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OSCE Round 2 > SCBD > Flashcards

SCBD Flashcards

1
Q

Outline ALS in adult

A

Declare arrest. Team leader. Assign roles. Airway, CPR, scribe.
A/B: BVM, adjuncts. LMA/intubation. ETCO2.
CPR - 30:2, 1/3 depth chest, rate 100 / min, lower 1/2 sternum, full recoil. Frequent changes. Avoid interruptions. Mechnical CPR.
Defib and rhythm check when available. COACHED algorithim for safety.
Continue CPR, O2 away, All away, charging, Head/middle/bottom, Eval rhythm, Defib/disarm.
Shockable: shock. 2nd shock 1mg adrenaline, 300 mcg amiodarone after 3rd shock.
Non-shockable. Adrenaline 1mg then every 2nd cycle.

Principles: good quality CPR with minimal interruptions, early defibrilation, identify & treat reversible causes. Shared mental model / closed loop communication.

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2
Q

Reversible causes in arrest

A

Hypoxia (O2)
Hypovolaemia (IVT)
Hypothermia (warm)
Hyper/hypo kalaemia or calcaemia (VBG)

Tension pneumothorax (US)
Tamponade (US)
Thrombus (ECG, US)
Toxins (NaHCO3, ECG, Hx)

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3
Q

Modifications of ALS in pregnancy

A

Causes: PE, trauma, toxicology

Manual displacement of uterus
Contact paeds and O&G
Prepare neonatal equipment
Hysterotomy at 3 min

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4
Q

Newborn life support

A 
Not breathing, poor tone 
Warm and stimulate 
HR < 100, gasping or apnoea? 
IPPV, O2 monitor (1 min of life) 
HR < 100 
Check for leak, open airway. Increase PEEP. Start O2. 
HR< 60 —> CPR, 3:1. 100% FiO2 
Intubate / LMA. Venous access. 
HR < 60, give adrenaline. 0.5 mls 1:10,000 IV (27-37/40 give 0.25 mls)

Adjusted O2 sat target to minutes of life. 80-90% at 5 min.

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5
Q

Paediatric ALS algorithim

A

A&B: open, 2 resuce breaths. Adjuncts. LMA / intubation. ETCO2.
CPR. 15:2. 1/3 depth chest, lower 1/2 sternum, appropriate for age technique, full recoil. 100 / min. Minimal interruption.
Defib on. Assess rhythm. COACHED.
Shockable 10 mcg/kg adrenaline (0.1 mls/kg 1:10000) after 2nd shock. Amiodarone 5mg/kg after 3rd shock.

Oxygenation (mostly hypoxic arrest)
Temperature, BSL.
Trauma.

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6
Q

Bradyarrhythmia management

A

Stable —> whatever.

Unstable —>
No pulse —> CPR and ACLS
Pulse present, but SBP < 90, heart faiulre
TARGET: HR > 60 and SBP > 90
- atropine 600 mcg IV Q3-5 min, to 3 mg.
- Adrenaline 10-20 mcg. Infusion, 10 mcg/min

  • isoprenaline 2–5 mcg/min

Pacing - external, 30 mA and increase.

Address cause

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7
Q

Unstable tachyarrhythmia management

A

Pulseless —> arrest mx ACLS

Unstable - SBP < 90, chest pain, heart failure, altered mental status

  • syncronized DC cardioversion with sedation.
  • Amiodarone 300 mg IV over 20 min and repeat DCR, then infusion 900 mg/24 hrs.

Stable

  • Regular broad complex tachycardia. Amiodarone 300 mg over 20-60 min plus infusion. DCR if unstable.
  • irregular broad complex. AF with BBB or WPW. DCR.
  • TDP. Correct electrolyte abn, Mg 10 mmol / 20 min. Then infusion. Pacing. Increase rate - isoprenaline or overdrive pacing.
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8
Q

Management of anaphylaxis

A

Resus, monitoring
Adrenaline 500 mcg IM (0.5 mls 1:1000) (10 mcg/kg, 0.01 mls/kg 1:1,000)
IV / IO
O2. Adrenaline neb.
Saline 20 mls /kg (1L)
Rpt adrenaline IM. Then Adrenaline infusion (1mg in 1L, 5 mls/kg/hr = 0.1 mcg/kg/min)

IV magnesium 0.2 mmol/kg IV
IV hydrocortisone
ECMO

Discharge criteria. Anaphylaxis management plan. Education on epipen how and when to use. Update medical record. Medialert bracelet.

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9
Q

Management of haemoptysis

A 
Resus, monitoring. Staff PPE. 
Sit upright, high flow O2, nasal prongs.
CXR 
Early airway management - Intubation. 
- double suction. VL / DL. large ETT (bronch). 
- bougie (partial view). 
- selective lung intubation 
- foley catheter occlusion 
- double lumen ETT 
- head up, affected lung down. 
Rx hypovolaemia 
Rx coagulopathy, TXA. 
CT, bronchoscopy 
Definitive care 
- bronchial artery embolisation 
- bronchoscopy & adrenaline 
- surgery
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10
Q

Management of haematemesis

A

Resus, monitoring, PPE
Intubation for airway protection
- double suction. VL/DL. NGT.
Treat hypovolaemia/haemorrhage. MTP. Target SBP 80, Hb 70.
Reverse coagulopathy. TXA, Vit K, PCC, platelets.

Gastroscopy / laparotomy
Ceftriaxone 2g IV (cirrhosis & varices)
Ocretotide 50 mcg IV (varices)
PPI 80 mg IV (PUD)

Minnesota tube 
Selective angiography (varices)
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11
Q

Management of PPH

A

Resus, monitoring, PPE
Call obstetrics / mid
2 x IV access, bloods x-match
Hypotension - IVT —> blood

Fundal rub (tone)
Ergometrine 250 mcg IV/IM (tone) & oxytocinon 10 units IV
IDC (tone)
Vaginal exam - lacerations (direct pressure), inversion (replace), tissue (remove).
TXA 1g
OT arranged
Bimanual uterine compression

Reverse coagulopathy, keep warm
Prostaglandin analogues (carboprost)
Bakri baloon
Compress external abdominal aorta

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12
Q

Management of eclampsia

A 
Resus, mointoring 
Left lateral tilt 
Notify obstetrics / anaesthetics / OT
A/B - support airway, o2, adjuncts 
Manage seizure 
- Midazolam 10mg IV 
- Magnesium 4g IV over 10 min. Then infusion 1-2 g / hr 
— target Mg level 2-3 
- Repeat midazolam 10mg IV 
- consider ddx, trauma, BSL, tox

Manage HTN, target SBP down 20-30 mmHg, to < 160 mmHg

  • hydralazine 5-10mg IV, over 5-10 min, infusion 5mg/hr
  • labetolol 20 mg IV, repeated 5-10 min, infusion 20-160 mg/hr

Foetal delivery
ICU

Complications:
APO & cerebral oedema - caution fluids
HELLP - haemolysis, low platelets, coagulopathy

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13
Q

Management acute glaucoma

A

Acetazolamide 500mg IV
Analgesia titrated IV morphine
Antiemetic - ondansetron

Pilocarpine 2% 1 drop Q5 min for 1 hour
Timolol 0.5% drops 1 drop Q30 min
Latanoprost 0.05% 1 drop

Opthalmology
Laser iridotomy

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14
Q

DKA

A

1) Fluids. Reverse shock, reverse dehydration.
2) Reverse ketosis. Insulin infusion 0.1 units/kg/hr. Aim decrease 5 mmol/hr. Add dextrose when BSL 15.
3) Manage electrolytes - potassium, sodium.
4) seek underlying cause. Abx.
5) Monitor for complications - cerebral oedema. Respiratory decompensation. Hypokalaemia, hypoglycaemia.

Resus area. Hourly VBG, BSL & ketones. ICU disposition. Endocrinology.
DVT prophylaxis. NGT if ileus. Fluid balance, IDC.

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15
Q

Management of laryngospasm

A

BVM 100% O2 with PEEP, 2 handed, optimise position. Suction.
Pressure at larsons point (behind lobule of pinna)
Ventilate with PEEP.
Seepen sedation / anaesthesia
Suxamethonium 0.1-0.5 mg/kg, of 1-2mg/kg full dose. No IV access, 3-4 mg/kg IM.
- intubate

ICU, debrief, open disclosure.

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16
Q

Issues to address in sexual assault

A

Pt has control, confidential unless imminient harm to others

  1. Physical injuries
  2. Sexual encounter, risk assessment
  3. STIs and pregnancy, blood tests.
  4. HIV and Hepatitis B
  5. Follow up and when to seeking help

PEP: < 72 hrs, high risk exposure, high risk source (MSM, IVDU, HIV prev > 1%, sex worker)

17
Q

Management of snakebite

A
  1. First aid. Pressure immobilisation bandage.
  2. Resuscitation. Resus area, ABC. Mx respiratory failure, seizure, haemorrhage.
  3. Determine if envenomed. Hx, Ex, Ix. Immediate sympt, local symptoms. Neuro/myo/coagulopathy.
    - nil evidence. Remove PIB, recheck symptoms. Bloods at 1,6,12 hrs. DC in daylight.
    - Symptoms or abn bloods - antivenom and reapply PIB.
  4. Determine type of antivenom. Brown/Tiger if SW/SE. Otherwise 1 vial polyvalent or SVDK.
  5. Manage complications
    - antivenom - anaphylaxis
    - neurotoxicity - intubation
    - coagulopathy - FFP for life threatening bleeding
    - Myotoxicity - 1-2 mls/kg/hr UO, alkalinize urine.
18
Q

DDx coagulopathy in snake bite

A 
APTT and INR only —> black snake. 
Neuro/myotoxicity? 
- no —> brown 
- yes, early —> taipan
- yes, late —> tiger
19
Q

DDx myotoxicity in snake envenomation (raised CK)

A

Alone —> black snake (and coagulation abn)

Neurotoxicity

  • yes, early —> taipan
  • yes, late —> tiger
20
Q

DDx neurotoxicity in snake envenomation

A

Normal bloods —> Death adder

Myotoxicity & VICC

  • Yes, early - taipan
  • Yes, late - tiger
21
Q

Management of choking child

A

Effective cough —> cough, support and assess

Ineffective cough

  • Conscious —> 5 back blows, 5 chest thrusts, assess and repeat
  • unconscious —> open airway, 2 breaths, CPR 15:2.
22
Q

Management of drowning

A

A & C-spine: Intubate. Anticipate rapid hypoxia.
B: Anticipate difficult ventilation. Increase PEEP. Lung protective ventilation.
C:
DEFG - BSL, rx 2 mls/kg 10% dextrose
E - warming (avoid hypo/hyperthermia)

Assess for trauma
Assess for medical cause - seizure, long QT, hypoglycaemia
Assess for NAI / poor supervision

Retrieval to PICU

Support for family. Avoid prognostication. Safety of other children. Possibility of NAI
Debrief team.

23
Q

Poor prognostic indicators in paediatric drowning

A 
Submersion > 5 min 
Time to BSL > 10 min 
CPR on arrival to hospital 
GCS < 5 
Hypothermia < 30 deg 
pH < 7.1 on arrival
24
Q

Anticoagulation reversal

A

Apixaban/rivaroxaban

  • TXA
  • PCC 50 units/kg
  • Adanexet if available

Dabigatran

  • Idaruzimab 5g IV
  • Consider dialysis

Warfarin

  • Vitamin K 10 mg
  • PCC 50 untis / kg
  • FFP 150 mls
25
Q

Management of severe asthma

A 
Resus, monitoring, team, PPE
Salbutamol 10mg nebulised 
- IV if very poor air entry. 
Iptratropium 500 mcg nebulised 
O2 to maintain spO2 92-96%
Sit upright
Hydrocortisone 200 mg Q6H.

Magnesium 0.2 mmol/kg 20 min
Aminophyline 10mg/kg IV
Salbutamol infusion - if poor AE
Adrenaline if peri-arrest IM / infusion.

NIV - Titrate FiO2. Reduced WOB. PEEP 5. PS 10. Fast insp flow.

Intubation: oxygenation, permissive hypercapnoea. Avoid dynamic hyperinflation. VC, TV 6 mls/kg, RR 6. I short: E Long, not stacking. PEEP 5. Pressure limit off. PPlat < 30.

  • Monitor for: pneumothorax, hypokalaemia, dynamic hyperinflation, hypotension.

ICU: Heliox, volatile anaesthetic, ECMO.

26
Q

Head injury management

A
  1. Protect airway. Neuroprotective intubation.
  2. Establish diagnosis with imaging.
  3. Reverse anticoagulation
  4. Definitive care. Neurosurgeons / transfer.
  5. Seek and treat complications.

Intubation. C-spine immobilisation. VL to minimise movement. Avoid hypoxia. Avoid hypotension, SBP 110-160. Maintain BSL. Improve cerebral venous drainage. Low normal Co2. Head up.

CT brain & other trauma imaging when safe.

Reverse anticoagulation.

Retrieval / neurosurgeons.

Complications

  • seziures: IV benzos. Avoid relaxant.
  • hypoglycaemia
  • hyponatraemia with SIADH, monitor urine OP.
  • avoid fluctuations in ICP, adequate sedation and analgesia.
  • raised ICP: mannitol or hypertonic saline, hyperventilate.
27
Q

Laryngospasm management

A

BVM with PEEP and 100% FiO2, 2 hands.
Summon help.
Ventilate via BVM. Pressure at larsons point (2 person technique)
Deepen sedation, propofol / ketamine.
Muscle relaxant. 0.1-0.3 mg suxamethonium IV, or 1-2 mg/kg IV, or 3-4 mg/kg IM.
Intubate.

Open disclosure. Team debrief.
M&M. Documentation.

28
Q

Management of aortic dissection

A

Analgesia, morphine titrated 2.5 mg increments, to 15 mg / pain score < 5
Control HR & BP to reduce shear stress
1. Metoprolol 1-2 mg IV over 1-2 min, Q2 min, target HR 60-80
2. GTN 10 mcg/min IV, titrated to achieve SBP 100-120.

Definitive care

  • Ascending aorta: CTS - open graft
  • Descending: IR or vascular, agressive medical management, or stent / surgical if extending (external leak, end organ vessel, continuing dissection)
29
Q

Management of leaking abdominal aortic aneurysm

A

Resus, monitoring, 2x large bore IV
Urgent vascular

Analgesia: IV morphine 2.5 mg, to pain score < 5
Target SBP 90
MTP

Surgery - open repair (mortality 5%), endovascular repair

30
Q

Management of AMI

A

O2 tagert SpOw 92-96%
Analgesia - morphine 2.5 mg IV titrated
Nitrates: reduce O2 demand vasodilation. 300-600 mcg SL, infusion. Not if inferior / RV ro aortic stenosis).

Urgent cath lab activation

Anti-platelet
- aspirin 300 mg PO (mortality benefit)
- ticagrelor 180 mg PO (reduces reinfarction) (or clopidogrel if suspecting tripple vessel disease)
Anticoagulation
- Heparin (reduces reinfarction) 500 units IV

31
Q

Assessment of collapsed neonate

A

Vitals - tachycardia, tachypnoea, hypotension (shock), fever (sepsis), apnoea (resp, central)
Cyanosis, WOB - need for resp support (PEEP, IPPV)
Pale, cold (shock)
Fontanelle (raised ICP, CNS)
Cardiac murmur (TOF, VSD)
Femoral pulses (Coartation)
Lung ausc (focal creps - pneumonia, widespread pulmonary oedema)
Abdomen & testes- tense, distended, masses, hernia (intussusception, volvulus, torsion)

ECG: SVT 
BSL: hypoglycaemia 
CXR: cardiomegaly, pneumonia 
VBG: lactate (IEM, shock, sepsis) 
Bloods: Fbe, cultures, CRP 
Urine & LP
32
Q

Management of acute agitation

A

Verbal de-escalation, enlist help of family
Offer oral sedation
Show of strength
Physical restraint, 5 person, coordianated
Chemical retraint. IM midazolam 5-10 mg, IM droperidol 5-10 mg, IM olanzapine 10mg.

Evalulate for acute medical causes
Assess for comorbid medical illness
Determine need for admission

33
Q

Management of suspected spinal cord injury & neurogenic shock

A

A: C-spine immobilisation, NGT, ETT if resp failure, exagerated vagal response (unopposed parasymp)
B: paradoxical breathing, VC impairment, maintain O2
C: early IDC, vasodilation, adequate volume (haemorrhage if tachy), norad if not. Target SBP 100-120.
D: Temperature control, avoid bladder distension, monitor for errection
E: pressure area care

GIT - ileus (NGT)

Monitor for autonomic dysreflexia - bradycardia, HTN. Rx GTN/nifedipine and treat cause.

34
Q

Management of patient with crush injury

A 
A: No suxamethonium 
B
C: IDC, urine OP 2-4 mls/kg/hr. Consider alkalinisation. Renal dialysis. 
D
Electrolytes: treat hyperkalaemia

Limbs: compartment syndrome, fasciotomy, amputation
Anticipate DIC

OSCE Round 2 (6 decks)

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