Anaesthetics Flashcards
(90 cards)
1
Q
What are the aims of the PHEA SOP? (2)
A
- To provide safe and effective anaesthesia for all critically ill/injured patients pre-hospital
- Ensure pre-hospital standards meet those in hospital and those set out by the Association of Anaesthesia pre-hospital guidelines
2
Q
What are the objectives of the PHEA SOP? (3)
A
- Define indications
- Describe procedure
- Describe failed intubation procedure
3
Q
What are the indications for PHEA? (6)
A
- Actual/impending airway compromise
- Ventilatory failure
- Unconsciousness for protection of airway and ventilatory support
- Humanitarian need
- Agitation post TBI
- Anticipated clinical course
4
Q
Describe LEMON?
A
L - ook
E -valuate (3/3/2)
M- allampati
O - bsrtuction
N - eck mobility
5
Q
Describe AMPLE
A
A -llergies
M - edication
P -MHx
L -ast ate
E - events today
6
Q
What is MOANs used to predict?
A
Difficulty with BVM
7
Q
Describe MOANS
A
M- ask seal difficult
O - besity
A - dvanced age
N - o teeth
S -nores
8
Q
What is the minimum period we should oxygenate for? (2)
A
- 3 mins
or
- 8 maximal insp/exp breaths if they are able
9
Q
How should self ventilating patients be pre-oyxgenated? (3)
A
- 15L via NRB
- 15 L Apox nc
- Head up/ reverse Trendelenburg on scoop
10
Q
Which self ventilating patients should be pre-oxygenated with BVM and PEEP valve?
A
- Pregnant
- Obese
- <93% SATs
11
Q
How should patients with facial injuries be pre-oxygenated?
A
Most comfortable position and maintaining airway (usually sat up)
12
Q
What should we ensure all patients having PHEA have set up in advance? (5)
A
- 2 x IV cannula
- Fluid running well
- Minimum observations - oximeter/ETC02, 3 lead, BP (on other arm to working cannula
- 2 x suction
- 2 x full oxygen cylinder
13
Q
Which patients does EHAAT research show have increase risk of hypotension post RSI? (3)
A
- RR > 25
- Age > 70
- Shock index > 1
14
Q
What type of weight should be used to calculate drug doses?
A
Estimated actual body weight
NB rocuronium should be IBW but for ease estimate actual body weight used
15
Q
What is the RSI drug regime for:
1. Standard
2. Shocked/frail patients
3. High dose
A
- Fentanyl 1mcg/kg, Ketamine 2mg/kg + rocuronium 2mg/kg (max 150mg)
- Ketamine 1mg/kg, rocuronium 2mg/kg (max 150mg)
- Fentanyl 2mcg/kg, ketamine 2mg/kg, rocuronium 2mg/kg (max 150mg/kg)
16
Q
Until what age should a MAC 4 blade be used?
A
> 12 years
17
Q
When should we draw up adrenaline/metaraminol with regards to RSI? (2)
A
- Isolated TBI
- Frail/ low BP and medical
18
Q
Which drugs should be discussed with consultant before use? (2)
A
- Thrombolytics
- Propofol
19
Q
When should apnoeic oxygenation be avoid (2) and why? (1)
A
- Facial #s
- Epistaxis
3, Can lead to pneumocephalus
20
Q
When should we BVM ventilate during pre-oxygenation? (2)
A
- Low SATs
- Reduced GCS requiring airway adjuncts/Igel
21
Q
What is the maximum tube length as per the SOP
A
Should be less than 23cm at the teeth
22
Q
What factors in pregnancy lead to a more difficult RSI? (4)
A
- Increased mucosal friability
- Larger breasts
- Increased gastric scecretions
- Decreased functional residual capacity
23
Q
What should we do in order to attempt positioning for RSI in pregnancy? (2)
A
- Ramp 20-30 degrees
- Left lateral tilt if visibly pregnant
24
Q
What must we do when considering RSI in children?
A
D/w consultant on call
25
Down to what age should we use a MAC 2?
6 months
26
Below 6 months of age what type of laryngoscope could be considered?
Miller if experience allows
27
Aside from the tube size, what other size should be confirmed during the RSI checklist in paeds?
Igel size
28
What should be done in a paeds RSI to try and reduce the dead space? (3)
1. Compress catheter mount
2. Paeds filter
3. Paeds ventilator circuit if TV <250ml
29
What is more important to ensure we have done post RSI in children compared to adults?
OG tube to decrease gastric volume and increase ventilation
30
What additional drug should be drawn up during a paeds RSI and at what dose?
Atropine
20mcg/kg
31
Outline the DOPESSS pneumonic
D - isplacement of tube
O - bstruction of tube
P - TX
E - quipment failure
S - pasm
S - ynchrony
S - tacking
32
What are the 30 sec drills?
S - uction
L - arygneal manipulation
I - nsert blade fully and withdraw
P - ositioning
D - eclare
33
How many attempts should be made to intubate?
2 attempts 1 operator + 1 additional attempt by another operator
34
If unable to intubate outline the next steps in order (3)
1. Igel (size 4 standard)
2. BVM with OP/NP
3. Surgical airway
35
What size ETT should be used in surgical airway?
6mm cuffed
36
What is the minimum time rocuronium should last?
30 mins
37
What should be handed over in terms of RSI when arriving at hospital? (3)
1. Grade view
2. Tube size
3. Last time muscle relaxant given
38
What are the aims and objective of the ventilation SOP? (4)
1. Ensures staff are familiar with ventilator checks for the Oxylog 3000 plus
2. Review the ventilators used by PHC staff
3. Detail procedure for checking ventilators
4. Provide a brief overview of patient ventilation
39
What tidal volume should be aim formed under normal conditions?
6-8ml/kg
40
What minute volume should we aim for under normal conditions?
70ml/kg
41
What is our standard ventilator setting?
VC-CMV (volume control, continuous mandatory ventilation)
42
When should pressure control ventilation be considered? (2)
1. Paediatrics <50kg
2. Significant lung pathology
43
What is the standard initial setting for peak inspiratory pressure according to the ventilation SOP?
40 cmH2O
44
What is the standard initial PEEP setting according to the ventilation SOP?
5cm H2O - compensates for ETT
45
How is the Oxylog 3000 plus described in the ventilation SOP? (3)
Time cycled
Volume controlled
Pressure controlled
Ventilator
46
When should we switch from an adult to a paeds ventilator circuit?
TV < 250ml
47
What is the battery life of an Oxylog 3000 Plus?
7.5 hours
48
What range of Fi02 can the Oxylog 3000 Plus deliver?
40-100%
49
What settings should we start with if we wish to deliver pressure control ventilation (PC-BIPAP)
Start with peak inspiratory 15-20cmH20 and then titrate to desired TV
50
What changes may need to be made if using a ventilator whilst CPR ongoing?
1. Pmax will need to be increased
51
If the ventilator isnt delivering good enough tidal volumes during cardiac arrest what should be done?
Switch to BVM
52
What button must we make sure if on whenever we are using the ventilator?
HME compensation is on 'yes'
53
When checking the EEAST DSAs oxygen supply for transfer, what must we check? (3)
1. Both 02 valves switched on (access via door on drivers side of truck )
2. Oxygen levels sufficient between the 2 cylinders
3. The correct cylinder is selected via the switch
54
What much oxygen is in a F cylinder?
1360 L
55
What are the aims and objectives of the analgesia + sedation SOP? (4)
1. To ensure all patients receive timely and effective assessment of pain, delivery of analgesia and where necessary, procedural sedation
2. Describe PHC analgesia and sedation drugs
3. Describe the specific indication and proper use of each drug
4. Analgesia is important on humanitarian grounds and also to meet clinical endpoints essential to the resusitation philosophy of the service
56
What does the analgesia/sedation SOP policy state about how these drugs should be delivered? (3)
Should be:
- diluted
- delivered IV
- titrated to effect
57
Which analgesia can be given IM according to the SOP? (3)
1. Fentanyl
2. Morphine
3. Ketamine
58
What is the label colour for?
1. Ketamine
2. Morphine
3. Fentanyly
4. Midazolam
1. Yellow
2. Blue
3. Blue
4. Orange
59
What is the analgesic dose of ketamine IV?
0.1mg/kg then 5-20mg bolus
Up to 0.5mg/kg in severe pain
60
What is the analgesic dose of ketamine IM?
1 mg/kg
61
What is the ketamine dose for procedural sedation IV?
0.5mg/kg followed by 10-20mg bolus
62
What is the IM dose of ketamine for sedation?
5mg/kg
63
What two concentrations do we carry of ketamine?
1. 200mg/20ml PFS = 10mg/ml
2. 500mg/10ml vial = 50mg/kg
64
What does the analgesia SOP suggest for morphine analgesic dose?
2mg bolus followed by 2mg aliquots
65
What dose the analgesia SOP state about analgesic dose fentanyl IV?
25mcg bolus IV followed by 25mcg aliquots
66
What is the dose of IN fentanyl?
1.5mcg/kg (max initial dose 100mcg) followed by a further 0.75-1.5mcg/kg second dose after 10 mins if needed
67
What strength fentanyl dose we carry?
500mcg/10ml PFS = 50mcg/ml
68
What is the sedation SOP state is the recommended doses for midazolam IV in adults? (2)
1. 2mg
2. 1mg if frail
69
What is the recommended dose of midazolam as an adjunct to ketamine to prevent emergence?
1-2mg
70
What is the recommended midazolam dose IV for maintenance of anasthesia?
0.5-1.0mg bolus
71
How do we draw up an adrenaline infusion post ROSC?
- Use 50ml syringe
- Add 10ml 1 in 10,000 adrenaline to 40ml normal saline = 20mcg/ml
- discard 10ml to allow syringe to fit in driver
72
At what rate should we set a post ROSC adrenaline infusion?
10-33ml/hr
73
What infusion should we use to maintain anaesthesia in an unstable patient who is 70kg
Ketamine
1mg/kg/hr
=70mg/hr
= 7ml 200mg/20ml ketamine/hr
74
What rates should be used for a ketamine infusion?
0.5 - 2.0 mg/kg/hr
start 1mg/kg/hr
75
What infusion should be used to maintain anaesthesia in a stable patient?
Midazolam/fentanyl
76
How should we draw up an midazolam/fentanyl infusion?
1. Midazolam 10mg/10ml syringe
2. Add 5ml 500mcg/10ml fentanyl (250mcg)
3. Add 5ml normal saline
77
What rate should we start a midazolam/fentanyl infusion?
0.1ml/kg/hr
78
What is the maximum rate for a midazolam/fentanyl infusion?
0.3ml/kg/hr
79
What rate should a midazolam/fentanyl infusion for a 70kg patient be started at?
7ml/hr
(0.1ml/kg/hr)
80
What are the concentrations of midazolam and and fentanyl in our infusions?
0.5mg/ml midazolam
12.5mcg/ml fentanly
81
How much dead space is there in a paeds HME filter?
25ml
82
How much dead space is there in an adult HME filter?
66ml
83
What is dead space?
The proportion of ventilated air that does not take part in gas exchange
84
What is the calculation for anatomical dead space?
2ml/kg
85
86
What is the TV below which we should switch to a paeds HME filter?
Less than 150ml
87
Minimum TV achievable of the oxylog ventilator?
50ml
88
How is shock index calculated?
HR / SBP
89
What shock index is associated with increased mortality?
> 1.0
90
