Resuscitation

Question 1

Define Shock

Answer 1

A state where oxygen demand is greater than supply

Question 2

Types of Shock

Answer 2

Hypovolemic
Obstructive
Cardiogenic
Distributive

Question 3

Causes of cardiogenic shock

Answer 3

Ischemia
Arrhythmia
Valvular dysfunction
B-Blocker / CCB overdose

Question 4

Causes of obstructive shock

Answer 4

Tamponade
Tension pneumo
PE

Question 5

Causes of distributive shock

Answer 5

Sepsis
Anaphylaxis
Pancreatitis
Neurogenic / spinal
Addison’s / Adrenal insufficiency
Toxins

Question 6

Predictors of difficult to BVM

Answer 6

Beard
Obese
Older (neck mobility)
Teeth (edentulous)
Sounds (snoring / obstruction)
- STOPBANG > 3
- Snores
- Tired
- Observed Apnea
- Pressure (BP)
- BMI > 35
- Age > 50
- Neck > 17”
- Gender (M)

Question 7

Predictors of difficult to Intubate / airway assessment

Answer 7

Look
Evaluate 3-3-2
Mallampatti
Obstruction / obesity
Neck Mobility

Question 8

Predictors of difficult to Supraglottic device

Answer 8

Restricted mouth opening
Obese/obstruction
Distorted anatomy
Stiff neck or lungs

Question 9

Etomidate Risk

Answer 9

Adrenal suppression
Myoclonus
Regional cerebral excitation

Dose 0.3 mg/kg (20 mg in average size)

Question 10

Propofol Risk

Answer 10

Decreased cardiac output
Peripheral vasodilation

Dose 1.5-3 mg/kg (150 mg in average size - less if old or sick)

Question 11

Ketamine Risks

Answer 11

Theoretical ICP increase (no evdience)
Bronchorrhea
Laryngospasm
Cardiac depression in patients with adrenal supression / catecholamine exhausted

Dose 1-2 mg/kg (1oo mg in average size)

Question 12

Succinylcholine Contraindications

Answer 12

known hypersensitivity
family hx of malignant hyperthermia
recent burn. trauma, crush injury, neuromuscular disease, denervation (stroke, spinal cord)

Question 13

Initial NPPV setting

Answer 13

iPAP = 10 cm
ePAP = 5 cm

Question 14

Initial vent setting for ARDS

Answer 14

SIMV @ 6 cc/kg, RR 12, FiO2 = 1, PEEP = 10, I:E = 1:2

Question 15

Vent setting in Asthma intubation

Answer 15

Volume - A/C or SIMV +PS
- 6-8 ml/kg
- RR 8-10 BPM
- I:E = 1:3-4
- FiO2 = 100%
- PEEP = 2-5 cmH2O

Question 16

Vent Settings in Neuro ICH

Answer 16

Have to avoid hypotension, hypercarbia and hypoxemia
- Prevent sympathetic response with large dose fentanyl and topicalization or IV lidocaine
- Fentanyl 2-3 mg/kg
- Esmolol 1.5 - 2 mg/kg
- Ketamine or Etomidate for induction

Vent settings: Aim for PCO2 ~ 35
- Low PEEP 5-10 cm H2O

Question 17

Vent and airway management in Metabolic Acidosis

Answer 17

Avoid intubation if possible - Minute ventilation needs HIGH
Settings: Assist Control 8ml/kg IBW
RR: 30 / min
(Require 120 ml/kg/min of minute ventilation, if attempting to reduce PCO2 may need 240 ,l/kg/min)
at 8 ml/kg - 30 BPM)

Question 18

Normal Electrolyte Lab Values

Answer 18

Osm - 287
Na - 135-145
Cl - 98-106
K - 3.5-5.0
Lactate < 2
pH 7.35-7.45

Question 19

IVC Measurements

Answer 19

1.3 - 2.5 cm normal.

Question 20

1st and 2nd line vasopressors in septic shock

Answer 20

norepinephrine
2nd - vasopressin or epi

Question 21

1st line vasopressors in neurogenic shoclk

Answer 21

Norepinephrine

Question 22

1st line pressors in Cardiogenic shock

Answer 22

Norepinephrine as 1st line
- Low dose Epi (0-5 mcg) may act as pure inotrope without effects on vasodilation
- Vasopressin helpful in patients with pulmonary HTN or tachycardia
1st line inotrope - Dobutamine

Question 23

Management of extravasation of pressors into peripheral tissues

Answer 23

Phentolamine injected into the site

Question 24

SIRS Definition

Answer 24

2+ of
T < 36 or >38
RR > 22 or pCO2 < 32
HR > 90
WBC < 4 or > 10 or> 10% bands

Question 25

Surviving sepsis guidelines in 2021 - First 3 hours

Answer 25

Measure a lactate Draw Blood Cx Give broad spectrum Abx Fluid bolus of 30 ml/kg of Ringers/Plasmalyte if lactate > 4 or hypotensive Early vasopressors if hypotensive despite fluid resuscitation. Redraw lactate if initially elevated

Question 26

ACLS Cardiac Arrest

Answer 26

Activate Emergency Response System Pulse check - if absent, immediate HQ CPR - 120 BPM - At least 5 cm with complete recoil If Shockable: - Shock as soon as advised - Continue CPR - Shock Q2 mins if remains shockable - Obtain airway and IV/IO Access - Epinephrine Q4 mins - Consider advanced capnography - If after 2 shocks still in VF or pulseless VT then Amiodarone (300 mg IV) If not shockable: - CPR - Epi Q4 mins - Think of reversible causes: Hypoxia, hypovolemia, hypothermia, acidosis, hypo/hyper K. Thrombosis (pulm or cardiac), tamponade, tension pneumo, toxins

Question 27

ACLS Brady with a pulse algorithm

Answer 27

HR < 50 1) Treat underlying cause. Give oxygen, cardiac monitor for rhythm, BP, IV/IO access, 12 lead ECG 2) Unstable: altered LOC, ischemic chest pain, acute heart failure, shock? - Yes: Atropine (0.5 mg bolus up to 3 mg). If ineffective - transcutaneous pacing or epi infusion (2-10 mcg/min) - No: monitor and observe 3) Expert consultation

Question 28

ACLS Tachy with a pulse Narrow Algorithm

Answer 28

HR > 150 Unstable: Acute HF, ischemic CP, hypotension, altered LOC Yes: Synchronized cardioversion No: ECG, IV access, Vagal maneuvers, Adenosine (6 mg IV push), B-blocker or CCB.

Question 29

ACLS Tachy with a pulse wide algorithm

Answer 29

HR > 150 Unstable: Acute HF, ischemic CP, hypotension, altered LOC Yes: Synchronized cardioversion No: ECG, IV access, Consider antiarrhythmic infusion: - Procainamide 20-50 mg/min to 15 mg/kg. Stop if hypotension or QT increases by 50% - Amiodarone: 150 mg over 10 mins, repeat if recurs.

Question 30

Vent Modes

Answer 30

Assist / Support - Patient triggered Control - Set times / RR

Question 31

Volume Control Variables and significance

Answer 31

Safest in ED Setting - Tidal Volume - Resp Rate (TV x RR = min vent) - FiO2 - PEEP (FiO2 PEEP, Oxygenation) - I:E ratio or flow rate (for Obstructive issues)

Question 32

Peak Flow Rate Standard Settings

Answer 32

60-100 L/min (100 is high end) (For RR 12 - I:E 1:4) 1 sec inspiration ~ 1 L

Question 33

Winter's Formula

Answer 33

HCO3 x 1.5 +8 +/- 2 - Optimized minute vent for metabolic acidosis.