Action steps

Question 1

Intraop actue hypoxia actions

Answer 1

1. check the color of the patient
2. check for a pulse
3. Check all vital signs
4. check for ETCO2
5. Take the patient off the ventilator and hand bag with 100% O2
6. Call for help
7. check the o2 monitor, peak airway pressure, and capnograph waveform
8. listen to the chest for bilateral breath souds. note chest rise (unilateral breath sounds: ETT is too deep, PNX, or tension PNX)
9. evaluate the ett. rule out kinking, mucus plug, herniated cuff. Pass the suction catheter or fiber optic scope. Check fro proper placement and position
10. listen to the chest for wheezing. give aerosolized albuterol for wheezing
11. if you thnk that the patient has bronchospasm, deepen the anesthetic
12. if deepening the anesthetic does not treat the bronchospasm, give IV epinephrine
13. order a chest x-ray

Question 2

Approach to reading EKGs

Answer 2

Rhythm: sinus or non-sinus

Regularity: regular or irregular

P wave: generated by atrial depolarization, best in lead 2 and V2, should be 2.5mm long and 2.5mm high

PR interval: generated by conduction fo the elctrical impulse through the atria and the AV node. should not be longer than 0.2 sec (5mm). 2nd degree type 2 and 3rd degree heart block require pacing

Q wave: should not be longer than 0.03 sec (could be sign of prior transmural infarction

QRS complex: ventricular depolarization and contraction: normal duration up to 0.12 seconds. Longer duration sign of hemi-block in the His bundles.

ST segment should be isoelectric. If depressed there is myocardial ischemia. If elevated there is myocardial necrosis. This is measured by the computer on the monitors and we need to take them seriously. Most sensitive lead for diagnosis of ischemia is V5. Next most sensitive lead is V4.

T wave: ventricular repolarization: should not be longer than 0.2 seconds. Should be concordant with total amplitude of QRS complex.

Axis: normal values range between -30 and +110 degrees. Look at the total amplitude of lead 1 and lead aVf. The vector of these 2 leads is where the axis lies.

Question 3

Anticipate massive blood loss

Answer 3

Large bore IV access
Large bore central introducer
Rapid transfuser and blood warming devices in room
10-15 units RBCs and 5 units FFP in room with additional in blood bank
Plan for intraop cell salvage
Discuss further possible interventions with surgeon: acute normovolemic hemodilution, administration of antifibrinolytic, such as aminocaproic acid or tranexemic acid.

Question 4

QI Steps

Answer 4

-Measure current outcomes and benchmarks if appropriate
• Devise change in practice in collaboration with stakeholders if appropriate
• Educate and train clinicians regarding change in practice as appropriate
• Implement change in practice
• Measure outcomes after change in practice

Question 5

Hypernatremia action steps

Answer 5

H&P: current meds, mental/neuro exam, determine volume status and water intake, signs and symptoms: thirst, diaphoresis, sweating, vomiting, polyuria

Measure urine osmolality, sodium concentration, integrity of ADH-renal system: urine osmolality should be 700-800 and additional ADH should not increase it.

Causes of hypernatremia with Uosm 700-800: unreplaced insensible loss: urine sodium concentratin should be less than 25 mEq/L, GI losses: urine sodium concentration should be less than 25 mEq/L, sodium overload: urine sodium concentration above 100mEq/L, defect in thirst: rare

If urine osmolality (Uosm less than 300 mOsm/L) is lower than plasma osmolality: consider diabetes insipidus

Administer ADH to distinguish between nephrogenic and central diabetes insipidus: give 10 mcg nasal synthetic desmopressin (DDAVP) or 5 units vasopressin subcutanesously.
Nephrogenic: little or no response to ADH
Central: appropriate increase in Uosm by greater than 50%
Consultation with nephrologist, endocrinologist, or neurologist to aid in diagnosis of diabetes insipidus

Measure urine solute concentration to confirm osmotic diuresis: gulcose and urea

Question 6

PSVT treatment

Answer 6

vagal maneuvers
adenosine 6mg rapid, followed by second and third dose if needed at 12-18mg per bolus
verapamil 2.5-10mg IV
Amiodarone 150mg infusion over 10 min
esmolol 1mg/kg volus IV and 50-200 mg/kg/min infusino
edrophonium 5-10mg IV bolus
give phenylephrine 100mcg IV if the patient is hypotensive
digoxin 0.5-1.0 mg IV
rapid overt pacing ina n attempt to capture the ectopic focus
Synchronized cardioversion in incremental doses of 50, 100, 200, 300, 360 joules; this shol dbe done immediately if the patient is hemodynamically unstable.

Question 7

treatment hypernatremia

Answer 7

determine volume status:
hypervolemia: diuretics and hemodialysis may be necessary

Free H2O deficit (in L of H2O) = {(plasma Na/140)-1} x kg x 0.6 in males (0.5 in females)

Goal less than or equal to 145
Replace half the deficit in first 24 hours, then other half over 2-3 days
Use 5% dextrose in water or 0.45% NaCl to correct the deficit
Monitor serum sodium every 1-2 hours to ensure a gradual correction (should not exceed 0.5 mEq/L per hour)

Question 8

treatment of diabetes insipidus

Answer 8

DDAVP
IV dosing 2-4 mcg, 1-2 times per day
Nasal spray 10-40mcg 1-2 times per day

Titrate to urine output, serum sodium, osmolality

Low Na diet
Low-dose thiazide diuretic
Carbamazepine: enhances vasopressin secretion
NSAIDS: impair renal prostglandin syntehsis, potentiate ADH action resulting in incrased urine osmolality and decreased urine volume.

Question 9

How would you awake intubate and induce this patient

Answer 9

I would

• optimize asthmatic condition with inhaled b-agonist
• provide aspiration ppx
• administer antisialogogue
• ensure adequate IV access, presence of fluids, emergency medications, difficult airway cart
• surgeon in room?
• place patient in position most comfortable (supine if no anterior mass etc)
• cannulate the femoral arteries with CPB on stand by
• provide adequate airway analgesia
• administer ketamine or dexmedetomidine
• eval airway with fiberoptic scope
• intubate with fiberoptic scope
• perform inhalational induction

Question 10

laryngospasm action steps

Answer 10

I would:
suction the airway
apply positive pressure mask ventilation
deepen anesthetic by...
administer IV propofol (lido if spont resp)
forceful jaw thrust
call for help
succinylcholine if no contraindication
attempt to pass ETT through closed vocal cords

Question 11

how will you induce cabg patient

Answer 11

assuming his airway were reassuring i would
place appropriate monitors

position in reverse t to improve resp mechanics, faciliate rapid intubation and reduce risk of passive regurg

note bseline cardiac function

preox with 100% fio2 and tight mask seal

provide aspiration ppx and apply cricoid pressure

induce with x meds and high dose of narcotics to avoid cv depression

intubate the patient

goals to provide a sufficient level of anesthesia to blunt the sympathetic response to intubation, while matinaining hemodynamic stability and safely securing the airway

Question 12

acute hypotension after induction action steps

Answer 12

i would
100% o2
ensure adequate vent and oxyg
auscultate the chest
verify the BP
check the ekg
confirm ETT position
obtain filling pressure and CO from PA cath
check electrolytes

decrease volatile
fluid bolus
tburg
small dose direct acting vasopressor

treat conservatvely if concern from tachycardia/htn

Question 13

how prepare to wean off cpb

Answer 13

ensure normothermia
correct any anemia, electrolte abnormalities/metabolic disturbances
turn on and check alarms and monitors
recalibrate and zero transducers
check lung compliance and initiate ventilation
snure the heart is de-aired
ensure adequate cardiac function using TEE and other hemodynamic data
administer benzos to preven awareness during reqarming
ensure availability of pacing device and resusciation drugs
during warming closely onitor cardiac fxn and administer inotrops and vasoactive drugs as necessary

Question 14

manage intraop malignant hyperthermia

Answer 14

I would:
call for help
call the MH hotline
discontinue all triggering agents
change to a clean circuit (new machine or O2 tank with ambu bag)
hyperventilate with 100% o2
start IV dantrolene 2-2 mg/kg IV bolus q5min up to 10 mg/kg, then start an infusion of 1-2 mg/kg/hr

monitor and treat acidosis with sodium bicarbonate
cool the patient aggressively with cooling blankets, cold IV NS, cold body cavity lavage, ice bags to the body (goal temp 38-39)

closely monitor urine output with a foley catheter. Maintain goal UOP greater than 1-2 ml/kg/hr using fluids, furosemide (1mg/kg IV) and amnnitol (0.25gm/kg IV) and watch for signs of myoglobinuria

send off frequent labs, ABG/VBG, electrolytes, hepatic fxn, coag panel, CBC, CK, serum glucose, urine myoglobin (follow closely for 24-48 hours)

treat hyperkalemia with combo of 0.1-0.2 U/kg of regular insulin and 500mg/kg of dextrose IV, calcium or bicarb

treat any arrhythmias that develop using amiodarone, lidocaine, adenosine, procainamide, or any other drugs indicated according tot he ACLS protocol. Dysrhythmias usually subside with resolution of the hypermetabolic phase (DO NOT use calcium channel blockers to treat them bc can worsen hyperkalemia)

correct metabolic acidosis with 1-2 mEq/kg IV of sodium bicarb based on arterial pH

have the surgeon stop the surgery as soon as possible; expedite or abort

consider a-line and central line

Question 15

manage post-op MH

Answer 15

alkalinize the urine and diurese, monitor for acute renal failure

follow CK levels to track the severity of the rhabdo

follow all labs and vital signs closely (watch out for hypothermia, hyperkalemia, hypokalemia, hypervolemic overshoot)

watch for signs of DIC, including thrombocytopnenia, hemolysis, abnormal bleeding

elevated liver fxns often in 12-36hrs post MH crisis

follow CNS serially

continue dantrolene 1mg/kg IV q4-6 hrs for up to 72 hrs after episode

submit forms to MH registry

continue to monitor the patient for upt o 72 hours in the SICU. measurements should include urine output, arterial blood gases, pH, serum electrolyte concentrations.

Question 16

difficult airway algorithm

Answer 16

optimize oxygenation throughout
limit attempts
call for help

if can mask:
limit attempts and consider awakening the patient
consider alternative intubation approaches, invasive access, or feasibility of other options

if can’t mask -> LMA
if LMA fails, limit attempts and consider invasive access, call for help
alternative approaches as prepare for invasive airway

in peds consider ecmo

Question 17

triggers for awake intubation

Answer 17

suspected difficult DL
suspected difficult ventilation with face mask/SGA
significant increased risk of aspiration
increased risk of rapid desaturation
suspected difficult emergency invasive airway

Question 18

determine cause of elevated creatinine

Answer 18

review meds and history
check urine na levels, urine osmolality, urine-to-plasma Cr ratio, urinary sediment level

Fluid challenge: if improve then pre-renal

If urine Na >10 and granular casts then its ATN

Hepatorenal syndrome has no improvement with fluid challenge, no proteinuris, low urinary Na conc, serum sodium <130

Question 19

Care for patient with hepatic encephalopathy

Answer 19

rule out other causes of mild confusion (drugs, wernicke’s for alcoholic)
treat inciting factors (bleeding varices, infection, hypovolemia, anemia)
eval for elevated ICP
avoid hypokalemia (increases ammonia production)
maintain normal art pH (alkalemia inc diffusion of mamonia accros blood brain barrier)
correct hypovolemia/anemia (optimize liver metabolisim of circulating toxins
cautious with psychoactive drugs (benzos)

Question 20

induce with aspiration risk

Answer 20

assuming reassuring airway, hemodynamic stability, appropriate monitors

administer 
metoclopramide
H2 blocker
sodium citrate
reverse trendelenburg
pre-oxygenate 100% for 5 min
cricoid pressure
lidocaine/fentanyl
propofol
paralytic
rapidly secure the airway

Question 21

treat hyperkalemia

Answer 21

calcium chloride or gluconate
ensure access to defibrillator and prepare to treat dysrhythmias
correct contributing factors (acidosis, hyponatremia, hypocalcemia)
administer insulin and glucose, b2 adrenergics (albuterol), sodium bicarb
hyperventilate the patient to promote alkalosis
consider hemodialysis

Question 22

neonatal resuscitation

Answer 22

warm, clear airway prn, dry/stimulate/reposition
evaluate respirations, HR, color

if apnea, HR < 100, or persistent cyanosis, then positive pressure ventilation

then if HR > 100, post-resus care
but,
if HR <60, chest compressions,
then epi (0.01mg/kg IV or 0.1mg/kg ETT) and/or volume (10 ml/kg o-neg blood, NS, or LR; albumin icnr mortality)

Question 23

drugs in neonatal resuscitation

Answer 23

bicarb - 4.2%, only if prolonged resuscitation and documented acidosis, 2 mEq/kg via umbilical catheter

naloxone - 0.01 mg/kg IV/IM/SQ/ETT but not if opioid addicted mother cuz could withdraw

epi - (0.01mg/kg IV or 0.1mg/kg ETT) for asystole or persistent bradycardia despine 30 sec of effective ventilation and chest compressions. can repeat q 3-5 min

atropine - 0.02mg/kg IV or 0.03 mg/kg ETT for bradycardia

calcium gluconate - 100mg/kg over 5-10 min for low CO IF FROM MAGNESIUM TOXICITY (mom on Mg infusion); keep on continuous EKG

fluids - o-neg or maternally cross-matched blood 10 ml/kg; or NS/LR 10 ml/kg; def not albumin (increased mortality)

Question 24

HELLP tx

Answer 24

mg
control bp (SBP<160 and DBP<105)
correct coagulopathy
corticosteroids for fetal lung maturity as time permits

Question 25

How to diagnose a PE

Answer 25

gold standard in pulmonary angiogram Lab not typically used Imaging: V/Q scan for patients with renal failure, CT scan is faster though, CT angiogram combined with CT venography has a higher sensitivity for VTE but does not rule out PE if negative

Question 26

Actions to reduce ICP

Answer 26

make sure no venous obstruction elevate head 15-30 degrees mannitol (only if BBB intact) furosemide (unless hypovolemic) barbiturate (reduce ICP and CMRO2)

Question 27

periop glucose actions

Answer 27

``` 2/3 dose nigiht prior no short-acting insulin morning of 1/2 usual morning dose intermediate/long check level when arrive at hospital check glucose at least hourly in periop period maintain between 120-180 ``` consider 2 continuous concurrent separate infusions of regular insulin and D5 1/2 NS

Question 28

recent stent, how eval cardiac status preop?

Answer 28

careful H&P - focus on comorbidities that can be cardiac related, obtain details on stent location and stent type and timing review previous medical records/tests related to cardiac fxn determine severity of CAD, what vessels, coag status, if he is optimized if diabetic assess for signs of autonomic neuropathy (could have painless MI), CV instability, myocardium at risk (angina, SOB, exercise intolerance) if elevated risk of MACE: determine functional capacity if less than 4 METS consult with surgeon if results would alter care (delay case vs undergo CABG/PCI) if positive results would alter care, then consider stress testing if negative, then would bedside echo prior to proceeding

Question 29

treat sepsis

Answer 29

obtain blood cx find source (imaging) empiric broad spectrum abx, narrow when able control source administer fluids (start with crystalloids) vasopressors (start norepi) inotropes (start dobutamine if norepi not working) maintain CVP 8-12, MAP greater than 65, UOP > 0.5 ml/kg/hr, maintain O2 sat, normal serum lactate transfuse PRN RBC, PLT, FFP consider corticosteroids, insulin, bicarb mechanical ventilation w PEEP, lung protective head up position reduce aspiration and VAP minimal sedation to shorten ICU stay avoid paralytic DVT ppx stress ulcer ppx daily spont vent trials

Question 30

Approach for preop hypertension

Answer 30

delay elective surgery 6-8 weeks to optimize BP of any patient who: - has SBP readings >180 or DBP >110 - has stage 1 or stage 2 HTN with concomitant end-organ damage - Is undergoing cardiac surgery, carotid surgery, or pheochromocytoma resection (weigh risks/benefits obvi)

Question 31

Peds difficult airway

Answer 31

limit attempts, call for help assess oxygenation/ventilation with face mask/SGA if adequate: consider emerging the pateint, limit attempts, be aware of passage of time, reassess ventilation after each attempt, consider alternative intubation approaches or feasibility of other options if marginal or impossible: exclude/treat anatomical and fxnl obstruction, consider calling for invasive access or ECMO if impossible, or becomes cannot intubate/cannot ventilate scenario, then: call for help/for invasive access, alternative intubation approaches as prepare for emergency invasive airway

Question 32

adult difficult airway

Answer 32

lkjh

Question 33

a-fib treatment priorities

Answer 33

``` 1 find the cause 2 fix the cause 3 slow the rate - (maybe dilt or beta blocker) 4 convert the rhythm 5 prevent thromboembolism ```

Question 34

neonate unable to ventilate after intubation

Answer 34

100% fio2 check circuit ensure patent ETT verify proper ETT placement (auscultation and fiberoptic scope) if correct, assume bronchospasm: identify and clear gastric material in oropharynx (could have caused bronchospasm) apply positive airway pressure deepen anesthetic with inhalational or other administer b2 agonist if persisted, administer small dose of epinephrine

Question 35

post extubatino croup action steps

Answer 35

dexamethasone humidify inspired gases nebulized racemic epi consider light sedation to improve patient cooperation ensure adequate hydration consider reintubation if cyanosis/hypoxic (use smaller tube and keep in place until swelling resolved)

Question 36

preop actions to reduce risk of carcinoid crisis

Answer 36

octreotide (somatostatin analogue) (preferably start 2 days prior) to reduce tumor secretion of serotonin optimize IV fluid volume anxiolytic to prevent stress-induced release of hormones from tumor H1 and H2 blockers to attenuate effects of histamine alpha and beta adrenergic receptor blockers to prevent catecholamine mediated release of vasoactive substances from teh tumor steroids may be beneficial 2/2 inhibition of the kallikrein cascade

Question 37

the thing i always forget to consider prior to induciton

Answer 37

consider decompressing stomach with OG or NG tube

Question 38

concern about obsese patient cardiac status, how evaluate

Answer 38

H&P: rule out active cardiac conditions (unstable/severe angina, arrhythmia, valvular disease) assess MACE risk with RCRI assess fxnl capacity ask about prior cardiac w/u if fxnl capacity <4 METS discuss further w/u (stress test) with surgeon and patient if it would impact decision making note: diabetes may mask angina

Question 39

what should you do before deep extubation

Answer 39

suction the stomach

Question 40

acls drugs

Answer 40

add them all

Question 41

stuff to always examine

Answer 41

airway, cv, pulm

Question 42

monomorphic vs polymorphic VT defib

Answer 42

monomorphic synchronized cardioversion | polymorphic - unsynchronized often required

Question 43

ACLS Cardiac arrest PEA and asystole

Answer 43

Perform the initial assessment Perform high-quality CPR Establish an airway and provide oxygen to keep oxygen saturation > 94% Monitor the victim’s heart rhythm and blood pressure If the patient is in asystole or PEA, this is NOT a shockable rhythm Continue high-quality CPR for 2 minutes (while others are attempting to establish IV or IO access) Give epinephrine 1 mg as soon as possible and every 3-5 minutes After 2 minutes of CPR, check rhythm If the monitor and assessment show VTach or VFib, move to VTach/VFib algorithm Evaluate and treat reversible causes If the patient attains Return of Spontaneous Circulation (ROSC), provide Post Cardiac Arrest Care

Question 44

ACLS Bradycardia Algorithm

Answer 44

Treatment for bradycardia should be based on controlling the symptoms and identifying the cause using the Hs and Ts Do not delay treatment but look for underlying causes of the bradycardia using the Hs and Ts. Maintain the airway and monitor cardiac rhythm, blood pressure and oxygen saturation. Insert an IV or IO for medications. If the patient is stable, call for consults. If the patient is symptomatic, administer atropine 1.0 mg IV or IO bolus and repeat the atropine every 3 to 5 minutes to a total dose of 3 mg: If atropine does not relieve the bradycardia, continue evaluating the patient to determine the underlying cause and consider transcutaneous pacing Consider an IV/IO dopamine infusion at 2-10 mcg/kg/minute Consider an IV/IO epinephrine infusion at 2-10 mcg/minute. In the cases of Mobitz type II second-degree heart block, third-degree AV block, or third-degree AV block with new widened QRS complex, atropine is unlikely to be effective. Consider transcutaneous pacing immediately or a beta-adrenergic infusion to increase heart rate.

Question 45

ACLS Tachycardia Algorithm

Answer 45

The ACLS Tachycardia Algorithm is used for patients who have marked tachycardia, usually greater than 150 beats per minute, and a palpable pulse. Some patients may have cardiovascular instability with tachycardia at heart rate less than 150 bpm. It is important to consider the clinical context when treating adult tachycardia. If a pulse cannot be felt after palpating for up to 10 seconds, move immediately to the ACLS Cardiac Arrest VTach and VFib Algorithm to provide treatment for pulseless ventricular tachycardia. The immediate response to an adult patient with tachycardia and a palpable pulse is To maintain an open airway Assist breathing if necessary Apply monitors to assess cardiac rhythm, blood pressure, blood oxygenation Provide supplement oxygen to maintain O2 saturation between 94% and 99% The main assessment in adult patients with tachycardia is to determine whether the patient is stable or not. Signs of cardiovascular instability are hypotension, signs of shock or acute heart failure (flash pulmonary edema, jugular venous distention), altered mental status, or ischemic chest pain. Unstable patients with tachycardia should be treated with synchronized cardioversion as soon as possible. Stable patients with tachycardia with a palpable pulse can be treated with more conservative measures first. Attempt vagal maneuvers If unsuccessful, administer adenosine 6 mg IV bolus followed by a rapid normal saline flush If unsuccessful, administer adenosine 12 mg IV bolus followed by a rapid normal saline flush Beta-blockers and calcium channel blockers may be considered for narrow QRS tachycardia (QRS <0.12 sec) For stable, wide QRS complex tachycardia (QRS ≥0.12 sec) Strongly consider expert consultation Consider procainamide 20-50 mg/min IV, OR Amiodarone 150 mg IV over 10 minutes, OR Sotalol 100 mg (1.5 mg/kg) over 5 minutes

Question 46

cardioversion rules

Answer 46

Cardioversion Rules QRS narrow and regular 50-100 Joules QRS narrow and irregular 120-200 Joules QRS wide and regular 100 Joules QRS wide and irregular Turn off the synchronized mode and defibrillate immediately

Question 47

ACLS In-Hospital Cardiac Arrest in Pregnancy Algorithm

Answer 47

Cardiac arrest that occurs in the hospital is handled differently than it is in other adults in some important ways. Cardiac arrest resuscitation of pregnant women focuses on resuscitating the mother primarily. Fetal monitoring should not be used during cardiac arrest in pregnant women, and if fetal monitors were in place, they should be removed during resuscitation. When possible, a specialized maternal cardiac arrest team should conduct the resuscitation. This team can take over for the first ACLS providers on the scene if they are not part of the maternal cardiac arrest team. Since pregnant women are more likely to have hypoxia in general, oxygenation and airway management should be prioritized over circulation, in some respects, like it is in the care of pediatric patients. Perform BLS/ACLS as would occur in any adult patient When possible, hand off care to the maternal cardiac arrest team For the mother: Support the airway and provide one breath every 6 seconds Give 100% oxygen If magnesium is being administered, stop it, and provide calcium chloride or calcium gluconate For the fetus: Relieve aortocaval compression by moving the uterus laterally Detach or do not use fetal monitors Prepare for Cesarean delivery If ROSC occurs, move to post-cardiac arrest care Pregnant women who remain comatose after resuscitation from cardiac arrest should receive targeted temperature management and fetal heart rate monitoring with OB/GYN support If ROSC does not occur within 5 minutes, consider perimortem Cesarean delivery The neonate should be evaluated for neonatal resuscitation

Question 48

ACLS Cardiac Arrest VTach and VFib Algorithm

Answer 48

Perform the initial assessment Perform high-quality CPR Establish an airway and provide oxygen to keep oxygen saturation > 94% Monitor the victim’s heart rhythm and blood pressure If the patient is in VTach or VFib, this IS a shockable rhythm Apply defibrillator pads (or paddles) and shock the patient with 120-200 Joules on a biphasic defibrillator or 360 Joules using a monophasic. Continue High Quality CPR for 2 minutes (while others are attempting to establish IV or IO access). After 2 minutes of CPR, check rhythm If the monitor and assessment show asystole or PEA, move to Asystole/ PEA algorithm Give epinephrine 1 mg every 3-5 minutes Continue High Quality CPR for 2 minutes (while others are attempting to establish IV or IO access). After 2 minutes of CPR, check rhythm If needed, administer shock Amiodarone IV 300 mg (preferable to lidocaine); May repeat 150 mg OR may use lidocaine 1-1.5 mg/kg After 2 minutes of CPR, check rhythm If needed, administer shock If the patient attains Return of Spontaneous Circulation (ROSC), provide Post Cardiac Arrest Care

Question 49

ACLS Post Cardiac Arrest Care Algorithm

Answer 49

Treatment for a victim of cardiac arrest must continue post resuscitation in order to optimize the outcomes. The post cardiac arrest care algorithm includes the following steps: Verify ROSC. Manage the airway including ETT placement and provide 10 breaths per minute. Using quantitative waveform capnography, titrate the oxygen to maintain a PETCO2 of 35-40 mm Hg. If you do not have access to a waveform capnography machine, titrate oxygen to keep the oxygen saturation 92% to 98%. Insert and maintain an IV for medication administration. Maintain systolic blood pressure above 90 mm Hg and/or mean arterial pressure above 65 mm Hg. For a low blood pressure, consider one or more of these treatments: Give 1 to 2 liters of saline or Ringer’s lactate IV fluid. Start an epinephrine IV or a dopamine IV infusion Consider norepinephrine for extremely low systolic blood pressure. Obtain a 12-lead ECG and rule out myocardial infarction. If myocardial infarction is suspected, consider percutaneous coronary intervention (PCI) to open the coronary arteries. Determine if the patient is comatose. If comatose: Targeted temperature management ASAP keeping body temp 32-36°C for 24 hours initially. Monitor EEG and assess for nonconvulsive seizures (treat if present) Obtain head CT Maintain oxygen, glucose, carbon dioxide, etc. Avoid barotrauma If NOT comatose (awake): Maintain oxygen, glucose, carbon dioxide, etc. Avoid barotrauma

Question 50

ACLS Acute Coronary Syndrome Algorithm

Answer 50

1. Assess patient for symptoms of acute coronary syndrome (ACS) ``` Crushing chest pain Pain radiates to jaw, arm, back Nausea/vomiting Sweating Shortness of breath 2. Rapid sequence of interventions and additional assessments ``` If no aspirin allergies, administer aspirin (patient should chew) If no contraindications, administer nitroglycerin Administer morphine, if needed Obtain 12-lead ECG Apply oxygen via nasal cannula if O2 <94% 3. Trained professional should assess ECG; ST-segment elevation myocardial infarction (STEMI) STEMI Complete fibrinolytic checklist Determine precise onset of symptoms, if possible Initiate Fibrinolysis/PCI protocol immediately Antiplatelet therapy Aspirin Platelet P2Y12 receptor blocker GP IIb/IIIa inhibitor (If destined for PCI) Anticoagulation Consider intravenous nitrates Consider morphine Beta-blockers (if no contraindications) Statin therapy Non-ST elevation ACS (unstable angina or non-ST elevation myocardial infarction (NSTEMI)) ``` Antiplatelet therapy Aspirin Platelet P2Y12 receptor blocker Anticoagulation Admit to monitored bed Consult Cardiology ```

Question 51

PALS Cardiac Arrest Algorithm

Answer 51

1. Activate emergency medical services, call a pediatric “code blue”, obtain AED or defibrillator 2. Is the rhythm shockable? Rhythm IS shockable (ventricular fibrillation or unstable ventricular tachycardia) 1. Administer shock at 2 Joules/kg 2. Administer high-quality CPR for 2 minutes 3. Check rhythm If not shockable, move to asystole/PEA rhythm protocol If shockable, continue 4. Administer shock at 4 Joules/kg 5. Administer epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes 6. Administer high-quality CPR for 2 minutes 7. Check rhythm If not shockable, move to asystole/PEA rhythm protocol If shockable, continue 8. Administer shock at >4 Joules/kg 9. Administer amiodarone 5 mg/kg IV (repeat 2 times if needed) or lidocaine 1 mg/kg IV 10. Administer high-quality CPR for 2 minutes 11. Check rhythm If not shockable, move to asystole/PEA rhythm protocol If shockable, repeat steps 8-11 Rhythm IS NOT shockable (asystole or pulseless electrical activity) 1. Administer high-quality CPR for 2 minutes 2. Administer epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes 3. Check rhythm If shockable, move to VF/VT rhythm protocol If not shockable, continue 4. Administer high-quality CPR for 2 minutes 5. Check rhythm If shockable, move to VF/VT rhythm protocol If not shockable, continue 6. Administer amiodarone 5 mg/kg IV (repeat 2 times if needed) 7. Administer high-quality CPR for 2 minutes 8. Check rhythm If shockable, move to shockable rhythm protocol If not shockable, continue CPR and medications

Question 52

extra monitor for aortic dissection

Answer 52

lumbar csf drain

Question 53

Epiglottitis management

Answer 53

supplemental o2 call ENT for possible surgical airway no invasive procedures (IV) until after airway mgmt) bag mask with 100% FiO2 If not oxygenating: one attempt at intubation by RSI, then surgical airway If oxygenating, move to OR for controlled intubation with ENT present DO NOT PLACE LMA Then abx are the treatment

Question 54

Oliguria management

Answer 54

AKI if increase serum cr by 0.3 in 48 hrs or 1.5x baseline ``` H&P History: med review vitals/hypotension review contrast? ``` ``` Physical: signs of volume contraction - pre renal; give volume drug rash - AIN blue toes - cholesterol emboli volume overload - cardiorenal syndrome ascites/jaundice - hepatorenal ``` labs: dipstick, albumin to cr ratio FeNa

Question 55

bradycardia with a pulse

Answer 55

check pulse airway 100% O2, confirm adequate vent and ox stop vagal stimuli (desufflate, remove pressure, remove retractors, drain bladder) ensure IV access ``` meds: decrease anesthetic? atropine 0.5-1 q3 min max 3mg then epi 5-10mcg consider dopamine gtt if stable consider glyco ``` pacing: place pads consider transcut, transvenous, esoph pacing consult ICU or cards consider a-line ABG, hgb, lytes, trop ischemia: 12-lead, BNP, serial trops

Question 56

DKA action steps

Answer 56

notify surgeon 10U IV insulin bolus NS fluid replacement check serum/urine ketones ABG, BUN, Cr, lytes anion gap insulin infusion (decr 75-100/hr so no cerebral edema) add 5% dextrose infusion when glucose reaches 250 (prevent hypoglyc and have energy source) replace potassium, phosphate, magnesium PRN monitor labs DKA risks arrhythmias and hypotesnion intraop

Question 57

mnemonic to come off pump

Answer 57

Temp - core >35.5 HCT hct>21 electrolytes - hypoCa, HyperK, hyperglycemia inotropes - esp with clamp>90m, preop dysfxn, poor protection Vasopressor - low SVR rewarming, frequent vasopressor by perfusion pacer/rate: intrinsic/paced 80-90, DDD unless sig bovie interference, always DDD to leave OR vent: recruitment (watch IMA), on vapor - on monitors - back to normal, paced mode TEE - eval for air, assess repair, bi-v fxn protamine: ask perfusion for correct dose, confirm surgeon ready, announce half-in and all-in

Question 58

mnemonic to go on pump

Answer 58

Perfusion - full flow, iso on, goal MAP Ventilator - off: manual mode, apl open, air/o2 50%, cpb mode. (on: decrease Vt and RR) Vapor - off Monitors: switch to bypass mode Fluids: continue carrier, stop others Patient: assess bilateral perfusion: skin color, cerebral ox, no vein congestion; confirm paralysis; bis <60 Urine: measure and empty Drugs: Stop inotropes (except milrinone), discuss vasopressin with perfusion if needed TEE: Freeze

Question 59

jaunidce action steps

Answer 59

prehepatic, hepatic or posthepatic prehapatic caused by increased production bilirubin from hemolysis or absorption of hematoma hepatic: hepatic injury (ischemia, drugs), intrinsic disorder, infection, hepatic congestion, halothane posthepatic: mechanical obstruction such as a stone H&P, look for hypotension, transfusion, medications, hepatomegaly, coagulopathy labs: LFTs (with conjugated and unconjugated bili), alk phos, H/H, abdominal ultrasound

Question 60

WPW tachyarrhythmia management

Answer 60

stable narrow complex (orthodromic): adenosine, then procainamide, then cardioversion stable wide complex (antidromic): procainamide, then cardioversion unstable: cardioversion

Question 61

PFT pearls

Answer 61

Obstructive: FEV/FVC ratio less than 0.7 severity indicated by FEV %age (moderate 60-70, moderately severe 50-60%) Restrictive: normal FEV/FVC ratio (>70%) reduction in TLC <80% predicted

Question 62

How to optimize COPD preop

Answer 62

``` smoking cessation 8 weeks preop chest physiotherapy bronchodilators glucocorticoids abx if infxn ``` ``` If emergent: bronchodilators supplemental O2 inhaled steroids abx if infxn ```

Question 63

Peds URI delay guidelines

Answer 63

(asthma does not have fever) elevated risk laryngospasm, bronchospasm, O2 desat events delay 4-6 weeks to allow pulm fxn return to nml if: - fever >38.5 - productive cough - mucopurulent secretions - malaise - pulm involvement (wheezing does not clear w cough) delay 2-4 weeks for mild sx IF require ETT and have additional risk factor (2nd hand smoke, underlying dz like asthma): sneezing mild nasal congestion nonproductive cough proceed w surgery if mild sx but does not requre ETT

Question 64

severe masseter muscle rigidity action

Answer 64

assume MH and begin MH treatment; cancel case if elective

Question 65

drug to not admin with dantrolene for MH

Answer 65

calcium channel blocker; can lead to hyperkalemia