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Emergency Med > Resuscitation & Shock - Exam 2 > Flashcards

Resuscitation & Shock - Exam 2 Flashcards

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1
Q

What is ET CO2? What is the goal in CPR?

A

a non-invasive technique that measures the partial pressure or maximal concentration of carbon dioxide (CO2) at the end of an exhaled breath, expressed as a percentage of CO2 or mmHg

ET CO2 CPR goal = least 10, 20 better

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2
Q

What is the goal of O2 saturation in resuscitation and shock?

A

SPO2 ≥ 95%

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3
Q

What are the 2 manual methods to open the airway? Which one should you NOT use with c-spine concerns?

A

jaw thrust

Chin lift :NOT with C-spine concerns

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4
Q

What are 4 airway adjuncts options? Which one is good for an intact gag reflex? Which one is a definitive airway?

A

Oropharyngeal Airway (OPA): NOT for intact gag reflex

Nasopharyngeal Airway (NPA): can use with intact gag reflex

Laryngeal Mask Airway (LMA):

**Endotracheal (ET) Tube -> a DEFINITIVE airway

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5
Q

What is the way to measure the correct oropharyngeal airway size?

A

measure mouth to earlobe to pick the correct size OPA

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6
Q

What is the purpose of an AMBU bag/Bag valve mask? What are the 3 indications?

A

To deliver positive pressure ventilation (PPV) to patient with insufficient or ineffective breaths

Hypercapnic or hypoxic respiratory failure
Apnea
AMS

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7
Q

What is the ideal way to bag someone? How hard should you squeeze the bag?

A

Ideal 2 people: 1 to seal, 1 to squeeze bag. Can attach to high flow oxygen

half squeeze -> watching for chest to rise

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8
Q

What is the normal size ET for a woman? man?

A

Woman: 7.5-8.0mm

Man: 8.0-8.5mm

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9
Q

What are the 2 different blade options for ET intubation? _____ and ____ are also used

A

MAC (curved): 3 or 4 MC

Miller (straight): 2 or 3 MC

bougie and Glidescope

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10
Q

What are the pros and cons of a MAC?

A

Less traumatic & less stimulation

Less of a view

Indirectly lifts epiglottis so less
likely to cause tachycardia or arrhythmias

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11
Q

What are the pros and cons of a Miller blade?

A

More traumatic & stimulating

More of a view

Directly lifts epiglottis so MORE
likely to cause tachycardia or arrhythmias - pediatrics

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12
Q

What are the 2 different NPPV options? When are they commonly used?

A

CPAP and BiPAP

Positive pressure airway support using PRESET volume/pressure of air inspired through face or nasal mask

Good alternative for COPD and pulmonary edema patients

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13
Q

What is the pt criteria need to be in order to use NPPV?

A

Patients need to be cooperative, alert & no cardiac ischemia, hypotension, or dysrhythmia

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14
Q

What is a CPAP? What level to start?

A

Positive pressure throughout respiratory cycle

5-15cm H2O and adjusted to response

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15
Q

What is a BiPAP? What are the starting values?

A

Different levels of pressure during inspiration and expiration

Start 8-10 H2O inspiratory, 3-4 H20 expiratory

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16
Q

_____ and _____ pt types are very good for BiPAP

A

Good for COPD with hypercapnia alone

and

mixed hypercapnic/hypoxemic
respiratory failure

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17
Q

______ is the MC way to ensure patent airway, prevent aspiration, & provide O2 & ventilation. **What should you do first?

A

Endotracheal intubation

**Pre-oxygenate all patients prior to intubation regardless of saturation with non-rebreather mask at max flow

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18
Q

How can you check that the ET tube is in the right place? How far should you insert in women? men? What should you do next?

A

once cords are visualized, pass the tube through and check placement with bilateral breath sounds and LACK of bowel sounds
can also note color flow and end tidal CO2

21cm in women, 23cm in men

confirm with CXR!!

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19
Q

What is the Mallampati score?

A
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20
Q

______ is the preferred method for securing the airway in the critically ill or injured patient. What is the order of events?

A

Rapid Sequence Intubation (RSI)

Simultaneous administration of induction (sedation) followed by neuromuscular blocking (paralytic) agent

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21
Q

How long should you pre-treat pts with O2 before RSI?

A

pre-oxygenate with 100% O2 for at least 3 minutes

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22
Q

What are your options for Induction (Sedation) IV Drugs? Which one is MC?

A

Etomidate (MC)

Propofol

ketamine

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23
Q

Etomidate is preferred is what 2 pt populations? Why?

A

good with hypotension or ICP pts (think stroke or increased ICP)

does NOT affect BP

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24
Q

______ is lipid soluble and acts on GABA

______ direct GABA activation

_______ NMDA receptor

A

Propofol: lipid soluble, acts on GABA

Etomidate (MC): direct GABA activation

Ketamine: dissociative anesthetic, NMDA receptor

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25
_____ should be AVOIDED in hypotension but can be used in long term sedation
propofol
26
_______ is good in bronchospam or hypotension and is used in kids
ketamine
27
What are the 2 paralytic IV drug options?
Succinylcholine Rocuronium
28
______ has a rapid onset and offset and messing with what electrolyte?
Succinylcholine: K
29
What 3 circumstances should you NOT use succinylcholine?
Do NOT use in neuromuscular, rhabdo or burn pts d/t hyperkalemia
30
______ is a paralytic drug that has a longer duration of action, approximately 45 minutes. What pt population should you NOT use this in? What is the MOA?
Rocuronium myasthenia gravis nondepolarizing agent
31
How often should you give a rescue breath in adult CPR? How many compressions in 1 minute? **How deep should you push?
1 breath every 5-6 seconds 100-120 per minute **2-2.4 inches
32
In an adult, with both 1 and 2+ rescuers what is the ratio for compressions to breaths?
1 rescuer: 30:2 2+ rescuer: 30:2
33
What is the compression rate for a child/infant? When should you start compressions in a child/infant? How many rescue breaths?
COMPRESSION RATE: 100-120 per minute 1 breath every 3-5 seconds Pulse <60bpm add compressions
34
In an infant, for both 1 and 2+ rescuers what is the ratio for compressions to breaths?
1 rescuer: 30:2 2+ rescuer: 15:2
35
What is the compression depth for a child? infant?
child: ⅓ depth of chest (2 in, 5 cm) infant: ⅓ depth of chest (1.5in, 4cm)
36
Draw the chart for CPR in an adult/child/infant
37
**What abnormal rhythms are considered shockable? What is the shockable rhythm algorithm?
VF/pulseless VT
38
In pVT/VF how many shocks are appropriate before drugs? Which drug is always given first? How many times can you give amiodarone or lidocaine?
2 shocks 1mg Epinephrine IV/IO q 3-5 minutes only given 2x
39
What are the first and second line dosing for amiodarone? lidocaine?
amiodarone: first dose: 300mg 2nd dose: 150mg lidocaine: first dose: 1-1.5mg/kg 2nd dose: 0.5-0.75 mg/kg
40
How long should you interrupt CPR for? How often should you check for pulse/rhythm?
10 seconds or less every 2 minutes
41
What are the CI to amiodarone?
bradycardia, 2nd or 3rd degree heart block, cardiogenic shock
42
What are the Hs and Ts of ACLS?
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypoglycemia Hypo/hyperkalemia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary
43
______ disorganized depolarization & contractions of ventricle with NO effective pumping. What will it look like on EKG?
ventricullar fibrillation No P or QRS waves, fine to course zigzag pattern
44
What are the differences between primary and secondary VF?
Primary: Sudden, unexpected VF without pre-existing heart failure or hemodynamic deterioration (no clear trigger) Secondary: Consequence of established heart problem usually result of severe HF or cardiogenic shock
45
What are some causes of vent fib? Which one is MC?
MC: Severe ischemic cardiac disease +/- acute MI Digoxin/Quinidine toxicity, chest trauma, hypothermia, hypo/hyperkalemia, mechanical stimulation, re-entry
46
coarse vent fib
47
fine vent fib
48
What is considered vent tachy? What is the usual HR? **What is the QRS axis showing?
3+ successive beats from ventricular ectopic pacemaker Usually 150-200bpm; Regular rhythm constant/wide QRS axis (>0.12 seconds)
49
What is the treatment for SVT?
tx with adenosine
50
What is the MC cause of vent tachycardia? Name 5 additional causes
MI & ischemic heart disease HCM, MVP, hypo/hyperkalemia, antiarrhythmic OD
51
What is the tx for vent tachy with a pulse?
Amiodarone IV 150mg over 10 min (first choice)
52
What is the tx for unstable vent tachy? What is considered unstable?
synchronized cardioversion hypotension, AMS, shock, acute heart failure, CP, no pulse!
53
vtach from the RIGHT ventricle
54
vent tachy from the LEFT ventricle
55
What is Torsade de Pointes? What is the BPM?
QRS axis swings from positive to negative w/ rate of 200-240bpm
56
What are the drugs that cause torsade de points? **What is the major one?
Zofran, Phenergan, Antipsychotics, FQ **Antipsychotics
57
What is first line tx for torsade de pointes with a pulse? without a pulse?
1st: Magnesium Sulfate 1-2g IV over 60-90 sec → infusion and transcutaneous pacing at 90-120bpm, correct hypokalemia no pulse = SHOCK
58
What is the tx for refractory torsade de pointes?
Isoproterenol
59
What is considered PEA?
Pulseless Electrical Activity (PEA) Electrical impulses w/o mechanical contraction of the heart
60
What are the big causes of PEA? what is the tx?
Hs and Ts: see previous card PEA= give IV/IO DRUGS!! (epinephrine!)
61
PEA organized rhythm without a pulse rhythm can be anything
62
What am I? What is the tx?
Asystole DRUGS!! epinephrine
63
What is considered 1st degree AV block? What are the causes? What is the tx?
Delay in conduction across AV node w/ PR >0.20 seconds (PR interval is 1 big box) can be normal, ↑ vagal tone, digoxin toxicity, inferior MI no tx required
64
What is 2nd degree AV block type 1?
Wenckebach Progressive prolongation of PR until blocked → dropped beat → cycle repeats. Usually only 1 atrial impulse is blocked at a time aka PR interval gets progressively longer until it drops
65
What are the causes of 2nd degree AV block type 1? What is the tx? Give both slow rate and unstable tx options
Inferior MI, digoxin toxicity, myocarditis, cardiac surgery no treatment needed unless there are s/s of hypoperfusion
66
What is 2nd degree AV block type II? What does it indicate?
Infranodal disease w/ constant PR interval w/ intermittent drops aka PR interval remains the same length and will have absent QRS complexes randomly Indicates significant damage to His-Purkinje conduction system
67
Is mobitz type I or II more dangerous? What can it progress to?
mobitz type II is more dangerous Can progress to 3 degree block in anterior MI
68
What is the treatment for 2nd degree AV block, mobitz type II? What is the definitve treatment?
1. Atropine* 0.5-1mg IV bolus q5min, titrate up to 2mg (max) 2. Transcutaneous pacing placed & initiated (if atropine did not work) 3. Transcutaneous Unsuccessful: Transvenous pacing via catheter Definitive: Permanent cardiac pacemaker!
69
What is a 3rd degree AV block?
No AV conduction; P & QRS beat on own w/ no communication aka the atrial and ventricles are doing their own thing and NOT communicating at all
70
What will a junctional 3rd degree block look like? What is the ventricular rate?
Ventricular rate of 40-60bpm originating above bifurcation of His bundle (SA node); Narrow QRS
71
What will a ventricular focus 3rd degree AV block look like? What will the ventricular rate be?
Ventricular focus: Ventricular rate <40bpm originating in bundle branch or Purkinje fibers; Wide QRS; Anterior MI
72
What is the tx for an unstable 3rd degree AV block?
Transcutaneous pacing till venous pacer placed, pacemaker
73
What is the tx for a stable 3rd degree AV block?
Stable: Atropine* 0.5-1mg IV bolus q5min → titrate till 2mg if needed Transcutaneous pacing Pacemaker
74
3rd degree AV block
75
How does the pediatric airway differ from an adult?
Smaller, more anterior airway, larger tongue and epiglottis
76
What do you need to do in order to get the right airway alignment in a child?
Cushion behind the shoulders to get the right airway alignment Chin lift and jaw thrust maneuvers
77
When bagging a pediatric pt, how many ml of air does a neonate and pediatric pt need? ____ is the needed tidal volume
neonate 240ml, pediatric 500ml 10-15ml
78
What type of blade is typically used in pediatric airway insertion? cuffed or uncuffed tubes?
typically miller blade with UNCUFFED tube in children less than 8
79
How often should a child be ventilated>
once every 3-5 seconds
80
_____ for size of tube and medication dosages in kiddos
Broselow tape
81
What is the SE of etomidate?
can cause myoclonus
82
How does pediatric RSI differ from adult RSI?
**Pretreatment: with Atropine 0.02mg/kg (max 1mg) Infant <1yo prep for vagal bradycardia or septic shock/hypotensions Child 5 or <5yo getting succinylcholine as paralytic
83
**In pediatrics, what induction medications require adjunct meds after intubation? Which one prefers hemodynamic stability? Which one requires higher doses in infants?
Etomidate -> preserves hemodynamic stability Propofol -> requires higher doses in infants
84
What are the 4 RSI adjunct medications in kiddos? Also give drug classes
Sedatives (Anxiolytic): Midazolam (Versed):Shorter acting Lorazepam (Ativan):Longer acting Analgesics: Fentanyl: short acting and will NOT bottom out BP Morphine: longer acting and may bottom out BP
85
What is a Brief resolved unexplained event (BRUE)?
A sudden, brief (<1 min), and now RESOLVED episode in an infant that includes 1 or more of the following: -Cyanosis or pallor -Absent, decreased, or irregular breathing -Marked change in tone (hyper- or hypotonia) -Altered level of responsiveness must NOT have an explanation for the episode
86
What is the treatment for BRUE with low risk characteristics?
Don’t require labs or continued workup, can offer observation 2-4 hours
87
What are the criteria to be considered a low risk for having a recurrence or serious underlying disorder? Must meet ALL criteria
Age >60 days If premature, born at gestational age ≥32 weeks and current postconceptional age is ≥45 weeks Occurrence of only 1 BRUE (no prior BRUE, and BRUE did not occur in clusters) Duration of BRUE <1 minute No cardiopulmonary resuscitation (CPR) by a trained medical provider was required No concerning historical features No concerning physical examination findings aka this was a one time thing and the kiddo does NOT have multiple events
88
Is there an association between BRUE and SIDS?
Educate the family there is no known association between BRUE low risk and SIDS
89
What is considered SIDS?
Sudden death of an infant <1 yo that remains unexplained after investigation and autopsy
90
What is the MC kiddo for SIDS?
MC: 2-4 months and 90% before 6 months midnight to 8am minorities and low socioeconomics addicts childcare settings
91
What are the 2 biggest risk factors for SIDS?
sleeping postition and maternal smoking
92
What are some prevention strategies for SIDS?
Supine position - back sleeping, firm surface, remove soft objects, no smoking, no cosleeping, avoid using car seat for sleeping, avoid overheating
93
What are protective factors for SIDS?
Breastfeeding room sharing pacifier use immunizations
94
What are the likely causes of pediatric cardiac arrest?
Resuscitation of neonates/peds primarily HYPOXIA from resp arrest or shock syndromes aka LUNGS are the problem in kiddos
95
What are the shock energy dosing in pediatrics?
1st shock 2J/kg 2nd shock 4J/kg 3rd shock greater than 4 but less than 10 (max 10J/kg)
96
How many times can you give amiodarone in kids ACLS? What should you NOT do?
can give amiodarone 3 times in peds (only 2 times in adults) DO NOT DELAY AIRWAY for vascular access
97
_____ and _____ often corrects the problem in pediatric dysrythmias. When should you start CPR?
oxygenate and ventilate If HR <60 → CPR!
98
What is the treatment for hypotension/shock in kiddos?
Epinephrine 0.01mg/kg
99
What is the treatment for vagal response/AV conduction in kiddos?
Atropine 0.02mg/kg (repeat x1, Min dose 0.1mg, max single dose 0.5mg) consider pacing in heart blocks, can still pace if the HR is slow
100
What is considered shock? What are the 4 categories?
Circulatory insufficiency → Imbalance between oxygen supply and demand of tissues HYPOPERFUSION hypovolemic cardiogenic distributive obstructive
101
What is considered hypovolemic shock? What are the 2 MC causes?
Insufficient volume to circulate leading to organ damage and eventually organ failure Severe dehydration or blood loss
102
What is the presentation of hypovolemic shock? What is the highlighted finding?
**HYPOTENSION (SBP <90), hypoperfusion, tachycardia
103
What is the treatment for hypovolemic shock?
104
What is the initial fluid bolus in hypovolemic shock?
Initial resuscitation phase: 0.9% NS, 20-40ml/kg over 10-20 min
105
What is the fluids ratio in acute hemorrhagic shock?
Infuse 3x the estimated blood loss; 1L of isotonic crystalloids → blood products
106
______ is the ideal blood replacement in hypovolemic shock. **What is the ratio in trauma patients?
PRBC PRBC: FFP: Platelet in 1:1:1
107
What vasopressors are given to hypovolemic shock pts after successful. resuscitation? What is the goal urine output?
Norepinephrine, Dobutamine, Dopamine Goal: output 0.5ml/kg/hr MAP 65-90
108
What is cardiogenic shock? What is the MC cause?
Insufficient cardiac output to meet metabolic demands of tissue/brain acute MI
109
What is the more important diagnostic in cardiogenic shock? What is the tx? What is persistent hypotension?
EKG (MOST IMPORTANT): look for MI Early Revascularization (PCI/Cath lab) is BEST Norepinephrine, dobutamine, dopamine: increase pressure and contractility to improve blood flow
110
What is the tx for acute mitral regurgitation causing cardiogenic shock?
Nitroprusside to decrease afterload with dobutamine
111
What is septic shock? What is the MC cause? Will have evidence of _______
Dysregulated host response to infection bacteria evidence of decreased tissue perfusion (organ failure)
112
______ is the MC cause of ARDS
sepsis
113
What is the treatment of septic shock? What is the ideal O2 stat? What is the fluid rate?
high flow O2 keeping O2 >90% 30 mL/kg NS or LR 500mL q5-10min, often takes 4-6L
114
What is the abx used in septic shock?
vanc and Zosyn
115
What is the cause of neurogenic shock? ______ is needed to dx
Lesion or injury to spinal cord, cerivcal spine or TBI → loss of vascular tone Body has trouble regulating blood pressure, heart rate and temperatute therefore decreased blood flow CT or MRI to fully diagnose
116
What is the tx for neurogenic shock?
IV Fluids and Vasopressors with alpha-activity (increase sympathetic tone)
117
What are the 3 common causes of obstructive shock?
tension pneumo pericardial tamponade massive PE
118
**What are the 3 components of Beck's triad?
hypotension, JVD, muffled heart sounds
119
What are the CI to peripheral IVs?
Phlebitis of extremity cellulitis over site potential or existing lymphedema or venous occlusive edema traumatic injury PROXIMAL to insertion site
120
What areas on a kiddos should you try first before moving on to IO? Where are IO lines placed?
AC, hand, foot, scalp proximal tibia: 1-2cm below tibial tuberosity
121
What are complications for IO access?
infection of bone (should remove IO device within 24 hours) fat embolism fractures extravasation: the leakage of fluid, such as blood, lymph, or medication, from a blood vessel into the surrounding tissues compartment syndrome
122
What are the 3 options for central line placement?
internal jugular subclavian femoral
123
Why would you want to place a central line?
in order to give medications, monitor central venous pressure, or insertion of transvenous pacemaker
124

Emergency Med (21 decks)

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