11 mmol/L
- blood is frozen
DROWNING - Assessment
HISTORY:
Precipitating event
- syncope
- seizure
- drugs / alcohol
- hyperventilation
- trauma
Type of immersion
- the type and temperature of the water
- the amount and type of water contamination
- time of submersion and removal, if known
- conscious state on removal from water
Prehospital care
- bystander resuscitation / details (who administered and method of CPR)
- time of EMS arrival and commencement of resuscitation
- vital signs and conscious state on arrival of EMS
- breathing spontaneously
- palpable pulse
- GCS
- vomiting during rescue or resuscitation (very common)
- transportation time
Past history
- epilepsy
- alcohol abuse
- drug ingestion
NAI
•consider non-accidental injury or neglect in children
DROWNING - MANAGEMENT
Management
•follow standard ACLS protocols
- chest compressions are ineffective in the water - immediately transfer to land or a boat
- attempt ventilation if unale to get patient out of the water
- consider additional initial ventilations as the injured lung may be harder to ventilate
Spinal immobilisation
•routine cervical spine immobilisation is not necessary
-potentially hazardous as vomiting common after drowning, particularly when CPR / ventilation provided
•immobilise if circumstances indicate trauma is likely
- history of diving
- use of a water slide
- motor vehicle crash
- signs of injury
- alcohol intoxication
•spinal injury in drowning is associated with clinical features of serious injury
Respiratory support
- focus of initial hospital care
- high risk of ARDS up to 72 hours following drowning
- alert, cooperative patients do not routinely require tracheal intubation
- intubate if pulmonary pathology does not respond to supplemental oxygen and CPAP
- if intubation required, support with controlled mechanical ventilation and PEEP
- use pressure-support ventilation starting at 10 cm H2O
- titrate CPAP or PEEP to maintain SpO2 ≥ 95%, using the lowest possible FiO2
Other pulmonary therapy
- antibiotics indicated if features of infection develop, guided by culture results
- consider antibiotics in paediatric pool drowning (due to aspiration of Pneumococcus in patient’s pharynx)
-although the evidence for efficacy is weak
- use broad spectrum antibiotics prior to culture results if submersion was in grossly contaminated water (e.g. sewerage)
- treat bronchospasm
- glucocorticoids ineffective for pulmonary complications in drowning
Circulatory support
•initial intravenous fluid therapy should be normal saline
-avoid hypotonic solutions
•hypovolaemia may be present following prolonged immersion, due to the hydrostatic pressure of the water on the body
-correct hypovolaemia but avoid excessive volumes due to the risk of pulmonary oedema
- monitor serum electrolytes
- invasive monitoring if concerned about intravascular volume
-prolonged inotropic support rarely needed
•consider ECMO if available
Cerebral resuscitation
- little research in this area
- restoration of spontaneous circulation a priority
- intracranial pressure management
- controversial area
- raised ICP may reflect hypoxic injury and treatment may not alter outcome
- consider ICP monitor if persistent coma despite correction of reversible causes
- target pCO2 25-30 mmHg if ICP raised
•induced hypothermia
- no convincing evidence for efficacy in drowning
- in the comatose patient with spontaneous circulation maintenance of T < 36C (as for post cardiac arrest) is reasonable
•other
- avoid hypoxia
- treat seizures
- prevent hyperthermia at all times
- maintain normoglycaemia
- insufficient evidence for other specific neuroresuscitative measures
Hypothermia
•manage according to standard protocols
