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EM quiz readings > Lecture 9: Resuscitation and Shock > Flashcards

Lecture 9: Resuscitation and Shock Flashcards

1
Q

What is often the first clinical sign of shock?

A

Hypotension

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2
Q

When we first suspect shock, what protocol do we begin with first? (5)

A
  • Airway
  • Breathing
  • Circulation
  • Deliver of O2
  • End Points
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3
Q

What MAP do we typically aim for in a hypotensive patient? What other end points do we want to meet?

A
  • MAP - > 65 mmHg
  • Central venous pressure of 8-12mmHg
  • ScvO2>70%
  • urine output >.5 mL/kg/hr
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4
Q

What are the 4 primary end goals during ED resuscitation of septic shock?

A
  1. MAP > 65 mmHg
  2. CVP of 8-12
  3. ScvO2 > 70% (Venous O2 Sat)
  4. Urine output > 0.5mL/kg/hr
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5
Q

Define shock

A

A state of circulatory insufficiency between tissue oxygen supply and demand, leading to end-organ dysfunction.

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6
Q

What characterizes distributive shock hemodynamically? (3)

A
  • Decreased preload
  • Decreased SVR
  • Mixed CO

Sepsis, neurogenic shock, anaphylaxis

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7
Q

What characterizes Hypovolemic shock hemodynamically? (3)

A
  • Decreased preload
  • Increased SVR
  • Decreased CO

Hemorrhage, capillary leak, GI losses, burns

increase d/t bodies attempt to make up for low volume
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8
Q

What characterizes cardiogenic shock hemodynamically? (4)

A
  • Increased preload
  • Increased afterload
  • Increased SVR
  • Decreased CO

MI, dysrhythmias, HF, valvular disease

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9
Q

What characterizes obstructive shock hemodynamically? (3)

A
  • Decreased preload
  • Increased SVR
  • Decreased CO

PE, pericardial tamponade, tension PTX

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10
Q

What is the MC type of shock?

A

Distributive

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11
Q

What is the MCC of cardiogenic shock?

A

AMI

dysrhythmias are also common!

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12
Q

how can cardiogenic shock vary with different arrhythmias

A

bradyarrhythmias - low CO
tachyarrhythmias - decreased preload and stroke volume

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13
Q

What is the primary intervention in acute ischemia-related cardiogenic shock?

A

Emergent revascularization

Ideally: PCI or CABG.

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14
Q

What kind of bacteria is MC in sepsis?

A

Gram positive (+)

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15
Q

What qualifies as septic shock?

A

Sepsis that also requires vasopressors after adequate resuscitation and elevated lactate

sepsis + vasopressors + evelated lactate

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16
Q

How do you assess for occult shock in those with s/s of infection and what is occult shock?

A
  • Occult = normal vital signs w elevated lactate!!! (googled this but also says “vital signs and lactate” in slides)
  • look for infection source! culture everything and look for surgical/gyn/indwelling medical device infection.

google: Occult shock is the state of early hypoperfusion causing a. metabolic acidosis that occurs in trauma patients, prior to. changes in vital signs.

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17
Q

Is a central venous catheter mandatory to resuscitate most patients in septic shock?

A

No, central venous pressure trends are more important than absolute values.

no idea what this means but sounds important

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18
Q

What are the primary management steps in Septic Shock management? (4)

A
  1. Empiric ABX ASAP
  2. 1-2L bolus of LR/IV crystalloid (may need more)
  3. Administer NE as first-line vasopressor if refractory hypotension is present.
  4. Consider dobutamine, packed RBCs, corticosteroids and CVP monitoring

May need more fluids

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19
Q

what occurs in neurogenic shock?

A
  1. loss of peripheral sympathetic innervation
  2. extreme vasodilation 2/2 loss of sympathetic arterial tone
  3. blood pooling in distal circulation w resultant hypotension
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20
Q

What almost always precipitates neurogenic shock?

A

Spinal cord injury!

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21
Q

Why is neurogenic shock unique in terms of presentation and initial assessment? (2)

A
  1. Warm to touch
  2. Bradycardiac

even if this is present, neurogenic shock cant be dx until other causes of hypotension are excluded.

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22
Q

What is the primary management for neurogenic shock?

A

Vasopressors

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23
Q

just glance at this in case she cray

A
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24
Q

what 2 positionings would you use to facilitate airway patency in a patient?

A
  1. extension of the neck w anterior displacement of the mandible (moves hyoid bone anteriorly and lifts epiglottis)
  2. sniffing position (forward flexion of neck with extension of the head.)
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25
What kind of position may help relieve upper airway obstructions and require minimal neck extension?
Sniffing position
26
What must you ensure prior to using an OPA for airway adjunct?
No gag reflex can be present ## Footnote used to prevent tongue from occluding hypopharynx
27
How do you place an oropharyngeal airway?
1. place in airway with concave portion cephalic 2. rotate 180 degrees after passing tongue ORRRR - Orient concave portion horizontal - rotate 90 degrees following curve of tongue after insertion
28
When would you use an NPA as an airway adjunct? (2)
* Intact gag reflex * Facial trauma
29
How do you insert an NPA?
1. properly size (corner of mouth to angle of mandible) 2. lubricate and insert horizontal to the palate w bevel oriented towards septum | insert parallel to nasal floor, not cephalad.
30
How much O2 is delivered with optimal BVM technique?
75%
31
What is the E-C technique for BVM? (2)
1. C shape with thumb and index finger on mask 2. 3-5th fingers in an E to lift mandible
32
What are the 7 indications for ETT?
* Respiratory failure * Apnea * Reduced LOC (think GCS < 8) * Rapid change in mental status * Airway injury or impending airway compromise * High risk for aspiration * Trauma to the larynx
33
What criteria is used to evaluate ease of intubation?
Mallampati criteria
34
Why do we preoxygenate prior to intubation and how? (3)
* Displacing nitrogen from alveoli to create a reservoir * Increases safe apndea time from 1 min to 8 mins * Done via 100% O2 for 3 mins using NRB @ 15LPM ideally. ## Footnote O2 desat to <70% is assocaited w increased risk of ysrhythmias, decompensation, and cardiac arrest!
35
What are the 2 blades used for ETT? | FYI
* MAC is less traumatic but less across the board * Miller is more traumatic but more across the board | Mac Miller
36
Which ETT blade is more associated with tachycardia and trauma?
Miller
37
Image of ETT tubing | FYI
38
What are the 5 factors that predict difficulty with mask ventilation?
* Facial hair * Obesity * No teeth * Advanced age * Snoring | Any 2 of the 5!
39
What is administered first in RSI: paralytic or sedative?
Sedative. | Date before you Succ ## Footnote You don't want to be paralyzed but awake.
40
What 5 factors predict difficulty with intubation?
* Facial hair * Obesity * Short neck * Short/long chin * Airway deformity
41
what is the MC RSI Sedative?
IV Etomidate
42
Which RSI sedative should be avoided in hypotensive patients?
Propofol
43
Which RSI sedative is a good option for bronchospasm or hypotension?
Ketamine
44
Why is Succinylcholine preferred among the paralytics?
Quick on/off
45
When is succinylcholine not used in RSI? (3)
* Neuromuscular disorder * denervation injury older than 7 days * burns older than 5 days | denervation and burn = risk of hyperkalemia
46
When is rocuronium CId?
Hx of myasthenia gravis | paralytic (non-depolarizing agent)
47
How many attempts constitute a failed airway?
3 failed attempts
48
What two things must be ensured if infusing vasopressors via a peripheral IV?
1. Cannot be a distal IV 2. Must be well-secured
49
what are CI for peripheral IV access? what do you do instead?
1. infusing sclerosing solutions 2. concentrated electrolyte or glucose solutions 3. cytotoxic chemotheraputic agents | instead insert IV central access for these!
50
what are indications for central Access IV's?
1. inability to obtain peripheral IV or CI to peripheral IV 2. access central circ needed for procedures 3. measure central venous pressure.
51
What are the primary sites to insert central lines? (3)
1. IJ 2. Subclavian 3. Femoral | Need to use US
52
What is the easiest site to insert a central line?
Femoral vein | Easy to palpate, but dirtiest area
53
Tx for VF (2)
1. Defibrillate @ 200J (biphasic) 2. CPR
54
When can epi be given during CPR and how often?
* Epi can be given after the 2nd shock attempt * Epi can be administered every 3-5 minutes * amiodarone or lidocaine may be used after epinephrine | 1mg IV
55
What is the tx for Asystole/PEA?
* CPR * Epi every 1-3 min * ABCDs * correct reversible causes * DO NOT SHOCK THIS RHYTHM
56
I thin kthis is the least confusing flow chart of all of them but thats just me
57
What are the reversible Hs for cardiac arrest? (5)
* Hypoxia * Hypovolemia * Hydrogen ion (acidosis) * Hypo/hyperkalemia * Hypothermia
58
What are the reversible Ts for cardiac arrest? (5)
* Tension PTX * Tamponade (cardiac) * Toxins * Thrombosis: pulmonary * Thrombosis: coronary
59
What rhythms fall under supraventricular arrhythmias?
* AF/Aflutter * AVNRT * AVRT (narrow/orthodromic AVRT)
60
What is the tx for SVT? (4)
1. Vagal maneuvers 2. Adenosine 6mg, then 12mg, then 12mg. 3. if converts, observe and monitor 4. if not, control rate
61
What is the tx for AF/Aflutter? (3)
1. BB 2. CCB 3. cardiovert if resistant
62
When would we convert AF urgently? (4)
1. Recent onset and RVR 2. Hypotension 3. MI 4. Pulmonary Edema
63
How do we treat unstable patients with long-standing afib
1. electro cardioversion is NOT likely to succeed 2. initiate hemodynamic resuscitation and ventricular rate control
64
How do we manage stable, low-risk AF pts? (3)
1. Rate control 2. Oral anticoagulants 3. Reevaluate in 3-4 weeks
65
What is the tx for VT without a pulse? With?
* Without a pulse: Defib at 200J * Pulse present: Procainamide/amiodarone
66
What are the 2 indications to emergently treat a bradyarrhythmia?
* HR < 50-60 + hypotension/hypoperfusion * Structural disease of the infranodal conduction system (close monitoring) | transcutaneous pacing
67
What heart blocks are most associated with needing emergent tx? (2)
* Mobitz type II 2nd degreee HB * 3rd degree HB | transcutaneous pacing
68
What is the ratio of compressions:ventilations for a 2 person rescue for a pediatric pt?
15:2 | Adult is 30:2. if only 1 rescuer do 30:2.
69
What is the primary etiology of pediatric arrest?
Respiratory
70
What are the 4 clinical features of a BRUE (Brief, resolved, and unexplained event)?
1. Cyanosis or pallor 2. Absent/decreased/irregular breathing 3. Marked change in tone 4. Altered level of responsiveness | Any of the 4
71
What are the 4 RFs for BRUEs in pediatric patients?
1. Feeding difficulties 2. Recent URI symptoms 3. **< 2 months old** 4. Hx of previous episodes
72
What is the criteria to be considered low-risk for recurrence after BRUE for a pediatric patient? (7)
1. > 60 days old 2. If a preemie, must have been GA >= 32wk and postconceptional age older than 45 wks 3. 1 BRUE only 4. BRUE < 1 min 5. No CPR needed 6. No concerning historical features 7. No concerning PE findings | Not advised to do routine testing
73
Top 2 RFs for SIDS
1. Smoking 2. Sleeping position of baby
74
Define SIDS
Unexpected death of infant < 1 yr old with no pathologic cause identifiable. | Leading cause of infant death between 1mo-1y.
75
When is resuscitation of SIDS NOT indicated?
* Rigor mortis * Livedo reticularis * pH < 6 * Significantly reduced core temperature without environmental hypothermia.
76
Prevention of SIDS (4)
1. Firm sleeping surface 2. No bed sharing/cosleeping 3. Don't overheat 4. Use pacifier
77
After what amount of time is pediatric resuscitation associated with a poor outcome?
> 20 minutes
78
In what situation might we continue CPR longer for a pedatric arrest? (2)
* **Presence of cardiac electrical activity** PLUS * **Hypothermia is underlying cause** | Can continue resuscitation while attempting core rewarming to 30C

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