Resuscitation in special circumstances Flashcards
How does acidosis affect serum potassium levels?
acidaemia causes an increase in serum potassium
List causes of Hyperkalaemia
- Renal failure
- Drugs (ACEI, ARB, Spiro, NSAID, BB, trimethoprim)
- tissue breakdown (rhabdo, tumour lysis, haemolysis, burns)
- Metabolic acidosis (DKA, renal failure)
- endocrine (addisons)
- spurious (clotted)
What ECG changes are seen with hyperkalaemia?
- Tall tented T waves (taller than R wave in more than one lead)
- short QT interval
- 1st degree AV block
- bradycardia
- ST depression
- flat or absent P waves
- Wide QRS
- Merging of S and T wave (sine wave pattern)
- VT
define mild hyperkalaemia. Treatment?
K5.5-5.9
address cause to correct (drugs/diet etc)
resonium
consider IV fluids
define moderate hyperkalaemia. Treatment?
K6-6.4, NO ECG changes
Shift K intracellularly - insulin 10U and 25g of glucose. monitor BSL. (onset 15-30min, max effect 30-60min, duration of action 4-6hr
remove K from the body - resonium
define severe hyperkalaemia. Treatment?
K>6.5
Seek help
ECG, if changes: 5-10mL 10% calcium chloride IV over 2-5min
shift K intracellularly - 10U insulin, 25g glucose. Salbutamol Nebs
Remove K from body - Resonium/Dialysis
consider IV fluids
Consider sodium bicarb 50mmol IV if severe acidosis or renal failure
Considerations for ALS during haemodialysis
ALS as normal
stop ultrafiltration (fluid removal)
fluid bolus
return patients blood volume and disconnect from the machine (some dialysis machines are defibrillator-proof tho)
leave dialysis access for drug admin
All Hs and Ts apply, but hyperK and APO are most common
What are the causes for hypokalaemia?
- GI losses (diarrhoea)
- Drugs (diuretics, laxatives, steroids)
- Renal (Renal tubular disorders, DI, dialysis)
- Endo (Cushings, hyperaldosteronism)
- Metabolic alkalosis
- magnesium depletion
- poor intake
Symptoms of hypokalaemia
- nerves and muscles mostly affected
- fatigue, weakness, cramps
- constipation
- in severe cases: rhabdo, ascending paralysis, resp muscle weakness
What are the ECG changes in hypokalaemia?
- U waves
- Flat T waves
- ST segment changes
- arrhythmias including AF, esp if on digoxin
Treatment of hypokalaemia periarrest and arrest?
Periarrest: 20mmol/hour or can go 2mmol/min for 10 min followed by 10mmol overe 5-10min
Arrest: 5mmol bolus followed by Mag 2g
giving Mg after K helps K uptake and maintenance of intracellular K particularly in the myocardium
Normal total calcium and ionized calcium levels? What is corrected Ca correcting for?
Total Ca: 2.2-2.6 mmol/L
Ionized Ca: 1.1-1.3mmol/L
corrected corrects for serum albumin
Causes of hypercalcaemia
- Primary or tertiary hyperparathyroidism
- Malignancy
- sarcoidosis
- drugs
Causes of hypocalcaemia
- chronic renal failure
- pancreatitis
- calcium channel blocker OD
- toxic shock syndrome
- Rhabdomyolysis
- tumour lysis syndrome
Causes of hypermagnesaemia
- renal failure
- iatrogenic
Causes of hypomagnesaemia
- GI loss
- polyuria
- starvation
- alcoholism
- malabsorption
Symptoms of hypercalcaemia
- Painful bones
- stones (renal and chole)
- abdominal pain (N/V/D)
- pysch tones
- cardiac - hypotension, arrhythmia, arrest
Symptoms of hypocalcaemia
- paraesthesia
- tetany
- seizures
- AV block
- arrest
Symptoms of hypermagnesaemia
- confusion
- weakness
- resp depression
- AV block
- arrest
Symptoms of hypomagnesaemia
- tremor
- ataxia
- nystagmus
- seizures
- TdP
- arrest
Treatment of hypercalcaemia
- IVT
- Frusemide
- hydrocortisone
- pamidronate
- treat cause
Treatment of hypocalcaemia
- CaCl 10% 10-40mL IV
- Mg
Treatment of hypermagnesaemia
- consider treating if >1.75mmol/L
- CaCl 10% 5-10 mL IV (can repeat)
- Saline diuresis with frusemide
- HDx
Treatment of hypomagnesaemia for different severities
- if severe or symptomatic 2g 50% Mg (8mmol) over 15min
- TdP: 2g 50% Mg (8mmol) over 1-2min
- seizure: 2g 50% Mg (8mmol) over 10min
What are the sepsis 6?
Give
- O2
- broad spectrum ABx
- fluid resus 250-500mL boluses to a max of 30mL/kg
Take
- blood cultures
- lactate
- urine output
Routes and doses of naloxone?
IV - 100-400mcg
IM - 400-800mcg
SC - 800mcg
titrate to effect to a total dose of 10mg
beware of precipitating opioid withdrawal
duration of action of naloxone is 45-75min, resp depression can occur for 4-5hr post OD, monitor need for ongoing Naloxone
What is the reversal agent for benzodiazepine overdose? What are the consideratons when using this drug
Flumazenil - cannot be used with history of seizures
can cause seizures, arrhythmia, hypotension and withdrawal in pt with benzo dependence and co-ingsetion with proconvulsant meds (TCAs)
What are the symptoms and effects of a TCA overdose? Treatment?
hypotension, seizures, coma, arrhythmias
cardiac effects mediated by anticholenergic and sodium channel blocking effects producint a broad complex tachy
hypotension results from alpha 1 block
other anticholenergic effects - mydriasis, fever, dry skin, delirium, tachycardia, ileus, urinary retention
Consider sodium bicarbonate if ventricular conduction abnormalities aim pH 7.45-7.55 which increase protein binding and sodium load
Symptoms and treatment of local anaesthetic toxicity
Symptoms: Agitation, confusion, loss of consciousness, seizure. Cardiovascular collapse with sinus bradycardia, conduction block, VT
Once recognized control seizures and do normal ALS
if no circulatory arrest: treat hypotension/arrhythmia as normal and consider IV lipid emulsion
if circulatory arrest: normal CPR, give lipid emulsion (recovery may take >1hr). Propofol may not be used as a substitute
Lipid emulsion:
immediately: 20% lipid emulsion 1.5mL/hg over 1 min and infusion at 15mL/kg/hr
after 5min: can repeat bolus if ongoing cardiovasc instability (up to 3 boluses including the first all 5 min apart). Can double infusion rate to 30mL/kg/hr at any time after 5 min if indicated
do not exceed a cumulative dose of 12mL/kg
Why might SaO2 decrease in an asthmatic post-bronchodilator?
beta-agonists cause bronchodilation and vasodilation which initially increases intrapulmonary shunting
Management options for asthma
- oxygen aiming SaO2 >92%
- salbutamol 2x 5mg nebs at a time 20minutely
- Pred 50mg or HCT 100mg 6hourly
- ipratropium bromide 500mcg nebs 20minutely
- Mg 10mmol over 20minutes
- aminophylline
- ketamine/propofol/sevoflurane/paralysis
- NIV/Intubation
- ECLS
When should intubation be considered in Asthma?
the last line, best avoided
consider if:
- decreasing conscious state
- persisting or worsening hypoxaemia
- deteriorating resp acidosis
- agitation/confusion
- progressive exhaustion
- arrest
Define Anaphylaxsis
-acute illness with typical skin features (urticarial rash/erythema/flushing/angioedema) AND resp or cardio or GI symptoms
OR
- any acute onset of hypotension/bronchospasm/upper airway obstruction where anaphylaxis is considered possible
usually occurs within 30min but can take up to 2 hours to develop
Treatment for anaphylaxis
- Adrenaline 0.5mg IM (0.5mL of 1:1000) or a 0.3mg epipen to middle third outer thigh. rpt in 5min if no improvement
- steroids. oral pred 1mg/kg up to 50mg. HCT 5mg/kg up to 200mg
- IVT bolus
- if stridor or upper airway obstruction neb adrenaline
- if wheeze neb salbutamol
- if ongoing shock inotropic support
observe for biphasic reaction
When should mast cell tryptase be taken for anaphylaxis?
Ideally 3 samples
- ASAP
- 1-2hr post-onset (this one at a minimum)
- 24hr post symptoms
Modifications to ALS for pregnancy
- get help from O+G/neonatologist/anos early
- after 20/40 need to go left lateral if a firm surface (tilting bed/theatre bed) is possible. otherwise manually displace uterus to the L to avoid IVC access.
- if concern for IVC compression IV/IO needs to be above the diaphragm
- early ETT as increased risk for asp
- prepare for CS early
Reversible causes of arrest in pregnancy?
- Haemorrhage - Ectopic, abruption, praevia, uterine rupture, placenta accretia/incretia/percretia
- preeclampsia/eclampsia
- amniotic fluid embolism
- PE
- acquired or congenital cardiovascular disease
- drugs (from Mg in preeclampsia, LA toxicity)
Management of haemorrhage in pregnancy
- IVT/MTP
- TXA and correction of coagulopathy
- Oxytocin, ergometrine, prostaglandins, uterine massage
- uterine suture/pack/balloon
- IR to embolize
- surgery
What is the aim for the timing of a perimortem Csection. how does gestation effect need for CS and likelihood of infant survival?
- aim is to deliver within 5 min of arrest
- <20/40 doesnt need perimortem CS, foetus unlikely to compramise maternal CO and viability is not possible
-20-23/40 initiate PMCS for mothers viability, infant survival is unlikely
>24/40 initiate to facilitate survival of both
why do drowning victims experience diuresis?
Aspirated water exerts hydrostatic pressure which draws volume centrally, body interprets this as hypervolaemia and causes diuresis
they are usually hypovolaemic due to this
What submersion times are associated with good outcomes? bad outcomes?
duration <10min associated with a very high chance of a good outcome
>25min have low chance of a good outcome
define hypothermia, classify mild-severe
Hypothermia is a core body temp <35
mild 32-35
mod 28-32
severe <28
how should core body temperatures be taken?
Lower third of the esophagus
bladder and rectal temps lag behind this
how is ALS modified in hypothermia
delay drugs until CORE temp >30 as metabolism is slowed and can cause toxic plasma levels. between 30-35 double time intervals
Arrhythmias associated with hypothermia?
brady then AF then VF
What is “Afterdrop”?
the continued fall in core temp after removal from cold stress due to heat redistribution within the body
has been attributed to returning of cold blood due to peripheral vasodilation (when first reheated)
Treatment for hypothermia?
Rewarm with combination of external and internal techniques (warm air ventilation, warm IVF, warm peritoneal levage, baer hugger)
if core <32 and K <8 consider VAECMO
Describe the pathophysiology of malignant hyperthermia. triggers? Tx?
MH-susceptible (MHS) patients have genetic skeletal muscle receptor abnormalities that allow excessive myoplasmic calcium accumulation in the presence of certain anesthetic triggering agents. The specific mechanisms by which anesthetics interact with these abnormal receptors and trigger an MH crisis have not been defined, but appear to involve magnesium-induced dysregulation of calcium transport through the ryanodine receptor
Triggers= volatile anaesthetics and succinylcholine
Tx= dantrolene (works on RYR1 to stop Ca going from SR to muscle cell)
describe the pressure immobilization technique for a snake bite
- apply a bandage firmly and tight over the bite site a finger may not easily slide between the bandage and skin. a 10-15cm wide elasticized bandage is preferred but crepe or clothing will work
- apply a further bandage from distal (fingers/toes) to proximal covering as much of limb as possible (aim is to restrict lymphatic flow)
- split or sling the limb to further immobilize
Which spider bite is bad?
Funnel web
Red back and white tail rarely cause problems. dont pressure immobilize redback or white tail bites
Symptoms and treatment for funnel web spider bite
2 phases initially: - pain - tachy, HTN, vasoconstriction - perioral tingling, tongue fasciculation - profuse sweating, watery eyes, headache - copious secretions of saliva and bronchorrhoea - abdo pain N/V, gastric dilation - muscular twitching - dyspnoea, non cardiogenic APO - alt GCS Secondary: - worsening APO - shock - drop GCS - Apnoea
Treatment:
- pressure immobilization
- antivenom
- atropine for secretions
- intubate for resp failure and high ICP
- NGT for gastric dilation
- paralysis for ETT and fasciculations
What are the symptoms of irukandji syndrome? ( lots of jellyfish do this, they have only 4 tentacles and some are too small to be seen)
- mod sting pain
- severe cramping pain everywhere
- impending doom
- N/V
- dyspnoea
- sweating
- heart failure, APO, hypertensive stroke
treatment is supportive :(
These jellys only north of bundaberg/geraldton
Box jellyfish (Chironex Fleckeri) sting symptoms and treatment
- severe pain at sting site
- whip like marks on skin
- restless and agitated
- N/V
- Dyspnoea and trouble swallowing/speaking
- arrhythmia
- resp/cardiac arrest
- paralysis of the heart
Treatment:
- apply vinegar (dont do this in nontropical regions, can cause nematocyst discharge for some jellys making it worse. use hot water in nontropical regions)
- antivenom
- magnesium
- analgesia
- ventilation
What are some normal ECG varients in bariatric patients?
- low voltage
- LAD
- flattened inferior-lateral T waves, atrial enlargement, false positive criteria for inferior MI
