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EM Exam #2 Retake > Lecture 9: Resuscitation and Shock > Flashcards

Lecture 9: Resuscitation and Shock Flashcards

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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?

A

> 65 mmHg

also Central Venous Pressure 8-12 mmHg

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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

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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

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12
Q

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

A

Emergent revascularization

Ideally: PCI or CABG.

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13
Q

What kind of bacteria is MC in sepsis?

A

Gram positive (+)

Staph, strep, enterococcus, clostridium, listeria

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14
Q

What qualifies as septic shock?

A

Sepsis that also requires vasopressors after adequate resuscitation and elevated lactate

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15
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 and CVP monitoring

May need more fluids

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16
Q

What almost always precipitates neurogenic shock?

A

Spinal cord injury!

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17
Q

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

A
  1. Warm to touch
  2. Bradycardiac
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18
Q

What is the primary management for neurogenic shock?

A

Vasopressors

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19
Q

What kind of position may help relieve upper airway obstructions and require minimal neck extension?

A

Sniffing position

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20
Q

What must you ensure prior to using an OPA for airway adjunct?

A

No gag reflex can be present

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21
Q

When would you use an NPA as an airway adjunct? (2)

A
  • Intact gag reflex
  • Absent any Facial trauma
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22
Q

How much O2 is delivered with optimal BVM technique?

A

75%

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23
Q

What is the E-C technique for BVM? (2)

A
  1. C shape with thumb and index finger on mask
  2. 3-5th fingers in an E to lift mandible
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24
Q

What are the 7 indications for ETT?

A
  • 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
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25
What criteria is used to evaluate ease of intubation?
Mallampati criteria
26
Why do we preoxygenate prior to intubation and how? (3)
* Displacing nitrogen from alveoli to create a reservoir * **Increases safe apnea time from 1 min to 8 mins** * Done via 100% O2 for 3 mins using NRB @ 15LPM ideally.
27
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 (maC is Curved) or MiLLer is like an LINE
28
Which ETT blade is more associated with tachycardia and trauma?
Miller
29
Image of ETT tubing | FYI
30
What are the 5 factors that predict difficulty with mask ventilation?
* Facial hair * Obesity * No teeth * Advanced age * Snoring | Any 2 of the 5!
31
What is administered first in RSI: paralytic or sedative?
Sedative. | Date before you Succ ## Footnote You don't want to be paralyzed but awake.
32
What 5 factors predict difficulty with intubation?
* Facial hair * Obesity * Short neck * Short/long chin * Airway deformity
33
Which RSI sedative should be avoided in hypotensive patients?
Propofol | Propofol makes your Pressure Fol
34
Which RSI sedative is a good option for bronchospasm or hypotension?
Ketamine
35
Why is Succinylcholine preferred among the paralytics?
Quick on/off
36
When is succinylcholine not used in RSI? (3)
* Neuromuscular disorder * Burns * Hyperkalemia | Succ is the only depolarizing NM blocker
37
When is rocuronium CId?
Hx of myasthenia gravis
38
How many attempts constitute a failed airway?
3 failed attempts
39
What two things must be ensured if infusing vasopressors via a peripheral IV?
1. Cannot be a distal IV 2. Must be well-secured
40
What are the primary sites to insert central lines? (3)
1. IJ 2. Subclavian 3. Femoral | Needs US
41
What is the easiest site to insert a central line?
Femoral vein | Easy to palpate, but dirtiest area
42
Tx for VF (2)
1. Defibrillate @ 200J (biphasic) 2. CPR
43
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 | 1mg IV
44
What is the tx for Asystole/PEA?
* CPR * Epi * ABCDs
45
What are the reversible Hs for cardiac arrest? (5)
* Hypoxia * Hypovolemia * Hydrogen ion (acidosis) * Hypo/hyperkalemia * Hypothermia
46
What are the reversible Ts for cardiac arrest? (5)
* Tension PTX * Tamponade (cardiac) * Toxins * Thrombosis: pulmonary * Thrombosis: coronary
47
What rhythms fall under supraventricular arrhythmias?
* AF/Aflutter * AVNRT * AVRT (narrow/orthodromic)
48
What is the tx for SVT? (2)
1. Vagal maneuvers 2. Adenosine 6mg, then 12mg, then 12mg.
49
What is the pharm tx for AF/Aflutter? (2)
1. BB 2. CCB
50
When would we convert AF urgently? (4)
1. Recent onset and RVR 2. Hypotension 3. MI 4. Pulmonary Edema
51
How do we manage stable, low-risk AF pts? (3)
1. Rate control 2. Oral anticoagulants 3. Reevaluate in 3-4 weeks
52
What is the tx for VT without a pulse? With?
* Without a pulse: Defib at 200J * Pulse present: Procainamide/amiodarone
53
What are the 2 indications to emergently treat a bradyarrhythmia?
* HR < 50-60 + hypotension/hypoperfusion * Structural disease of the infranodal conduction system (close monitoring)
54
What heart blocks are most associated with needing emergent tx? (2)
* Mobitz type II 2nd degree HB * 3rd degree HB | Immune to atropine injection usually
55
What is the ratio of compressions:ventilations for a 2 person rescue for a pediatric pt?
15:2 | Adult is 30:2
56
What is the primary etiology of pediatric arrest?
Respiratory
57
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
58
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
59
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
60
Top 2 RFs for SIDS
1. Smoking 2. Sleeping position of baby
61
Define SIDS
Unexpected death of infant < 1 yr old with no pathologic cause identifiable. | Leading cause of infant death between 1mo-1y.
62
When is resuscitation of SIDS NOT indicated?
* Rigor mortis * Livedo reticularis * pH < 6 * Significantly reduced core temperature without environmental hypothermia.
63
Prevention of SIDS (4)
1. Firm sleeping surface 2. No bed sharing/cosleeping 3. Don't overheat 4. Use pacifier
64
After what amount of time is pediatric resuscitation associated with a poor outcome?
> 20 minutes
65
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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