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Advanced life support > 12. Resuscitation in special circumstances > Flashcards

12. Resuscitation in special circumstances Flashcards

1
Q

What is the definition of hyperkalaemia and severe hyperkalaemia?

A
  • Hyperkalaemia is defined as K >5.5 mmol/L
  • Severe hyperkalaemia is defined as K >6.5 mmol/L
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2
Q

What are the causes of hyperkalaemia?

A
  1. Renal failure
  2. Drugs
  3. Tissue breakdown
  4. Metabolic acidosis
  5. Endocrine disorders
  6. Diet
  7. Spurious (e.g. pseudo-hyperkalaemia)
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3
Q

What ECG changes are associated with hyperkalaemia?

A
  1. First-degree heart block (PR >2s)
  2. Flattened or absent P waves
  3. Tall, tented T waves
  4. ST-depression
  5. S & T wave merging,
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4
Q

What are the principles of hyperkalaemia treatment?

A
  1. cardiac protection
  2. shifting K into cells
  3. removing K from the body
  4. monitoring serum K and glucose
  5. preventing recurrence
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5
Q

What are the main risks associated with hyperkalaemia?

A
  • Hypoglycaemia due to insulin-glucose
  • Tissue necrosis secondary to extravasation of IV Ca
  • Rebound hyperkalaemia following effects of drug wears off
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6
Q

How is mild hyperkalaemia (5.5-5.9 mmol/L) treated?

A
  1. Correct cause of hyperkalaemia and avoid further elevation
  2. Potassium binders to remove K from the body
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7
Q

How is moderate hyperkalaemia (6.0-6.4) treated?

A
  1. Insulin-glucose (10 units short acting insulin with 25g glucose IV over 15-30mins)
  2. Remove K from the body using K chelators or dialysis
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8
Q

How is severe hyperkalaemia (>6.5) without ECG changes treated?

A
  1. Seek expert advice
  2. Insulin-glucose
  3. Salbutamol 10-20mg nebulised
  4. K chelators or dialysis
  5. Commence continuous cardiac monitoring
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9
Q

How is severe hyperkalaemia (>6.5) with ECG changes managed?

A
  1. Seek expert advice
  2. Calcium chloride/gluconate for cardiac protection
  3. Insulin-glucose or salbutamol
  4. Consider dialysis at outset to remove K
  5. Continuous cardiac monitoring
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10
Q

What are the causes of hypokalaemia?

A
  1. gastrointestinal loss
  2. drugs
  3. renal loss
  4. endocrine disorders
  5. metabolic alkalosis
  6. magnesium depletion
  7. poor dietary intake
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11
Q

What ECG changes are associated with hypokalaemia?

A
  1. U waves
  2. T wave flattening
  3. ST-segment changes
  4. arrhythmias
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12
Q

What is generally considered the maximum safe rate of K infusion?

A

20mmol/hr

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13
Q

What are some causes and treatments for other types of electrolyte disorders?

A
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14
Q

What are general therapies that may be used in cases of poisoning?

A
  1. Acivated charcoal - may be effective against certain types of poisoning
  2. Whole bowel irrigation - effective against sustained-release enteric coated drugs, oral iron poisoning and ingested drug packets
  3. Urine alkalinisation - effective in mild cases of salicylate poisoning
  4. Haemodialysis - effective for drugs and metabolites with low molecular weight
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15
Q

What specific treatment is given for opioid poisoning and at what doses?

A
  • Naloxone
  • Initial dose 400mcg IV, 800mcg IM/SC, 2mg IN
  • Can be titrated up to max dose of 10mg in severe opioid toxicity
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16
Q

When may flumazenil be used for benzodiazepine toxicity?

A

When there is no risk or history of seizures

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17
Q

What specific treatments may be considered for severe tricyclic antidepressant toxicity?

A
  1. Sodium bicarbonate
  2. Aim for pH target of 7.45-7.55
18
Q

What specific treatments can be given for local anaesthetic toxicity and at what dose?

A
  • Lipid emulsion
  • 1.5mL/kg 20% bolus for up to 3 doses
  • 15mL/kg/hr infusion
  • Max dose 12mL/kg
19
Q

What specific treatments can be used for stimulant (e.g. cocaine, amphetamine) toxicity?

A
  • Small doses of IV benzodiazepines
  • GTN/phentolamine for cocaine-induced coronary vasospasms
20
Q

What are the feaatures of severe asthma?

A
  • History of near-fatal asthma attacks
  • Hospitalisation or emergency care for asthma in past year
  • requiring 3 or more classes of asthma medication
  • adverse behavioural/psychologial factors
21
Q

What are the features of asthma attacks of varying severity?

A
22
Q

What are the causes of cardiac arrest in severe asthma?

A
  • Severe bronchospasms and mucous plugging causing asphyxia
  • Cardiac arrhythmias caused by hypoxia, stimulant drugs or electrolyte imbalance
  • Dynamic hyperinflation during mechanical ventilation
  • Tension pneumothorax
23
Q

What are the treatments for severe asthma?

A
  • Salbutamol 5mg nebulised every 15-30mins
  • Nebulised ipratropium (500mcg 4-6hrly)
  • Steroids (prednsolone PO or hydrocortisone IV)
  • Magnesium sulfate 2g over 20mins
  • Aminophylline 5mg/kg IV loading, followied by infusion of 500-700mcg/kg/hr, maintain plasma theophylline level <20mcg/mL
24
Q

When should tracheal intubation be considered in severe asthma?

A
  • Despite pharmacological intervention, there is:
    1. deteriorating peak flow
    2. decreasing conscious level
    3. persisting/worsening hypoxia
    4. deteriorating respiratory acidosis
    5. severe agitation leading to poor complicance with oxygen mask
    6. progressive exhausion
    7. respiratory/cardiac arrest
  • Raised PCO2 alone is not an indication for tracheal intubation
25
Q

What modifications to ALS may be required in asthma?

A
  • Ventilation may cause dynamic hyperinflation of lungs. If this is the case, compression of chest wall with period of apnoea may be useful
  • Dynamic hyperinflation may increase thoracic impedence and so require greater shock energy
26
Q

What criteria are required for diagnosis of anaphylaxis?

A
  1. Sudden onset ad rapid progression of symptoms
  2. Life-threatening airway and/or breathing and/or circulatory problems
  3. Skin andor mucosal changes (flushing, urticaria, angioedema)
27
Q

What is the algorithm for initial management of anaphylaxis?

A
28
Q

When should samples of mast cell tryptase be taken in suspected anaphylaxis?

A
  • Minimum - one sample within 2hrs of reaction onset
  • Ideally - 3 timed samples:
    1. Sample 1 - as soon as possible
    2. Sample 2 - 1-2hrs after symptom onset
    3. Sample 3 - 24hrs after symptom onset
29
Q

What is the algorithm for managing refractory anaphylaxis?

A
30
Q

What modifications to CPR should be made in pregnant patients?

A
  • Left-lateral displacement of uterus to the left to minimise IVC compression, ideally using left lateral tilt
  • Ideally, obtain venous access above diaphragm
  • Prepare for emergency c-section early
  • Consider early tracheal intubation as risk of aspiration is high in pregnancy
31
Q

What are the principles governing emergency c-section according to gestational age?

A
  • <20 wkGA - Emergency c-section should not be considered as uterus unlikely to compress IVC
  • 20-23 wkGA - Initiate emergency c-section to allow resuscitiation of mother, fetus unlikely to survive
  • > 24wkGA - Initiate emergency c-section and try to save both fetus and mother
32
Q

What dose of TXA can be used for traumatic haemorrhage?

A

Loading dose 1g over 10mins followed by infusion 1g/8hrs

33
Q

What are clinical signs of tension pneumothorax?

A
  • Respiratory distress or hypoxia
  • Haemodynamic compromise
  • Absent breath sounds on auscultation
  • Chest crepitations
  • Subcutaneous emphysema
  • Tracheal deviation
  • Jugular venous distension
34
Q

What are the specific treatments used to treat tension pneumothorax?

A
  • Needle decompression - 2nd intercostal space midclavicular line or 4-5th intercostal space mid-axillary line ; use wide-bore non-kinking needle
  • Open thoracostomy
  • Clamshell thoracotomy
35
Q

What durations of submersion are associated with good and poor outcomes?

A
  • Submersion for 5-10 minutes associated with good outcomes
  • Submersion for >20 minutes associated with poor outcomes
36
Q

What modification should be made to ALS in drowned patients?

A

A, B:
* Give 5 initial ventilations

C:
* Pulse alone is poor sole indicator of cardiac output in wet cold drowned patients, use ECG and end-tidal CO2 as adjuncts as soon as possible
* Dry the patient’s chest before applying defibrillator pads
* Most drowned patients are hypovolaemic, give fluids as soonas possible

37
Q

What are the stages of hypothermia?

A
  1. Stage 1 - mild hypothermia (conscious, shivering, core temp 35-32C)
  2. Stage 2 - moderate hypothermia (impaired consciousness without shivering, core temp 32-28C)
  3. Stage 3 - severe hypothermia (unconscious, vital signs present, core temp <24C)
  4. Stage 4 - death due to irreversible hypothermia (core temp <11.8C)
38
Q

What modifications should be made to ALS algorithm in hypothermic patients?

A
  1. Withhold cardiac arrest drugs until temp >30C at which point double normal drug intervals until >35C when normal intervals can be restored
  2. If initial VF, give up to 3 shocks but if unsuccessful, withhold further shocks until temp >30C
39
Q

What are the methods for rewarming patients in hospitals?

A
  1. Forced warm air
  2. Warm IV fluids
  3. ECMO
40
Q

What are the critera for heat stroke?

A
  1. Severe hyperthermia >40C
  2. Neurological symptoms including confusion, seizures, coma
  3. Exposure to high environmental temps or strenuous exercise
41
Q

What modifications need to be made to ALS algorithm post-surgery?

A

Use adrenaline in increments rather than full 1mg at once

42
Q

What modifications should be made in cardiac arrest post-cardiac surgery?

A
  1. Use adrenaline carefully
  2. If not responsive to 3 stacked shocks, for retrosternotomy and internal defibrillation of 20J

Advanced life support (15 decks)

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