Resus Flashcards

Question

Airway- what changes need to be thought about for intubation obese pt

Answer 1

Buy time- NIV/ delayed SI Indications- do in DEM or OT Get help- ent/ anos Ramp- tragus to eternal notch Aponeic O2- 15L/Min Minimal drugs- ketamine or ROC Pre O2- PEEP/ BVM/ NIV Plan for difficulty Post- intubated care

Answer 2

Optimise the pt- pressors or IVF Drug choice- ketamine 0.5mg/kg ROC 1.6mg/kg Reduce induction drug dose Increased muscle relaxant dose Maintain resp comp increased RR

Answer 3

Pneumothorax Dynamic hyperinflation Hypotension- decreased venous return and increased auto prep Think- D- dislodged tube O- obstructed tube P- pneumothorax E- quipment failure S- stacking

Answer 4

Become hypotensive- give IVF prior DelayedSI- NIV/ BVM/ PEEP Drugs- ketamine 1-2 mg/kg - b agonist and bronchodilator ROC- 1.2 mg/kg IV Larger ETT size to reduce breath stacking ++ bronchodilators prior or post- IV salbutamol or IV adrenaline

Answer 5

Vent- VC and SIMV TV 6ml/kg RR 6-8 Prolonged I:E ratio 1:4 reduce breath stacking

Answer 6

Similar concept difficulties for obese pt Similar size ETT size Intubate- in L lateral posturing wedge right hip Laringoscope short handle Kessel blade

Answer 7

Neostigmine adult 2.5mg + atropine 1.2mg Child 0.08mg/kg Suggamedex- normal 16mg/kg

Answer 8

Vec- non depolarising 10mg powder dilute 10mg in 10ml saline-1mg/ml Dose 0.1mg/kg adult 10mg Induction- 0.3mg/kg RSI Duration 30 mins

Answer 9

Non depolarising ROC- 50mg in 5ml dilute 10mg/ml Induction 1-1.2 mg/kg adult 100mg Maintence 0.6mg/kg Onset duration 45-60 secs Duration 20-35 mins Metabolised liver Adverse effects- hypersensitivity/ tachycardia/ pain on injection/ if anticonvulsant- increased dose ROSC

Answer 10

Depolarising CI- congenital myopathy Neurology condition in last 6 months Burns to 20% TBSA Infection Hyper K and Hypo k Adverse K- hyper K in burn pt Muscle fasiculations Bradycardia esp in child Decreased LOS tone- GORD/asp Malignant hypothermia Aponea Increased intraoccular pressure

Answer 11

Presentation 100mg in 2ml as 50mg/ml Dose- 1.5mg-2mg/kg adult 1-2.5 ml adult 100-150mg Duration- 10mins Rapid onset- fasicukations 30secs relax 45-60sec 2 phases 1- depolarising fasiculations flaccid paralysis 2- de- sensitising membrane desensitised early depolarised again

Answer 12

Minimise changed in BP- reduced induction dose- ketamine 1mgkg fentanyl 2-3mcg/kg ROC 1.2mg/kg Anticipate difficult if collar- inline stabilisation or BURP Neuroprotective- head 30 degrees/ neck clear/ saO2 >90 PCO2 35-45 MAP>80 normothermia/ normoglycaemia Na 135-145

Answer 13

Large limbs—> diaphragm —> small trunk —> Larangeal—> eye muscles

Answer 14

Steps 1- stabilise thyroid cartridge 2- palpate cricoid membrane 3- 4cm vertical incision into CTM 4- wide horizontal incision CTM 5- dilate finger- confirm location 6- bougie—> size 6 ETT 7- connect and confirm

Answer 15

SVR 800-100 MAP >65 C.O- 4-8L/min HR 60-100 SV 60-100ml per beat SBP 100-140 mmHg DBP 60-90 mmHg

Answer 16

Stop fluid losses IVF 20ml/kg 0.9% Haemorrhage- stop/ blood/ OT Vasopressors NA- 5mcg/kg/min or 5ml/hr titrate Metaraminol 0.5mg blouses infusion 5-10mcg/hr Dopamine 1-5mcg/hr Inotropes Adrenaline 10mcg bolus 5ml/hr or 5mcg/min/hr- titrate Isoprenaline 5mcg/hr Dobutamine no peripheral effect-1-40mcg/hr titrate Adrenal insufficiency- hydrocortisone 200mg

Answer 17

Class 1- normal vitals/ <15% loss Class 2- tachycardia 15-30% loss Class 3- hypotension 30-30% loss Class 4- ALOC > 40% losses (>2L) Volume assess- US- IVC collapse Pulse pressure CVP changes Passive leg raise- like giving 300ml bolus

Answer 18

Reduced SV or reduced CO Intravascular losses- Blood losses - external= trauma - Internal= Haemothorax/ Haemoperitoneium/ retroperitoneal and pelvis Plasma losses - burns/ sweat or dehydration/ pancreatitis/ ascites/ peritonitis/ liver disease/ erythroderma/ phemphihoid Extravascular GIT- D and Vs or bowel obstruction Renal- Adrenal insufficiency/ DM Diabetes insipidus Diuretics Polymeric intrinsic renal disease

Answer 19

Myocardial inability to supply adequate O2 for tissue perfusion 1- reduced contractility- SV low - AMI - myocarditis - myocardial contusion - cardiomyopathy - etoh/ infection - Toxin- B blocker or Ca ch blocker 2. Inadequate filling- diastolic dysfunction I. E Right ventricular infarct 3. Arrhythmia - AF/VT/ Bradycardia 4. failure forward flow- LVOT obstruction-HOCM/ Ruptured free walk or papillary muscle Stenosis AS or MS Thrombus

Answer 20

1. Clinical end pt- HR/ BP/CRT/ U.O/ CVP/ lactate 2. Dynamic tests - passive leg raise assess BP or pulse pressure on artline Advantage- repeatable and non invasive Disadvantage- not reliable severe hypovol 3- US assess SV on echo Lung- b lines signs of APO iVC collapsible

Answer 21

AMI- PCI or thrombolysis NSTEMI - aspirin300mg ticagrelor 180mg load/ heparin 5000IU/ O2 Analgesia- fentanyl 25mcg +\- NA/ adrenaline or dopamine Dobutamine - 1st inotrope choice in cardiogenic shock Non meds Insta aortic balloon pump ECMO for reversible causes of cardiogenic shock

Answer 22

Shock secondary to altered venous capacitance or tone - anaphylaxis/ neurogenic/ septic shock - adrenal insufficiency - thyrotoxicosis - liver failure - SIRS- burns/ pancreatitis Things that decrease SVR Mx- IVF Adrenaline- anaphylaxis NA others

Answer 23

Spinal shock refers to temporary loss of all neuroglogic activity below level of injury - motor/ sensory and autonomic - paralysis/ loss sensation - does not cause hypotension or bradycardia

Answer 24

Altered venous capcitence +\- vascular tone Secondary to autonomic dysfunction caused by spinal injury above level of T6 Characterised by- Flaccid paralysis/ hypotension and bradycardia Urinary retention- below the level and resp compromise c3/4/5

Answer 25

Shock= a state of circulatory failure resulting in inadequate perfusion and oxygenation. Targets MAP- 65mmHg HR <100 SBP >90 Caprefill <4 seconds CVP>10 U.O >0.5 ml/kg/hr adult or >1-2 ml/kg/hr peads Lactate <2

Answer 26

Good correlation VBG/ glucose/ urea/ CRT/ Hb/ Hct/ albumin and chloride Bad correlation WCC/ PLTS/ Na/ K/ Ca/ venous O2

Answer 27

Extravasation Infection- OM Fracture Necrosis of bone Compartment syndrome Failure Injury surrounding structure- vessel/ nerve Damage in child to ephyseal growth plate

Answer 28

Proximal Tibia- @ tibial tuberosity 1-2cm medial and 1-2 cm down Proximal humerus- @ greater tubercle with adducted shoulder Distal femur - anterolateral surface 3cm above lateral console Distal Tibia - 2cm above medial malleolus

Answer 29

Overlying infection to site Bone fracture at site- risk compartment syndrome Bone disorder I.e osteogenesis imperfecta Ipsilateral vascular injury

Answer 30

CPR + vent > 10mins of effective ALS with no ROSC Individual case decision/ team decision DO NOT initiate Resus gestation <23/40 or BW <400g as 1% chance of survival Or if anencephaly or trisomy 13 or 18

Answer 31

Trauma- accident or NAI- hx/exam odd story Heart disease- cyanosis/ pre and post distal sats/ sob/sweaty/ murmur/ FTT Endocrine or electrolytes- CAH ambiguous genital high K and low Na. Txt 25mg hydrocortisone Metabolic - BSL high or low. Inborn error of metabolism- urea cycle- raised ammonia. Organic acids- hAGMA Sepsis- TORCH infections/ dex- 0.15mg/kg cefoaxaime 50mg/kg ampicillin 50mg/kg and aciclovir 10mg/kg Formula or feeding- too strong or too weak- BSL- hyper/hypo Na Intestinal catastrophe- intussception/ pyloric stenosis/ NEC or Hirshsprungs Toxin- nai opiate/ TCA Seizure or CNS abnormalities - midaz / phenobarbitone 20mg/kg or Keppra 20-60mg/kg

Answer 32

Toxoplasmosis Other - syphilus/ parvovirus Rubella CMV Herpes/ HIV

Answer 33

1- get help- PICU/ Peads 2- warm/ stimulate/ 360 degree access/ ABCD and APGAR 3- A + B- head neutral- neopuff/ t piece - PPV 30cm H2O and Fio2 21% but HR <60 Fio2 100% persistent tachyponea intubate 4- c- 1-2 IV attempts IO or scalp/ umbilical access- bloods/ vbg/ culture and BSL- metabolic and hypoglycaemic screen and ammonia level IVF 0.9% nacl 10-20mg/kg rpt 10mg/kg if needed. DEFG- 5ml/kg 10% dextrose if BSL< 2.8 maintenance at 5mg/kg/min Seizure- midaz 0.1mg/kg Phenobarbital 10-20mg/kg

Answer 34

Baby born start APGAR taken at 1min/5 min and 10 mins 0 1 2 Appearance Blue/pale bluish. Pink Pulse rate. Absent. <100. >100 Grimace Absent. Yes. cough Activity. Limp. Flex. Active RR Absent. Irreg. cry

Answer 35

1- secure airway- ETT 2- maintain vent pao2 60-90 PCO2 35-40 mmHg 3- secure IV avoid hypotension 4- close monitor- SCN or PICU ? Sedation 5- seek complications of end organ injury 6- communicate/ debris and family counsel

Answer 36

Protective SIMV 6-8ml\kg RR- 16-18 Pmax <40 cmH2O Plateau pressure- <30 FiO2- 88-95% I:E 1:1.5 Restrictive asthma/copd SIMV 4-6ml/kg RR6-8 Pmax <45 Plateau pressure <30 fIO2 88-95% I:E 1:4 or 1:5 Sedation and paralysis Permissive hypercapneia if PH>7.1

Answer 37

Indications- bipap mx increase airway resistance cpap- all else Awake and point breathing pt Co operative Free of excess secretions Increased WOB T1RF- hypoxia- apo/ post extubation stridor/ hypoxia pneumonia T2RF- copd/ asthma- high CO2- tired pt- neuromuscular weak- M.gravis/ dmd/SMA/ upper spinal cord injury Contraindications Claustrophobia Uncooperative ALOC Obtunded Facial anomalies or trauma Vomiting Haemoptysis or haematemsis Airway- can’t protect - no gag/ ++ secretions Note may cause increased intrathoracic pressure

Answer 38

A- airway/-aspiration/ aweophagos- delay to definitive tube B barotruma or PTx C hypotension due increased intrathoracic pressure D- disability- raised ICP/ not tolerating E- excess O2 G gastric insufflation Aspiration- vomit Epistaxis Facial skin necrosis

Answer 39

Bipap- IPAP (insp pressure =Peep+PS and EPAP- PEEP IPAP start 8-10 and PEEP 5cm H20 COPD/ASTHMA and APO CPAP- continuous fixed amount positive end exp pressure though entire vent cycle usually 5-10cmH20 Aim to increase alveolar vent- splint end bronchioles. Reverse hypercap Increase alveolar recruitment and decrease work of breathing and reduced LV after load increase CO Caveat- can increase intrathoracic pressures and reduce preload to heart

Answer 40

Aim to reduced volumes and barotrsums and biotrauma Lung protective ventilation Berlin definition- ARDS - acute onset <1/52 - bilateral opacities and infiltrates consistent APO - no evidence of HF or overload Low PaO2:FiO2 ratio <200mmHg Mode- pressure controlled - pmax 30cmH2O - plateau pressures 30 FiO2- keep SaO2 >90 Tv 6ml\kg PEEP start 5cm and titrate up I:E 1:2 Permissive hypercap

Answer 41

A- adjuncts npa= tip of nose to tragus Neonate in neutral position Child- neck flex and head extended Head tilt/ chin lift/ BVM- may cause resistance in point breathing child Neopuff in neonate T- piece- up 20kg child - low resistance and assist with TV no valve apply PEEP fingers Tube- ETT uncuffed age/4 +4 B- 15:2 with 2 rescue breaths to start and neonates 3:1 C- umbilical access/ scalp acces and IO D defib at 4J/kg

Answer 42

A- assess gasps/ aponea give PPV- neopuff or BVM or T Piece Rate 40-60 On FiO2 21% Pressure max 30 cmH2O HR<60- start compressions and FiO2 100% B- saO2 on pre ductal side right arm C- HR < 100 ass airway and start PPV if HR<60 ratio 3:1 rate 100 FiO2 100% Adrenaline 10mcgkg every 3-5 mins Glucose 5ml/kg of 10% dextrose

Answer 43

Lignocaine- 1mg/kg IV/IO Adrenaline 10mcg/kg IV/IO- non shockable immediate with VT or VF after 2nd shock Amiodarone- 5mg/kg IV/IO - 3rd shock or non shockable immediate Glucose- 5ml/kg 10% dextrose Mag- 0.1-0.2 mmol/kg- torsades NaHC03- 1-2mmol/kg metabolic acidosis Calcium gluconate 0.7mg/kg and calcium chloride 0.2mg/kg Atropine 20mcg/kg Naloxone 0.1mg/kg

Answer 44

Mitochondria 1st effected - 2 to decreased tissue perfusion and reduced O2 delivery Results in decreased perfusion to vital organs Increased alveolar vent Reduced base excess more neg

Answer 45

1 hypovolaemic - trauma/ haemhorsggic - GIT losses/ dehydration - 3rd spacing- burns 2- Cardiogenic - STEMI/ ACS Myocarditis Arrhythmia Septal wall rupture Cardiomyopathy B/ Ca ch overdose CHF 3- obstructive- physical obstruction limits CO - PE/ tension PTX/ cardiac effusion/ tamponade/ severe AS or MR/ PDA closure/ HOC. Or air or amniotic embolism 4- distributive shock - septic shock - anaphylaxis - neurogenic - burns - drug OD - adrenal crisis 5- cellular toxin induced - CO - cyanide - methaemoglobinaemia - hydrogen sulphide

Answer 46

Marker of shock- BPlow/ RR high/ Tachycardia Lactate and BE- BE is the metabolic component of acid/ base status +2 to -2 How much HCO3 used up More acidosis higher neg base - eg -6 is very sick Lactate is by product secondary to tissue hypoxia but can also be due to non hypoxia lactate >4 very sick

Answer 47

Systemic inflammatory response syndrome- Temperature <36 or >38.3 HR>90 RR>20 CO2 <32 WBC <4000 or > 12000

Answer 48

Sepsis- SIRS with suspected source of infection Severe sepsis- sepsis + organ dysfunction raised lactate/ raised CRT/ decreased UP deranged LFTs

Answer 49

Severe sepsis plus tissue hypoperfusion despite an adequate fluid challenge

Answer 50

Need 4-6 1- I’ll appearance or ALOC 2- HR>100 3- RR>20 PaCO2 <32 4- BE >-4 or lactate >4 5 U.O < 0.5ml/kg/hr 6 arterial hypotension constant > 30 mins

Answer 51

Try to achieve in first 6 hrs - map >65 - u.O > 0.5ml/kg/hr - CVP > 8-12 - central Venus O2 > 70mmHg or mixed venous O2 >65 maggots Normalise lactate

Answer 52

1- minimise myocardial O2 demand- ie take away WOB and intubate 2 maximise cardiac output - fill tank IVF 250ml map >65 - stimulate the heart- dobutamine 0-5 mcg/kg/min start at 2.5 mcg/kg/min and nitrate - add peripheral squeeze- preload- NA 5mcg/kg/min and titrate - reduced O2 req- do we need to I and V pt and take over do they have WOB - disposition- Cathlab? iCU? Ecmo? CCU ?

Resus Flashcards

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