SCBD Flashcards
Outline ALS in adult
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.
Reversible causes in arrest
Hypoxia (O2)
Hypovolaemia (IVT)
Hypothermia (warm)
Hyper/hypo kalaemia or calcaemia (VBG)
Tension pneumothorax (US)
Tamponade (US)
Thrombus (ECG, US)
Toxins (NaHCO3, ECG, Hx)
Modifications of ALS in pregnancy
Causes: PE, trauma, toxicology
Manual displacement of uterus
Contact paeds and O&G
Prepare neonatal equipment
Hysterotomy at 3 min
Newborn life support
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.
Paediatric ALS algorithim
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.
Bradyarrhythmia management
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
Unstable tachyarrhythmia management
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.
Management of anaphylaxis
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.
Management of haemoptysis
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
Management of haematemesis
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)
Management of PPH
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
Management of eclampsia
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
Management acute glaucoma
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
DKA
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.
Management of laryngospasm
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.
Issues to address in sexual assault
Pt has control, confidential unless imminient harm to others
- Physical injuries
- Sexual encounter, risk assessment
- STIs and pregnancy, blood tests.
- HIV and Hepatitis B
- Follow up and when to seeking help
PEP: < 72 hrs, high risk exposure, high risk source (MSM, IVDU, HIV prev > 1%, sex worker)
Management of snakebite
- First aid. Pressure immobilisation bandage.
- Resuscitation. Resus area, ABC. Mx respiratory failure, seizure, haemorrhage.
- 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. - Determine type of antivenom. Brown/Tiger if SW/SE. Otherwise 1 vial polyvalent or SVDK.
- Manage complications
- antivenom - anaphylaxis
- neurotoxicity - intubation
- coagulopathy - FFP for life threatening bleeding
- Myotoxicity - 1-2 mls/kg/hr UO, alkalinize urine.
DDx coagulopathy in snake bite
APTT and INR only —> black snake. Neuro/myotoxicity? - no —> brown - yes, early —> taipan - yes, late —> tiger
DDx myotoxicity in snake envenomation (raised CK)
Alone —> black snake (and coagulation abn)
Neurotoxicity
- yes, early —> taipan
- yes, late —> tiger
DDx neurotoxicity in snake envenomation
Normal bloods —> Death adder
Myotoxicity & VICC
- Yes, early - taipan
- Yes, late - tiger
Management of choking child
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.
Management of drowning
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.
Poor prognostic indicators in paediatric drowning
Submersion > 5 min Time to BSL > 10 min CPR on arrival to hospital GCS < 5 Hypothermia < 30 deg pH < 7.1 on arrival
Anticoagulation reversal
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
Management of severe asthma
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.
Head injury management
- Protect airway. Neuroprotective intubation.
- Establish diagnosis with imaging.
- Reverse anticoagulation
- Definitive care. Neurosurgeons / transfer.
- 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.
Laryngospasm management
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.
Management of aortic dissection
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)
Management of leaking abdominal aortic aneurysm
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
Management of AMI
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
Assessment of collapsed neonate
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
Management of acute agitation
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
Management of suspected spinal cord injury & neurogenic shock
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.
Management of patient with crush injury
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
