Life support Flashcards
1
Q
If patients temp <30 degrees and in arrest/arrythmia/SBP <90 what should we do?
A
Transfer to ECMO centre
2
Q
If temp <30 degrees what change should we make to the ALS algorithm? (2)
A
- Don’t give adrenaline
- If 3 shocks unsuccessful don’t shock again until >30 degrees
3
Q
When temp is 30-34 degrees what should we do with adrenaline?
A
Increase interval to 6-10min
4
Q
What is the treatment for malignant hyperthermia? (4)
A
- Stop triggering agent
- Target normocapnia
- Active cooling
- Dantrolene
5
Q
How long should patients be observed following malignant hyperthermia?
A
72 hours - 25% relapse
6
Q
How long should we perform CPR if we thrombolyse PE?
A
60-90 mins
7
Q
What dose ALSG state is managment of tension PTX in arrest?
A
Thoracostomy
Can use needle decompression if quicker but needs to be followed up by thoracostomy and chest drain
8
Q
What is the difference between laryngectomy and tracheostomy in relations to resus?
A
Laryngectomy patients do not have a patent airway and therefore oral measures will not work at all
9
Q
If suspecting an issue with a tracheostomy what is the very first step to assess?
A
Look/listen/feel mouth and trachy
ETC02 and Mapleson C can help
10
Q
If you have assessed a trachy and suspect an occlusion what is the first step in the algorithm following the initial look/listen/feel?
A
Remove any speaking valve or cap and inner tubs and place a suction catheter down
If is passes then it is at least partially patent
11
Q
If you have removed a tracheostomy inner tube but cannot pass a suction catheter down if, what is the next step in the algorithm?
A
Deflate the cuff
If improves then either partial tube obstruction or diplaced
12
Q
You have removed the inner tube of a trachy and deflated it with no effect. What is the next step?
A
Remove trachy tube
13
Q
What are the primary emergency oxygenation maneuvers once a tracheostomy has been removed because it wasn’t working? (2)
A
- Standard oral oxygenation measure (facemask/adjuncts)
- Tracheostomy stoma ventilation (paeds face mask/LMA to stoma)
14
Q
What are the secondary emergency oxygenation measures once a tracheostomy has been removed? (2)
A
- Oral intubation (uncut tube and advance beyond stoma)
- Stoma intubation - small trachy tube/size 6 ETT cuffed, consider fibre-optic or bougie
15
Q
What are the 5 types of heat illness?
A
16
Q
What are the 3 cardinal signs of heat stroke?
A
- Temp >40 degrees
- Encephalopathy
- Anhydrosis
17
Q
What is the underlying mechanism that makes heat stroke different from heat exhuastion?
A
SIRS response leading to multi-organ failure with encephalopathy predominating
18
Q
What biochemical abnormalities can be seen in heat stroke? (6)
A
19
Q
What are the two types of decompression injury?
A
- Decompression sickness - evolved gas being release
2.Arterial gas embolism (AGE) - escaped gas bubble in arterial system (either via alveolar rupture or venous gas via overwhelming lung filtration of PFO/VSD/ASD)
20
Q
In neonatal resus what are the fist steps to take when the baby is born? (4)
A
- Delay cord clamping if possible
- Start clock
- Wrap + stimulate
- Head neutral
21
Q
If a baby has been stimulated and is not breathing what is the next steps (3)
A
- 5 inflation breaths (30cmH20)
- 5-6cmH20 PEEP
- Oximetry +/- ECG
22
Q
Following 5 inflations breaths the baby is still not breathing - what are the next steps? (5)
A
- Check position
- 2 person technique
- Suction
- Repeat 5 inflation breaths
- Consider increasing pressure
23
Q
You have delivered 5 inflation breaths to a neonate and the chest is now moving - now what?
A
30 secs ventilation breaths once confirmed still no pulse/HR <60bpm
24
Q
Following 30 secs ventilation breaths there is no pulse or HR <60bpm - what are your next steps? (5)
A
- 3:1 breaths:compressions
- 100% Fi02
- Reassess every 30 secs
- Consider I+V with size 3 ETT
- IV access and drugs
25
With regards to neonatal resusitation what should be done if a baby is < 32 weeks in terms of heating?
1. Place undried in plastic wrap
2. Under radiant heat
26
What Fi02 should be used in the first stages of neonatal resus based on gestational age? (3)
1. > 32 weeks - 21%
2. 28-31 weeks 21-30%
3. < 28 weeks 30%
27
What are appropriate pre-ductal SATs (right hand) in terms of term after birth (3)
1. 2 mins = 65%
2. 5 mins = 85%
2. 10mins = 90%
28
What should we aim to do with cord clamping in neonatal resus? (3)
1. Aim to delay at least 60 secs until after lungs aerated
2. If practical can keep unclamped
3. If < 28/40 'cord milking' - milk mothers blood to baby
29
When should drugs be used in neonatal resus?
If no CO despite good ventilation and chest compressions
30
What dose of adrenaline should be used in neonatal resus? (2)
20mcg/kg (0.2mk/kg 1 in 10,000)
No response consider increasing to 30 mcg/kg
31
When should sodium bicarbonate be used in neonatal resus and what dose?
1. Prolonged resus
2. 1-2mmol/kg
(2-4ml/kg 4.2 bicarbonate (not 8.4%)
32
What dose of atropine and calcium should be used in neonatal resus?
No role in neonatal resus
33
When should stopping neonatal resusitation be considered?
After 20 mins if all reversible causes have been considered
34
What ratio compressions should be used in paeds resus?
15:2
35
What size BVM should be used in paeds resus?
< 1 year = 500ml bag
> 1 year = 1600ml bag
36
How long should IV access take place for before switching to IO?
2 attempts or 90 secs then IO
37
What is the dose of atropine in paeds resus?
20mcg/kg (minumum 100mcg)
38
What is the dose of amioderone in paeds resus?
5mg/kg
39
What is the dose of lidocaine (can be used instead of amioderone) in paeds resus?
1mg/kg
40
What is the dose of magnesium in paeds resus?
25-50mg over several minutes (polymorphic VT)
41
What dose of calcium chloride should be used in paeds resus?
0.2ml/kg of 10%
42
What dose of sodium bicarbonate should be used in paeds resus?
1-2ml/kg 8.4%
(dont mix with adrenaline as it inactivates adrenaline)
43
What is the dose of glucose in paeds resus?
2ml/kg 10% dextrose
44
What is the dose of adrenaline in paeds resus?
10mcg/kg IV 1:10,000
45
What is the dose of lorazepam in paeds resus?
0.1mg/kg
46
What is the dose of PR diazepam in paeds resus?
0.5mg/kg
47
What is the dose of buccal midazolam in paeds resus?
0.5mg/kg
48
What is the ETT size calculation in paeds
(age/4) + 4
49
What is the ETT length calculation in paeds?
(age/2) + 12
50
How can sinus tachy vs SVT be determined in paeds?
1. SR HR <200bpm
2. p waves upright 1 in SR
3. Hx of shock if sinus
4. Beat to beat variation in SR
51
What is the SVT algorithm in paeds? (5)
1. Valsalva (cold water in neonates/babies, hand stand in kids)
2. Adenosine:
Up to 1 year: 150 mcg kg-1, increase 50–100 mcg kg-1
every 1–2 min. Maximum single dose: Neonates 300
mcg kg-1, Infants 500 mcg kg-1)
1–11 years: 100 mcg kg-1 increase 50–100 mcg kg-1
every 1–2 min. Maximum single dose: 500 mcg kg-1
(max. 12 mg)
12–17 years: 3 mg IV, if required increase to 6 mg
after 1–2 min, then 12 mg after 1–2 min
3. Consider cardioversion or amioderone
52
DV cardioversion in paeds VT what is the voltage? (2)
1. 2J/kg
2. If fails 4J/kg
53
What is the dose of magneisum in torsades des pointes in paeds?
25-50mg/kg
54
In the paeds choking algorithm what should be done for a conscious infant (<1) who has a poor cough?
5 back blows (head downward and prone) followed by 5 thrusts (supine and chest position as CPR) continually until resolution or reduced GCS
55
In the paeds choking algorithm what should be done for a conscious child > 1 who has a poor cough?
5 back blows (head down, forward leaning) followed by 5 thrusts (abdominal thrust) continually until resolution or reduced GCS
56
What is the paeds choking algorithm for unconscious patients? (7)
1. Lie flat and open mouth - look for FB
2. If seen - 1 x finger sweep
3. McGills/direct laryngoscopy
4. Attempt x 5 rescue breaths
5. No chest rise - reposition head
6. CPR 15:2 checking for FB every time airway opened
7. No improvement and hypoxic - surgical airway
57
What are the adrenaline dose for paeds anaphx? (3)
1. > 12 = 500mcg (0.5ml 1:1000)
2. 6-12 = 300mcg (0.3ml)
3. < 6 year = 150mcg (0.15ml)
58
What is the IV dose of adrenaline for paeds anaphx?
1mcg/kg 1:10,000
adult dose = 50mcg
59
What are the paediatric chlorphenamine doses? (4)
1. > 12 year = 10mg
2. 6-12 years = 5mg
3. < 6 year = 2.5mg
4. < 6 months = 250mcg/kg
60
What are the paediatric hydrocortisone doses for allergy? (4)
1. > 12 years = 200mg
2. 6-12year = 100mg
3. < 6 years = 50mg
4 < 6 months = 25mg
61
When should tryptase measurements be taken?
Immediately and then another sample < 4 hours
62
What is refractory anaph and how should it be treated?
1. 2 or more doses of adrenaline with no improvement
2. Adrenaline infusion
= 1mg (1ml of 1mg/ml 1:000) in 100ml normal saline
Start at 0.5/1.0 ml/kg/hr
63
What are the contraindications to Penthrox?
C - linically significant cardiac or resp disease
H - hypersensitivity to methoxyflurane (or any flurinated gas)
E - stablished hx of malignant hyperthermia
C - onsciousness altered
K - kidneys (eGFR <45) or liver disease
64
What is the gauge and flow rate of an orange cannula?
14G and 240ml/hr
65
What is the gauge and flow rate of a grey cannula?
16 G and 180ml/min
66
What is the gauge and flow rate of a green cannula?
18G and 90ml/min
67
What is the gauge and flow rate of a pink cannula?
20G and 60ml/min
68
What is the gauge and flow of a blue cannula?
22G and 36ml/min
69
What is the gauge and flow rate of a yellow cannula?
24G and 20ml/min
70
What do the resus council recommend for DC shock J in AF/SVT?
70-120 J
71
What does resus council recommend for initial shock J in pulsed VT in adults?
120-150 J
72
How many attempts does DASS say is maximum for tracheal intubation?
3 - change something each time
73
Following failed intubation what does DASS recommend moving onto as second line?
Igel
74
What is the Parkland formula
2-4ml x weight(kg) x TBSA burns
Usually use 3 ml
75
Over what period should fluid calculated by the Parkland formula be given?
First half in 8 hours, then second half over 16 hours
76
When should an escharotomy be perfored?
With deep burns skin can become stiff. In chest this can impair ventilation and in the limbs circulation
77
How is an escharotomy performed?
1.The limb should be kept in the anatomical position.
2. The area is cleaned and incised along the anatomical lines with a scalpel down to the fat
3. The incision should not go down to the muscle or fascia
4.For the limbs the incisions need to release both medial and lateral aspects
5. For the chest the incision needs to release the whole breast plate
78
What biochemical marker suggests a likely poor outcome in hypothermic arrests?
K+ >10
79
What are the recommended methods for measuring temperature in severe hypothermia? (3)
1. Tympanic (accurate to 20degrees C)
2. Oesophageal
3. Intravascular
Not rectal
80
At what voltage should you start at to defibrillate AF or SVT?
70-120 J
81
At what voltage should you start at to cardiovert VT?
120-150J
82
What are the escalating doses of adenosine in adults who are in SVT but stable?
6mg
12mg
18mg
83
Describe the anaesthetic intubation grades
84
How do we convert L/min to Fi02?
(L/min x 4) + 20
e.g. (5L/min x 4) = 40
85
Describe the Mallampati scoring system
Class I: Soft palate, uvula, fauces, pillars visible.
Class II: Soft palate, major part of uvula, fauces visible.
Class III: Soft palate, base of uvula visible.
Class IV: Only hard palate visible.
86
What are the ranges for mild/moderate and severe hypothermia?
Mild = 32-35 degrees
Moderate = 28-32 degrees
Severe = 24-28 degrees
87
Describe the APGAR scoring system
A-ppearance
0 - pale/blue
1 - pink body, blue extremities
2 - pink
Pulse
0 - absent
1 - < 100
2. > 100
G-rimace
0 - nil
1 - some movement
2 - cry
A-ctivity
0 - limp
1 - some flexion of extremities
2 - well flexed
R - espirations
0 - absent
1 - weak cry or hypoventilation
2 - good
88
Describe the Swiss staging system for hypothermia? (5)
1. Mild (Stage I) – conscious with shivering. 32 to 35°C.
2. Moderate (Stage II) – Altered mental status without shivering. 28 to 32°C.
3. Severe (Stage III) – Unconscious. 24 to 28°C
4. Very Severe (Stage IV) – Apparent death. Core temperature 13.7 to 24°C (resuscitation may be possible). Remember cold delays the brain death.
5. Death (Stage V) – Death due to irreversible hypothermia. Core temperature <9 to 13.7°C (resuscitation not possible).
89
How long should be check for signs of life in hypothermic arrest?
1 minute
90
What does METHANE stand for?
M - ajor incident declared
E - xact location
T - type of incident
H - azards
A - Access/egress
N - Number and type of casualties
E - emergency services present/requried
91
What is the breakdown of the 'rule of 9s'? (6)
1. Head and neck - 9%
2. Anterior trunk - 18%
3. Posterior trunk - 18%
4. Upper extremity - 9%
5. Lower extremity - 18%
6. Perineum - 1%
92
When is entonox c/i? (6)
1. Head injury
2. Chest injury
3. Suspected bowel obstruction
4. Middle ear disease
5. Early pregnancy
6. B12/folate deficiency
93
Describe the ASA grading
1. normal
2. mild systemic disease
3. severe systemic disease -
4. severe systemic disease, constant threat to life e.g. unstable angina, DKA
5. moribund, will die without operation
94
Describe the LEMON anaesthetic assessment
1. L-ook externally
2. E - valuate using '3,3,2'
3 fingers mouth opening
3 fingers from mentum for hyoid
2 fingers between hyoid and throid gland
3. Mallampati
4. Obstruction/obesity
5. Neck mobility
95
In hypoxia during mechanical ventilation what does the mnemonic DOPES stand for?
D: Dislodgement of the tube – check depth of tube against recorded depth at intubation. Is
ETCO2 still connected and recording?
O: Obstruction – can a suction catheter be passed?
P: Pneumothorax
E: Equipment failure – disconnect ventilator and return to manual BVM.
S: Stacked breaths – especially auto-PEEP in COPD/asthma. Disconnect from ventilator.
96
What dose of glucose should be used in prolonged neonatal resus?
250mg/kg = 2.5ml 10% dextrose /kg
97
How is coronary perfusion pressure calculated?
CPP = DBP - LV end diastolic pressure
98
What DBP should we aim for in arrest and why?
>30mmHg
CPP should aim for >20mmHg
CPP = DBP - LV end diastolic pressure
LV end diastolic pressure approx 10mmHg (variable in arrest)
99
Where should IM adrenaline be given?
Anterolateral aspect of middle third of thigh
100
What is the IV dose of adrenaline for anaphx?
50mcg in adults
1mcg/kg paeds
101
What rate should an adrenaline infusion be set up at for refractory anaphx?
1mcg/kg/min
= 1ml/kg/hr (1ml 1:1000 in 100ml normal saline)
102
In the ALS bradycardia algorithm what are the 4 life threatening signs?
1. Shock
2. Syncope
3. Myocardial ischaemia
4. Heart failure
103
In the ALS bradycardia algorithm what are the 4 factors that suggest increased risk of asystole and therefore should have intervention even if no life threatening signs?
1. Recent asystole
2. Mobitz II
3. Complete HB with broad QRS
4. Ventricular pause > 3secs
104
What are the interim measures recommended by ALS whilst awaiting transvenous pacing in bradycardia? (5)
1. Atropine 500mcg to maxium 3mg
2. Isoprenaline 5mcg/min IV
3. Adrenaline 2-10mcg/min IV
4. Alternative drugs*
5. Transcutaneous pacing
*
- aminophylline
- dopamine
- glucagon (if betablocker/CCB OD)
- glycopyrrolate instead of atropine
105
How should amiodarone be administered?
Over 10-60mins in large bore cannula
(decrease risk of hypotension and thrombophlebitis)
106
What is the mechanism of action of metoprolol?
Selective beta-1 antagonist, has negligible beta-2 affect
107
What is Mendelsons syndrome?
Chemical pneumonitis after being exposed to acidic material (gastric contents)
108
What is the ALS treatment for hyperkalaemic arrest? (4)
1. Protect the heart: give 10 mL calcium chloride 10% IV Consider repeating dose if cardiac arrest is refractory or prolonged.
2. Shift potassium into cells: Give 10 units soluble insulin and 25 g glucose IV by rapid injection.
3. Shift potassium into cells: Give 50 mmol sodium bicarbonate (50 mL 8.4% solution) IV by rapid injection.
4. Remove potassium from the body: Consider dialysis for refractory hyperkalaemic cardiac arrest.
109
Outside of echo, what 2 signs to ALS mention as supporting PE?
1. Low ETC02 despite good CPR (<1.7 KPa)
2. PEA
110
Under what gestation should a neonate be placed in a food grade plastic wrap or bag?
<32/40
111
What temperature drop in neonates leads to what increase in mortality?
Drop in temp of 1degree C or more below 36.5 degrees C increases mortality by 28%
112
Why do SATs need to be from the right hand in neonates?
Right arm supplied by brachiocephalic artery which branches off the arch of aorta before ductus arteriosus. This is more reflective of neonates true oxygenation status during transition from foetal circulation
113
How long should inflation breaths be?
2-3 secs
114
How many neonates as a %:
1. Will start breathing within 60-90 secs of birth
2. Start breathing after drying/stimulation
3. Need PPV
4. Need compressions
1. 85%
2. Further 10%
3. 5%
4. 0.3%
115
Why is a pale neonate worse than a blue neonate following birth?
Because pale indicates likely both CV and respiratory collapse, blue only respiratory
116
How should an airway be suctioned in neonates?
Direct vision with large bore catheter
117
Under what weight and gestation are IGels c/i in neonates?
< 34/40 or < 2kg
118
If colloid needed in neonatal resusitation what should be used?
O-ve blood
119
How often should neonates be reassesed in resus?
Every 30 secs
120
When can intratracheal route of adrenaline be used in neonatal resus and what is the dose?
If no other access available
100mcg/kg (1ml of 1:10,000)
121
Describe primary and secondary apnoea in the neonate
Primary: Failure to breath leads to anoxia and inhibition of neural respiratory centre. There will be rapid, regular breathing followed by the primary apnoea period within 2-3mins. Associated with bradycardia.
Secondary: If no intervention, at approx 12 mins irregular, gasping breaths with whole body shuddering (primitive spinal gasps). If this fails to aerate the lungs secondary apnoea follows. This is terminal apnoea and associated with drop in MAP and further bradycardia.
122
How long does progression from primary to secondary apnoea take?
Approx 20 mins
123
Why can an oesophageal intubation be even harder to recognise in neonates?
Because they are so small you get chest rise and transmitted sounds from stomach
124
In the resus council algorithm for refractory anaphx what is the initial treatment for adults + paeds?
1. Fluid bolus (10ml/kg in paeds, 500ml/1000ml adults)
and
2. Adrenaline infusion =
1mg (1ml of 1:1000 adrenaline) into 100ml normal saline and commence 0.5-1.0ml/kg/hr and titrate to affect
125
According to resus counil refractory anaphx alorigthm what should be considered if poor response to adrenaline infusion? (3)
1. Add second vasopressor (metaraminol/noradrenaline/vasopressin)
2. If on beta blocker consider glucgaon
3. Consider ECMO
126
What do resus council paeds status algorithm state for second line agents and which one has the best evidence?
* Levetiracetam 30–60 mg kg-1 (over 5 min, max 3 g)
OR
* Phenytoin 20 mg kg-1 **by slow IV infusion
over 20 min with ECG monitorin**g
OR
* Phenobarbital 20 mg kg-1 by IV infusion over 5 min
All have been shown to be equally effective if several trials
127
After what period of time does likelihood or seizure termination decrease and what consequence does this have to the status algorithm
After 5 mins which is when resus council define status
Means first dose benzo should only be given after 5 mins.
128
When giving phenytoin IV, what must be considerd?
If given as bolus will lead to bradycardia/hypotension +/- asystole
129
What induction agents are mentioned by resus council for third line status tx?
There is no evidence for the ideal third line agent:
1. thiopentone,
2. propofol
3. ketamine
4. midazolam
all appropriate
130
What are the differences between paeds BLS in hospital and OOH? (2)
1. If alone perform 1 minute chest compressions before calling for help if no phone. If have phone and can use speaker do asap.
2. CPR - 30:2 to decrease number of changes of position. If not willing/unable to ventilate then compression only
131
What depth should paeds CPR be performed to?
If infant chest compression depth should be 4cm, if child then 5cm
132
In anaphx first aid what is recommended immediately after calling for help? (2)
1. Lie flat (+/- legs up) (left lateral if pregnant)
2. Remove trigger
133
In the paeds tracheostomy algorithm what should be done initially if the patient is breathing? (6)
1. Check safety
2. Stimulate
3. Shout for help
4. Oxygen to face and trachy
5. Open airway
6. Capnography
134
In a breathing child, following initial measures what should be done and how next in the trachy algorithm?
Remove HME, speaking valve and change inner tube then pass suction catheter
If can pass catheter then at least partially unobstructed so suction and continue assessment
135
In the paeds trachy algorithm what should be done if you are unable to pass a suction catheter and how is this performed?
Change trachy
1. Deflate cuff
1. First change - same size
2. Second change - 0.5 size smaller
3. Third change over suction catheter to guide
Assess response to each change, if unsuccessful remove the tube
136
If a child is not breathing, what does the trachy algorithm state should be done first?
5 rescue breaths:
- if patent upper airway using mouth
- if obstructed upper airway then via trachy/stoma
If no signs of life start CPR 15:2
137
What are the primary oxygenation maneuvers in the paeds tracheostomy algorithm?
1. Standard oral: cover stoma and BVM +/- adjucts or SGA
2. Stoma : either paeds facemask applied to stoma or SGA
138
What are the secondary oxygenation maeuvers in the paeds tracheostomy algorithm?
1. Oral intubation: uncut tube advanced below the stoma 0.5 size smaller than trachy size
2. Attemp stoma intubation: size 3.0mm ETT or trachy
Ideally with difficult airway expert + fibreoptics
139
How does RCUK define bradycardia in terms of HR?
< 1 years = < 80bpm
> 1 years = < 60bpm
140
In the paeds bradycardia algorithm what is the first step? (RCUK)
Adequate oxygenation - either with via facemask or PPV
141
Following optimal oxygenation in a paeds bradycardia algorithm defines the next step? (RCUK)
If unconscious commence CPR
If conscious move on to next step
142
In a child who is bradycardic but conscious and has been optimally oxygenated, what should be the next steps? (RCUK) (3)
1. Atropine if suspected excessive vagal tone (20mck/kg and max 300mcg)
2. If no response to atropine consider adrenaline
3. Paced rarely required and should be guided by aetiology
143
What does RCUK suggest makes SVT more likely than sinus tachy in infants and children?
Abrupt onset and:
Infants: HR >220bpm
Children: HR > 180bpm
144
In decompensated SVT what does RCUK recommend in paeds? (5)
DC cardioversion with sedation:
1st shock = 1J/kg
2nd shock = 2J/kg
Consider up to 4J/kg
Consider adenosine BEFORE third shock and give slowly (>20mins)
If delay to cardioversion and IVA consider atropine
145
In decompensated broad complex tachy paeds what does RCUK recommend doing in conscious and unconscious patients?
Conscious = sedation +
Unconscious = immediate cardioversion
1st shock = 1J/kg
2nd shock = 2J/kg
Consider up to 4J/kg
Consider amioderone BEFORE third shock and give slowly (>20mins)
146
If no IVA what does RCUK recommend for sedation for paeds cardioversion?
IN or IM ketamine - do no delay cardioversion for IVA if decompensated.
147
What are the 5th centile BPs that RCUK use to define hypotension and decompensation needing cardioversion for each age group? (4)
1 month = SBP 50
1 year = SBP 70
5 years = SBP 75
10 years = SBP 80
148
What is the adrenaline dose for paeds bradycardia? (RCUK)
10mcg/kg and repeat if needed
149
What is the dose of magnesium to be used in polymorphic VT in paeds?
25-50mg/kg up to 2g given over 15 mins (can be repeated)
150
In arrest what should be the defib voltage in monophasic and biphasic defibrillators?
4J/kg
151
In life threatening asthma, what is the safe dose of IV salbutamol given slowly?
250mcg IV
152
With (end inspiratory) plateau pressure:
1. What is it used as a surrogate marker of
2. What is its clinical relevance to PHEM?
3. How is it measured
4. What is considered high
1. End inspiratory volume
2. Used to measure dynamic hyperinflation e.g COPD/asthma ventilation
3. End inspiratory occlusion for 3 seconds e.g insp hold
4. >26 cmH20
153
What is more specific to risk of barotrauma plateau pressure or peak pressure?
Plateau pressure as it is the pressure delivered to the alveoli
154
What are the physiological targets for post ROSC paeds patients (RCUK)? (5)
1. Avoid MAP <5th percentile
2. Pac02 = 4.5-6.0 kPa (don't use ETCO2)
3. Pa02 10-13 kPa (or 94-98% SATs)
4. Mandatory targeted temperature 36-37.2 degrees
5. Normoglycaemia
155
At what gestation should we move from palliative focussed care to active?
22 + 0
(i.e 21+6 no resus)
156
After what gestational age does outcome improve significantly?
24 weeks
157
What factors (aside from the gestation) have been shown to worsen prognosis in extreme premature birth (22-26 weeks)? (6)
1. Born early in gestational week
2. Male
3. FGR
4. Twins or more
5. No antenatal steroids
6. Born DGH
158
Describe how BAPM recommend managing extreme premature births with comfort centred care?
1. No PPV
2. Oxygen if parents want
3. Counsel that there maybe some movement breathing and that baby may live for about an hour (average <24/40)
4. Allow as much time as they want with baby
159
If gestation unknown/unclear and no previous counseling of parents, what does BAPM recommend in terms of resusitation?
If not obviously <22/40 or <350g then reasonable to provisionally commence resus, and redirect to palliation if poor response
160
What is the mortality and chance of disability for babies born:
1. 22/40
2. 23/40
3. 24/40
Mortality
1. 7/10
2. 6/10
3. 4/10
Born with severe disability
1. 1 in 3
2. 1 in 4
3. 1 in 7
161
If gestation <37/40, where does BAPM recommend baby being born/transferred if possible?
Level 3 NICU
162
What does the RCUK guideline state should be the sequence of events in maternal cardiac arrest?
1. Confirm and call for help 'obstetric arrest'
2. Lie flat and manual displacement uterus
3. CPR
4. Pads
5. Airway
163
What is the preferred method for performing CPR in infants?
Two thumb encircling technique
164
What were the findings of the AIRWAYS 2 trial?
1. No change in functional outcome SGA/ETT
2. No increased aspiration/regurge
3. SGA first pass success higher
165
What are the conditions in which resusitation can be witheld/discontinued by EMT/paramedic? (5) (JRCALC)
1. DNACPR
2. LPA (with decisions related to life sustaining tx) refuses CPR
3. Patient known to be in final stage of irreversible condition where CPR inappropriate
4. Submersion (see drowning)
5. No realistic chance of success (criteria exist)
166
What criteria need to be meet for EMTS/paramedics to decide no realistic chance of success of resus? (JRCALC)
If ALL the following exist together:
1. > 15 mins since CPR onset
2. > 15 mins without bystander CPR
3. No exclusion criteria (drowning/hypothermia/poisoning/OD/pregnancy/paeds)
4. Asystole > 30 secs on ECG screen
167
Once resusitation has been commenced, what criteria do paramedics need to terminate CPR? (JRCALC)
1. All reversible causes addressed
2. Persistently and continuously asystolic 30 minutes
3. None of the following:
- pregnancy
- hypothermic
- OD
- anyone under 18 yrs
168
What does JRCALC state with regards to PEA?
1. US may help with prognosis
2. If PEA following 30 mins may need to ask for senior clinical advice
169
What factors have been shown to have better outcomes in PEA? (JRCALC)
1. Young age
2. MI
3. PE
4. Reversible causes e.g. hypothermia
170
What does JRCALC state about agonal rhythms in arrest?
Can be treated as asytole
171
What do JRCALC and RCUK state with regards to refractory VF?
1. JRCALC advocates going to 'cardiac arrest centre' with CPR ongoing as MI likely cause
-
2. RCUK - escalating voltage shocks and AP pad placement. No DSD outside of research. Lidocaine 100mg IV followed by 50mg after fifth instead of amioderone acceptable
172
What does JRCALC recommend with regards to first line benzo in status?
1. Midazolam 10mg buccal
2. 20mg diazepam PR
3. 10mg diazepam IV
- Buccal midazolam first line if no IVA, don't delay to insert cannula.
- PR diazepam if no buccal but ? slower
173
Which neonates are currently considered for therapeutic hypothermia in the UK, and that does this consist of
1. Evidence of moderate-severe hypoxic ischaemic encephalopathy (HIE)
2. 72 hours of cooling to a core temperature of 33‐34°C started within six hours of birth
174
What are the criteria than need to be met for therapeutic hypothermia to be commenced on neonates?
>36/40 +
1. Evidence of perinatal hypoxia/ischeamia
· Apgar score of <5 at 10 minutes after birth
· Continued need for resuscitation at 10
minutes after birth
· Acidosis defined as any occurrence of:
pH <7.00
Base deficit >16mmol/l
in any cord or baby gas sample within 60
minutes of birth
+
2. Evidence of significant ischaemic encephalopathy
-altered state of
consciousness (lethargy, stupor or coma)
AND at least one of the
following:
· hypotonia
· abnormal reflexes including oculomotor or
pupillary abnormalities
· absent or weak suck
· clinical seizures
+
3. EEG abnormal
175
What is the survival focused care algorithm for extreme pre-term?
1. Optimise ambient temperature
2. Defer cord clamping
60 seconds
3. Maintain baby’s heat:
- Place feet-first in a polythene bag up to the neck, do not dry beforehand
- Hat and warm blanket over polythene bag
- Place swaddled baby on a heated mattress if available
4. Maintain airway position, inflation + ventilation breaths using pre-term FM
- Do not unwrap baby to reassess
5. Chest compression
Not indicated below 24 weeks’ gestation
6. Consider reorientation of care where absent heart rate despite airway support,
and destination not imminent If in doubt, continue ventilation breaths until arrival
176
At what gestation are chest compressions indicated in extreme pre-term neonates?
24 weeks or above
177
What is an Aintree Catheter?
for exchanging EET/trachy or Igel to ETT
- pass through existing ETT/SGA/trachy
- can oxygenate through catheter
- can also place bronchoscope in catheter so can be passed under direct vision (useful particularly if IGel to ETT)
- then can place new tube over catheter and remove catheter
178
What is RCUKs position on suction based airway clearance devices (for choking)
No evidence - does not support
179
What is likely to have the biggest impact on OOHCA survival?
Adding to school curriculum
180
How should a towel be used to help to correct neutral position for airway?
2cm thick towel under shoulders
181
How should prostaglandins be delivered in CHD?
5-10mcg/kg/min as an infusion (never bolus)
182
What are the end points for fluid resusitation in sespis (4 )(RCUK)
1. CRT >2
2. UO >1ml/kg;hr
2. Normal pulses
4. Normal mentation
183
If using an adrenaline infusion for sepsis peripherally, what should be done?
Dilute it from recommended RCUK starting dose (0.05-0.3mcg/kg/hr)
184
What should be remembered when giving phenytoin IV?
Rapid bolus can lead to hypotension/bradycardia and arrhythmia
185
What dose of steroids should be given in paeds asthma?
4ml/kg hydrocortisone
186
What are the loading doses and administration of anti-epileptics in paeds status ?(RCUK0
1. Keppra 40mg/kg (max 3g) over 5 mins
-
2. Phenytoin 20mg/kg (over 20mins + with ECG monitoring)
-
3. Phenobarbitol 20mg/kg (over 5 mins)
187
What level of Na+ does RCUK recommend treatment and what is the dose?
Na+ 125
3ml/kg of 3% saline
188
What is the minimum distance defib pads should be from an ICD/PPM?
8cm
189
When can adult defib pads be used on children?
> 8yrs or > 25kg
190
Under what age should a dose attenuator be used in paeds defib?
< 8 years (should have paeds pad as well)
191
How far should free flowing oxygen be away from a defib?
>1m
192
What voltage should be used for internal defibrillation?
10-20J (never >50J)
193
What is the most common trigger for anaphx in:
1. young people?
2. elderly people
1. Food
2. Medication
194
What are the differences in presentation (generally) between food and medication anaphx?
Food: usually younger, slower onset and increased breathing issues
Meds: older patient, quicker onset and predominantly circulatory issues
195
What should be the first step in managing anaphx?
Lie patient down, ideally legs up
196
What is the bolus dose IV adrenaline in adult anaphx?
50mcg
197
