Flashcards in Stab room Deck (50):
What is a good alternative to "bagging up" an obese patient that is prone to desaturating quickly
What is the dose of lidocaine in the acute treatment of ventricular arrhythmias?
1 to 1.5mg/kg (usual dose is 100mg)
How often can lidocaine be redone in the acute treatment of ventricular arrhythmias, and at what dose? What is the max dose
0.5 to 0.75mg/kg can be repeated every 5 to 10 minutes. Max dose is 300mg in 1 hour.
What types of lines should we place for E-CPR?
Right femoral vein - smak catheter
Left femoral artery - smak catheter
(But with patients with larger body habitus, consider cordis catheter, as we have had a case where we lost the smak catheters)
What are the patient characteristics for E-CPR
Age 18 to 65
Can't be a nursing home resident
No pre-existing organ failure
What are the physiologic criteria for E-CPR
etCO2 > 10
SpO2 > 85% or PaO2 > 50
Need all 3 of these
On bedside ultrasound, how should the IVC be interpreted if tamponade is being considered?
Per Rob, "you can't have tamponade if the IVC is collapsing"
In a patient with tamponade complicating aortic dissection, how could pericardiocentesis make things worse? Does it have a role?
Pericardiocentesis in this situation would likely result in a higher cardiac output, increasing the dp/dt forces, which may worsen the dissection, and promote more blood from going from the true lumen in to the false lumen. That said, if a patient is truly in shock and under perfused, pericardiocentesis should still be performed if there is a delay to OR, but only remove as much as is necessary to improve the hemodynamics.
What is the dose of atracurium?
Ideal body weight.
What size blade should be used for a term newborn? Premie?
Miller 1 for term, miller 0 for premie.
Where should an O2 sat be measured on a newborn?
Right hand - it's preductal
What is the very first things I should be doing when an obtunded patient is being brought in to the stab room, particularly one that is being bagged
1. Check for a pulse
2. Ultrasound prior to transfer to the cart
(remember the 26 yo who died who came in being bagged and blue, who I didn't recognize arrest promptly in)
What are the ECG findings of right heart strain?
1. Right axis deviation
2. Big R wave in V1 and V2
3. SI, QII, TIII
4. T wave inversions in precordial leads
What is the dose of physostigmine? What are potential complications? How long does it last?
Give 2mg IV over 5 minutes. Seizure and bradycardia, especially if pushed too fast. Lasts about 1 hour.
What are 2 situations in which to potentially use a King instead of an ILMA for a supraglottic airway?
1. Compromised ability to oxygenate - a king seals in such a way that it can have a higher driving pressure in the setting of a reduced lung compliance. ARDS and difficult to oxygenate patients are a good one.
2. A king may be able to seat in setting where the airway anatomy is somewhat distorted
What is the dose of rocuronium? How long does it last?
1mg/kg. 30 to 40 minutes.
What is the reversal agent for rocuronium? What is the dose? What agents does it work for?
Sugammadex. 16mg/kg for immediate reversal. Smaller doses are listed for less urgent reveral. Rocuronium and vecuronium.
What is the starting dose and range of clevidipine?
Starting: 1mg to 2mg / hr. Can be doubled every 90 seconds. Range: Max is probably 16mg/hr. Each 1mg probably lowers the SBP 2 to 4 mmHg per uptodate.
If you want to give positive pressure (BVM or ventilator) to a person with a tracheostomy, what needs to be in place?
The balloon needs to be inflated on the tracheostomy, if it's cuffed. If it doesn't have cuff, need to exchange it for one with a cuff or an endotracheal tube.
When intubating an obese person, if the chest is so high that is making insertion of the blade difficult, what can be done?
Use a snub handle on the blade. Unfortunately, not available for CMAC.
How can intubating in a low volume state precipitate arrest? how to prevent this?
When intubating, venous return is decreased, can precipitate arrest? To prevent this, consider volume resuscitating first if airway management isn't needed immediately.
How should chest tubes be used to rewarm in hypothermia?
Insert 2 on each side, one anterior and one posterior. Put in warm saline in the anterior one, then gravity will cause the saline to exist the lower tube.
Below what temperature should epinephrine not be used?
Below 30 degrees. Doesn't work due to altered pharmacodynamics. Might be harmful.
After what temperature is defibrillation indicated in hypothermia? What should be done below this temperature with regards to defibrillation?
30 degrees. Below this, if a shockable rhythm is present, attempt 3 times, then no further until above 30 degrees.
If a bladder rupture is visualized on a trauma CT scan, what should be done with regards to subsequent imaging?
Gopal recommends getting a CT cystogram at the time of the CT.
What are the ranges of hypothermia? What treatment is indicated at each range?
32 to 35 (Mild) - Shivering will be present, passive rewarming only.
28 to 32 (Moderate) - Bair hugger, endovascular, IV fluids, bladder-thoracic-peritoneal lavage, warmed air
24 to 28 (Severe) - ECMO
Below 24 (Profound) - usually dead
What is the smallest size ET tube that the pediatric bougie will go through?
4.0, but even so, it will be pretty difficult to fit a 4.0 tube over it.
What size ET tube should be used in a cricothyrotomy?
6.0. Side note - needs to be obtained from the pediatric bay
If a Macgill forceps is slipping off when attempting to grip a solid object, what can be done to increase the friction?
Put tape on the ends of the macgill. This will increase the friction and ability to grip. This should have been considered in a child who ended up having a tack stuck in his trachea just below the cords with the sharp end pointing towards the mouth. Th macgill in this case ended up sliding off. Unfortunately, when the tam decided to intubation, the tack went further down and completely obstructed the airway and the kid died.
When the lung is expanded on one side and potentially even pushing the mediastinum over, what should be considered once tension pneumothorax is ruled out?
Foreign body in the main stem bronchus on that side. It causes air to be able to get in, but not out, so the lung hyperinflates. I learned this from a case of a head injured patient who was having oxygenation difficulties, who later in the SICU was found to have a tooth that he aspirated in the right mainstream bronchus
How high should the femoral arterial and venous lines be placed in the refractory arrest protocol?
Arterial: Superior to the superficial and deep femoral artery brach.
Venous: Also high
They both need to go as high as possible, , above the inguinal ligament
What is the difference between the 4 french and 6 french smak catheters?
The 4 french is the one we should typically use. The 6 french, in addition to being wider, is also longer, but the canula is different and can be somewhat confusing.
What are 4 different ways of dealing with bleeding from a neck mass?
If oozing, try pressure with gauze soaked in afrin or gauze soaked in tranexamic acid. A third option is silver nitrate sticks to chemically cauterize. 4th option, particularly if looks like a big vessel, is to suture.
Before doing a cervical check in late pregnancy, what should be done?
Check the position of the cervix
How is failure to capture for a pacemaker recognized? What five things that can cause this?
Failure to capture is recognized when pacer spikes are visible, without beats following them. Hyperkalemia, ischemia, drug toxicity, poor lead contact, fibrosis around the lead tip.
What are four causes of failure to pace in which a pacemaker spike WILL NOT be visible?
Oversensing, broken leads (as assessed by chest x-ray), leads detached from generator, generator malfunction (including low battery)
What are the steps in the emergency management of a pacemaker failing to pace?
1. Treat hyperkalemia or drug toxicity
2. Treat ischemia
3. Magnet application if no pacer spikes
4. External pacing
5. Transvenous pacing
6. Chronotropic support with Isoproterenol, Epinephrine, or Dopamine to increase ventricular escape rate.
For a pacemaker, what is undersensing? What is oversensing?
In undersensing, the pacemaker fails to sense the intrinsic rate, and inappropriately tries to pace. In oversensing, the pacemaker senses beats when they actually aren't occurring, and will inappropriately not pace.
What medication and dose is indicated in major bleeding in hemophilia A?
Factor 8, 50 units/kg
What medication and dose is indicated in major bleeding in hemophilia B?
Factor 9, 100 to 120 units/kg
What are two reasons a cricothyrotomy is contraindicated in children?
1. Funnel shaped airway with narrowest part at the cricocoid ring (rather than the vocal cords), which can cause subglottic stenosis, 2. Cricothyrotomy in kids is thought to more likely damage the cricoid cartilage and other laryngeal structures
What are 4 reasons kids with trisomy 21 have difficult airways?
1. Large tongue and small mouth
2. Atlanto-occipital instability - need c-spine stabilization
3. Prone to bradyarrhythmias
4. High incidence of subglottic stenosis and tracheomalacia/narrow glottis
Does high dose insulin in the setting of CC or BB overdose have a greater impact on the heart rate or contractility? What adjunctive therapy might be needed?
Contractility. Heart rate may be relatively bradycardic, but can be paced (ideally transvenously) if needed
What is the role of the pop off valve on a pediatric BVM? Is there ever a time to disable it?
The pop off valve is designed to limit pressures when bagging a child, as there is a tendency to be too aggressive. However, sometimes high airway pressures might be needed to oxygenate, such as when lung compliance is low (e.g. bad pulmonary edema in a 6 week old arrest patient). To disable the pop off valve, slide the white plastic piece over it so it doesn't pop off.
What type of ET tube does Reardon use in a full term newborn?
3.0 cuffed. This is different than what the standard sizing would recommend (which is a 4.0). A 3.0 is the smallest cuffed tube.
When should we be using cuffed tubes in pediatric patients?
All the time
What juvenile T waves? At what ages should they be present? If the T waves are instead upright, what should be considered?
T wave inversions in leads V1 through V3, should be present from about a few weeks old to about 8 years, with some variability. The ST segment should be normal. Neonates and older kids should have upright T waves in V1 through V3. If upright (especially with a big R wave in V1), RVH should be considered
Aside from juvenile T waves, what is another normal variant that can be a cause for T waves in children?
African American kids (up to young adults) can have inverted T waves in V1 through V3 that also have some ST elevation associated with them.
What should I do with dressings I encounter in the stab room?
Take them down, every time, all the time, even in critically ill patients. (Remember the case of the cardiac arrest guy who turned out to have a necrotic foot and fulminant sepsis, and I failed to examine his foot well - went to the OR with podiatry after getting up to the MICU but still died, which was expected)