Crises Flashcards
(18 cards)
Difficult ventilation? Consider … and do …
Consider ... light anesthesia brochospasm, analphylaxis, PTX endobronchial intubation (typ 21 F, 23 M) kinked or occluded ETT machine problems
Do …
auscultate
suction the ETT
ventilate with an Ambu bag to eliminate machine problems
Treatment for bronchospasm
sevo/Forane are bronchodilators propofol and ketamine are as well albuterol, ipratropium epi steroids (to help later, not now) ... consider whether breaths are stacking!
Anaphylaxis treatment
FLuids
Epi
Steroids
H1/H2 antihistamines (Benadryl, cetirazine)
Needle cricothyroidotomy technique
Supplies: antiseptic 14ga or bigger Angiocath 10ml syringe with 5 ml saline in it jet ventilator
Procedure:
Prep
Palpate cricothyroid membrane with nondom hand
Attach syringe to Angiocath and enter membrane at 45 degree angle caudad, withdrawing as you go
There will be a pop and bubbles when you enter airway
Thread the Angiocath and attach it to the jet ventilator
Basic branches of the Difficult Airway Algorithm
First, a failed asleep intubation
Attempt mask and/or SGA (LMA) ventilation
Success? - NON EMERGENCY pathway
Failure? - EMERGENCY pathway
NON EMERGENCY:
try other methods
multiple failures? - END GAME
EMERGENCY:
Call for help!
Maybe emergency non invasive (combitube, rigid bronch)
If success, go to END GAME
If fail, or maybe right away: surgical airway or needle cric
END GAME:
Consider surgical airway, awakening patient, or “other options”
Sudden decrease in ETCO2, DDx
ESOPHAGEAL INTUBATION
MONITOR: Sample-line air leak, analyzer error
OBSTRUCTION: brochospasm, COPD, tube kink
LOW CARDIAC OUTPUT
HYPERVENTILATION: machine setting, pain, anxiety, or metabolic acidosis (PaCO2 will be low)
PE: thrombo, air, fat, CO2, amniotic fluid (PaCO2 will be high)
Intraop hypoxemia presentation, 4 immediate actions, and Ddx (3 equipment, 7 patient)
Presents as: HTN, agitation, decreased SpO2, cyanosis -> symptoms of cardiac and neurologic hypoxia
Immediately: increase FiO2 to 100%, titrate PEEP auscultate for breath sounds check ETCO2 -- still ventilating? consider intubation if not already done
Ddx: esophageal intubation disconnection from vent or O2 source right mainstem airway obstruction or mucus plug atelectasis bronchospasm Ptx pulmonary edema aspiration low cardiac output
Pneumothorax and tension PTX - presentation, diagnosis, treatment
presentation ranges from nothing to:
hypoxia, tachypnea, tachycardia, chest pain
hypotension can occur with tension PTX (due to kinking of major vessels with mediastinal shift)
Diagnosis: auscultation, CXR, percussion
Tx: 100% O2, and decompress pleural space using a large needle at the bottom of the second intercostal space (first is bordered by clavicle) at mid-clavicular line
Pulmonary Edema - signs, symptoms, management
Signs: hypoxemia, decreased SpO2
Symptoms: distress, tachycardia, agitation
Management: 100% FiO2, PEEP, diuresis, intubate. If ?cardiogenic, consider afterload reduction with NTG, with pressors
Rate control in afib, 4 drugs
Beta-blockers (metoprol 2.5 mg) to start
Calcium channel blockers (diltiazem 0.25 mg/kg IV x 1)
Amiodarone
Digoxin only if in heart failure
BRADYCARDIA - immediate mgmt, Ddx, subsequent mgmt, special considerations
tell surgeon to stop it, if it’s iatrogenic
atropine 0.4 mg q 5 minutes
transcutaneous pacing if tissue hypoperfusion is occurring
Ddx:
Drugs - beta or calcium-channel blockers, excessive narcotics
Physiologic - vagal stim, carotid sinus hypersensitivity, high intraocular pressure, high SVR
cardiac tamponade
hypoxia, acidosis, electrolyte abnormalities
Subsequent mgmt:
transvenous pacing if transcutaneous fails
epi or dopamine infusion
permanent pacemaker
Special considerations: atropine works at the AV node, likely won’t help if the brady is below that. Glucagon can be used if beta-blockers are the culprit.
Narrow tachycardia, management and Ddx
Immediate mgmt (if unstable of course):
adenosine 6 mg rapid push, repeat 12 mg x2, then …
stable regular? treat underlying cause
stable irregular? rate control with diltiazem 15 mg over 20 minutes or metoprolol 5 mg IV
unstable sinus? try beta blockers, or DC cardioversion
unstable non-sinus? DC cardioversion
Ddx: sinus tachy atrial tachy multifocal atrial tachy re-entrant tachy (WPW) junctional tachy afib aflutter
Vfib management
1) Immediate 360J monophasic / 200J biphasic shock, q 2 minutes if necessary
2) ventilate with mask if necessary, intubate when feasible
3) Begin CPR right after shock, go for two minutes without pausing to check rhythm or pulse
4) give epi 1 mg IV every 3 to 5 minutes
Cardiac tamponade - presentation, management
Presentation: dyspnea orthopnea tachycardia JVD distant heart sounds pulsus paradoxus (SBP drops by >= 10 during inspiration) Beck's triad: small quiet heart, rising venous pressure, hypotension
Immediate management:
emergency pericardiocentesis
fluid to increase preload
maintain heart rate and rhythm
Immediate management of hypertension
Consider medication error
Increase depth of anesthesia
Beta blockers (labetalol) if not brady; hydralazine if brady
nicardipine
Sodium NTP if situation is life threatening
Treatment of LAST, Local Anesthetic Systemic Toxicity
FIRST: airway management (ventilate with 100% O2), seizure suppression (benzos, avoid propofol), alert nearest facility with cardiopulmonary bypass capability
MANAGEMENT OF CARDIAC DYSRHYTHMIAS: ACLS will require prolonged effort, med adjustments. AVOID vasopressin, Ca channel blockers, beta blockers, and local anesthetic. REDUCE epi dose to under 1 mcg/kg
LIPID EMULSION (20%, 2mg/ml): BOLUS 1.5 mL/kg (or 100 ml) over 1 minute, fast. Then continuous INFUSION at 0.25 mL/kg/min, around 1000ml/hr. REBOLUS once or twice if necessary. DOUBLE INFUSION if BP remains low. CONTINUE INFUSION at least 10 minutes after circulatory stability.
hypoxia
FILL IN
STEMI, ST depression
FILL IN
