Module 1 - Shock, Geriatrics, RSI

Question 1

Describe the role of universal screening of ED patients for IPV and other social issues.

Answer 1

• opportunity to access resources

Question 2

What is included in a comprehensive subjective history?

Answer 2

• ETOH
• Smoking
• Illicit druge use
• Interpersonal violence

Question 3

What are the 7 P’s of rapid sequence intubation?

Answer 3

1. Prepare
2. Protection and position
3. Preoxygenate
4. Pretreat
5. Paralysis and Induction (induction first!)
6. Proof of placement
7. Post-intubation care

Question 4

What is involved in post-intubation care?

Answer 4

• Re-check ABCs and full vitals
• Secure ETT + document
• Tubes (OG, foley, CVCs, ART lines)
• Sedation & analgesia
• Mechanical ventilation (BVM vs. ventilator)

Question 5

What are common presentations of ecotopic pregnancy?

Answer 5

• first trimester bleeding
• abdominal pain
• missed menstrual period

Question 6

What are the clinical features of a ruptured ectopic pregnancy?

Answer 6

• hypotension
• tachycardia
• moderate to severe abdominal pain
• peritoneal signs (rebound tenderness)

Question 7

What are the two treatments for ectopic pregnancies?

Answer 7

1. Surgical management (for unstable patients)
2. Medical management (stable patients)

Question 8

What is the name of the medication used in the medical management of an ectopic pregnancy?

Answer 8

Methotrexate (MTX) - inhibits DNA synthesis and cell replication

Question 9

What are the three stages of shock?

Answer 9

1. Compensated
2. Uncompensated
3. Irreversivle

Question 10

What are some signs and symptoms of shock?

Answer 10

• tachycardia
• hypotension
• tachypnea
• cool and clammy extremities
• oliguria
• dysglycemia
• delirium

Question 11

What are the 4 types of shock?

Answer 11

1. Hypovolemic
2. Cardiogenic
3. Distributive (sepsis, neurogenic, anaphylactic)
4. Obstructive

Question 12

True or False:
Vital signs may be normal in compensated shock

Answer 12

True
- Body is able to maintain cardiac output
- Cellular damage is STILL happening

Question 13

What is the key to treating all types of shock?

Answer 13

Early recognition and intervention

Question 14

What is the first line drug of choice in anaphlaxsis?

Answer 14

Epinephrine

Question 15

What is the first line druge of choice in vasodilatory and septic shock?

Answer 15

Norepinephrine

Question 16

When is dopamine used?

Answer 16

Vasodilatory shock associated with BRADYCARDIA

Question 17

What does dobutamine do?

Answer 17

• Increases contractility of the heart
• Vasodilation (decreases SVR)
  Can help improve CO by decreasing afterload, making it easier for the heart to eject blood with each contraction

Question 18

What do colloid fluids contain?

Answer 18

Contain undissolved particles (protein, sugar, starch) that are too BIG to pass through capillary

Question 19

What effect do colloids have? (Isotonic, Hypotonic, or Hypertonic)?

Answer 19

Hypertonic
- pull fluid from tissues into vasculature

Question 20

What does fresh frozen plasma contain?

Answer 20

Albumin, Globulins, Antibodies, Plasma clotting factors

Question 21

What are the components of the “Geriatric Giant”?

Answer 21

• Delirium
• Depression
• Dementia
• Drugs
• De-conditioning
• Falls
• Pain
• Incontinence
• Malnutrition / Dehydration
• Sleep disturbance
• Elder abuse

Question 22

What are some cardiac changes that happen in older adults?

Answer 22

• cardiac muscles thicken
• arteries stiffen
• valves stiffen
• conductivity altered

Question 23

What are some respiratory changes that happen in older adults?

Answer 23

• rigidity of chest wall
• enlargement of chest wall
• lung tissues diminish

Question 24

What are some renal changes that happen in older adults?

Answer 24

• Less renin production
• Decrease in filtration
• Decrease ability to concentrate urine
• Decrease in renal blood flow

Question 25

What are signs of multiple organ dysfunction in septic shock? *

Answer 25

- Altered mental status - tachypnea - poor cap refill - hypotension - tachycardia - thrombocytopenia (increase d-dimer) - metabolic acidosis (increase lactate) - urine output < 0.5 mL/kg/hr)

Question 26

What are the endothelia cell dysfunctions that leads to multiple organ dysfunction?*

Answer 26

- capillary leak - microvascular thrombus - cell adhesion - tissue hypoxia - apoptosis - impaired vascular tone - free radical damage

Question 27

What can make for a difficult airway with RSI?

Answer 27

- Obesity - Short or wide neck - Obvious signs of deformity

Question 28

What are the two paralytics that are commonly used in RSI?

Answer 28

- Roccuronium (non-depolarizing) - Succinylcholine (depolarizing)

Question 29

Which is longer acting, Roc or Succ?

Answer 29

Roccuronium

Question 30

In what cases does Succinylcholine have to be used carefully?

Answer 30

- Hyperkalemia (K+) - Renal Failure - Burns - Conditions that increase neuromuscular blockade (low Ca+, low K+, high Mg+, metabolic acidosis)

Question 31

What is the name of the reversal agent for rocuronium?

Answer 31

Sugammadex

Question 31

What are the drugs used for induction?

Answer 31

- Propofol - Ketamine - Etomidate - Midazolam

Question 32

What are the hazards of using Propofol?

Answer 32

- HYPOTENSION - decreased HR - allergy to eggs, soy, peanuts - no analgesic effect

Question 33

What is ketamine used for?

Answer 33

Induction for RSI

Question 34

What is a potential side effect of ketamine?

Answer 34

May enhance pressor response - increase HR - increase BP - decrease RR

Question 35

What is fentanyl used for?

Answer 35

Analgesic

Question 36

What is a potential hazard of using Fentanyl?

Answer 36

- Decrease RR - Decrease HR

Question 37

What is the antidote for too much fentanyl?

Answer 37

Naloxone

Question 38

What is Phenylephrine used for?

Answer 38

Treatment of vasodilation and hypotension during anesthesia - treatment of +++ low BP

Question 39

What are some hazards of using phenylephrine?

Answer 39

- PVCs - VT - Increased BP - Can't use with sulfite allergy - Causes severe peripheral vasoconstriction and reduced blood flow to organs

Question 40

What is a side effect of Etomidate?

Answer 40

Can block the adrenal glands production of cortisol (stress hormone) that actually aids the body to deal with cardiovascular effects of sepsis, including hypotension - can also decrease BP - increase HR

Question 41

What is a side effect of Midazolam?

Answer 41

Hypotension Respiratory depression

Question 42

What is considered in "Prepare & Plan" during RSI?

Answer 42

- gather the team - vocalized plan and reason - backup plan(s) - prepare equipment and drugs (suction, oxygen, BVM, laryngoscope, ETT, OPA, bougie, RSI + pressers, EtCO2, SpO2, tele, NIBP)

Question 43

What is considered in "Protection & Position" during RSI?

Answer 43

- consider c-spine - adjust patient prior to or after induction and paralytics given to ensure adequate ergonomics

Question 44

What is considered during "Pre-oxygenate" during RSI?

Answer 44

- 100% FiO2 for 3-5 minutes - NRB, BVM, BiPap - consider apneic oxygenation with nasal prongs - advise physician when saturations reach a predetermined cutoff number to reduce potential harm (SpO2)

Question 45

What is considered during "Pre-treatment" during RSI?

Answer 45

- Atropine - prevent bradycardia in children - Lidocaine - neuroprotection in head injury, decrease airway reactivity in asthma - Fentanyl - neuroprotection in head injury - Rocuronium - prevent fasciculations from Succinylcholine ***These are not routinely seen in practice

Question 46

What is the goal of the induction agent during RSI?

Answer 46

To provide rapid unconsciousness, unresponsiveness, amnesia, and analgesia *Always give induction agent prior to paralytic

Question 47

What is the goal of the paralytic agent during RSI?

Answer 47

Muscle paralysis to create an optimal environment for intubation

Question 48

How is "Proof is Placement" verified during RSI?

Answer 48

- Visualization of tube through vocal cords - Equal chest rise + fall - Auscultation - no epigastric gurgling - EtCO2 waveform capnography > 30 - Colourmetric - purple to gold if CO2 present (Gold is Good!) - Portable chest xray

Question 49

What is the expected capnography with CPR?

Answer 49

10