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Flashcards in Emergency Med Deck (37):
1

Chest compression rate for CPR

100/minute....provide at least 30 before giving rescue breaths. Allow Chest to recoil after each compression.

2

True or False: Compression-only CPR is superior to no CPR

True (exception drowning rescues and pediatric arrests should include rescue breaths if possible)

3

ACLS Shockable Rhythms

VF/VT

4

ACLS not-shockable rhythms

Asystole and PEA

5

ACLS Sequence for VF or VT

1. Start CPR for 2 min immediately after Shock, then recheck rhythm
2. Administer epi 1 mg IV/Intraosseously every 3-5 min
3. vasopression 40 units can replace 1st or 2nd dose of epi
4. If VF/VT persist after 3 shock consider amiodarone
5. Amiodarone 300mg IV/IO

6

ACLS Sequence for PEA or Asystole

Use CPR with CAB sequence for 2 minutes, then recheck rhythm.
Administer epi 1 mg every 3-5 min
Vasopression 40 units IV/IO can replace 1st or 2nd dose of Epi

Treatmetn reversible causes.

7

Reversible Causes of Cardiac Arrest (H's and T's)

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hyperkalemia/hypokalemia
Hypothermia
Toxins (and drug overdose)
Tamponade
Thrombosis (pulmonary or coronary)
Tension pneumothorax)

8

Epinephrine

alpha-receptor agonist- increases cerebral and myocardial perfusion through vasoconstrictive effects.
B-receptor agonist- increases myocardial oxygen demand (considered a negative effect of epi)
Pulseless arrest dosing 1 mg every 3-5 min
Can be given by endotracheal route 2-2.5 mg diluted with 10ml of sterile water.

9

Vasopressin

Vasopresson 1 receptor agonist- causes vasoconstriction in the skin and skeletal muscles

Vasopression 2 receptor aonigsts- causes vasoconstriction in the mesenteric circulation

Vital organs recieve inreased perfusion secondary to stimulation of vasopressin 1 and 2 by shunting blood flow.

Half-life is 10-20 min, so repeat dosing is not indicated

Pulseless arrest dosing 40 units IV/IO to replace 1st or 2nd dose of epi

Absorbed by the tracheal route but a dose recommendation has not been established.

10

Amiodarone

First-line antiarrhythmic for VF/VT unresponsive to shock, CPR, and vasopressor administration

Antagonizes potassium, sodium, and calcium channels as well as blocks alpha and B receptors

Dosing for refractory VF/VT 300mg IV/IO push may repeat 150mg if needed.

If there is a ROSC, a maintenance iV infusion can be initiated at 1 mg/min for 6 hours, then 0.5mg/min for 18 hours.

11

Lidocaine

Inhibits sodium influx through ion channels, historically used for VF/VT

Second line agent b/c lidocaine us is associated with a higher rate of asystole and lower survival rates to hospital admission compared with amiodarone.

Dosing 1.5mg/kg Iv/IO up to a maximal dose of 3 mg/kg. Can be administered by endotracheal route.

12

Magnesium Sulfate

Effective for torsades depoints even in the absence of hypomagnesemia

Improves potassium transport and shortens the QT interval

Dose is 1-2 g diluted in 10ml of D5W

13

Medications absorbed by the trachea (NAVEL)

Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine

14

Type 1 Immunoglobulin E (IgE) mediated Reactio

Immediated hypersensitivity
Bronchospasm, laryngeal edema, anaphylaxis, urticaria, angioedemia.

15

Type II IgG or immunoglobulin M (IgM) mediated

Cytotoxic response occurs when the drug binds with immunoglobulins and leads to cell destruction.

Ex. Hemolytic anemia (Methyldopa, quinidine, pcn)
Thrombocytopenia (heparin, LMWH, quinidine, sulfonamide antibiotics)
Granulocytopenia

16

Type III: IgG or IgM

IgG or IgM complexes with drugs, which can then deposit in vessel walls and lead to inflammation and tissue damage.

Ex: Serum sickness (fever, rash, urticaria, arthalgia, lymphadenopathy) Drug ex. PCN, sulfonamide antibitocis, phenytoin, ASA, murine monoclonal antibodies.

17

Type IV T-cell mediated

Classically termed delayed hyper sensitivity

T-cells recognize antigens using receptors on the cell surface and release cytokines directly or in conjunction with effector cells such as eosinophils, monocytes or neutrophils.

Ex. Contact dermatitis
Maculopapular rash
Drug ex. ampicillin, amoxicillin, sulfonamide antibiotics, phenytoin, carbamazepine.

Bullous exanthema (Erthema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) least severe to most severe respectively.

Drug exm. Sulfonamide antibiotics, allopurinol, carbamazepine, phenytoin, sometimes associated with viral infections.

Other Type IV reactiosn

Fixed drug eruptiosn (well defined rash borders, red slightly elevated) Ex. sulfonamide, tetracycline, NSAID, carbamazepine, cirpo

Drug Rash with eosinophila and systemic symptoms. Hepatitius can occur in 60% of these casues (phenytoin, phenobarbital, carbamazepine, sulfonamide, allopurinol, dapsone.

18

Eosinophilia

If possitive test supports the diagnosis of drug-induced allergic reaction. If negative, does not rule out the drug-induced allergic causes.

19

Combs test

Antiglobulin test

Positive in drug-induced hemolytic anemia

Direct: antiglobulins are combined with the patient's red blood cells. If the red blood cells are coated with antibodies, there is agglutination.

20

Cutaneous warning signs for severe reactions (SJS, TEN)

elevated temp, malaise, erythematous edema of the face, target lesions, confluent erythema covering much of the body surface, mucosal involvement, lesions that are hemorrhagic or palpable, painful skin on touch.

21

Management of Hypersensitivity Rxn

Symptomatic Tx (Antihistamines, NSAIDS, Glucocorticoids)

Severe (SJS, TEN)- consider burn center care, fluids, nutrition, support, skin care, avoid topical sulfonamide products. Opthalmoloist required, topical opthalmolgic corticosteriods are usually required. IV IG 2-3 g/kg over 3-5 days. Systemic Corticosterioids are controversial.

22

Patients with amoxicillin allergy should avoid cephalosporins that share a common side chain...

Cefadroxil, cefprozil

23

Patients with ampicillin allergy should avoid cephalosporins that share a common side chain....

cephalexin, cefaclor

24

True or False...There is conclusive evidence of cross-reactibity b/t the sulfonamide antibiotics and other sulfonamides such as carbonic anhydrase inhibitors, sulfonylureas, lopp diuretics, thiazide diuretics, Cox-2 inhibitors.

False...no conclusive evidence.

25

Pseudo-allergies

Direct release of mediators from mast cells and basophils

Rxn are immediate and do not require previous exposure

Common examples include opiates, radiocontrast media, colloid volume expanders, iron dextran, aspirin, and NSAIDs.

26

Anaphylaxis Clinical Features

Rapid onset, life-threatening respiratory or cardiobascular collapse.
Skin involvement in 90% of cases (ie urticaria, rash, swelling, pruritus)
Respiratory invovlement in up to 70% (Nasal sx, upper airway, lower respiratory (SOB, chest tightness))
GI tract in up to 45% (NVD, abdominal pain)
Cardiovascular in up to 45% (chest pain tachycardia, bradycardia, hypotension, shock) Up to 50% fluid shift from the intravascular compartment in 10 min
Central nervous system in up to 15% (headache, dizziness, confusion, tunnel vision)

27

Anaphylaxis Differential Dx

1. Scrombroid poisoning (histamine poisoning caused by eating spoiled fish)
2. Angioedema
3. Severe asthma
4. Vasovagal rxn

28

Epinephrine

Cornerstone of tx for anaphylaxis

Administer IM in the thigh

Adults 0.2-0.5 mg IM
Pediatric patients 0.01 mg/kg IM up to 0.3 mg

Home Kits- kids weighing less than 30 kg get 0.15 mg, more than 30kg get 0.3 mg

Administer every 5-15 min as needed.

If fails, could use IV but not generally recommended d/t arrhythmias, myocardial ischemia, and severe hypotension.

29

When epi fails to reverse hypotension

Isontonic crystalloids (eg. 0.9% NaCL)

Adults 500-1000 ml
Pediatric patients 20ml/kg

Colloid infusions should not be used because they can cause anaphylaxis.

30

Other Acute treatment for anaphylaxis

1. Oxygen
2. Antihistamine (diphenhydramine & also cimetidine and ranitidine if combined with diphenhyramine improved cutaneous sx and tachycardia)
3. Glucocorticoids
4. Glucagon

31

Angioedema

Edema of skin or mucous membranes, non-pitting, sudden onset, mild to severe.

causes: allergic

non-allergic
Aspirin and NSAIDS rxn develop within 4 hours
Radiocontrast media

ACE-Inhibitor
Can occur in 1 day to 5 years later.

32

Gastric Decontamination-Poisoning

Not routinely indicated

Syrup of ipecac no longer recommended

Single-dose activated charcoal, may be useful for toxins known to bind to activated charcoal when exposure is less than 1 hour.

Multi-dose activated charcoal-useful for selected life-threatening exposures to the following toxins, carbamazepine, dapsone, phenobarbital, quinine, theophylline. (b/c of enterohepatic circulation)

Whole bowel irrigation (useful to expel contents of the GI tract

Orogastric lavage, if exposure is less than 1 hour and life threatening.

33

Antidote for Benzodiazepine

Flumazenil

34

Antidote for digoxin

Digoxin immune Fab

35

Antidote for Acetaminophen

N-acetylcysteine

36

Antidote for b-blockers

Glucagon

37

Antidote for Isoniazide

Pyridoxine