Resuscitation & Shock - Exam 2 Flashcards
What is ET CO2? What is the goal in CPR?
a non-invasive technique that measures the partial pressure or maximal concentration of carbon dioxide (CO2) at the end of an exhaled breath, expressed as a percentage of CO2 or mmHg
ET CO2 CPR goal = least 10, 20 better
What is the goal of O2 saturation in resuscitation and shock?
SPO2 ≥ 95%
What are the 2 manual methods to open the airway? Which one should you NOT use with c-spine concerns?
jaw thrust
Chin lift :NOT with C-spine concerns
What are 4 airway adjuncts options? Which one is good for an intact gag reflex? Which one is a definitive airway?
Oropharyngeal Airway (OPA): NOT for intact gag reflex
Nasopharyngeal Airway (NPA): can use with intact gag reflex
Laryngeal Mask Airway (LMA):
**Endotracheal (ET) Tube -> a DEFINITIVE airway
What is the way to measure the correct oropharyngeal airway size?
measure mouth to earlobe to pick the correct size OPA
What is the purpose of an AMBU bag/Bag valve mask? What are the 3 indications?
To deliver positive pressure ventilation (PPV) to patient with insufficient or ineffective breaths
Hypercapnic or hypoxic respiratory failure
Apnea
AMS
What is the ideal way to bag someone? How hard should you squeeze the bag?
Ideal 2 people: 1 to seal, 1 to squeeze bag. Can attach to high flow oxygen
half squeeze -> watching for chest to rise
What is the normal size ET for a woman? man?
Woman: 7.5-8.0mm
Man: 8.0-8.5mm
What are the 2 different blade options for ET intubation? _____ and ____ are also used
MAC (curved): 3 or 4 MC
Miller (straight): 2 or 3 MC
bougie and Glidescope
What are the pros and cons of a MAC?
Less traumatic & less stimulation
Less of a view
Indirectly lifts epiglottis so less
likely to cause tachycardia or arrhythmias
What are the pros and cons of a Miller blade?
More traumatic & stimulating
More of a view
Directly lifts epiglottis so MORE
likely to cause tachycardia or arrhythmias - pediatrics
What are the 2 different NPPV options? When are they commonly used?
CPAP and BiPAP
Positive pressure airway support using PRESET volume/pressure of air inspired through face or nasal mask
Good alternative for COPD and pulmonary edema patients
What is the pt criteria need to be in order to use NPPV?
Patients need to be cooperative, alert & no cardiac ischemia, hypotension, or dysrhythmia
What is a CPAP? What level to start?
Positive pressure throughout respiratory cycle
5-15cm H2O and adjusted to response
What is a BiPAP? What are the starting values?
Different levels of pressure during inspiration and expiration
Start 8-10 H2O inspiratory, 3-4 H20 expiratory
_____ and _____ pt types are very good for BiPAP
Good for COPD with hypercapnia alone
and
mixed hypercapnic/hypoxemic
respiratory failure
______ is the MC way to ensure patent airway, prevent aspiration, & provide O2 & ventilation. **What should you do first?
Endotracheal intubation
**Pre-oxygenate all patients prior to intubation regardless of saturation with non-rebreather mask at max flow
How can you check that the ET tube is in the right place? How far should you insert in women? men? What should you do next?
once cords are visualized, pass the tube through and check placement with bilateral breath sounds and LACK of bowel sounds
can also note color flow and end tidal CO2
21cm in women, 23cm in men
confirm with CXR!!
What is the Mallampati score?
______ is the preferred method for securing the airway in the critically ill or injured patient. What is the order of events?
Rapid Sequence Intubation (RSI)
Simultaneous administration of induction (sedation) followed by neuromuscular blocking (paralytic) agent
How long should you pre-treat pts with O2 before RSI?
pre-oxygenate with 100% O2 for at least 3 minutes
What are your options for Induction (Sedation) IV Drugs? Which one is MC?
Etomidate (MC)
Propofol
ketamine
Etomidate is preferred is what 2 pt populations? Why?
good with hypotension or ICP pts (think stroke or increased ICP)
does NOT affect BP
______ is lipid soluble and acts on GABA
______ direct GABA activation
_______ NMDA receptor
Propofol: lipid soluble, acts on GABA
Etomidate (MC): direct GABA activation
Ketamine: dissociative anesthetic, NMDA receptor
_____ should be AVOIDED in hypotension but can be used in long term sedation
propofol
_______ is good in bronchospam or hypotension and is used in kids
ketamine
What are the 2 paralytic IV drug options?
Succinylcholine
Rocuronium
______ has a rapid onset and offset and messing with what electrolyte?
Succinylcholine:
K
What 3 circumstances should you NOT use succinylcholine?
Do NOT use in neuromuscular, rhabdo or burn pts d/t hyperkalemia
______ is a paralytic drug that has a longer duration of action, approximately 45 minutes. What pt population should you NOT use this in? What is the MOA?
Rocuronium
myasthenia gravis
nondepolarizing agent
How often should you give a rescue breath in adult CPR? How many compressions in 1 minute? **How deep should you push?
1 breath every 5-6 seconds
100-120 per minute
**2-2.4 inches
In an adult, with both 1 and 2+ rescuers what is the ratio for compressions to breaths?
1 rescuer: 30:2
2+ rescuer: 30:2
What is the compression rate for a child/infant? When should you start compressions in a child/infant? How many rescue breaths?
COMPRESSION RATE: 100-120 per minute
1 breath every 3-5 seconds
Pulse <60bpm add compressions
In an infant, for both 1 and 2+ rescuers what is the ratio for compressions to breaths?
1 rescuer: 30:2
2+ rescuer: 15:2
What is the compression depth for a child? infant?
child: ⅓ depth of chest
(2 in, 5 cm)
infant: ⅓ depth of chest
(1.5in, 4cm)
Draw the chart for CPR in an adult/child/infant
**What abnormal rhythms are considered shockable? What is the shockable rhythm algorithm?
VF/pulseless VT
In pVT/VF how many shocks are appropriate before drugs? Which drug is always given first? How many times can you give amiodarone or lidocaine?
2 shocks
1mg Epinephrine IV/IO q 3-5 minutes
only given 2x
What are the first and second line dosing for amiodarone? lidocaine?
amiodarone:
first dose: 300mg
2nd dose: 150mg
lidocaine:
first dose: 1-1.5mg/kg
2nd dose: 0.5-0.75 mg/kg
How long should you interrupt CPR for? How often should you check for pulse/rhythm?
10 seconds or less
every 2 minutes
What are the CI to amiodarone?
bradycardia, 2nd or 3rd degree heart block, cardiogenic shock
What are the Hs and Ts of ACLS?
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypoglycemia
Hypo/hyperkalemia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
______ disorganized depolarization & contractions of ventricle with NO effective pumping. What will it look like on EKG?
ventricullar fibrillation
No P or QRS waves, fine to course zigzag pattern
What are the differences between primary and secondary VF?
Primary: Sudden, unexpected VF without pre-existing heart failure or hemodynamic deterioration (no clear trigger)
Secondary: Consequence of established heart problem usually result of severe HF or cardiogenic shock
What are some causes of vent fib? Which one is MC?
MC: Severe ischemic cardiac disease +/- acute MI
Digoxin/Quinidine toxicity, chest trauma, hypothermia, hypo/hyperkalemia, mechanical stimulation, re-entry
coarse vent fib
fine vent fib
What is considered vent tachy? What is the usual HR? **What is the QRS axis showing?
3+ successive beats from ventricular ectopic pacemaker
Usually 150-200bpm; Regular rhythm
constant/wide QRS axis (>0.12 seconds)
What is the treatment for SVT?
tx with adenosine
What is the MC cause of vent tachycardia? Name 5 additional causes
MI & ischemic heart disease
HCM, MVP, hypo/hyperkalemia, antiarrhythmic OD
What is the tx for vent tachy with a pulse?
Amiodarone IV 150mg over 10 min (first choice)
What is the tx for unstable vent tachy? What is considered unstable?
synchronized cardioversion
hypotension, AMS, shock, acute heart failure, CP, no pulse!
vtach from the RIGHT ventricle
vent tachy from the LEFT ventricle
What is Torsade de Pointes? What is the BPM?
QRS axis swings from positive to negative w/ rate of 200-240bpm
What are the drugs that cause torsade de points? **What is the major one?
Zofran, Phenergan, Antipsychotics, FQ
**Antipsychotics
What is first line tx for torsade de pointes with a pulse? without a pulse?
1st: Magnesium Sulfate 1-2g IV over 60-90 sec → infusion
and transcutaneous pacing at 90-120bpm, correct hypokalemia
no pulse = SHOCK
What is the tx for refractory torsade de pointes?
Isoproterenol
What is considered PEA?
Pulseless Electrical Activity (PEA)
Electrical impulses w/o mechanical contraction of the heart
What are the big causes of PEA? what is the tx?
Hs and Ts: see previous card
PEA= give IV/IO DRUGS!! (epinephrine!)
PEA
organized rhythm without a pulse
rhythm can be anything
What am I? What is the tx?
Asystole
DRUGS!! epinephrine
What is considered 1st degree AV block? What are the causes? What is the tx?
Delay in conduction across AV node w/ PR >0.20 seconds (PR interval is 1 big box)
can be normal, ↑ vagal tone, digoxin toxicity, inferior MI
no tx required
What is 2nd degree AV block type 1?
Wenckebach
Progressive prolongation of PR until blocked → dropped beat → cycle repeats. Usually only 1 atrial impulse is blocked at a time
aka PR interval gets progressively longer until it drops
What are the causes of 2nd degree AV block type 1? What is the tx? Give both slow rate and unstable tx options
Inferior MI, digoxin toxicity, myocarditis, cardiac surgery
no treatment needed unless there are s/s of hypoperfusion
What is 2nd degree AV block type II? What does it indicate?
Infranodal disease w/ constant PR interval
w/ intermittent drops
aka PR interval remains the same length and will have absent QRS complexes randomly
Indicates significant damage to His-Purkinje conduction system
Is mobitz type I or II more dangerous? What can it progress to?
mobitz type II is more dangerous
Can progress to 3 degree block in anterior MI
What is the treatment for 2nd degree AV block, mobitz type II? What is the definitve treatment?
- Atropine* 0.5-1mg IV bolus q5min, titrate up to 2mg (max)
- Transcutaneous pacing placed & initiated (if atropine did not work)
- Transcutaneous Unsuccessful: Transvenous pacing via catheter
Definitive: Permanent cardiac pacemaker!
What is a 3rd degree AV block?
No AV conduction; P & QRS beat on own w/ no communication
aka the atrial and ventricles are doing their own thing and NOT communicating at all
What will a junctional 3rd degree block look like? What is the ventricular rate?
Ventricular rate of 40-60bpm originating above bifurcation of His bundle (SA node); Narrow QRS
What will a ventricular focus 3rd degree AV block look like? What will the ventricular rate be?
Ventricular focus: Ventricular rate <40bpm originating in bundle branch or Purkinje fibers; Wide QRS; Anterior MI
What is the tx for an unstable 3rd degree AV block?
Transcutaneous pacing till venous pacer placed, pacemaker
What is the tx for a stable 3rd degree AV block?
Stable:
Atropine* 0.5-1mg IV bolus q5min → titrate till 2mg if needed
Transcutaneous pacing
Pacemaker
3rd degree AV block
How does the pediatric airway differ from an adult?
Smaller, more anterior airway, larger tongue and epiglottis
What do you need to do in order to get the right airway alignment in a child?
Cushion behind the shoulders to get the right airway alignment
Chin lift and jaw thrust maneuvers
When bagging a pediatric pt, how many ml of air does a neonate and pediatric pt need? ____ is the needed tidal volume
neonate 240ml, pediatric 500ml
10-15ml
What type of blade is typically used in pediatric airway insertion? cuffed or uncuffed tubes?
typically miller blade with UNCUFFED tube in children less than 8
How often should a child be ventilated>
once every 3-5 seconds
_____ for size of tube and medication dosages in kiddos
Broselow tape
What is the SE of etomidate?
can cause myoclonus
How does pediatric RSI differ from adult RSI?
**Pretreatment: with Atropine 0.02mg/kg (max 1mg)
Infant <1yo prep for vagal bradycardia or septic shock/hypotensions
Child 5 or <5yo getting succinylcholine as paralytic
**In pediatrics, what induction medications require adjunct meds after intubation? Which one prefers hemodynamic stability? Which one requires higher doses in infants?
Etomidate -> preserves hemodynamic stability
Propofol -> requires higher doses in infants
What are the 4 RSI adjunct medications in kiddos? Also give drug classes
Sedatives (Anxiolytic):
Midazolam (Versed):Shorter acting
Lorazepam (Ativan):Longer acting
Analgesics:
Fentanyl: short acting and will NOT bottom out BP
Morphine: longer acting and may bottom out BP
What is a Brief resolved unexplained event (BRUE)?
A sudden, brief (<1 min), and now RESOLVED episode in an infant that includes 1 or more of the following:
-Cyanosis or pallor
-Absent, decreased, or irregular breathing
-Marked change in tone (hyper- or hypotonia)
-Altered level of responsiveness
must NOT have an explanation for the episode
What is the treatment for BRUE with low risk characteristics?
Don’t require labs or continued workup, can offer observation 2-4 hours
What are the criteria to be considered a low risk for having a recurrence or serious underlying disorder? Must meet ALL criteria
Age >60 days
If premature, born at gestational age ≥32 weeks and current postconceptional age is ≥45 weeks
Occurrence of only 1 BRUE (no prior BRUE, and BRUE did not occur in clusters)
Duration of BRUE <1 minute
No cardiopulmonary resuscitation (CPR) by a trained medical provider was required
No concerning historical features
No concerning physical examination findings
aka this was a one time thing and the kiddo does NOT have multiple events
Is there an association between BRUE and SIDS?
Educate the family there is no known association between BRUE low risk and SIDS
What is considered SIDS?
Sudden death of an infant <1 yo that remains unexplained after investigation and autopsy
What is the MC kiddo for SIDS?
MC: 2-4 months and 90% before 6 months
midnight to 8am
minorities and low socioeconomics
addicts
childcare settings
What are the 2 biggest risk factors for SIDS?
sleeping postition and maternal smoking
What are some prevention strategies for SIDS?
Supine position - back sleeping, firm surface, remove soft objects, no smoking, no cosleeping, avoid using car seat for sleeping, avoid overheating
What are protective factors for SIDS?
Breastfeeding
room sharing
pacifier use
immunizations
What are the likely causes of pediatric cardiac arrest?
Resuscitation of neonates/peds primarily HYPOXIA from resp arrest or shock syndromes
aka LUNGS are the problem in kiddos
What are the shock energy dosing in pediatrics?
1st shock 2J/kg
2nd shock 4J/kg
3rd shock greater than 4 but less than 10 (max 10J/kg)
How many times can you give amiodarone in kids ACLS? What should you NOT do?
can give amiodarone 3 times in peds (only 2 times in adults)
DO NOT DELAY AIRWAY for vascular access
_____ and _____ often corrects the problem in pediatric dysrythmias. When should you start CPR?
oxygenate and ventilate
If HR <60 → CPR!
What is the treatment for hypotension/shock in kiddos?
Epinephrine 0.01mg/kg
What is the treatment for vagal response/AV conduction in kiddos?
Atropine 0.02mg/kg
(repeat x1, Min dose 0.1mg, max single dose 0.5mg)
consider pacing in heart blocks, can still pace if the HR is slow
What is considered shock? What are the 4 categories?
Circulatory insufficiency → Imbalance between oxygen supply and demand of tissues
HYPOPERFUSION
hypovolemic
cardiogenic
distributive
obstructive
What is considered hypovolemic shock? What are the 2 MC causes?
Insufficient volume to circulate leading to
organ damage and eventually organ failure
Severe dehydration or blood loss
What is the presentation of hypovolemic shock? What is the highlighted finding?
**HYPOTENSION (SBP <90), hypoperfusion, tachycardia
What is the treatment for hypovolemic shock?
What is the initial fluid bolus in hypovolemic shock?
Initial resuscitation phase: 0.9% NS, 20-40ml/kg over 10-20 min
What is the fluids ratio in acute hemorrhagic shock?
Infuse 3x the estimated blood loss; 1L of isotonic crystalloids → blood products
______ is the ideal blood replacement in hypovolemic shock. **What is the ratio in trauma patients?
PRBC
PRBC: FFP: Platelet in 1:1:1
What vasopressors are given to hypovolemic shock pts after successful. resuscitation? What is the goal urine output?
Norepinephrine, Dobutamine, Dopamine
Goal: output 0.5ml/kg/hr
MAP 65-90
What is cardiogenic shock? What is the MC cause?
Insufficient cardiac output to meet metabolic demands of tissue/brain
acute MI
What is the more important diagnostic in cardiogenic shock? What is the tx? What is persistent hypotension?
EKG (MOST IMPORTANT): look for MI
Early Revascularization (PCI/Cath lab) is BEST
Norepinephrine, dobutamine, dopamine: increase pressure and contractility to improve blood flow
What is the tx for acute mitral regurgitation causing cardiogenic shock?
Nitroprusside to decrease afterload with dobutamine
What is septic shock? What is the MC cause? Will have evidence of _______
Dysregulated host response to infection
bacteria
evidence of decreased tissue perfusion (organ failure)
______ is the MC cause of ARDS
sepsis
What is the treatment of septic shock? What is the ideal O2 stat? What is the fluid rate?
high flow O2 keeping O2 >90%
30 mL/kg NS or LR
500mL q5-10min, often takes 4-6L
What is the abx used in septic shock?
vanc and Zosyn
What is the cause of neurogenic shock? ______ is needed to dx
Lesion or injury to spinal cord, cerivcal spine or TBI → loss of vascular tone
Body has trouble regulating blood pressure, heart rate and temperatute therefore decreased blood flow
CT or MRI to fully diagnose
What is the tx for neurogenic shock?
IV Fluids and Vasopressors with alpha-activity (increase sympathetic tone)
What are the 3 common causes of obstructive shock?
tension pneumo
pericardial tamponade
massive PE
**What are the 3 components of Beck’s triad?
hypotension, JVD, muffled heart sounds
What are the CI to peripheral IVs?
Phlebitis of extremity
cellulitis over site
potential or existing lymphedema or venous occlusive edema
traumatic injury PROXIMAL to insertion site
What areas on a kiddos should you try first before moving on to IO? Where are IO lines placed?
AC, hand, foot, scalp
proximal tibia: 1-2cm below tibial tuberosity
What are complications for IO access?
infection of bone (should remove IO device within 24 hours)
fat embolism
fractures
extravasation: the leakage of fluid, such as blood, lymph, or medication, from a blood vessel into the surrounding tissues
compartment syndrome
What are the 3 options for central line placement?
internal jugular
subclavian
femoral
Why would you want to place a central line?
in order to give medications, monitor central venous pressure, or insertion of transvenous pacemaker
