Sim Learning Objectives Flashcards
Basic Approach to Unresponsive Patient
1 - CHECK A PULSE
2- If no pulse, CPR
If pulse, proceed to ABCs, monitors
3 - Think of reversible causes
- hypoxia (15L non-rebreather)
- hypovolemia (fluids)
- opioid OD (narcan - 1 cc, 2 cc, 4 cc STOP)
- hypoglycemia (give D50)
4 - If no reversible causes move to bag-mask ventilation and possible intubation
5 Indications for BVM
1 - inc WOB (inc RR, diaphoretic, accessory muscles)
2 - AMS
3 - Refractory hypoxemia (SHUNT)
4 - low O2 sat with bradycardia
5 - Apnea
Steps Prior to RSI and Intubation
Hx
- Contraindications to sux (kidney problems? myalgias? prior adverse effect? can you move all extremities?)
- Last meal?
- Pt wt?
PE
- Look inside their airway
- Meas thyromental (3 fingers) and thyrohyoid (2 fingers) distances
Pre-oxygenate
Ask nurse to draw up meds - .03 mg/kg etomidate + 1 mg/kg sux or rocuronium
Double check the IV
Equipment - suction, laryngoscope, ET tube w/ stylete, syringe, CO2 detector
Shunt v. Dead Space
Shunt - perfusing alveoli without ventilation
- does not improve with inc FIO2, need PEEP
- blood, pus, water, atelectasis, ARDS
Dead Space - ventilation without perfusion
- PE
- Responds to inc FIO2
Vent Setting Basics
Mode - assist/control v. support
Target - based on volume more often than pressure
FIO2 - start at 40 and go up or start at 100 and go down (avoid free radicals at < 60)
Tidal volume - goal = 6 cc/kg ideal body wt
RR - calculate to get ideal minute ventilation of 8-10 L based on tidal volume used; may inc if resp acidosis and vice versa
PEA
pulseless electrical activity - DO NOT SHOCK OR GIVE AMIO (just epi q 5 min and pulse checks q 2 min)
- Hypovolemia - fluids
- Hypoxia - BVM
- Hyperkalemia - calcium carbonate, Na bicarb, insulin + D50
- H+ acidosis - Na bicarb
- Hypothermia - warm
- Tension pneumothorax - needle decompression
- Tamponade - pericardiocentesis
Differential for Bradycardia
Severe hypoxia
Vasovagal
Normal variation if well-conditioned
Ca channel blockers, beta blockers, digoxin
MI (RCA supplies SA node)
AV block
Treatment of Bradycardia
1 - pulse ox, give O2 if low
2 - atropine.5-1.0 mg IV
3 - push dose epi (1 cc 1:10,000 with 9 cc NS)
4 - pacing if unstable / if Mobitz type 2 or 3rd degree AV block
Approach to Tachycardia
Wide or narrow QRS?
Regular or irregular?
P wave activity?
Approach to Seizing Pt
1 - ABCs (intubate if cannot protect airway), monitors, IV, roll to L side
2 - Check glucose (D50)
3 - lorazepam 2 mg x5 (10 mg total)
4 - phenytoin / fosphenytoin
5 - phenobarb / valproic acid
6 - intubation (prop, midazolam, ketamine)
Approach to Desat Pt with Trach v. Laryngectomy
Trach - < 7 days or > 7 days?
- if < 7 then need to intubate from above
- If > 7 then can pass new trach tube
Laryngectomy - DO NOT INTUBATE FROM ABOVE; ETT or trach tube in stoma
Seizure Work-up
CBC CMP AED level - if sz history CT head ABG Tox screen EEG
**ask about alcohol and benzo use for withdrawal
Hypertensive Emergency (definition and tx)
> 180 sys OR > 120 diastolic
+ end organ damage
- AMS
- Stroke
- Retinopathy
- ACS
- Dissection
- Flash pulmonary edema
- Hematuria
- AKI
Tx = lower MAP 10-20% first hour then another 5-15% over 24 hrs (nicardipine, labetolol, hydralazine, methyl dopa)
SBP Goals in Stroke and Intracranial Bleeds
SAH - < 120
ICH - < 140
Hemorrhagic CVA - < 140
Ischemic CVA w/ tpa - < 180
Ischemic CVA w/o tpa - < 220
Tx of Aortic Dissection
HR control not BP control (HR < 60)
Labetolol
Contraindications to tPA in CVA (10)
- sig head trauma or stroke within last 3 mo
- Sx of SAH
- Arterial puncture at non-compressive site in last 7 days
- Hx previous intracranial hemorrhage
- Intracranial neoplasm, aneurysm or AV malformation
- Recent intracranial or intraspinal surgery
- BP > 185/110
- Active internal bleeding
- Bleeding problem (platelets < 100,000, on A/C)
- CT showing multi-lobar infarct
