Procedures I

Question 1

Name three (of four listed) ways to increase the prominence of the enterojugular vein before performing an EJ.

Answer 1

1. Lower the head of the bed / raise the feet;
2. Valsalva (have the patient “bear down”);
3. Place a stethoscope around the neck to occlude the distal vein;
4. Percuss the vein (smack it);

Note: Once the vein has been identified, feel free to mark it with a sharpie;

- https://www.youtube.com/watch?v=JIP5p8E0ejw

Question 2

When preparing for synchronized cardioversion with the LIFEPAK 15, which lead should be selected for view?

Answer 2

1. Lead II, or the lead with the greatest QRS amplitude;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 3

When preparing for synchronized cardioversion with the LIFEPAK 15, what should be confirmed after pressing the SYNC button and before charging the monitor?

Answer 3

1. Confirm that a triangle sense marker appears near the middle of each QRS complex.

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 4

When preparing for synchronized cardioversion with the LIFEPAK 15, what should be done if triangle sense markers do not appear after the SYNC button has been pressed (or if the markers appear in the wrong locations, e.g. on the T wave)?

Answer 4

1. Adjust the ECG size or select another lead;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 5

When preparing for synchronized cardioversion with the LIFEPAK 15, at what point does Stryker recommend that the electrical therapy pads be placed?

Answer 5

1. After ECG monitoring and synchronization have been achieved with the ECG cables / electrodes;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 6

When preparing for synchronized cardioversion of a narrow, regular rhythm, the AHA recommends an initial dose of ___ J for adults.

Answer 6

1. 50-100 J (biphasic or monophasic);

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Adult Tachycardia with a Pulse Algorhythm

Question 7

When preparing for synchronized cardioversion of a narrow, irregular rhythm, the AHA recommends an initial dose of ___ J for adults.

Answer 7

1. 120-200 J biphasic (or 200 J monophasic);

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Adult Tachycardia with a Pulse Algorhythm

Question 8

When preparing for synchronized cardioversion of a wide, regular rhythm, the AHA recommends an initial dose of ___ J for adults.

Answer 8

1. 100 J;

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Adult Tachycardia with a Pulse Algorhythm

Question 9

When preparing for synchronized cardioversion of a wide, irregular rhythm, the AHA recommends an initial dose of ___ J for adults.

Answer 9

1. The AHA recommends defibrillation for this rhythm, not synchronized cardioversion;

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Adult Tachycardia with a Pulse Algorhythm

Question 10

After failed rhythm conversion from an initial synchronized cardioversion shock, the AHA recommends increasing the energy in a ___ fashion, per ___.

Answer 10

1. Stepwise;
2. Manufacturer;
   * AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Electrical Cardioversion Algorithm;*

Question 11

When preparing for synchronized cardioversion, if delays in synchronization occur and the patient’s clinical condition is critical, what does the AHA recommend?

Answer 11

1. Immediately resort to unsynchronized shocks;

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Electrical Cardioversion Algorithm

Question 12

When performing synchronized cardioversion requiring a stepwise increase in energy, the sync mode should be reset (or verified to still be set) after each shock delivery, as most defibrillators default back to unsynchronized mode. Why does this default exist?

Answer 12

1. This default allows for an immediate defibrillation if the cardioversion produces VF;

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Electrical Cardioversion Algorithm

Question 13

When preparing to perform synchronized cardioversion on a pediatric patient (for all applicable rhythms), what initial energy does does the AHA recommend?

Answer 13

1. 0.5-1 J/kg;

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Steps for Pediatric Defibrillation and Cardioversion

Question 14

When performing synchronized cardioversion on a pediatric patient (for all applicable rhythms), what dose of energy does does the AHA recommend for follow-up shocks beyond the initial does?

Answer 14

1. 2 J/kg;

AHA 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers, Steps for Pediatric Defibrillation and Cardioversion

Question 15

When performing a synchronized cardioversion with the LIFEPAK 15, ___ and ___ the shock button on the difibrillator until the ___.

Answer 15

1. Press;
2. Hold;
3. ENERGY DELIVERED message appears on the screen;

Question 16

When preparing to perform noninvasive transcutaneous pacing with the LIFEPAK 15, after applying the ECG and the electrical therapy electrodes, press the ___ button and confirm that the ___ marker is near the ___.

Answer 16

1. PACER;
2. Triangle sense marker;
3. Middle of each QRS;
   * Stryker LIFEPAK 15 monitor/defibrillator poster, 2019*

Question 17

When preparing to perform noninvasive transcutaneous pacing with the LIFEPAK 15, after confirming placement of the trinagle sense marker near the middle of each QRS, press the ___ button to _(objective)_, then the ___ button until _(objective)_.

Answer 17

1. RATE;
2. Select the desired pacing rate;
3. CURRENT;
4. Electrical capture occurs;
   * Stryker LIFEPAK 15 monitor/defibrillator poster, 2019*

Question 18

When performing noninvasive transcutaneous pacing with the LIFEPAK 15, Stryker recommends checking ___ and ___ to verify mechanical capture.

Answer 18

1. Blood pressure;
2. Pulse;
   * Stryker LIFEPAK 15 monitor/defibrillator poster, 2019*

Question 19

How may temporary viewing of a patient’s underlying rhythm be achieved during noninvasive transcutanous pacing?

Answer 19

1. PAUSE button;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 20

The ___ button on the LIFEPAK 15 initiates analysis in AED mode.

Answer 20

1. ANALYZE;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 21

The ___ button on the LIFEPAK 15 initiates (or silences) the metronome feature.

Answer 21

1. CPR;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 22

When performing SPO₂ monitoring with a LIFEPAK 15, on which finger does Stryker recommend placing the sensor? How is it recommended that the cable be oriented?

Answer 22

1. The ring finger of the non-dominant hand;
2. Orient the cable on the back of the patient’s hand;
   * Stryker LIFEPAK 15 monitor/defibrillator poster, 2019*

Question 23

On the LIFEPAK 15, only ___® sensors are capable of reading SpCO / SpMet.

Answer 23

1. Rainbow;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 24

When SpCO or SpMet are selected for readout on the LIFEPAK 15, the selected value will only display for ___ seconds.

Answer 24

1. 10;

Stryker LIFEPAK 15 monitor/defibrillator poster, 2019

Question 25

On the LIFEPAK 15, if SpCO or SpMet readings are above normal limits (SpCO greater than \_\_\_%, SpMet greater than \_\_\_%) an advisory message will occur.

Answer 25

1. 10; 2. 3; * Stryker LIFEPAK 15 monitor/defibrillator poster, 2019*

Question 26

What causes the ALARM APNEA message to appear on the LIFEPAK 15 during EtCO₂ monitoring?

Answer 26

1. No breath has been detected for 30 seconds since the last valid breath (\> 8 mmHg); ## Footnote *Stryker LIFEPAK 15 monitor/defibrillator poster, 2019*

Question 27

Name four (of six listed) methods for increasing the success rate of nasogastric tube placement in a sedated, intubated patient.

Answer 27

1. Lift the thyroid cartilate upward and rightward (facilitates separation of larynx and esophagus); 2. Deflate the endotracheal balloon cuff (facilitates separation of larynx and esophagus); 3. Flex the patient's neck (facilitates passages of NG tube along posterior pharynx); 4. Stiffen the NG tube (e.g. by refrigeration or use of an inner catheter / guidewire); 5. Insert the NG tube perpendicularly to a length equal to the distance from the patient's nostril to their mandibular angle, then rotate 180 degrees before advancing further(facilitates passages of NG tube along posterior pharynx); 6. Pull the NG tube out of the Patient's mouth with Magill forcepts, place the straight end of a bougie introducer into the distal suction hole of the NG tube, pull the tube back into the pharynx and guide it into the esophagus using the bougie. * https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2044.2005.04418.x* * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637449/*

Question 28

Nasogastric tubes should generally be inserted to the \_\_\_-\_\_\_ cm mark in an adult patient. Gastric placement of an NG tube may be confirmed in the field by \_\_\_.

Answer 28

1. 50-55; 2. Auscultation; * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637449/*

Question 29

\_\_\_ cricothyrotomy is indicated as a life-saving, last-resort procedure in children younger than ___ years who present or progress to the "can't intubate, can't oxygenate" scenario and whose obstruction is ___ to tglottic opening.

Answer 29

1. Needle; 2. 10; 3. Proximal (or cephalad); Major Memory System: A record player's needle drops on the **eighties'** (10) best album, Thriller. *The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306*

Question 30

The classic indication for needle cricothyrotomy is \_(condition)\_ where ___ and ___ are judged to have failed.

Answer 30

1. Epiglottitis; 2. Bag mask ventilation (BMV); 3. Intubation; _Note: Other indications include facial trauma, angioedema, and other conditions that preclude access to the glottic opening from above._ *The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306*

Question 31

Needle cricothyrotomy would be of questionable value in a patient with croup because the obstruction is \_(location)\_.

Answer 31

1. Subglottic; ## Footnote *The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306*

Question 32

When preparing for a percutaneous needle tracheostomy (PNT) or "needle cric," in what position should the child be placed?

Answer 32

1. Supine with the head extended over a towel under the shoulder; ## Footnote *The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306*

Question 33

In small children, it may be impossible to precisely locate the cricothyroid membrane, so the ___ is utilized for access (hence the name ___ versus "needle cric").

Answer 33

1. Proximal trachea; 2. Percutaneous Needle Tracheostomy (PNT); * The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306*

Question 34

When performing a percutaneous needle tracheostomy, consider the trachea as one would a large vein, and cannulate it with the catheter-over-needle device directed caudad at a ___ degree angle.

Answer 34

1. 30; _Major Memory System: Michael Jackson **hums** (30) while his Thriller album rotates under the needle of a record player._ *The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306*

Question 35

Once an airway circuit has been constructed, all needed supplies gathered, and the patient has been positioned correctly, what is the basic six-step procedure for completing a percutaneous needle tracheostomy (aka "needle cric") (as adapted from The Walls Manual of Emergency Airway Management)?

Answer 35

1. Disinfect anterior neck; 2. Locate and mark cricothyroid membrane (or poxmal trachea when membrane cannot be distinguished) 3. Pierce with angiocath at 30 degree angle caudad; 4. Remove needle while inserting catheter hub-to-skin; 5. Attach partially-depleted 10 cc NS preload and spirate air to confirm placement; 6. Attach PNT circuit and secure with tape; * The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306 (adaptation by Scott Berdan)*

Question 36

In order to prevent breath-stacking and barotrauma during BMV of a percutaneous needle tracheostomy, the operator must allow for full expiration through the patient's ___ and not through the catheter. This can be accomplished by watching for \_\_\_.

Answer 36

1. Glottis; 2. The chest to fall after inspiration; * The Walls Manual of Emergency Airway Management, Fifth Edition, 2018, p. 306*

Question 37

Name the four basic components of a percutaneous needle trachesostomy airway circuit (as adapted from The Walls Manual of Emergency Airway Management).

Answer 37

1. Neonatal or pediatric BVM (with pop-off valve closed); 2. BVM adapter from2.5 mm ID ET Tube; 3. Final 6” section of an I.V. administration set (cut-off); 4. 14G IV catheter;

Question 38

Generally speaking, nasal intubation may be performed ___ or with ___ assistance.

Answer 38

1. Blind; 2. Fiberoptic; * https://litfl.com/nasal-intubation/*

Question 39

Nasal intubation should be considered when \_(general condition)\_. Give two (of three listed) examples).

Answer 39

1. Oral intubation is not feasible; 2. Swollen tongue (Glossitis; e.g., angioedema); 3. Mechanical obstructions to mouth opening (e.g., mandibular fixation and trismus); 4. Fixed neck contracture and limited mouth opening; * https://litfl.com/nasal-intubation/* _Note: "It is best in patients who are not critically hypoxic and in whom there is obvious oral pathology making intubation and ventilation through the mouth problematic."_ *https://epmonthly.com/article/nasal-intubation/*

Question 40

Dr. Rich Levitan describes his method of performing blind nasal intubation with these five words: \_\_\_.

Answer 40

1. Spray - Trumpet - Spray - Tube - Spray; ## Footnote _Note: Spray consists of 5-10 cc of 4% topical lidocaine with oxymetazoline._ *https://litfl.com/nasal-intubation/*

Question 41

Describe the seven general steps of the Berdan Method of Prehospital Blind Nasal Intubation.

Answer 41

1. Sedate patient with Ketamine (2 mg/kg IV/IO or 4 mg/kg IM) and support oxygenation with BVM; 2. Apply 2-3 sprays of Oxymetazoline into each naris; 3. Lubricate two nasal trumpets with 2% lidocaine jelly, insert, remove from target naris after one minute; 4. Place nasal cannula at 15 lpm in secondary naris (or mouth) for passive / apneic oxygenation; 5. Lubricate tracheal tube with 2% lidocaine jelly (as large as will fit into the naris and be tolerated, generally at least 7.0 mm ID), attach BAAM whistle and insert (keeping the proximal end of the tube directed toward the patient's contralateral nipple) until loud breath sounds are audible (approximately 15 cm); 6. Pass tracheal tube through cords during inhalation, confirm placement and secure in place; 7. Administer Rocuronium (1 mg/kg IV/IO); * https://litfl.com/nasal-intubation/ (as adapted by Scott Berdan)*

Question 42

Singluar form of the word "nares." This word translates to the layman's term \_\_\_.

Answer 42

1. Naris; 2. Nostril; * https://www.medicinenet.com/script/main/art.asp?articlekey=25480*

Question 43

When passing a nasal trumpet or nasotracheal tube, ensure the \_(tube feature)\_ faces the \_(body structure)\_ laterally. Ensure the tube is advanced along both the \_(body structure)\_ medially and the ___ of the nasal cavity (which is \_(geometrical term)\_ to the plane of the face).

Answer 43

1. Bevel; 2. Turbinates; 3. Septum; 4. Floor; 5. Perpindicular; * https://litfl.com/nasal-intubation/*

Question 44

Tracheal tubes utilized for nasotracheal intubation should typically be placed ___ cm at the nose for women and ___ cm at the nose for men.

Answer 44

1. 26; 2. 28; * https://litfl.com/nasal-intubation/*

Question 45

Generally speaking (although not allowed by written order through the PCPs), with regard to ___ intubation, "topicalization is essential not only for patient comfort, but also to ensure proper placement. Without proper topicalization, the patient will gag, cough, and swallow the tube, preventing it from going into the trachea."

Answer 45

1. Nasal; ## Footnote *https://epmonthly.com/article/nasal-intubation/*

Question 46

According to Dr. Levitan, with regard to nasal intubation, "conscious sedation for intubation, using a combination of \_(drug)\_ and \_(drug)\_, may be appropriate and improve patient comfort, depending on the situation. In the patient is too agitated to permit the procedure, small aliquots of \_(drug)\_ (10 mg IV, repeated up to 40-50 mg total, although more can be given if needed) with \_(drug)\_ works magically well to facilitate the procedure.

Answer 46

1. Fentanyl; 2. Midazolam; 3. Ketamine; 4. Midazolam; * https://epmonthly.com/article/nasal-intubation/*

Question 47

What does BAAM stand for with regard to a BAAM whistle?

Answer 47

**BAAM** ## Footnote **B - B**eck **A - A**irflow **A - A**irway **M - M**onitor *https://epmonthly.com/article/nasal-intubation/*

Question 48

Successful tracheal passage during nasotracheal intubation will induce laryngeal reflexes (e.g., coughing), loss of phonation, and air movement throught the tube. If not already done, it may be necessary to ___ because passage of the tube may elicit arm movement, head turning, and other efforts to remove the tube.

Answer 48

1. Restrain the patient's arms; ## Footnote *https://epmonthly.com/article/nasal-intubation/*