Resuscitation Flashcards

Question

Shock: How do you identify cardiogenic shock? Why is this important?

Answer 1

- Measure pulmonary capillary wedge pressure → proxy for preload - It is important as IV fluid should not be given in cardiogenic shock; it will cause rapid pulmonary oedema and will lead to the patient deteriorating

Answer 2

- FBC - U&E - LFT - coagulation panel - ABG/VBG → raised lactate (type A lactic acidosis)

Answer 3

Fluid challenge: - 500ml of crystalloid in less than 15 minutes - Monitor BP and end-organ function to look for improvement, while auscultating and monitoring SpO₂ to look for pulmonary oedema - Repeat until BP normalised or until fluid is no longer tolerated

Answer 4

- Hb ≤ 70g/L - Target after transfusion = 70-90g/L

Answer 5

- Hb ≤ 80g/L (transfuse earlier as higher risk) - Target after transfusion = 80-100g/L

Answer 6

- When a patient has some of their own blood taken and stored, ready to be transfused back into them if needed

Answer 7

- Removal of WBCs (reduces risk of CMV, EBV transmission) - Blood samples are tested for many transmissible diseases in the blood bank - Irradiation - this further depletes T-lymphocytes. Indications include immunodeficiency and Hodgkin lymphoma

Answer 8

\< 30 x 10⁹ if clinically significant bleeding

Answer 9

\< 10 x 10⁹

Answer 10

- Chronic bone marrow failure - Autoimmune thrombocytopenia (e.g. ITP) - Heparin-induced thrombocytopenia - Thrombotic thrombocytopenic purpura

Answer 11

- 'Clinically significant' but not 'major' haemorrhage - PT ratio or APTT ratio \> 1.5

Answer 12

- Solution containing vWF, factor VIII:C, fibrinogen, fibronectin and factor XIII - Used to replace fibrinogen - Suited for patients with 'clinically significant' but not 'major' haemorrhage with fibrinogen levels \< 1.5g/L

Answer 13

Reversal of anticoagulation in patients with severe haemorrhage (including any intracerebral bleeding)

Answer 14

Use the universal donors: - Packed red cells: O (Rh negative if possible) - FFP: Blood type AB - Platelets: less important but AB Rh -ve if possible

Answer 15

* Can the patient speak? * If yes, patent → move on to B * Inspect the airway for foreign bodies * Check for signs of partial/complete obstruction * Signs of partial obstruction = cough, hoarseness, stridor, snoring * Signs of complete obstruction = inability to speak or cry out, absent breath sounds, cyanosis & profound hypoxia * Aspirate the airway with a suction catheter (if appropriate) * If no reflex response (coughing/gagging) or the breathing rate is less than 8 per-minute → call anaesthetist to intubate

Answer 16

* Head tilt chin lift (should be avoided if there's concern for c-spine injury) * Jaw thrust (doesn't require c-spine to be cleared) * Bag-mask ventilation * Indicated to preoxygenate before intubation or as part of CPR * Insertion of a basic airway adjunct * Oropharyngeal airway if patient is unconscious * Nasopharyngeal if patient is conscious. Contraindicated in basal skull fractures ('panda eyes', haemotympanum, mastoid bruising

Answer 17

* Inability to maintain the airway: general anaesthetic, airway obstruction, reduced GCS, absent protective reflexes (gag/cough) * Inability to maintain ventilation: severe acute COPD/asthma * Conditions with a high risk of deterioration: anaphylaxis, severe septic shock, multisystem shock

Answer 18

* Needle cricothyrotomy * A large-bore cannula is inserted through the cricoid membrane * Indicated in young children (can't have surgical cricothyrotomy) * Indicated in adults when the practitioner is not comfortable performing a surgical cricothyrotomy * Surgical cricothyrotomy

Answer 19

**_Examination_** * Inspection * Appearance * Apnoea * Signs of lethargy or distress * Speaking in full sentences? * Vital signs * Respiratory rate * SpO₂ * Specific signs * Tracheal deviation * Paradoxical chest wall movement * Increased respiratory effort * Auscultation * Air entry * Pathological breath sounds * Percussion * Hyperresonance/dullness **_Rapid/bedside investigations_** * ABG * VBG is likely sufficient if no respiratory distress * Consider bedside CXR and/or lung ultrasound

Answer 20

* Apnoea/fulminant respiratory failure: * Bag-mask ventilation * Basic airway adjuncts * Prepare for intubation and ventilation * High-flow oxygen for all critically ill patients (except MI if they're maintaining saturations or known CO₂-retaining COPD patients) * If detected, provide emergency treatment of: * Tension pneumothorax * Needle thoracotomy decompression → chest drain * Massive haemothorax/pleural effusion * Insert a chest drain * Bronchospasm * Administer bronchodilators (neb salbutamol & ipratropium, IV magnesium sulfate) * Acute severe pulmonary oedema * Administer diuretics

Answer 21

1. Assess skin appearance (e.g. pallor, mottling, cyanosis, diaphoresis) 2. Check pulses 3. Check HR and BP 4. If shocked: * Initiate sepsis six, record qSOFA score if Sepsis confirmed * Check for signs of end organ damage * Check for signs of active bleeding * Take clotting screen, G&S and crossmatch if bleeding significant 5. Auscultate the heart * Muffled may indicate pneumothorax or tamponade * Murmurs * Friction rub suggests pericarditis 6. Assess volume status * Mucous membranes * JVP * CRT 7. Obtain 12 lead ECG 8. Consider other bedside tests such as a FAST scan, cardiac echo or CXR

Answer 22

* Establish (preferably x2) large-bore IV access * Always give haemodynamic support\* * Fluid challenge (500ml IV crystalloid in \< 5 minutes, 250ml if small & frail) * Vasopressors if not responding to fluid * The threshold depends on cause e.g. HHS may benefit from many litres of fluid while an elderly lady with cardiogenic shock may respond more poorly to small amounts. * Haemorrhagic shock * Blood transfusion * Emergency haemostatic measures (e.g. pressure, packing wound) * Obstructive shock * Cardiac tamponade: pericardiocentesis/thoracostomy * Tension pneumothorax: needle decompression → chest drain * Massive PE: thrombolysis * Distributive shock * Anaphylactic: IM adrenaline * Septic shock: empiric IV antibiotics according to local policy * Adrenal crisis: IV hydrocortisone

Answer 23

Very much depends on what was found during the assessment * Hypertensive crisis * Cautious use of IV antihypertensives * Identify and manage any arrhythmias * Identify and manage any cardiac ischaemia * Treat any electrolyte disturbances that may compromise circulation * Rapid vascular surgery transfer if ruptured AAA or aortic dissection * etc. etc.

Answer 24

* Evaluate consciousness * GCS * AVPU * Identify readily-apparent possible underlying aetiology * Head and neck trauma * Hemiplegia * Seizure activity * Toxins on clothes/skin * Check blood glucose level * Examine pupils * Evaluate for: * Lateralising signs * Signs of raised ICP * Meningism * Identify any classic toxidromes * Consider: * 12 lead ECG * Toxicology screen * Neuroimaging (e.g. CT head)

Answer 25

* "If GCS ≤ **8** then intu**bate**" * Agitated or violent patients * De-escalate if possible * Consider the need to restrain and/or administer calming medication if the patient remains a risk to themself or others * Suspected brain injury → initiate protective measures * Maintain adequate perfusion * Optimise oxygenation & ensure normocapnia * Provide emergency treatment for: * Status epilepticus: IV lorazepam 5mg → lorazepam 5mg → phenytoin infusion * Hypoglycaemia: IV glucose * Intoxication/poisoning: administer antidote (search toxbase if unsure) * Meningitis: IV antibiotics according to local policy * Correct severe electrolyte abnormalities (beware overly rapid correction → cerebral oedema) * Consider need for escalation

Answer 26

* Fully undress patient * Safely examine patient's back (using c-spine precautions if necessary) * Check for clues that may indicate the underlying condition: * Triggers of anaphylaxis e.g. latex, insect stings * Signs of trauma e.g. stab wounds, burns * Rash e.g. petechiae * Sources of sepsis e.g. infected wounds, gangrene * Toxins and drugs - needle track marks, medication patches * Other small wounds or foreign bodies e.g. insect bites, ticks * Measure core body temperature

Answer 27

* Remove all potential causes for deterioration * Allergens * Transdermal medication patches * Provide clean, dry clothing e.g. hospital gown * Manage body temperature * Hypothermia * Warm IV fluid * Active warming e.g. 'bear-hugger' * Hyperthermia * Begin surface cooling * Consider cool IV fluids * Antipyretics (not for environmental or malignant hyperthermia) * Dantrolene for malignant hyperthermia * Treat underlying pathology e.g. infection, trauma, intoxication etc.

Resuscitation Flashcards

(52 cards)