Chapter 12 Flashcards

Question

Categorisation of asthma severity

Answer 1

Acute severe - any of RR >25 PEF 33-50% best or predicted HR >110 Inability to complete sentences in one breath Life-threatening - any of (in acute severe) Clinical signs - altered consciousness, exhaustion, arrhythmia, hypotension, cyanosis, silent chest, poor respiratory effort PEF less than 33% best/predicted Pa02 less than 8 Normal paCO2 (4.6-6) SpO2 less than 92% Near-fatal Raised pCO2 and/or mechanical ventilation with raised ventilation pressures

Answer 2

Oxygen - target 94-98% Salbutamol/ipratropium Steroids IV magnesium sulphate 2g if not responding to bronchodilators Consider IV salbutamol, aminophylline Intensive care assessment Consider tracheal intubation if deteriorating despite drug therapy

Answer 3

Intubate early Use 10 breaths/minute If dynamic hyperinflation suspected can try chest wall compression or apnoeic period to relieve gas-trapping Hyperinflation increases transthoracic impedance but should be compensated for by defib - as usual consider increasing defib energy if not initially successful Look for reversible causes - always consider tension pneumothorax in asthma

Answer 4

2% progress to cardiac arrest, 1% fatality

Answer 5

Sudden onset and rapid progression of symptoms Airway/breathing and/or circulation compromise Skin and/or mucosal changes - absent in 20% Exposure to allergen supports diagnosis

Answer 6

Do not walk/stand Remove trigger if possible e.g. stop infusions Monitor with pulse ox, BP, 3-lead ECG High flow oxygen, target sats 94-98% Give adrenaline - 0.5ml 1:1000 adrenaline IM Repeat doses at 5 minute intervals dependent on patients response Site for injection is anterolateral aspect of the middle third of the thigh Can use nebulised adrenaline as an adjunct to treat upper airway obstruction If refractory may need adrenaline infusion Give IVF challenge (crystalloid) Consider early tracheal intubation

Answer 7

Not routinely recommended Antihistamines can be given for cutaneous symptoms once patient stabilised Can consider given steroids after initial resus for refractory anaphylaxis

Answer 8

Standard ALS Give 1mg adrenaline IV

Answer 9

Minimum - one sample within 2 hours of start of symptoms Ideally - one sample at onset of symptoms, second sample at 1-2 hours, third sample at 24 hours

Answer 10

0.5-1ml/kg/hour in adults and children

Answer 11

At any stage in pregnancy to 6 weeks post-partum 1 in 36,000 pregnancies

Answer 12

Place in left lateral position or manually displace uterus to the left if not possible - prevents compression of IVC Usual ALS principles Get obstetric, anaesthetic and neonatal help IV/IO access above diaphragm after 20 weeks (IVC compression) Prepare for emergency CS Increased risk of aspiration of gastric contents - early tracheal inbutation Usual defibrillation energy

Answer 13

Haemorrhage Drugs (e.g. magnesium for pre-eclampsia - give calcium) Cardiovascular disease - MI, dissection, aneurysm Pre-eclampsia and eclampsia Amniotic fluid embolism PE

Answer 14

Relieves IVC compression and may improve resuscitation of mother Allows for resuscitation of neonate Allows access for aortic clamping, internal cardiac massage Gestation less than 20 weeks - don't do, unlikely to compromise cardiac output and fetus not viable Gestation 20-23 weeks - do to allow for resuscitation of mother, survival of infant unlikely Gestation over 24 weeks - do to allow resuscitation of mother and infant

Answer 15

Actual or near cardiac arrest due to blunt impact to chest wall. Can cause VF/VT.

Answer 16

Permissive hypotension - caution in TBI as may have raised intracranial pressure requiring higher cerebral perfusion pressure TXA ideally within 1 hour, no later than 4 hours Out-of-hospital - only essential interventions, rapid transfer to hospital. Don't delay for spinal immobilisation.

Answer 17

Chest compressions - may not be effective if other causes e.g. tamponade/tension pneumothorax, need to consider and treat these early Focused USS to diagnose Prolonged CPR unlikely to be successful - stop if >20 minutes, excluded reversible causes, no cardiac activity on USS

Answer 18

External compressible haemorrhage - elevation and direct pressure +/- dressing, tourniquet, topical haemostatic agents Non-compressible haemorrhage - splints including pelvic binder, manage with blood products, IVF, TXA until surgical/radiological control Immediate aortic occlusion in uncontrollable infradiaphragmatic torso haemorrhage - resuscitative thoracotomy and cross-clamping of descending aorta Neurogenic shock can exacerbate - fluid replacement and vasopressors if required IO access if IV not feasible

Answer 19

Warm, vasodilated peripheries Loss of reflexes below injured segment Severe hypotension and bradycardia

Answer 20

Resuscitative thoracotomy with clamshell incision and opening of pericardium Not reliable to do needle pericardiocentesis with or without US guidance as blood likely to be clotted

Answer 21

Trauma Asthma or other pulmonary disease Clinical procedures e.g. CVC insertion

Answer 22

Needle decompression - long, non-kinking needle in 4th/5th intercostal space, mid-axillary line. Open thoracostomy as soon as appropriately trained clinicians present. Open thoracostomy - incision in 5th intercostal space, mid-axillary line and dissection into pleural space Chest drain should be sited following ROSC

Answer 23

5 in 10,000 Asystole in 41% VF in 35% PEA in 14% Best chance of survival - PEA

Answer 24

Invasive arterial blood pressure monitoring Attach defib pads pre-operatively Use warmed fluids/air to prevent hypothermia Ensure adequate IV access Adjust table to allow optimal chest compressions - can be done in prone position Use waveform capnography to monitor airway Give adrenaline in 50-100mcg increments rather than 1mg bolus for ALS reasons, give 50mcg boluses for anaphylaxis Stop operating unless you are treating a reversible cause of arrest

Answer 25

Hypovolaemia - bleeding Tension pneumothorax Loss of airway Anaphylaxis - most commonly due to neuromuscular blockers Vagal stimulation - causes bradycardia/asystole

Answer 26

Stop surgical activity causing vagal stimulation Give atropine Start CPR

Answer 27

External chest compressions - aim for SBP over 60, DBP over 25 at rate of 100-120 per minute If not achieving will need emergency retrosternotomy - indicates may have cardiac tamponade and/or hypovolaemia Consider other reversible causes - hypoxia, tension pneumothorax, pacing failure Treat witnesses VF/VT arrest with 3 successive shocks - if fails triggers need for emergency retrosternotomy Internal defibrillation if retrosternotomy performed with 20J Use adrenaline cautiously, IV doses up to 100mcg Atropine not recommended - pacing

Answer 28

350 accidental deaths in the UK from drowning each year M > F Commonest aged 20-30 Mostly in inland waters during summer

Answer 29

Submersion - initially breath hold reflex, swallows water. Hypoxia and hypercapnia develop. Reflex laryngospasm can prevent water entry to lungs. Eventually reflexes stop and aspirate water. Bradycardia due to hypoxia is what causes arrest. Immersion - hypothermia causes arrest (although may cause aspiration if splashes/unconscious)

Answer 30

Try to rescue without entry to water If need to enter water better to have two people and take life jacket, flotation device or boat Efforts based on likelihood of survival - good chance if 5-10 minutes submersion, poor outcome if >25 minutes Review efforts at 30 and 60 minutes. May be appropriate up to 90 minutes in children and very cold water (hypothermic neuroprotective effect) Consider in water ventilation if delay reaching land Remove from water quickly - low risk spinal injury unless dive into shallow water Keep horizontal - hypovolaemia can cause collapse/arrest after removal from water

Answer 31

Check for response Likely to have agonal breathing Give 5 ventilations with oxygen if possible Start chest compressions if no response - 30:2 Can bring up lots of foam - water mixed with surfactant and air Regurgitation of stomach contents and water common - turn on side and remove regurgitated material using suction if possiblw

Answer 32

High flow oxygen Consider early intubation - reduced pulmonary compliance means SGA might not be effective PEEP values should be 5-10cm, may require 15-20 if severely hypoxaemic Insert NG to decompress stomach Palpation of pulse not reliable - use ECG, end-tidal CO2, consider echo ALS according to standard algorithm Treat hypothermia Likely to be hypovolaemic - give IVF

Answer 33

Pneumonia common but prophylactic antibiotics not recommended. May be used if grossly contaminated water e.g. sewage

Answer 34

Body temp below 35 Mild 32-35 Moderate 28-32 Severe below 28 Stage I - mild hypothermia Conscious, shivering Core temp 32-35 Stage II - moderate hypothermia Impaired consciousness, not shivering Core temp 28-32 Stage III - severe hypothermia Unconscious, vital signs present Core temp 24-28 Stage IV - cardiac arrest or low flow state No or minimal vital signs Core temp less than 24 Stage V - death due to irreversible hypothermia Core temp less than 11.8

Answer 35

Need low-reading thermometer Core temp in lower third of oesophagus is well correlated with heart temp - need an advanced airway Tympanic probe reliable but may be lower than core temp in cold environment Rectal/bladder temp measurement lag behind core temp - aren't recommended in severe hypothermia Need to use consistent measure throughout resus/rewarming

Answer 36

Hypothermia has protective effect on brain and vital organs Can have good neurological recovery even after prolonged cardiac arrest if deep hypothermia before asphyxia Can cause very slow, low volume irregular pulse and unrecordable blood pressure No signs of life are not reliable for declaring death

Answer 37

Check for signs of life for up to 1 minute If doubt start CPR Can make chest compressions difficult due to stiffness of chest wall - consider use of mechanical chest compression devices Early tracheal intubation Drug metabolism slow - withhold adrenaline until core temp over 30 Once core temp 30 double time between doses (e.g. adrenaline 6-10 minutes) As normothermia approached (over 35) return to normal standard drug protocols If VF detected - defibrillate as standard. If unsuccessful after 3 shocks don't give more until temp >30 Perform continuous CPR if able, can give delayed CPR (core temp under 28 can give CPR for 5 mins then stop for 5 mins, core temp under 20 can give CPR for 5 mins then stop for up to 10 mins)

Answer 38

Out-of-hospital Removal from cold environment Severe hypothermia - immobilise (risk of triggering VF) Remove wet clothes If mild - exercise to rewarm, insulation and passive rewarming Moderate - heat packs to abdomen Transfer quickly to hospital In-hospital Pre-arrest - forced warmed air, warmed IVF Deteriorating/arrest - non-extracorporeal rewarming (forced warm air, warmed IVF, peritoneal lavage) if not able to transfer to ECMO centre within 6 hours, ECMO if able

Answer 39

Severe hyperthermia with body temperature over 40 Neurological symptoms including confusion, seizure, coma Exposure to high environmental temperatures or recent strenuous physical exertion Other symptoms - tachycardia, tachpnoea, hypotension, organ failure, dry/hot skin

Answer 40

Drug toxicity Drug withdrawal Neuroleptic malignant syndrome Serotonin syndrome Sepsis Endocrine disorders - thyroid storm, phaeochromocytoma

Answer 41

Cooling to less than 39 degrees Methods including misting, fanning, cool IVF, cold water immersion Isotonic or hypertonic fluids (hypertonic to correct hyponatraemia) Manage seizures Correct electrolytes If cardiac arrest - continue cooling and follow ALS algorithm

Answer 42

Genetic sensitivity of skeletal muscles to volatile anaesthetics and depolarising neuromuscular blocking drugs occuring during or after anaesthesia

Answer 43

Stop triggering agents Give oxygen Correct acidosis and electrolyte abnormalities Start active cooling Give dantrolene If cardiac arrest - follow ALS algorithm, active cooling

Answer 44

Difficult chest compressions - from head, depth 6cm IV access difficult - IO access may be required Minimise bag-valve ventilation May be leak from SGA - need to continue 30:2 CPR Tracheal intubation early Escalate defib energy to maximum for repeated shocks

Chapter 12 Flashcards

(69 cards)