Resuscitation

Question 1

Management of severe asthma

Answer 1

Complications:
Breath stacking
Dynamic hyperinflation
-> tension pneumothorax
Anaphylaxis
Inadequate fluid resuscitation

Always disconnect the ventilator
Plateau pressure 30 (alveolar pressure)
Peak pressure high

Question 2

Modified PESI score

Answer 2

Age > 80
Sats < 90
Systolic < 100
PR > 110

If score > 0 then 9% risk of death

Question 3

The crashing tracheostomy patient

Answer 3

Call for help: ENT, anaesthetics

A: assess the tracheostomy, is it dislodged, is it bleeding

B: apply O2 to face and over tracheostomy site

C: core actions, remove cannula and suction tracheostomy, then deflate cuff if present, if unable to pass suction catheter and no improvement with deflated cuff may have to remove tracheostomy tube

T: Tube, remove tracheostomy, attempt intubation from above (use ketamine for awake look then paralysis of have good view) if unsuccessful then fibre optic of stoma, pass bougie and size 6 ETT, risk of creating a false tract/bleeding

Question 4

Bleeding tracheostomy

Answer 4

Causes: tracheoinnominate fistula, vessel erosion, granulation tissue

Steps
- suction to remove clots
- overinflate cuff to 50mls to provide tamponade
- remove cuff and provide direct pressure to bleeding site anteriorly
- correct coagulopathy

Urgent ENT input for consideration of vessel ligation.
Consider pulmonary causes for haemoptysis.

May have to intubate

Question 5

Massive haemoptysis

Answer 5

Causes:
Infection: mycobacteria, fungal, TB, lung abscess
Iatrogenic: bronchoscopy
Trauma: blunt injury
Neoplastic: bronchogenic carcinoma, pulmonary mets
Vascular: AVM
Coagulopathy
Vasculitis: wegeners
Pulmonary: bronchiectasis

Aims
1. Protect ventilation and oxygenation
2. Aggressive resus
3. Source control
4. Correct coagulopathy

ED approach:
1. Call for help, early involvement of anaesthetics, ICU, respiratory physicians, interventional radiology (surgeons)
2. 100% oxygen via NRB, large bore IV access and urgent group and hold to blood bank, mobile CXR
3. Assign assistant to suctioning and seat patient upright, if possible, until definitive airway established
4. If able to identify affected lung position this downwards
5. Early intubation and double lung ventilation with largest ETT possible
6. Transition to unilateral lung ventilation if expertise present
7. Concurrent resuscitation with blood products once available (crystalloid initially) – anticipate need for massive transfusion protocol activation
8. Correct coagulopathy
9. Urgent definitive management – bronchoscopy, angiography, surgery
10. ICU admission/retrieval.

Place limits of care, discuss with family, advanced care directives