Resuscitation, Anaesthetics,ITU Flashcards
(84 cards)
1
Q
What is the difference between an anaphylaxis and anaphylactoid reaction?
A
An anaphylactoid reaction is a type of anaphylaxis which does not involve an allergic reaction but is due to direct mast cell degranulation
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction to a trigger, such as an allergy (NHS UK, 2018; RCPCH, 2011)
2
Q
What alternative to IV acetylcysteine can you prescribe a patient that has taken a significant paracetamol overdose?
A
NAC has been given orally at the following dose:
Loading dose:
140 mg/kg given as a 5% solution.
If only a higher percentage is available dilute to 5% with juice/cola or water (Toxbase, 2018).
Maintenance doses:
70 mg/kg as a 5% solution every 4 hours.
(Toxbase, 2018).
Methionine was formerly an option for the treatment of paracetamol poisoning, but has been discontinued in UK (Toxbase, 2018).
3
Q
What are the common causes of cardiac arrest in pregnancy?
A
- embolization ( Pulmonary embolism/amniotic fluid )
- antepartum haemorage
- sepsis
- Hypertensive disorder in pregnancy ( pre-eclampsia/eclampsia )
- ACS
- acute aortic dissection
4
Q
Name TWO modifications of cardiac arrest in pregnancy you should implement as per ALS guidelines?
A
- Activate Obstetrics Cardiac Arrest and you should get expert help from obstetrician, anaesthetist and neonatologist
- LEFT LATERAL TILT 15-30 degrees
If tilt is not feasible, maintain left uterine displacement manually - Due to potential IVC compression, IV or IO access should be established above diaphragm
- Attempt early intubation due to high risk aspiration secondary to gravid uterus
- Position hands higher on the sternum during CPR for advanced pregnancy
5
Q
briefly describe the procedure to performing a surgical airway/cricothyrodotomy in a patient that needs an emergency airway
A
- Perform a laryngeal handshake to identify the cricothyroid membrane
- Perform a transverse stab incision through cricothyroid membrane
- Turn blade through 90 (sharp edge caudally)
- Slide coude tip of bougie along blade into trachea
- Railroad lubricated 6.0mm cuffed tracheal tube into trachea
- Ventilate, inflate cuff and confirm position with capnography
- Secure tube
6
Q
According to DAS intubation guidelines 2015 - what plans would you set out in order to prepare for a difficult airway ?
A
Plan A Laryngoscopy
If tracheal intubation is unsuccessful
Plan B Insertion of Supraglottic Airway Device
If you fail to ventilate with a Supraglottic Airway Device
Plan C Final attempt at face mask ventilation
If you cannot intubate and cannot ventilate
Plan D Perform Emergency Front of Neck Access
TRY REMEMBER: laryngoscopy (A ) is a SAD ( 2 )Face mask ventilation ( 3 ) with FONA ( 4 )
7
Q
What are the standard defib pad position/placement?
A
right sternal ( below the clavicle ) & left apical ( in mid axillary line at the position of the 6th electrode )
8
Q
Is external mechanical compression devices more effective than manual chest compression?
A
Rescucitation council ( UK ) recommends that automated mechanical chest compression devices should not be used routinely to replace manual chest compression
9
Q
what changes to the standard approcah would you make in resuscitation of a pregnant female in cardiac arrest?
A
- HIgher hand position for chest compression
- manually displace the uterus to the left
- if it is difficult to place the apical defibrillator electrode, use an anterior-posterior or bi-axillary approach
- consider using tracheal tube 0.5 - 1.0mm smaller than usual
- establish IV access at a level above the diaphragm
- If resuscitation attempts fail to achieve ROSC, consider an immediate caesarian section to deliver the fetus within 5 minutes of the mothers cardiac arrest
10
Q
Which 2 criteria [0.5 each] should be met to suggest that anaphylaxis is highly likely as per ALS guidelines
A
- sudden onset and rapid deterioration of symptoms
2. life threatening airway and/ breathing an / circulation problem
11
Q
What are the life threatening differential diagnosis of anaphylaxis?
A
- life threatening asthma
- septic shock
- choking
- angioedema
12
Q
Your patient has been successfully treated for anaphylaxis as per ALS guidelines. Your consultant advises to keep her under observation for 6 hours.
Give ONE reason for keeping her under observation [0.5] and give ONE piece of advice you would give her before sending home after period of observation [0.5]
A
- possibility of biphasic reaction with incidence of 1-20%
2. possibility of continued absorption of allergen
13
Q
Can you outline the non-anaesthetic treatments for patients with laryngospasm?
A
- gentle suction secretions
- high flow oxygen via tight fitting mask
- positive pressure ventilation to splint open the airway
- LArsons maneuvre - which can open the airway and break the spasm. jaw thrust with anterior pressure applied to the mandible in the laryngospasm notch.
14
Q
Describe Larson’s maneuvre to relieve laryngospasm?
A
jaw thrust with anterior pressure applied to the mandible in the laryngospasm notch.
15
Q
can you name the 4 components that make up a mapleson C ( water circuit )?
A
- reservoir bag
- Fresh Gas flow
- APL valve ( adjustable pressure limiting )
- connection to face mask
16
Q
What are the 2 main advantages of using a Mapleson C ( water cirsuit ) over a bag valve mask attached to a reservoir bag?
A
- less resistance to spontaneous breathing - ( because exhaled gas exits via APL )
- reduce barotraum - because mapleson C allows adjustment of pressures in assisted ventialtion
17
Q
According to ASA classification :
How would you differentiate between Minimal sedation, moderate, deep and GA?
A
Minimal: ( anxiolysis )
drug induced depression of conciousness in which….
patient responds to normal verbal commands
Moderate Sedation: ( concious sedation)
drug induced depression of conciousness in which…
Patient responds purposefully to verbal commands ( either alone or accompanied by light tactile stimulation )
Deep sedation:
drug induced depression of conciousness in which..
Patient cannot be easily roused, but
responds purposefully to repeated verbal or painful stimuli
GA:
Drug induced loss of conciousness in which…
Patient are not rousable even by painful stimulation
18
Q
According to ASA classification:
How do you achieve minimal, moderate and deep sedation and what is the minimum monitoring required.
A
Minimal sedation:
use entonox
monitoring required: pulse oximetry
Moderate sedation:
combination of opiates and benzo’s
monitoring required:
Deep sedation
19
Q
In a patient whose ETT has become dislodged, outline 4 points in your initial management of this patient?
A
- call for help ( anaesthetist )
- switch to 100% oxygen
- check the circuit and ett to make sure fully out the
trachea and not blocked or rescuable - use airway maneuvres to open the airway
- use face mask ventilation to re-oxygenate the patient.
20
Q
What are the most common causes of post-intubation hypoxia?
A
DOPE:
- Displacement
- Obstruction ( mucous/kinking )
- Pneumothorax
- Equipment failure
21
Q
- Why is etomidate a good induction agent in trauma patients?
- what is the dose?
- are the side effects?
- explain why it is not a good maintenance agent?
A
- due to ists cardiovascular stability, causes less hypotension at induction than other agents.
- dose: 0.3mg/kg
- side effects:
- pain on injection
- thrombophlebitis
- nausea and vomiting
- adrenal-cortical suppression
- pain on injection and adrenal cortical depression
22
Q
Give the IV doses and a unique side effect of the following:
Ketamine dose Thipentone dose propofol dose fentanyl dose etomidate dose
atracurium dose
rocuronium dose
suxemethonium dose
A
- ketamine 1.5mg/kg ( 1mg/kg acceptable )
- thipentone 3-5mg/kg
- propofol 1-2mg/kg ( 1mg/kg acceptable )
- fentanyl 2-10mcg/kg
- etomidate 0.3mg/kg
- atracurium dose: 0.6mg/kg ( half of rocuronium )
- rocuroniumm: 1.2mg/kg
- depolarising suxemethonium: 1.5mg/kg
23
Q
- Name the potential side effects of suxemethonium
- What are the complications
- what are the contra-indications
A
- complications of suxemethonium
- suxemethonium aponea
- malignant hyperthermia
- RHAMBDOMYLISIS (as acomplication of hyperthermia)
- hyperkalaemia
- raised intra-ocular pressure
- major burns ( after 24hours )
- hyperkalaemia
- severe muscle trauma
- spinal cord injury causing paraplegia ( between day 10-100 )
- history of malignant hyperthermia
24
Q
What is the mechanism of action of ketamine?
What makes it a good agent to use in trauma patients?
A
NMDA receptor antagonist.
it is cardiovascularly stable and does not cause hypotension and is favoured in trauma patients.
causes tachycardia, increase in blood pressure, CVP & C.O due to an increase in sympathetic tone.
duration of action is 5-10 minutes.
25
What is the side effects of ketamine?
But what is unique about its properties in comparison to all the other anaesthetic agents?
SIDE EFFECTS OF KETAMINE:
nause, vomiting
Hypertension,
dissociative state
nystagmus, diplopia
UNIQUE QUALITY:
it is the only anaesthetic agent available that has
analgesic, hypnotic, and amnesic properties. can be used IV or IM. also used PO, PR, IN. ( IM dose is 10mg/kg )
26
What is the ASA classification of patients according to disease/ health status of a patient?
I - fit and healthy
II - mild systemic disease
III - severe systemic disease
VI - severe systemic disease with constant threat to life
V - severe systemic disease with patient moribund not
expected to survive without operation
VI - severe systemic disease with patient declared brain
dead
27
list 5 Contra-indications to procedural sedation in the ED?
PAtient factors:
* 1- ASA>4
* 2- patient has an allergy to the relevant medication
* 3- high risk for vomiting aspiration
Staff factors:
* 4- appropriately trained staff not available to perform sedation
Equipment factors:
* 5- appropriate monitoring and resuscitation fascilities not available
28
In a patient on face mask oxygen that needs transfer from ED to THeatres - how would you calculate the oxgygen requirement?
and which oxygen cylinder would you use?
CALCULATION OF OXYGEN REQUIREMENT for a patient on face mask oxygen :
2 x ((FLow ( litres/min ) x duration of transfer time ( minutes ) ))
oxygen cylinder size code:
* C - 170
* D - 340
* E - 680
* F - 1360
29
COmplication of ventral venous access?
!. pneumothoraz
2. haemothorax
3. chylothorax
4. air embolism
5. cardiac arythmia
6. arterial puncture
7. central venous perforation
30
What is your IMMEDIATE management for local anaesthetic toxicity according to the AAGBI guidelines?
* 1. Stop injecting the LA
* 2. Call for help
* 3. Maintain the airway and, if necessary, secure it
with a tracheal tube
* 4. Give 100% oxygen and ensure adequate lung
ventilation (hyperventilation may help by
increasing plasma pH in the presence of metabolic
acidosis)
* 5. Confirm or establish intravenous access
* 6. Control seizures: give a benzodiazepine,
thiopental or propofol in small incremental doses
* 7. Consider drawing blood for analysis, but do not
delay definitive treatment to do this
31
What is the discharge criteria for patients following procedural sedation?
* 1. patient return to their baseline conciousness
* 2. vitals observations return to normal limits for patient
* 3. Respiratory status is not compromised
* 4. N&V, Pain and discomfort has been adressed
32
What is the criteria for ARDS?
How would you set the ventilator for protective lung ventilation?
1. Acute with onset over 1 week or less
2. bilateral opascities on cxr/ct consistent with pulmonary oedema
3. respiratory failure not fully explained by heart failure
of fluid overlad
Protective lung ventilation:
* calculate ideal body weight (
* select any ventilator mode
* achieve low tidal volume ventilation 6ml/kg
* set RR to maintain optimal minute volume ( not > 35/min)
* aim SP02 88-95%
* increase PEEP with increasing Fi02 aim for plateu pressure <30mmhg
* allow permisive hypercapnoea
33
4 ventilatory induced lung injury?
1. volutrauma
2. barotrauma
3. atelectrauma
4. biotrauma
34
1. What are the side effects of thipoental sodium?
2. Whar are the side effects of etomidate?
3. what are the side effects of suxemethonium?
4. What are the side effects of rocuronium?
5. what are the side effects of propofol?
6. What are the side effects of ketamine?
1. S.E of thipoental sodium:
* bad for heart ( hypotension, myocardial depression, arrythmias ) bad for skin ( rash,hypersensitivity reactions)
2. S.E of Etomidate:
* Pain on injection...phlebitis...& venous thrombosis,
adrenal-cortical suppression , N&V
3. S.E of suxemethonium:
* Malignant hyperthermia, rhabdomylisis, hyperkalaemia, ventricular arrythmia, cardiac arrest, sux apnoea
4. S.E of rocuronium
5. S.E of propofol
* pain on injection...phlebitis...& thrombosis, transient apnoea, headache
6. S.E of ketamine
* N&V, Hypertension, diplopia , rash
35
How do you assess for a difficult airway?
```
L- look
E - evaluate 3-3-2
M - Mallampati - SUFP or hard pallate only
O - Obstructive
N - neck mobility
```
36
What is the mallampati scoring system and what does it comprise of?
It is a tool used to predict the ease of intubation
It comprises of a visual assessment of the distance from the tongue base to the roof of the mouth looking at the hard pallate, soft pallate, uvula, fauces, pillars.
37
A. What internal diameter ETT sizes would you choose for the following age patients?:
1. neonate
2. 6 month old
3. 1 year old
4. above 1 year old
B. How do you calculate the length of ETT/NTT to use?
A> Internal diameters
1. 3.5mm
2. 4mm
3. 4.5mm
4. above 1 year old: age/4 +4
B. Length of ETT & NTT
```
ETT = age /2 +12
NTT = age/2 + 15
```
38
What are the various ventilator settings for the following :
1. ideal body weight
2. tidal volume
3. rate
4. PEEP
1. females = height in cm - 110 vs males = height in cm -100
2. 6-8ml/kg
3. 10-15breaths per minute
4. 0-20cmh20
39
What are the contra-indications to using entonox?
Contra-indications to using entonox:
1. diving injury
2. reduced level of conciousness
3. middle ear disease
4. sinus disease
5. pneumothorax
6. bowel obstruction
40
According to the RCOA &RCEM guidelines, Which 4 types of monitoring are recommended in order to perform deep sedation?
* ECG
* NIBP ( non-invasive blood pressure monitoring )
* Pulse oximetry
* canography
41
What maneuvres can you try to assist a difficult intubation?
1. re-position patient - neck flex 35 degrees onto chest, face extension 15 degrees
2. reduce cricoid force
3. attempt BURP
4. use a GEB ( gum elastic bougie )
5. try alternate laryngoscopy blade ( miller.mcoy )
42
What is the cause and relevance of cardiogenic oscillations on capnography appearance?
cardiogenic oscillations are caused by changes in thoracic volume secondary to expansion and contraction of the myocardium with each heartbeat.
usually seen in patients with small tidal volumes and are of little physiological consequences.
43
What is Sellick's maneuvre?
SEllick manoeuvre is cricoid pressure applied during endotracheal intubation in a RSI to prevent regurgitation of gastric contents.
BURP maneuvre is pressure applied to the anterior aspect of the larynx to fascilitate an improved view of the glottis during laryngoscopy and endotracheal intubation.
Dont confuse the 2. One is used to prevent regurgitation during RSI, the other is used to improve the view of the glottis during laryngoscopy.
44
You have been asked to accompany a mechanically ventilated patient to the ICU which is 15 minutes away. his ventilator settings are as follows: tidal volume 500ml, Fi02 0.5 rate is 15 per minute. what is the total oxygen requirement for this transfer?
oxygen required=
(( Fi02 x MV) + oxygen required by the ventilator ) X 2 X the transfer time )
MV = 500ML x 15 = 7.5L
Oxygen required = ( 0.5 x 7.5 ) + 1 Litre ) X 2x 15min
4.75 x2x15 =142.5 L
45
What is the difference of type 1 vs type 2 respiratory failure?
Type 1 respiratory failure occurs when there is a problem with oxygenation resulting in hypoxaemia
Type 2 respiratory failure occures when there is inadequate alveolar ventilation resulting in both hypoxaemia and hypercapnoea characterised by :
reduced Pa02 < 8 kPa
elevated PaCO2 > 6.7 kPa
reduced PH < 7.35
46
Which conditions commonly cause type 2 respiratory failure?
```
Extreme obesity
obstructive sleep apnoea
chest deformity ( kyphoscoliosis )
exacerbation of COPD
Life threatening asthma
```
47
What is the new definition of sepsis?
life threatening organ dysfunction caused by dysregulated host response to infection
48
What is the qSOFA score
it is a bedside tool designed to identify patients with suspected infection who are at greater risk of a poor outcome outside of the ICU using 3 criteria: SBP, RR, altered mental state. the presence of 2 or more is associated with the greater risk of death or longer length of stay in ICU
49
Name 2 clinical bedside tests you can perform to reassess the patients volume status and tissue perfusion?
1. dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
2. bedside cardiovascular ultrasound
50
What is the difference between CPAP and BiPAP?
and what is pressure support?
CPAP:
is continuous PAP throughout the entire respiratory cycle
BiPAP:
uses a time or flow -cycled change between 2 applied levels of PAP. 1 pressure is selected for inspiration and 1 for expiration
Pressure support:
is the difference between inspiratory and expiratory pressure.
51
What is the BTS criteria to starting NIV in a patient with COPD exacerbation?
What setting would you start the NIV on?
PH < 7.35
PC02 > 6.5kpa
RR > 23
if persiting after bronchodilator therapy and controlled oxygen
Ventilator setting:
52
WHat are the complications of NIV?
1. anxiety/clasutrophobia
2. ulceration and pressure necrosis
3. gastric distension and vomiting
4. raised intracranial and intra-ocular pressure
5. but hypotension if hypovolaemia present
53
You have intubated an asthmatic patient. how would you set the ventilator?
1. permissive hypercapnoea - allowing the PaCO2 levels to rise and preventing hyperinflation.
2. RR 6-8 breaths /min
3. TV 6-8ml/kg
54
What are the absolute contra-indications for NIV?
1. facial traum/burns
2. lack of patient consent/unco-operative patient
3. unconcious patient
4. untreated pneumothorax
5. intractable vomiting
6. respiratory arrest
7. cardiac arrest
55
List 3 indications for RSI in an acute asthmatic patient?
1. Severe hypoxia
2. Respiratory arrest
3. cardiac arrest
56
How do you perform a radial nerve block?
* best with wrist held in slight dorsiflexion
* LA infiltrated SC around radial and dorsum side
* approx 3 scm proximal to radial styloid
* aim medially towards radial artery
57
What are the indications for insertion of an arterial line?
What 2 main methods of insertion of an arterial line do you know?
2 main indications for insertion of A-line:
1. continous beat-to-beat blood pressure monitoring
2. when frequent arterial blood gas analysis is required
2 main methods of insertion:
* over-the-needle
* over-the-wire
58
Which LA nad at what maximum dose is recommended by RCEM for bier's block?
Name 1 complication specific to this gent and which treatment should be instituted if this complication occurs?
0.5% of 1% Prilocaine - max dose 3mg/kg.
Methaemoglobinaemia is specific to prilocaine, and if it occurs - treat with IV methylene blue 1-2mg/kg
Contra-indication for methylene blue is G6PD deficiency
59
Can you name 4 complications of arterial line insertion?
What are the contra-indications to insertion of arterial line?
4 COMPLICATIONS OF ARTERIAL LINE INSERTION:
1. haemorage
2. air embolism
3. line sepsis
4. Thrombosis
CONTRA-INDICATIONS OF INSERTION OF ARTERIAL LINE?
* absent pulse or klnown arterial insufficiency
* Raynaud's syndrome
* Buerger's disease
* Full thickness burns at placement site
60
What are the contra-indications for inserting a central venous line into the jugular vein?
1. coagulopathy
2. raised intra-cranial pressure ( would be unable to lie the patient head down )
3. Lack of patient consent/unco-operative patient
4. obstructed vein ( thrombosis )
5. overlying skin infection
61
Can you name 2 immediate complications associated with central venous catheterization?
1. Haemothorax
2. pneumothorax
3. chylothorax ( thoracic duct injury )
4. accidental arterial puncture
5. arrythmias
6. air embolus
62
Why is the radial artery the preferred choice for arterial line palcement?
1. lowest complication rates in comparison to other sites
2. easily loactable and superficial artery which aids insertion
3. It's superficial nature also makes it easily compressable for haemostasis
63
What anatomical landmark would you use to locate the femoral artery? explain?
the femoral artery can be located just distal to the midpoint of the inguinal ligament ( midway betweeen ASIS and PT. )
here it lies medial to the femoral nerve and lateral to the femoral vein.
64
Outline the anatomical landmarks that will aid you to identify the external jugular vein for venous cannulation?
it can be located in the posterior triangle of the nexk. it follows a course that runs roughly from the ear lobe to the mid clavicle
65
What are the contra-indications to performing a Bier's block?
Contra-indications to performing a bier's block:
```
Raynauds syndrome
morbidly obese
monckberg's calcinosis
scleroderma
sickle cell disease
infection in the affected limb
unco-operative patient
```
66
How would you anatomically locate the femoral vein?
Located in the femoral triangle ( a depression situated inferior to the inguinal ligament )
1-2cm below the inguinal ligament
medial to the femoral artery
67
What type of hypersentivity reaction causes anaphylaxis and name the antibodies involved.
Anaphylaxis - is a Type 1 hypersentivity reaction by Allergen reacting to specific IGE antibodies
68
You are treating a patient for anaphylaxis. He is known to have hypertension and takes bisoprolol.
The gentleman’s Blood pressure is <80mm HG despite fluids,Hydrocortisone and 2 doses of adrenaline.
Other than ionotropes which drug and dose would you consider in his case?
If patient is on a betablocker and hypotension is unresponsive to Adrenaline and fluids consider Glucagon 5mg i.v.
69
At what intervals should mast cell trayptase levels be measured in patients presenting with anaphylaxis?
* as soon as possible after immediate treatment
* 1-2 hours after onset of symptoms
* 24 hours after onset of symptoms
at lease 2 samples must be taken
70
List 2 non-allergic, non-ace-Inhibitor causes of angio-oedema
1. NSAIDS
2. Hereditary c1 esterase deficiency
3. Acquired C1 esterase inhibitor deficiency – caused by *lymphoma
* connective tissue disorders i.e SLE
4. Idiopathic
71
ACE induced Angiooedema is related to accumulation of predominantly which inflammatory mediator?
bradykinin
72
give a differential diagnosis for angio-oedema?
1. cellulitis
2. erysipilas
3. lymphoedema
4. connective tissue disorders
73
What would be the specific treatment for ACE inhibitor induced angiooedema.
For ACE inhibitor Angiooedema- treatment is Bradykinin b2 inhibitor ( ICATIBANT )
– see article http://www.ncbi.nlm.nih.gov/pubmed/25629740
74
List 2 immediate and 2 early complications of a needle cricothyroidotomy in an emergency?
IMMEDIATE COMPLICATIONS:
1.Hypoxia
2.subcutaneous emphysema
3·needle displacement- kinking
4.·Misplacement of tube - subcutaneous emphysema.
5.·Embolus- from insufflations into vessel
6.·Haemorrhage-bleeding from small veins or arterial
from thyroid lamina artery
7. ·Oesophageal or mediastinal perforation
EARLY COMPLICATIONS:
1.· Pneumothorax
2. ·Laceration of trachea, oesophagus or recurrent
laryngeal nerve
3. ·Vocal cord injury
4. ·Laryngeal disruption
5. Aspiration
75
List any late complications of emergency cricothyroidotomy
LATE COMPLICATIONS
```
1· Tracheal or subglottic stenosis
2· Swallowing dysfunction
3· Tube obstruction
4· Tracheo-oesophageal fistula
5· Infection and late bleeding
6· Tracheomalacia
7; Persistent stoma
```
76
What predictors of difficult Laryngoscopy would you look for on assessment of a patient?
1. Mandibular opening- 2-3 finger breadths (atleast 4cm)
2. ·Mentum to hyoid bone distance- 3-4 fingers breadth
3. ·Mallampati scoring -
Class1- Visible Faucial pillars, soft palate and uvula
class 2- Visible Faucial pillars, soft palate- uvula masked
by base of tongue
Class 3- only base of uvula visualised
Class 4- no structures visible
4. Neck mobility- Atlanto -occipital extension
77
Local anaesthetic agent Prilocaine when used in regional anaesthetic blocks can cause a specific toxicity. What is this called and how do you treat this condition.?
Methaemoglobinaemia.
This happens with Prilocaine dose> 16mg/kg
Treatment is with IV 1% methylene blue 1-2mg/kg
78
describe the anatmoical landmarks for a median nerve wrist block
Injection site-between Flexor Carpi radialis and Palmaris longus on the proximal wrist crease
79
describe the anatomical landmarks for an ulnar nerve wrist block
Injection site is past the Tendon of flexor carpi ulnaris in the vicinity of ulnar artery- felt by pulsation.
80
A patient presents to the ED with ARDS. He is intubated and ventilated.
What ventilator settings will you apply to conform to protective lung ventilation strategies?
Resource:
https://www.ficm.ac.uk/sites/default/files/ficm_ics_ards_guideline_-_july_2018.pdf
1. Low tidal volume ventilation <6 ml/Kg IBW3 of ideal body weight
2. Plateau pressure <30cmH2O
3. Prone positioning (>12 hr/day)
4. Neuro-muscular blockade (first 48 hour)
81
What are the goals of Lung protective ventilation strategies in ARDS?
* essentially low tidal volume ventilation reduces ventilator-associated lung injury (VALI) i.e.
- volutrauma (hyperinflation and shearing injury)
- barotrauma (alveolar rupture and pneumothorax)
- biotrauma (release of inflammatory mediators)
82
Which patients require a prolonged period of observations after an anaphylactic reaction?
RCEM Learning SAQ
UK Resuscitation council states that the following group of patients may require prolonged observation as they have a high risk of prolonged anaphylactic reactions:
1. Known asthmatics
2. Previous history of biphasic reactions
3. Possibility of continuing absorption of allergen
4. Severe reactions with slow onset caused by idiopathic anaphylaxis
5. Patients presenting in the evening or at night or those who may not be able to respond to any deterioration.
83
List three body systems that may typically be affected in an episode of hereditary angioedema.
RCEM Learning SAQ
1. Skin
2. respiratory
3. Gastro-intestinal tract
84
What 2 treatments are usually available to treat angio-oedema in the ED?
RCEM Learning SAQ
1. C1 Esterase Inhibitor Replacement Protein
i. e. Cinryze or Berinert
2. Fresh Frozen Plasma
