chapter 12- resuscitation in special circumstances

Question 1

causes of hyperkalaemia?

Answer 1

renal failure
drugs - ACE-I, ARB, Kt sparing diuretics, saids, bb
tissue breakdown- rhabdomyolysis, tumour lysis, haemolysis
metabolic disorders
endocrine disorders e.g. addisons
diet

Question 2

ECG changes associated with hyperkalaemia?

Answer 2

tall tented T waves
first degree heart block
flat or absent P waves
ST depression
ST merging
widened QRS
VT
bradycardia

Question 3

Management of hyperkalaemia principles?

Answer 3

1) cardiac protection
2) shift K into the cells
3) remove K from the body
4) monitor K and glucose
5) prevent from reoccurring

Question 4

Risks associated with treatment of hyperkalaemia?

Answer 4

hypoglycaemia following insulin administration
Tissue necrosis
rebound hyperkalaemia

Question 5

management of hyperkalaemia in patient not in cardiac arrest?

Answer 5

10 ml calcium gluconate 10% IV

10 units of insulin in 25g glucose

Question 6

management of hyperkalaemia in patient in cardiac arrest?

Answer 6

10 ml calcium gluconate 10% IV
10 units of insulin in 25g glucose
50mmol sodium bicarbonate (50ml of 8.4%) IV if severe renal failure
consider dialysis

Question 7

causes of hypokalaemia?

Answer 7

diarrhoea
drugs - diuretics, laxatives, steroids
renal losses - diabetes insipidus
endocrine disorders - cushings 
metabolic alkalosis

Question 8

ECG changes hypokalaemia?

Answer 8

U waves
T wave flattening
ST segment changes

Question 9

sepsis 6?

Answer 9

HIGH FLOW O2
IV ABX
IVF

URINE OUTPUT
BLOOD CULTURES
LACTATE

Question 10

Doses of IM, IV, SC and IN naloxone?

Answer 10

400 mcg IV
800mcg IM
800mcg SVC
2mg IN

Question 11

what is the duration of naloxone?

Answer 11

45-70 mins

Question 12

ECG changes in TCA overdose?

Answer 12

widening of QRS
RAD
tachycardia

Question 13

first line management of stimulant overdose?

Answer 13

small doses of benzodiazepines

GTN to relieve coronary vasoconstriction

Question 14

symptoms of stimulant overdose?

Answer 14

agitation, symptomatic tachycardia, hypertensive crisis, hyperthermia, MI

Question 15

what is the definition of anaphylaxis?

Answer 15

serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death. It is characterised any potentially life threatening compromise in airway, breathing and/or circulation.

Question 16

Criteria for anaphylaxis?

Answer 16

1) sudden onset and rapidly progressing symptoms
2) life threatening airway and/or breathing and/or circulation problems
3) skin and/or mucosal changes (flushing, urticaria, angioedema)

Question 17

what are some of the airway, breathing and circulation features of anaphylaxis?

Answer 17

A: airway swelling, hoarse voice, stridor
B: SOB, wheeze, patient becoming tired, cyanosis, respiratory arret
C: pale, clammy, tachycardia, hypotension, decreased consciousness, MI/cardiac arrest
D:

Question 18

what is the algorithm for management of anaphylaxis?

Answer 18

1) AE
2) diagnosis - look out for sudden onset of airway, breathing and/or circulatory problems and usually skin changes
3) call for HELP
4) remove trigger + lie patient flat (if pregnant - lie of left side)
5) give IM ADRENALINE (0.5mg, i.e 0.5ml of 1:1000 adrenaline)
6) establish airway, give high flow O2, apply monitoring
7) if no response - repeat IM adrenaline after 5 mins + IV fluid bolus
8) if no improvement despite 2x doses - follow refractory anaphylaxis algorithm

Question 19

where should IM adrenaline be given in anaphylaxis?

Answer 19

anterolateral aspect middle third of thigh

Question 20

what is the refractory anaphylaxis algorithm?

Answer 20

1) establish IV/IO access + seek critical care
2) give rapid fluid bolus + start adrenaline infusion - 1mg adrenaline in 100ml of NaCL - ON A SEPARATE LINE and start at 0.5ml/kg/hr and titter according to response
3) give IM adrenaline every 5 mins until adrenaline infusion has been started

if there is partial airway obstruction - nebuliser adrenaline (5mg of 1mg/ml)

if severe/persistent bronchospasm - nebulised salbutamol and ipratropium with O2, and consider infusion of aminophylline or salbutamol

Question 21

what are the timings of mast cell tryptase measuring?

Answer 21

initial sample ASAP
second sample 1-2h (but no later than 4h)
third sample 24h - to provide baseline

Question 22

what are the features of life threatening asthma?

Answer 22

altered consciousness 
exhaustion 
arrhythmia 
hypotension 
cyanosis
silent chest
poor expiratory effort 
PEF < 33%
SpO2 < 92% 
PaO2 < 8
normal PaCO2

Question 23

what are the features of near fatal asthma?

Answer 23

raised PaCO2

Mechanical ventilation with raised inflation pressures

Question 24

what are the features of severe asthma?

Answer 24

PEF 33-55% of best predicted
RR > 25
HR >110
inability to complete sentences

Question 25

what are the causes of cardiorespiratory arrest in asthma?

Answer 25

severe bronchospasm and mucous plugging cardiac arrhythmias caused by hypoxia dynamic hyperinflation can occur in mechanically vented patients (auto-PEEP is caused by air trapping and breath stacking causing gradual build up of pressure and reduced venous return) tension pnuemothorax

Question 26

Management of severe asthma attack?

Answer 26

O2 to achieve 94-98% SpO2 salbutamol 5mg NEB back to back ipratropium bromide 500mcg NEB back to back Hydrocortisone 100mg IV MgSo4 2g (8mmol) IV 20 mins consider aminophylline (5mg/kg loading dose) IVF

Question 27

criteria for considering tracheal intubation in asthma?

Answer 27

``` deteriorating peak flow decreasing conscioussness worsening hypoxaemia deteriorating resp acidosis severe agitation, confusion, fighting against the mask progressive exhaustion resp or cardiac arrest ```

Question 28

what position should a pregnant woman be placed in during emergency situation to prevent cardiac arrest?

Answer 28

left lateral position OR manually displace the uterus to the left

Question 29

where should IV access be ideally placed in a pregnant woman during cardiac arrest?

Answer 29

above the diaphragm, as after 20 weeks gestation the uterus can press down on the IVC impeding venous return and cardiac output.

Question 30

what position should a pregnant woman be in during chest compressions?

Answer 30

left lateral tilt if possible | manually displace the uterus to the left

Question 31

when should a peri-mortem c section be performed?

Answer 31

Foetus older than 20 weeks gestation and no ROSC within 5 mins

Question 32

signs of tension pneumothorax?

Answer 32

``` respiratory distress prior to cardiac arrest haemodynamic compromise absent breath sounds on auscultation chest crepitations subcutaneous emphysema tracheal deviation jugular vein distension ```

Question 33

management of tension pneumothorax?

Answer 33

needle decompression- needle is inserted into the 2nd intercostal space (just above third rib), or the 4th/5th intercostal space at the mid axillary line