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CMT-uno > Shock/ACLS/Diagnostics > Flashcards

Shock/ACLS/Diagnostics Flashcards

1
Q

ABCDE algorithm

A

Airway
Breathing
Circulation
Disability
Exposure

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2
Q

How do I know the airway is adequate?

A

Patient is alert and oriented.
Patient is talking normally.
There is no evidence of injury to the head or neck.
You have assessed and reassessed for deterioration.

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3
Q

Signs and symptoms of airway compromise

A

High index of suspicion
Change in voice / sore throat
Noisy breathing (snoring and stridor)
Dyspnea and agitation
Tachypnea
Abnormal breathing pattern
Low oxygen saturation (late sign)

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4
Q

what is the most difinitive way to manage airway?

A

oral intubation

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5
Q

How to assess Breathing

A
  1. assess along with airway
  2. determine whether respirations are adequate
  3. determine if both lungs are working equally- auscultation, expansion, palpation, percussion
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6
Q

Percussion of pneumo vs hemo-thorax

A

hypo-resonant= hemothorax
hyper-resonance = pneumothorax

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7
Q

signs and symptoms of tension pneumothorax

A
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8
Q

ABCDE

Assess circulation

A

Ensure adequate tissue oxygenation and delivery and blood volume

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9
Q

What to do for circulation in trauma

A

STOP THE BLEEDING!
EXTERNAL HEMORRHAGE
Usually just need pressure
Coagulating agents (EX: Quikclot) may be helpful
Suture closed quickly (Don’t worry about cosmesis. You can re-do it later.)
Tourniquets on extremities. Try not to use for over 1 hour.

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10
Q

Blood pressure calculation

A

Systemic vascular resistence

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11
Q

What is the first factor to change in BP?

A

The SVR is the first thing to change. It will become higher.

Capillary refill can easily be assessed at the fingers or toes.
Delay of greater than 2 secondsshould be suspicious for blood loss, even if the BP is normal

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12
Q

Heart rate can be an indicator of hemorrhagic shock in about 50% of trauma patients

who are people that can fool you?

A

Children
Elderly—heart blocks, dysrhythmia, medication
Trained athletes
Pacemaker patients
Pregnant patients

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13
Q

when should you take manual BP?

A

All initial trauma BP should be MANUAL not automated.

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14
Q

what do you do if you cannot get pedal or radial pulse?

A

IO access - quickest is tibia

sternal and humeral also acceptable

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15
Q

what do you do if you give 1L of crystalloid (IV fluid) and the patient is still hypotensive

A

assume hemorrhage, GIVE WHOLE BLOOD

If you must givecomponent therapy, give 1:1:1 PRBC:FFP:PLATELETS

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16
Q

Permissive hypotension

A

just know basics for exam

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17
Q

What is a FAST

A

bedside echo

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18
Q

Sx of pericardial tamponade

A

Beck’s Triad is a common board exam question.
ECG Triad
POCUS Triad
Can occur with as little as 50-60cc of blood in the pericardium

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19
Q

Becks Triad

A
  1. hypotension
  2. JVD jugular vein distension
  3. muffled heart sounds
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20
Q

cardiac tamponade & pericarditis

ECG Triad

A
  1. Sinus Tachycardia
  2. low voltage
  3. electrical alternans
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21
Q

Causes other than hemorrhagic shock for hypotension

A
  1. neurogenic shock
  2. cardiogenic shock
  3. septic shock

slide 40

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22
Q

Trauma in Pregnancy

A

O negative mothers get RHOGAM

Fetal distress may be a sign of hemorrhage

Mothers will need a pelvic exam to check for blood. Possible premature labor and placental abruption.

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23
Q

ABCDE

Disability Assessment

A

Assess pupils
Level of consciousness
Response to stimuli
AVPU scale
Glasgow Coma Scale (GCS)

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24
Q

AVPU scale

A

Alert
Responsive to vocal stimuli
Responsive to painful stimuli
Unresponsive

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25
Q

if you see tracheal deviation and diminished breath sounds what do you think of?

A

tension pneumothorax

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26
Q

what to do when GCS less than 8

A

If not already done, intubate
Frequently repeat neuro exam and document
CT scan ASAP
Early neurosurgical consultation

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27
Q

ABCDE

Exposure

what to do

A

Remove all clothes & blankets
Thorough physical exam
Re-cover with warm blankets
Prevent hypothermia

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28
Q

If unresponsive to 1000 cc IVF begin

intravenous fluid

A

blood transfusion

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29
Q

Contraindications to NG tube placement in trauma

A

Severe midface trauma

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30
Q

Distributive Shock

General

A

Excess vasodilation and altered distribution of blood flow: decrease CO, decrease SVR, decrease PCWP

4 types

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31
Q

Distributive shock

4 types

A

Septic shock: look for signs infection; treat infection

Anaphylactic shock: IgE mediated; look signs allgergic reaction; treat allergy

Neurogenic Shock: acute spinal cord injury, anesthesia; fluids/pressors/steroids

Endocrine shock: adrenal insufficiency; IV hydrocortisone- does not respond to fluids/pressors

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32
Q

Obstructive Shock

general

A

Decrease blood flow due to physical obstruction of heart or great vessels- pressure decreases heart’s ability to pump blood

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33
Q

obstructive shock

Management

A

Oxygen, fluid resuscitation, inotropic support, mechanical support ( IABP)

Treat underlying cause:
Pulmonary emboli: CT PE protocol; heparin, thrombolytics
Pericardial tamponade: echocardiogram; pericardiocentesis
Tension pneumothorax: xray; needle decompression
Dissection: EFAST, CTA, TEE; surgical cx

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34
Q

Cardiogenic Shock

general

A

Decrease cardiac output, decrease perfusion, increase systemic vascular resistance (often increase respiratory effort)
Etiology: myocardial infarction, myocarditis, valvular disease, congenital heart disease, cardiomyopathy, arrhythmias

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35
Q

cardiogenic shock

presentation

A

Decrease cardiac output (with preserved volume; CVP 8-12, PCWP > 15), hypotension, vasoconstriction ( increase SVR)

36
Q

Cardiogenic Shock

Management

A

Oxygen, fluid resuscitation ( smaller amount bc not a volume problem), inotropic support (rx to increase cardiac output: dobutamine, epinephrine, amrinone), consider Intra-aortic balloon pump

37
Q

Hypovolemic Shock

general

A

Loss of blood or volume (hemorrhage/volume loss)
Etiology: GI bleed, AAA rupture, hemoptysis, trauma, ectopic pregnancy, postpartum hemorrhage, vomiting, bowel obstruction, pancreatitis, burns, diabetic ketoacidosis

38
Q

hypovolemic shock

presentaion

A

Tachycardia, hypotension, decrease urine output, pale cool skin/extremities, decrease capillary refill, poor skin turgor, dry mucous membranes, altered mental status (usually no assoc respiratory symptoms)

Vasoconstriction (increased SVR), hypotension, decrease cardiac output and decrease pulmonary capillary pressure

39
Q

hypovolemic shock

management

A

ABCDE, 2 large bore iv lines or central line, volume resuscitation, control source of hemorrhage, prevent hypothermia, treat coagulopathies
Universal blood is O-negative
Consider transfusion of whole blood

40
Q

Circulatory Shock

general

A

In adequate perfusion due to low cardiac output or low systemic vascular resistance

4 types of circulatory shock
Hypovolemic ( loss of blood or fluid)
Cardiogenic ( reduced cardiac output)
Obstructive (obstruction to circulation)
Distributive (maldistribution of circulation)

41
Q

Circulatory Shock

Presentation of shock

A

Due to inadequate perfusion/oxygenation will see altered mental status, decrease peripheral pulses, tachycardia, cool/mottled skin, hypotension

42
Q

circulatory shock

Management

A

Airway: assess
Breathing: reduce workload assoc with tachypnea ( +/- mechanical ventilation/sedation)
Circulation: fluid resuscitation ( NS/LR vs whole blood), monitor urine output, HR, BP
Delivery of Oxygen: ABGs, lactate levels
Endpoint of Resuscitation: urine output, HR, BP

43
Q

what does epi do

A

increases CO but decreases SVR

systemic vascular resistance

44
Q

glossary of terms

GDMT
OMT
EF
HFrEF
HFpEF
HEmrEF
RSVP

A

GDMT: Guideline-directed medical therapy
OMT: optimal medical therapy
EF: Ejection fraction
HFrEF: Heart failure with reduced left ventricular ejection fraction (EF≤0.40)
HFpEF: Heart failure with preserved left ventricular ejection fraction (EF≥0.50)
HFmrEF: Heart failure with midrange ejection fraction (EF<0.50 but >0.40)
RVSP: Right ventricular systolic pressure

45
Q

what is normal EF

A

55-65%

46
Q

Tests of perfusion

A

Treadmill ( bruce protocol)
Treadmill with MPS
Stress echo
PET
arteriogram

determine if the heart is getting enough O2

47
Q

Plain stress test or exercise stress test

A

Information about perfusion, chronotropic competence, METs, arrhythmia, exercise tolerance

look at ST on ECG - checking for blockage

bruce protocol- start walking w specific increase in incline and speed on treadmill

Lexiscan- medication you can give a pt that cannot ambulate to get HR up

48
Q

chronotropic competence/incompetence

A

Incompetence is the inability to get HR up to expected max (age adjusted)

49
Q

stress test

Instructions to patient:

A

hold BB/ CCB (diltiazem) 48 hours if treadmill, no caffeine 24 hours

50
Q
A
51
Q

Patient presents to stress lab for stress test. bp 220/100 hr-125 rr-16.

A

cancel stress test

52
Q

Patient presents to stress lab for plain treadmill r/o ischemia. Resting ECG reveals LBBB

A

contraindicated bc left bundle branch block could mask ST changes

they would need a stress test with imaging

53
Q

Patient presents for plain treadmill to evaluate for chronotropic incompetence. They did NOT hold their BB

A

stop test, reshcedule or switch to lexiscan

54
Q

Sress Echo

A

Information about heart valves and est RVSP (R ventricular systolic pressure)
Can look for ASD/VSDs ( bubble study)

test for perfusion

limited by larger body habitus

55
Q

tests for anatomy

6

A

Cardiac CTA
Heart Catheterization
Cardiac MRI
2-d echocardiogram (echo)
Transesophageal echocardiogram (TEE)
Cardiac MRA

56
Q

Cardiac CTA

A=angiogram

A

A coronary computed tomography angiogram (CTA) uses advanced CT technology, along with intravenous (IV) contrast material (dye), to obtain high-resolution, 3D pictures of the moving heart and great vessels

at time of test HR must be <60 - might give BB to pt
must be able to hold breath for 20 sec intervals

57
Q
A

cardiac CTA

57
Q

Alternative to stress echo

A

MPS- but has radioactive dye?

58
Q

Heart Cath

A

Dye exposure

LEFT heart cath
they go into artery usually femoral or radial, then put puffs of due to look at all the arteries

Right cath
looks at hemodynamics of the heart, checks pressures of ventricles and atria, does not go into arteries

59
Q

Flow wire (FFR) heart cath

A

put wire in that checks pressure where there are lesions in vessels to it it is hemodynamically significant

60
Q

Heart cath intravascular ultrasound (IVUS)

A

get US of actual lesion inside vessel/heart

61
Q

Left heart cath PROs

A

PRO:
99.9% accurate “the dye don’t lie”
Can evaluate anatomy and perfusion, details of lesion
Quick turn around/ immediate interpretation
Final stop- can determine +/- “fix” while there

62
Q

What do you do for following findings in patient pending heart cath?
A- GFR 45, creat 1.9 on metformin and ace?
B-severe hx peripheral artery disease with decreased femoral pulse
C- allergy to contrast dye
D- patient on warfarin/apixaban
E- patient on asa and Plavix daily

A

A- hold metformin/ace 48 hours, pre hydrate NS, watch creatinine for spike first 48 hours, NO LV gram- no dye exposure! ( can get echo to evaluate LV)
B- notify surgeon, evaluate other access sites esp radial arteries vs L groin
C- what is allergy? Pre medicate
D- when was last dose? Why are they on it/ can it be held?
E-do nothing, they can continue meds

63
Q

after stent placement pts are prescribed for a year

A

dual antiplatelet

64
Q

When will I order a LHC? Left heart cath

A

-STEMI/ACS
+ ischemia on stress test
+ >80% lesion on CTA
Pre-valve work up
If you have high suspicion for blockage- this is the only was to “fix” it

65
Q

Right heart cath

A

Measures pressures in the chambers of the heart:
RA: right atrial pressure
RV: right ventricular pressure
PA: pulmonary artery pressure
PCW: pulmonary capillary wedge
LA: left atrial pressure
LV: left ventricular pressure

66
Q

Echocardiogram

A

for anatomy of heart and perfusion

Trans thoracic ( TTE) vs trans esophageal (TEE)
Ultrasound to evaluate the heart tissues ( muscle and valves) and their movement

MOST ACCURATE TEST for ejection fraction (EF)

67
Q

Cardiac MRI
magnetic resonance imaging

A

Imaging for anatomy of heart

information re cardiovascular tissue/muscle (congenital defects, valves, vasculature), muscle function (inflammatory) and tumors
May be used for pre-procedural/surgical “mapping”

68
Q

55 yo male referred after work up for syncope revealed significant left ventricular hypertrophy on echo with severe diastolic dysfunction- no valvular disease, ef 65%
What test do you order to find out more about his muscle?

A

Cardiac mri

worried about amloidosis

69
Q

Cardiac MRA

A

seen in stroke protocol, no radiation, with or w/o dye

information about vessels not muscle or tissue

70
Q
A
71
Q

Test for electrophysiology

5

A

ECG
Telemetry
Ambulatory Electronic monitoring (AEM)
Treadmill
EP study

72
Q

telemetry

A

Continuous tracing usually 2-5 leads
Primarily for arrythmia detection but can see ST segment

73
Q

Ambulatory Event Monitoring

A

Worn by patient for period of time
Can be continuous or triggered
Duration 24 hours-4 weeks
Important to order correctly based on symptoms
Keep in mind skin sensitivity

74
Q

29 yo presents for episodes of palpitations 2-3 hours in duration 1-2 x a week. Most conclusive initial test:
1- ECG
2- AEM 48 hours
3-AEM 30 days
4- refer for EP test

A

3-AEM 30 days

75
Q

Treadmill

A

perfusion and electrical
Ecg tracing during test will show heart rate variability, exercise/rate induced changes
Important concept: patient terminated vs technician terminated

76
Q

EP study

A

advanced invasive testing of electrical system of the heart performed by EP
Can perform mapping, induce arrythmias
Requires venous access

77
Q

Arterial Brachial Index (ABI)

A

Looking for peripheral arterial disease
if range is .7 or less refer to cardio
if mild you treat with asa and statan

78
Q

58 yo female presents with complaints of R buttock burning when she walks. PMHX: DM, HTN, elevated BMI. Improves with rest, worsens w activity. No trauma/injury. Physical exam unremarkable
1- ultrasound lower extremities
2- CTA
3- arteriogram
4- ABIs

A

4- ABIs bc non invasive

79
Q

62 yo Male pmhx: htn, tobacco, fam hx AAA presents for yearly follow up. you note enlarged abdominal aorta on physical exam.
1) echo
2) CTA
3) abdominal ultrasound
4) mra

A

3) abdominal ultrasound

80
Q

84 yo presents visual disturbances. Reports intermittent “blind spots” resolve spontaneously. Just had eye exam and told normal. Pmhx: HTN ( diet), arthritis. No Rx. VS WNL. On physical exam R carotid bruit
1- MRA
2-CTA
3-carotid doppler
4-coronary calcium score

A

3-carotid doppler

81
Q

Patient PMHx CAD, HTN, HLP presents for follow up stress test results. Asymptomatic with no complaints MPS report reads:
10 minutes of bruce protocol , 12 METS , no CP, no ecg changes. Nl vs. No reversible ischemia with global hypokinesis EF 40%.

What do you do?
1-tell them test results look good. Continue tlc/rx
2-send for heart cath
3-order echocardiogram
4-order MUGA

A

3-order echocardiogram
Asx but echo to check EF

82
Q

what do you need to know

You need to be comfortable with when to/not to/how to order: plain stress test, stress test w imaging ( MPS/stress echo), echocardiogram, heart cath
* if echocardiogram shows hypertrophy ( > 1.5mm) and you need to rule out infiltrative disease order MRI
* to concretely r/o blockage need heart cath
*echo is starting place to work up valves/murmurs

A
83
Q

62yo pt pmhx: HTN, DM presents yearly ov. No complaints. Rx: lisinopril 10 mg po BID, metformin 500 mg po bid. Vs: 148/90, 88, 16. on physical exam you hear a II/VI crescendo decrescendo murmur.
1-ECG
2- stress test
3-echo
4-stress echo

A

3-echo to check valves

84
Q

56 yo male CAD hx PCI last year, HTN, HLP, DM, + tobacco presents with exertional chest wall discomfort , assoc DOE, DAT. No symptoms at rest. Rx: asa 81mg daily, atorvastatin 40 mg hs, metoprolol 50 mg po bid, metformin 500 mg po bid. Vs: 128/72, 68, 16. physical exam: WNL
1- ecg
2-stress echo
3-stress MPS
4-heart cath
5-troponin
*any instructions to the patient?

A

2-stress echo- if blockage found then heart cath

not MPS because probably took metropolol that day, could do lexiscan

stable angina

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