Resuscitation in special circumstances

Question 1

What is the normal value of K+?
What is considered hyper-K+?
What is severe?

What is hypo-K?
What is severe?

Answer 1

3.5-5.0mmol/l
>5.5
>6.5

<3.5mmol/l
<2.5mmol/l

Question 2

If pH decreases, what is likely to happen to k+

if pH increases, what is likely to happen to k+

Answer 2

k>

<k

Question 3

How do recognise hyperkalaemia?

Answer 3

Tall peaked waves (greater than R wave)
Paraesthesia
Weakness
Merging s and t waves (Sine waves)

Question 4

For mild elevation of k+, give? (5.0-5.9)

Answer 4

Resonium/polystyrene 15-30g

Question 5

For moderate (without ECG changes), give? (6.0-6.4)

Answer 5

10 Units insulin + 25g dextrose over 15-30 mins, resonium

Question 6

For severe hyperkalemia without ECG changes, give? (>or equal 6.5)

Answer 6

glucose/insulin/IV fluids/ventolin (10-20mg nebs), resonium, ?dialysis

Question 7

For severe hyperkalemia, with ECG changes, give?

Answer 7

Calcium chloride (2-5min), glucose/insulin, ventolin, IVT, resonium, dialysis,

Question 8

For cardiac arrest with hyperkalemia, give?

Answer 8

Rapid injection of: calcium, insulin/glucose, sodium bic.

Question 9

What is hypokalaemia?

Severe?

What is some clinical signs?

Answer 9

<3.5mmol

<2.5mmol

weakness, cramps, constipation, rhabdo

Question 10

What is the ECG sign of hypokalaemia?

Answer 10

U waves / T wave flattening, maybe AF

Question 11

During cardiac arrest with hypokalaemia, what do you give?

Answer 11

MgSo4 (2g) and 5mmol K+

Question 12

What is the max dose of k+?

Answer 12

20mmol/h

rapid infusion can be done where peri arrest (2mmol/min for 10 mins)

Question 13

Familiarise yourself with p. 134

Question 14

What is sepsis and what is the sepsis six?

Answer 14

SIRS or organ failure
lactate >4mmol/l
hypotension
oliguria
confusion

Sepsis six:
Give O2
Blood cultures
Give broad spectrum abx
Fluid resus (250-500ml bolus)
Measure lactate
Measure urine

Question 15

For opioids, give?

Answer 15

naloxone (100mcg titration up to 800mcg)

Question 16

For Benzos, give?

Answer 16

Flumazenil

Question 17

For TCAs, (amitriptyline, -amine, doxepin), give?

Clinical signs?

When a child arrives in a shockable rhythm, assume?

Answer 17

Sodium bic (go for pH 7.45-7.55)

Hypotension, seizures, arrhythmias

Question 18

Give lipid emulsion to who?

Answer 18

Those with local anaesthetic toxicity seen in cardiovascular / cerebral collapse

How much? 1.5ml/kg then 15ml/kg/hr (After 5 mins, give up to two more boluses with 5 mins between), double rate of infusion.

Question 19

What treats malignant hyperthermia?

Answer 19

Dantrolene (eg. MDMA)

Question 20

For asthma, give?

Answer 20

2x5mg ventolin with aim of SaO2 greater or equal to 92%
atrovent 500mcg
10mmol MgSo4
pred 50mg / hydrocort 100mg

consider iv ventolin if not possible to give airway
consider aminophylline in severe asthma

Half the doses for kids

Question 21

What signs of tension pneumothorax are there?

Answer 21

subcutaneous emphysema
tracheal deviation
unilateral expansion of the chest wall

Question 22

Anaphylaxis is met on what three criteria

Answer 22

1. Sudden onset
2. Airway, Breathing or Circulatory compromise
3. Skin / mucosal changes (Sometimes not there)

There can also be gastro sx.

Question 23

Adult anaphylaxis algo

Answer 23

Question 24

What modifications should be done in cardiac arrest of pregnant woman?

Answer 24

Displace the uterus to the left (esp after 20 weeks)

Add left lateral tilt

If initial resusciation fails, you will need to deliver (preferably in 5 mins) - this helps the mother and a potential viable pregnancy (under 20 weeks not needed, however, needed if 24-25 weeks)

Question 25

What is commotio cardis?

Answer 25

Actual or near cardiac arrest caused by blunt impact to the chest

Question 26

In trauma, prolonged CPR (no response in 20 min), has what?

Answer 26

Poor survival and CPR needs to be stopped

Question 27

In tension pneumothorax, where is the needle put for needle decompression?

Answer 27

2nd intercostal, mid clavicle Or 5th intercostal mid axilla

Question 28

When does a cardiac tamponade occur?

Answer 28

In cardiac surgery or trauma. The pericardial sac is filled with fluid under pressure. Ultrasound can help diagnose

Question 29

What is the treatment of cardiac tamponade?

Answer 29

In trauma, immediate thoracotomy is needed

Question 30

What is submersion?

Answer 30

When the face is underwater -> Asphexia -> Cardiac arrest Less than 10 min - good outcomes More than 25 min - bad outcomes

Question 31

What is immersion?

Answer 31

Head above water like with life vest -> Hypothermia

Question 32

What is the role of hydrostatic pressure in drowning? (common in long immersion)

Answer 32

Hydrostatic pressure causes redistribution of fluid from periphery to central which is sensed by the body as hypervolemia that leads to diuresis, natriuresis, kaliuresis When you get them out of the water, keep horizontal otherwise cardiovascular collapse can occur

Question 33

When drowning, what rhythm comes first?

Answer 33

Bradycardia

Question 34

What airway breathing modifications may be needed after drowning?

Answer 34

Early intubation Peep may need to be as high as 15-20cm H2O but you start with 5-10.

Question 35

What form of measurement should be used in hypothermia (less than 35 degrees celsius)? (severe is less than 28 degrees celsius)

Answer 35

Thermocouple tympanic Low reading thermometer (using lower third of the oesophagus) - rectal and urinary are not recommended in severe hypothermia

Question 36

What are some physiological principles of hypothermia that effects resucitation?

Answer 36

1. Cellular oxygen consumption reduces by 6% for every 1 degree drop 2. At 18 degrees celsius, the brain can tolerate circulatory arrest for 10x longer than at 37 degrees celsius 3. Intermittent CPR is possible with min CPR and <5 mins of not 4. Avalanche victims that have been under for >60 mins are unlikely to survive. 5. Avalanche victims are unlikely to survive with potassium >8mmol/L 6. Arrhythmias often revert to normal as the body warms

Question 37

How long do you check for signs of life in a hypothermic patient?

Answer 37

1 min (Palpate, ECG, maybe Doppler)

Question 38

Should you withhold ALS drugs in the hypothermic patient and when do you start giving?

Answer 38

Yes and give when core temperature is 30 degrees or greater

Question 39

If VF persists after 3 shocks, then what in hypothermic patient?

Answer 39

Delay until temperature >28 degrees-30degrees

Question 40

What are the stages and the general rewarming strategies?

Answer 40

Stage 1: 32-35 (shivering) - Blankets, foil, cap, let them exercise as more effective than shivering -> send to normal hospital Stage 2-5: Chemical heat packs to the trunk -> Hospital with ECMO In hospital rewarm with warm air ventilation and warmed fluids. Passive rewarming can cause peripheral vasodilation.

Question 41

In hypothermia, watch for afterdrop, which is?

Answer 41

A continuing fall in body temperate after removal from the cold environment

Question 42

What is heat stroke?

Answer 42

>40.6 degrees celsius + systemic inflammatory response, change in mental state and some organ dysfunction Elderly are at greater risk Signs and sx: core temp hot, dry skin or sweating fatigue, headache, d+v, fainting arrthymia / hypotension ARDS CNS like seizures / coma liver / renal failure rhabdo

Question 43

What is the general principles of cooling?

Answer 43

Do it rapidly Cool drinks Fanning the undressed patient and spraying tepid water Ice packs over axillae, groins, neck Cool IV fluids Intravascular cooling catheters

Question 44

What causes death from electrical shock?

Answer 44

Tetany does not help (can't let go) Respiratory / Cardiac arrest VF can be initiated by the electricity causes R on T Tissue damage occurs Hand to hand is the worst pathway

Question 45

What should you treat / look out for in electric shock?

Answer 45

Burns Early intubation IV fluids / urine output