1
Q
What kind of drugs end in lol?
A
Beta blockers.
eg. atenalol
2
Q
What kind of drug end in pril?
A
Ace inhibitors
eg. Ramparil
3
Q
What drug names end in sartan?
A
Angiotensin 2 receptor antagonists
4
Q
What drug names end in zole?
A
Reflux meds
5
Q
How many small squares constitute significant ST elevation?
A
- Small square above the isoelectric line in the limb leads
- Small squares above the isoelectric line in the chest leads
6
Q
Before you call a code STEMI, what requirements do you need to meet for ECG (in addition to the other requirements?
A
- St elevation of at least 1 mm (1 small square) in two or more contiguous limb leads
AND/OR
- ST elevation of at least 2 mm (two small squares) in 2 or more contiguous chest leads
- Normal QRS complex duration
OR
A RBBB is present, therefore accounting for the extended QRS duration.
7
Q
When you see a QRS that is abnormally wide, but there is a p wave associated with each QRS….what should you look for straight away?
A
A right or left bundle branch block.
Check V1.
Then check lead V6.
8
Q
What are the patient criteria necessary for a code STEMI?
A
- Symptoms consistent with ACS
- Ongoing, unrelieved chest pain
- GCS = 15
- Onset < 12 hours prior
- PCI facility within 60 minute drive.
9
Q
What are the considerations before giving GTN?
A
- Appropriate rate and rhythm.
eg. AF is a preload + rate dependent rhythm. So it may be contraindicated in some circumstances. For example, loss of atrial kick means that starlings law, or in other words myocyte stretch is driving cardiac output. If you drop preload, you can create ischemia.
eg. Inferior infarct is also a preload dependent rythmn, when it involves significantly the right ventricle.
eg. Giving GTN to a patient with HR above 110 is dicey if that can’t downregulate such as in AF…. They may be rate dependent, and reducing preload would enhance ischemia. - Appropriate blood pressure - specifically a MAP above 65
- No use of PDE-5 inhibitors. Erectile dysfunction agents.
10
Q
What is V4r lead and when would you use it?
A
You can take the V4 line, and place it on the other side of the chest. You can do so, when a patient has ST elevation in the inferior leads (2, 3, avf) because you are looking at the right ventricle with v4r in order to ascertain if there is RV involvement (ST elevation in v4r)
11
Q
What would an extended PR interval potentially indicate?
A
Some involvement of the AV node, whos function it is to slow conduction from the SA node and the atrial depolarisation, so that it is completed before ventricle depolarisation and contraction.
12
Q
What is the only contraindication for ondansatron?
A
Long QT syndrome
13
Q
What class of drug is ondansatron?
A
Highly selective 5-HT3 receptor antagonist
14
Q
Name 4 common blood thinner medications?
A
- Apixaban
- Rivoroxaban
- Saralto
- Warfarin
15
Q
What two key obs would you expect in PE?
A
- Low SP02 in the setting of
2. hypotension.
16
Q
If you are uncertain about chest pain what should you assume?
A
Assume it’s chest pain and treat accordingly.
17
Q
What can hide a STEMI? And what is a STEMI equivalent?
A
- Bundle branch blocks can hide a STEMI.
- ST elevation or depression in the setting of a BBB can be ignored.
- A LBBB is a STEMI equivalent
18
Q
What two lines are best for seeing AF activity/fibrillation?
A
- V1
2. AvR
19
Q
What ECG signs would you see in pericarditis?
A
- Global ST elevation.
2. PR Depression
20
Q
Stridor is a sign of?
What does it sound like?
A
- Upper respiratory issue. It can be heard without a stethascope and is a high pitched wheeze
Inspiratory stridor occurs when your child breathes in and it indicates a collapse of tissue above the vocal cords.
Expiratory stridor occurs when your child breathes out and it indicates a problem further down the windpipe.
Biphasic stridor occurs when your child breathes in and out, and it indicates a narrowing of the subglottis, the cartilage right below the vocal cords.
21
Q
How does a wheeze sound compared to a stridor?
What does wheeze indicate?
A
It is much lower pitch. And comes from deeper in the lungs. From the bases of the lungs, rather than the axis.
Wheezing most often comes from the small breathing tubes (bronchial tubes) deep in the lungs
22
Q
What indicates a poor pleth wave?
A
- uneven shape
- Not passing through both ‘lines’
- Sats will be unreliable in these cases.
23
Q
Sp02 has a delay of approximately?
A
2-4 minutes behind ACTUAL realtime breathing changes.
24
Q
What are some very troubling respiratory signs in children?
A
- Nasal Flare
- Mouth breathing (children are typically nose breathers)
- Intercostal retractions
- Chest moves when breathing (children are normally belly breathers).
25
When considering the Asthma CPG, is a patient has any severe or life threatening symptoms...they should go into which category?
The higher category
26
What is a crucial thing to ask on EVERY asthma job?
1. Ask for a patient management plan
2. If the plan has not been tried. Follow this as it is tried and tested for the patient. If tried and failed proceed to SAAS treatment protocols.
27
What is an anticholinergic?
An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. These agents inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells.
28
What kind of drug is ipratropium?
1. an anticholinergic - It is an M3 receptor cell agonist (a type of Ach (acetylcholine) receptor that provides parasympathetic innervation to the lungs causing bronchoconstriction.
29
What is the downside of a Neb?
It can reduce Fi02 by up to 30%.
30
What is the minimum MAP required for perfusion?
65
31
If a patient is potentially going to decline into hypovolemic shock...what should be the first treatment priority.
Basic cares:
1. Haemorrhage control - excluding/ignoring cavities such as uterus, rectum ect.
2. Splinting - In particular CT6 splint.
3. Posturing - sliding patients from bed or chair to floor is acceptable.
4. Oxygen. When a patient is in a shocked state, they require 02.
5. Pain relief. First line should be PENTHROX. Do not forget.
32
What is the line of ascending pain relief options?
1. Splinting
2. Posture.
3. Temperature
4. Penthrox
5. Paracetamol
6. IN fentanyl
7. IV fentanyl.
33
What is the time for peak blood concentration of Fentanyl?
5-8 minutes. You can only give more fentanyl after 5 minutes has expired.
34
When providing additional breaths in asthma how many breaths should you give IPPV?
< 6 per minute is good for patients that are not breathing. For those that are breathing, you can do a breath after every exhalation. The END of each exhalation will provide the rate.
35
What is the minimum oxygen rate for a non-rebreather?
12 litres.
36
What oxygen settings work with a neb?
8 litres ONLY.
37
What is the max oxygen rate for nasal specs?
4 litres max.
38
What is the minimum oxygen rate for a hudson mask?
6 litres.
39
What is a key part of a secondary survey that you cannot miss?
You need to auscultate the chest and look for breathing sounds, check for JVD, and tracheal deviation.
Always consider a tension pneumo in every traumatised patient.
40
What oxygen sats are we aiming for in COPD patients?
between 88% and 92%
41
When providing nebs to COPD patients, why should we note the time - ASIDE from just the PCR requirements?
You need to limit high flow oxygen exposure.
After every SIX minutes you need to reassess!!!
42
Do we give adrenaline in COPD?
No - Never.
43
What expiratory sound is an early sign of APO?
Wheeze.
44
What is the key age group effected by croup?
From 6 months to 6 years old.
45
What are some key differentiators between croup and epglottitis?
What is another less obvious croup mimic?
1. There is no cough with epiglottitis.
2. epiglottitis will involve drooling + leaning forward potentially.
3. Airway obstruction is a sneaky mimic of croup.
46
What is the technique to align a paediatric airway in an arrest?
It can be good to place a towel under the shoulders to open the airway. Their airways open at more neutral positions...when compared to adults that have their neck pulled back and C shaped airway is more open.
47
What is the triple airway manoeuvre?
1. Head tilt
2. Chin lift
3. Jaw thrust.
48
What is a crucial step to assessing paediatric breathing, different from adults?
You MUST expose the chest + belly. This tells you a lot.
49
What are some symptoms of croup?
1. Nasal flaring
2. Chest breathing
3. Intercostal recession
4. Recent Hx of flu-like symptoms
5. Hoarse voice
6. Barking cough
50
Why does croup effecting breathing so significantly ?
Any small change in diameter has an exponential increase in pressure. This is the same mechanism as vasodilation/constriction and why it is so effective.
So a small decrease in diameter, causes an exponential increase in the pressure needed to generate effective airflow for breathing.
51
What is the paediatric assessment triangle>
1. Behaviour/appearance
2. Work of breathing
3. Circulation of the skin.
52
TICLS is a handy acronym for assessing paediatrics. What does it stand for?
```
T - Tone
I - Interactiveness
C - Consolability
L - Look/Gaze
S - Speech / Cry
```
53
What is a tool to use for categorising the severity of croup?
The westley croup score - look this up and use.
The two worse signs are
altered conciousness
Cyanosis
54
Can a pede travel being held by mum?
Never - the PEDE must always be in the PEDEMATE.
55
What are the three key symptoms of anaphylaxis?
1. Angiooedema
2. Hypotension
3. Bronchocontriction
56
What is the key difference between asthma and anaphylaxis.
Asthma is a localised inflammatory response within the lungs and bronchioles. That has systemic consequences if intrathoracic pressure creates obstruction, or hypoaemia occurs.
Anaphylaxis is a systemic inflammatory response, that causes widespread changes systemically to capillaries, and the lungs.
57
As a general rule all patients in a shocked state require?
High flow oxygen. 15 litres with a non-rebreather when using portable oxygen.
58
What are key skills an ICP can value add for anaphylaxis?
1. Adrenaline infusion (works amazingly)
2. Hydrocortisone injection (slow acting)
3. Cric (only in extremis).
59
What are two key signs of perfusion issues?
Dizziness.
Altered GCS
60
What is a good guide to providing fluid as it pertains to age, and the suggested aliquots?
1. Younger patients can tolerate more fluid - 200 ml fluid challenge is a good approach initially. Reassess
2. Older patients can tolerate less fluid - 100 ml fluid challenge is a good approach initially. Reassess
61
What is the preferred site for IM administration in SAAS?
The thigh
62
What are some signs of angiooedema?
1. Tingles or itch in the throat
| 2. Change in voice
63
What is a key historical detail in anaphylaxis?
Time of onset. If the changes have been occuring for hours, dont stress. You have time.
64
in which condition, and circumstances, would you withhold ondansatron?
for anaphylaxis if the patient ate the allergen. Therefore vomiting it up would be beneficial.
65
What is the acronym for qSOFA assessments of SEPSIS?
H - Hypotension
A - Altered conciousness
T - Tachnypnoea
66
How would you differentiate between SEPSIS and MENINGECOCCAL ?
Time of onset.
Meninggecoccal has a quick/24 hour decline from slightly sick to violently ill.
Sepsis will have a clinical course accross multiple days.
67
When presented with a crack femur. What should you prioritise?
Retracting the limb. Give penthrane and go because its a huge space for bleeding and may lead to hypotension.
68
Why do patients with infections present with higher BGS results?
Cortisol is the stress response hormone, and released in infective processes.
A primary action of this hormone, is that it breaks down glucagon, and hence rising blood sugar.
69
Why is insulin alone, taken by a patient not enough to correct HYPERglycemia?
Because insulin and potassium are co-transported into the cell. So there may be an associated inbalance of potassium that needs to be corrected.
70
What is the approximate tidal volumes of males and females?
Male = 500 ml
Female = 400 ml.
71
Overall when it comes to V/Q matching we typically have more of what?
More perfusion - as a general statement.
72
Different parts of the lung have different V/Q ratios. Explain this
In the upper lungs, ventilation is greater than perfusion.
In the lower lungs perfusion is greater than ventilation. This means that the concentration of c02 is greater in this region of the lungs, as less 02 - which is a result of less ventilation.
73
What are the two types of v/q mismatches?
A shunt -> A poorly ventilated alvioli is well perfused. Hence blood flow is being directed to poorly ventilated lung units and gas exchange is impaired. An example of this is Asthma.
Dead Space -> A well ventilated alviolar unit is poorly perfused. An example of this is pulmonary embolism in which the thrombus is impairing blood flow.
74
The dead space within a bag valve mask extends from which two points?
From the mask to the rubber valve. Beyond the valve it is not deadspace.
75
define dead space?
In physiology, dead space is the volume of air which is inhaled that does not take part in the gas exchange.
This is because:
1. It remains in the conducting airways without interacting with alvioli.
2. It reaches alveoli that are not perfused or poorly perfused
76
What is the normal amount of dead space for an adult?
150 ml
77
What two adjuncts increase dead space in a bag valve mask?
1. The IPPV inline nebuliser for respiratory arrest scenarios.
2. the filter
78
Why do we remove the filter for paeds in arrest? What is the weight cutoff?
< 40 kg = remove the filter
The filter adds dead space, comparatively the dead space is a larger proportion of volume -> compared to an adult. Hence, this dead space has a more detrimental effect and is more difficult to overcome.
This increases work of breathing unnecessarily.
79
When comparing Etc02 (expiratory measured) with pac02 (arterial c02) which figure is typically larger or smaller?
ETc02 is typically a LESSER value than pac02. It is not an accurate reflection of pac02.
80
ETc02 is typically described as an elephant under a blanket, explain what each part of the waveform represents within the respiration cycle.
1. The isoelectric line represents the inspiratory baseline (c02 is low because intake of high concentration oxygen)
2. The upstroke is the beginning of expiration (increasing c02 as expiration ramps up). it doesnt instantly shoot up because dead space has to be overcome.
3. The expiratory plataeu is the flat line at the top of the waveform where c02 expiration peaks.
4. The expiratory downstroke occurs as c02 expiration is used up...a straight drop back down to baseline as inspiration begins again at the isolelectric line.
81
Why is ETc02 a good measure for compressions in cardiac arrest?
In cardiac arrest ventilations should be a constant, as should be metabolic factors. Hence the primary variable should be perfusion. Therefore, increased c02 waveforms should indicate better compressions/perfusion ...which leads to better clearance of waste products during positive pressure ventilation.
82
What is a key feature of gaining ROSC, as it pertains to perfusion?
If when you gain ROSC, the beat is weak....you can and SHOULD continue compressions for a full 2 minute interval.
83
What should an ETc02 waveform look like when ROSC is approaching?
It should be getting progressively bigger. A bigger As elephant trend....may mean ROSC is imminent.
As perfusion increases, better c02 clearance occurs during respiration and hence etc02 increases.
84
If you were providing CPR, and the waveform for ETc02 is increasing, how might this influence drug administration during cardiac arrest?
It would be appropriate to withhold adrenaline in this situation, until next charge and check to look for pulse and ROSC.
85
What two purposes does capnography serve in post-ROSC patients?
1. We can maintain ventilation rates per minute
| 2. It can show a declining waveform (reduced perfusion) and give a lead indicator for imminent arrest.
86
Once a patient has had ROSC, what actions should the clinician take for the next two minute cycle coming up?
Still complete the next two minute cycle because the cardiac output is still rather weak, and this is necessary.
87
What RESP rate should be maintained post ROSC?
10 per minute.
88
If ETC02 flatlines what action should you take?
1. Check patient
| 2. Check equipment such as misted tubing or kinks in the tubing (both commmon).
89
Why is the filter on the BVM more important with ETC02 monitoring?
It helps reduce misting which can mess with the reading. It is placed ABOVE the blue filter, obviously.
90
What is a key KPI for SAAS regarding pain?
We aim to have a pain reduction of 50% as a KPI for SAAS.
91
What drug is eliquis? What is it also known as?
Eliquis is a blood thinner. It is also known as apixaban.
92
In shock what kind of compensatory mechanism is enacted for blood pressure improvement?
The renin/aldosterone/angiotensin system.
93
If you took a patients blood pressure supine or seated. And then took it again whilst standing. What degree of drop would be concerning?
> 20 mmHg.
94
Patients with black faeces or emesis, often have bleeding higher up in the GI tract (eg. coffee ground vomit). What is a trick for young players for patients that present just with black faeces?
Patients taking iron supplements will often have black faeces.
95
How do you spell the D word for loose stools?
Diarrhea
96
When attending a nursing home and approached by a staffer, what is a good first question?
Establish who you are talking to, if possible you may want to speak with the RN. In some cases RNs are casual and will know nothing of the patient, in that cirumstance a carer who knows the patient well may be a better bet.
97
What sort of presentation might you expect in an anemic patient? What is a great check to do on these patients?
Haemoglobin and iron (which is attached) are responsible for giving blood its red colour. Hence, anemic patients will have reduced hematocrit and therefore present as pale.
You can check these patients by pulling down the eye lid and checking the pinkness of the membranes.
98
What factors in a formula determine MAP (not talking about calculating MAP here)? How does this relate to fluids in hypovolemic shock?
MAP = CO x SVR (systemic vascular resistance).
In shock we may give fluid to improve cardiac output.
99
Cardiac output is HR x SV...what improves stroke volume in hypovolemic shock? What is the formula?
Giving fluid improved stroke volume, and therefore improves MAP (CO x SVR).
The formula for SV is:
SV = Preload (ventricular filling) - afterload (resistance).
100
In hypovolemic shock there is an autonomic sympathetic response, where does this happen in the veins, arteries, both similtaneously? or one more than another?
This change occurs predominately in venous system to improve preload.
101
In shock what deadly cycle can occur in the heart?
A lack of preload causes ischemia in the myocytes, the ventricles stiffen, reducing cardiac output further -> lead to more stiffening/worsening ischmia/function of the heart.
102
In shock what deadly cycle can occur with the kidneys?
You need energy/ATP to release renin -> With diversion of blood there may be less blood flow and hence less oxygen available -> a lack of perfusion is also contributing to this -> This means less renin released -> Less GFR -> Less venous return -> and more reductions in GFR.
103
What is the shock triad of death?
1. Acidosis (lack of waste removal/circulation)
2. Hypothermia (diversion of blood centrally, and hence loss of heat until a change of core temperature)
3. Coagulopathy.
104
What less obvious factor should you always monitor and manage in your shocked patients?
Hypothermia. Part of the triad of death this needs to be managed simultaneously in your shocked state patients.
105
What happens to clot processes when a patient is hypothermic?
It inhibits clot formation.
106
In patients with traumatic limb injuries, what should we check as standard?
Colour
Warmth
Sensation.
107
How many litres of blood are in the thigh?
2-3 litres.
108
How many litres of blood can be held in the retroperitoneal space?
5 litres
109
How many litres of blood does an adult male have in total?
5 litres approximately.
110
Typically you would only decompress a chest if there was a lack of a radial + symptoms + mechanism. What signs might lead you to decompress before a loss of radial?
1. Rapidly deteriorating obs
2. Symptoms of a pneumo:
- Jugular vein distention
- Chest trauma
- Decreased air entry on one side / Lack of breath sounds one side
- Loss of GCS...this occurs before loss of radial pulse.
3. Mechanism consistent with tension pneumothorax.
111
The vena cava has a pressure of how much before it is occluded?
only 5 - 10 mmHg
112
From how many weeks does a woman enter the third trimester?
What are the other weeks/trimesters?
1st trimester: Up to 12 weeks
2nd trimester: Up to 28 weeks
3rd trimester: 28 weeks to 40 (approximate birth)
113
If a pregnant woman experiences trauma, what treatment is provided? What is the criteria for which pregnant women get this?
The women need to be in the 3rd trimester, which is from 28 weeks - 40 weeks.
If clear trauma experiences then provide:
- Left lateral posture (this is literally a tiny sheet just barely picking up the hip off the ground)
- Provide fluids in 250 ml aliquots up to 1000 ml.
- Transport to Flinders as they can treat mum AND bubs. Unlike the RAH. However if life or death go to the nearest hospital.
114
When providing the prepackaged intra-nasal fentanyl spray, what is each dose, and what is the max?
Each spray is 25 m
115
How quick do they expect a torniquet and a CT6 to be applied in the intern exam?
torniquet = 30 seconds
CT6 = 2 minutes.
116
If you need to apply a CT6 AND a pelvic binder. What should be actively considered?
You NEED to put the binder on first.
117
What are key vital signs, that might indicate that a patient is decompensating due to a tension pneumo, and hence, decompression may need to occur before loss of radial?
Need to be present:
- Mechanism Of Injury
- Loss of breath sounds
- Signs of decompensation
Signs of Decompensation:
- Elevated RR
- Decreasing GCS (Changes)
- Elevated HR (or potentially drops in HR if following tachycardia).
- Low SP02.
118
What is the goal of treatment in burns, what is the primary model we use to understand it?
The Jackson burn model.
1. Zone of coagulation (dead/necrotic tissue - irreversible tissue destruction)
2. Zone of stasis (zone of secondary injury / Ischemia - potentially saveable tissue if we minimise expansion of the coagulation zone -> potentially reversible if ischemia is reversed.
3. Zone of hyperaemia. A reversible increase in blood flow and inflammation - FLUID ZONE.
Goal of treatment is reversal of ischemia and minimising hyperaemia.
119
What is a key feature of burn patients in terms of respiratory function (think MOI)
Smoke particles exacerbate asthma - You may need to manage bronchospasm.
Fire also consumes oxygen - So patients may be saturating poorly.
120
Key signs of airway burn?
1. Hoarse voice
2. Soot around mouth
3. Difficulty swallowing.
121
Why dont we use ICE in burns?
1. It is very effective at cooling, however the vasoconstriction that it causes is significant.
2. This vasocontriction doesnt allow fluid through to the zone of stasis
3. Hence 02 delivery is worse, ischemia within the stasis zone increases -> coagulation zone expands.
122
How do you manage airway burns differently from regular burns?
1. Extrication is priority 1
2. Skip 20 minutes of running water, but use burn aid en route.
3. Ignore destination triage tool and go to closest hospital.
123
Why is saline ineffective as cooling /running water en route for a burn?
1. Just not enough of it for 20 minutes and not high enough flow.
124
How might you get a BP and cannulate a patient with severe burns on the upper limbs?
1. Bariatric cuff used on a thigh for BP
| 2. Cannulate a vein in the foot.
125
What should guide your administration of fluids in burns?
Parklands formula.
4 x TBSA x weight = Total Mls.
1/2 of total is given over the first 8 hours
Next 1/2 over the following 16
126
What is a key consideration when exstimating total burn surface area?
Superficial burns are not considered burns when calculating TBSA.
127
For simple burns what hospitals are appropriate?
Flinders, Lyall Mac, QEH
128
For major burns, what hospital?
RAH - Best burns unit.
129
Pregnant women receive fluid in trauma, when reassessing what signs indicate enough fluid has been given?
1. Normotension
| 2. Reduction in HR.
130
When documenting a cardiac arrest, you would neve say the rhythm was PEA, what would you say?
Wide complex PEA
or
Narrow complex PEA.
131
SAAS often advocates for placing defib pads anterior and posterior. What is the alternative placement.
1. Under R) clavical
| 2. L) Mid-axillary
132
What is the rough hierarchy of consent?
Check your card insert
133
Why might you see fixed/dilated pupils.
After death, you lose muscle tone. This includes the iris, which can no longer contract. Hence the dilation.
The size of the pupil is controlled by the activities of two muscles: the circumferential sphincter muscle found in the margin of the iris, innervated by the parasympathetic nervous system: and the iris dilator muscle, running radially from the iris root to the peripheral border of the sphincter. The iris dilator fibers contain α-adrenergic sympathetic receptors that respond to changes in sympathetic tonus and changes in the blood level of circulating catecholamines.
134
What is pooled lividity?
Cells rupture en masse, and hence there is a red flushing of the skin. It appears as a blueish/purplish bruise.
135
What is commonly mistaken as pooled livity?
Skin mottling - CPR needs to occur if there is skin mottling .
136
You are mid-cycle in CPR, and planning on providing adrenaline...what must you consider before administering the drug.
Drugs can only be given in the first 1 minute of a cycle. If later than that, delay to the next round.
137
In Wide or Narrow complex PEA, what might this indicate??
Wide complex PEA - > Think metabolic
Narrow complex PEA -> think obstruction/thrombus/tnesion pneumo.
138
How many breaths do we give to unconcious/post rosc patients?
Why?
What situations might they breath more?
1. We give 10 per minute
2. Lower c02 can cause vasoconstriction of cerebral arteries. Additionally, 10 per minute is adequate for pa02.
3. You might breath more, if they are breathing independently and you are supporting their breathing.
139
How many ml of 02 is within the BVM?
900 ml.
140
How much does a standard male breath, in terms of volume? Females?
Males 500 ml approx.
Females 400 ml approx.
141
What are the principles (Think CPG) of fluid administration in the post ROSC patient?
1. Total fluid amount is 10 ml / kg -> up to a max of 1000 ml.
2. Fluids should be administered until a SBP >100 occurs, or a palpable radial pulse is evident.
142
If you were to see ST elevation in a post ROSC patient, -> consider one thing, and then take action in what way?
1. Consider that the heart may be stunned after a cardiac arrest, and the rhythm may be less reliable
2. Activate a code STEMI (even though not stable GCS there is an exclusion for post ROSC patients).
143
In the post ROSC patient we should always check?
BGL - > we need to aim for between 4 - 10 mmol.
144
What are normal BGL results for the non diabetic patient?
- Between 4.0 and 5.4 mmol/L fasted.
| - After eating -> up to 7.8 mmol/L .
145
In what situation would you predominately utilise a naso-gastric tube?
If you suspect, and need to correct gastric insufflation.
146
If you suspect that a child has swallowed an object, and is unconcious...what should you consider regarding laringascopy?
Children have a hyper vagal response, you may see a drop in blood pressure or heart rate.
147
What is the ratio for paediatric arrest, and how does it differ?
15:2 is the ratio. You break for breaths in paeds. I believe this is the case, even if an advanced airway is in situ?
148
In which paed patients would you use an OPA vs exclude an OPA?
Patients < 40 kg = no OPA
Patients > 40 kg = OPA.
149
What is a key complication in paediatric arrest, and how would it be managed?
1. A key complication is gastric insufflation due to the size of the BVM
2. OGT tubes are used to manage should this arise in practice.
150
What is a key difference, in the way one should manage a traumatic cardiac arrest?
What are the reversible traumatic causes in the algorithm?
1. No signs of life -> place on pads
2. Start CPR
3. Charge and check.
4. non-shockable -> discontinue CPR and move to reversible causes:
- Control airway (Think suction + airway device such as i-gel).
- Haemorrhage control (Think stopping bleeds/Compression/Tornique/Pelvic binder/CT-6).
- Bilateral chest decompression (think decompressing one side and reassessing -> BEFORE decompressing the other side).
- Fluid resuscitation (think 30 ml per kilo, instead of the normal 20 ml per kilo). Reassess every 500 ml of fluid.
151
We only give fluids within a standard cardiac arrest, if we suspect a haemorrhage OR if there is an obstructive cause of arrest. What case is borderline obstructive?
1. Asthma. Can be obstructive OR can be a standard arrest and reason is hypoxaemia. Fluid is probably borderline but id say they would do it.
152
What kind of traumatic arrest would you NOT withhold CPR?
A PR bleed arrest.
153
- How should you approach spinal within the primary survey?
Think
```
A- Airway
B - Breathing
C - Circulation
D - Disability -> Spinal/Cspine
E - Exposure.
```
154
When considering the new C-Spine criteria for SAAS -> how does it work for paeds and adults?
1. Anyone who has a 'nexus criteria' factor -> gets a passport and 'goes to canada '
2. Paeds never go to canada. They stay on page 1 for the 'nexus criteria'.
155
You have a seizing patient and provide midaz. The siezure stops. Then it starts again. How soon can you give midaz?
What is the exception?
It needs to be > 5 minutes since the start of the siezure.
The exception is if:
1. Aspiration
2. Hypoxaemia
3. Risk of injuring themselves or others due to practicalities of the seizure.
156
What are three key risks in seizures?
1. Aspiration
2. Hypoxaemia
3. Risk of injuring themselves or others due to practicalities of the seizure.
157
A seizure is considered status epilepticus when?
1. Any seizure > 5 minutes in duration.
158
What should you consider with a focal seizure?
It may progress to a generalised seizure
159
What are the intrinsic rates of the heart?
SA node: 60–100 bpm
Atrial : 60–80 bpm
Junctional: 40–60 bpm
Ventricular: 20–40 bpm
160
Neurogenic shock is often above?
T6
161
Where is the SAAS preferred site for IM injections?
The thigh.
162
What is the maximum dose for a paramedic giving midaz?
Two doses max.
163
When you are putting in an NPA, what are two requirements involved in the insertion?
What is commonly missed and can fail on the exam?
1. Cophenelcane + Lube.
| 2. A cophenelcane DRUG check is often missed. instant fail.
164
If a patient had a hypoglycaemic seizure, and their BGL is now 5.0, however they are still unconcious, should you give more glucose?
No - You do not want to risk hyperglycemia under any circumstances when providing glucose.
Secondarily, this indicates that low sugar is not the reason for reduced mental status.
165
What should you consider when it pertains to head injury severity, and the CPG for head injuries?
Minor head injuries, should not be treated with the 'severe head injury' CPG.
166
Why do people die when they are hit in the temple?
The temporal artery is located there, and may dissect.
167
If someone was king hit, and was knocked unconcious...and then regained consciousness...what is the risk?
The patient may have an epidural bleed (Bleeding between the dura mater and the skull).
Quite often, and epidural bleed will cause unconcioussness -> followed by a 'lucid interval'. They eventually drop dead because the bleed is arterial and hence a QUICK decline.
168
What should you know about head injuries and TNT?
Never, ever, TNT a head injury.
169
What vessels are involved in a subdural haemorrhage?
These are often VENOUS bleeds and hence slower than an epidural bleed.
170
What type of head injury are elderly people more at risk for?
Subdural haemorrhage. This is because they have brain atrophy, and there is less flex between the bridging veins.
171
What is unique about subarachnoid haemorrhages?
They can be spontaneous, often the site of a berry anyurism rupture
172
What sort of symptoms might you expect in a subarachnoid bleed?
- Photophobia
- Vomiting
- Siezures
These symptoms occur because the meninges are irritated due to blood in the CSF.
173
What is the munro kelli hypothesis?
That the skull is a closed system. It is composed of brain matter, blood and cerebral spinal fluid. Any increase in one of these constituents DEMANDS a reduction in another part because the cranial cavity is finite in space and has no expansion.
Hence, CSF is the first to reduce/compensate when there is rising ICP.
174
What occurs within neurons chemically when there is an ischemic stroke?
There is a lack of oxygen delivered to neurons. The ATPase pump within neuron cells is an ATP dependent process which requires oxygen. A lack of 02 causes a failure of this pump...there is an inflow of sodium.
Water follows the sodium according to osmosis. This causes swelling/lysing of cells.
ICP raises in line with swelling/cell death due to ionic dysregulation.
175
You have a stroke patient who is experiencing a siezure. You need to give midazolam to stop the siezure. What is the downside?
1. Midaz reduces the GCS of patients -> this increases patient risk
2. Midazolam does cause some respiratory depression. It effects the central respiratory drive centre (Medullary respiratory centre?)
https: //www.ncbi.nlm.nih.gov/pubmed/7457966
176
Why do we posture patients at 30 degrees in severe head injury?
According to the munro-kelli hypothesis, cranial cavity made up of blood, brain tissue and CSF.
By posturing in this manner, we use gravity to increase venous drainage. This deoxygenated blood exits the cranial cavity more quickly. This reduces the intracranial pressure for these patients.
177
Why should you use tape, rather than string to secure an airway in a patient with raising ICP (severe head injury/ CVA) ?
Because string can impede jugular vein flow...hence lead to a rise in ICP - > not best practice for this reason.
178
What do we need to be cautious with, as it pertains to airways and patients with severe head injury or CVA?
We need to ensure that we do not force an airway device in, if there is significant gag reflex. GCS is crucial to determining what may be appropriate.
GCS 8 = Too high a risk
GCS 5-6 = Good canidate for trying airway management.
Considering NPA is a great option in these situations but consider base of skull fracture. Any gagging whilst inserting, discontinue potentially, and aim to use an NPA instead.
Gagging increases intrathoracic pressure -> this decreases jugular vein drainage -> this increases blood volume in the cranial cavity, and hence increases ICP.
179
Would you give ondansatron prophylactically in a patient with severe head injury / stroke / Siezure?
Typically you would not. Ondansatron is a 5-HT receptor antagonist that blocks seratonin binding to the receptors in the CTZ (chemoreceptor trigger zone - within the medulla). Hence it works on blood born/chemical stimulus....
this is different from other ach (acetyonlcholine) receptors in the other part of the vomiting centre (within the medulla) which is a primary NEUROTRANSMITTER.
For this reason the NEUROLOGICAL nausea pathways are not effected greatly by ondansatron, but it is worth trying if they present due to low degree of risk associated with the medication.
180
When is ICP higher, when standing or lying down?
It is lowest when standing due to venous drainage...think syncope/restoration of perfusion mechanisms in the brain.
Venous drainage is maximised, and hence standing ICP is 2-3 mmHg.
Supine, it is 10 - 155 mmHg.
181
In head injury (severe) how much fluid is given?
We aim for a MAP of 90 mmHg.
182
If a patient with a neurological condition, is breathing slowly..what does this indicate?
It indicates that the brainstem is involved.
183
You approach a patient who is unconcious, you check pupils and they are unresponsive. Breathing is 18 per min at this stage. What is your first action? Why?
A sluggish pupil may be difficult to distinguish from a fixed pupil and may be an early focal sign of an expanding intracranial lesion and increased intracranial pressure.
You should call for BACKUP immediately.
The reason is that this patient has a potential neurological ischaemic head injury. They are likely to become COMBATIVE due to irritated neurons from a lack of 02. THINK about PULLING out your LINE and PULLING off their HUDSON. Nightmare.
An ICP has the ability to SEDATE these partients. Additionally, MEDSTAR has the capability to RSI these patients.
184
Explain what you should expect from examination of pupils? What can it indicate?
Reaction to light
When light is shone into the eye the pupil should contract immediately. The withdrawal of the light should produce an immediate and brisk dilatation of the pupil. This is called the direct light reflex.
Introducing the light into one pupil should cause a similar, simultaneous contraction in the other pupil. When the light is withdrawn from one eye, the opposite pupil should dilate simultaneously. This response is called the consensual light reflex.
- A sluggish pupil may be difficult to distinguish from a fixed pupil and may be an early focal sign of an expanding intracranial lesion and increased intracranial pressure.
- One dilated or fixed pupil may indicate an expanding/developing intracranial lesion, compressing the oculomotor nerve on the same side of the brain as the affected pupil.
- Non-reactive, pinpoint pupils are seen with opiate overdose and pontine haemorrhage;
- The parasympathetic nerve fibres of the third cranial nerve (oculomotor nerve) control constriction of the pupil. Compression of this nerve will result in fixed, dilated pupils;
- Antimuscarinics dilate the pupil. For example, the action of atropine sulphate one per cent (eye drops) lasts for 7-12 days after topical application. The effects of intravenous atropine sulphate on the pupil are dose-related and higher doses dilate the pupil further;
- Non-reactive pupils may also be caused by local damage;
https: //www.nursingtimes.net/clinical-archive/neurology/assessment-of-consciousness-part-one/203405.article
185
When you see a blown pupil it indicates compression and swelling on which side of the brain?
The same side as the affected eye
186
What is the cushings triad? What should this triad prompt in terms of management?
The Triad:
- irregular respiration
- Bradycardia
- Widened pulse pressure.
This should prompt you to HYPERVENTILATE the patient as a last ditch effort at survival.
187
Why do we sometimes hyperventilate patients at risk of coning (cushings triad)?
We are aiming to induce hypocapnia. Hypocapnia causes cerebral vasoconstriction.
In the context of ICP so high, that it would cause coning...this reduced cerebral blood volume would lower ICP.
188
Why is mannitol used in severe head injury?
If a patient has high ICP, they aim to lower blood volume in the cranial vault to lower ICP.
Despite its widespread use and proven effectiveness in lowering ICP, the mechanism by which mannitol produces its effect on brain volume and ICP remain poorly understood. Two potential explanations have been proposed.
1. One theory argues that mannitol lowers ICP by reducing cerebral blood volume (CBV), either by raising blood pressure 1 or by reducing blood viscosity, which induces a reflex of cerbral vasoconstriction
2. The second theory contends that mannitol acts by directly reducing brain water (it is a diuretic). The effect of osmotic agents on CBV has never been assessed in humans.
189
What can medstar offer to help with raising ICP?
1. RSI for combative / hypoxaemic patients
2. Mannitol
3. Ventilators (extremely good apparently, much better than manual).
190
What is a sign of a good airway
1. NO SNORING
2. Good rise and fall
3. No resistance to bagging
191
What is a key goal of treatment in optiate induced hypoventilation?
We want to have patients MAINTAINING their own airway and restablish a gag reflex.
HOWEVER,
If they could remain unconscious that is also ideal. We want them saturating well, good rise and fall.
192
What are the two effects of opiates?
1. Respiratory depression
| 2. CNS DEPRESSION!!!
193
What should you consider regarding half life as it pertains to giving naloxone to an opiate overdose?
How long does naloxone last for?
The half life of naloxone is much shorter than that of opiates such as heroin. If you leave these patients, they can have a relapse of opiate effect.
Naloxone has an effect between 60 and 90 minutes.
194
What is the preferred method of administration for Naloxone?
IV
195
How much naloxone do we give to pedes?
400 mcg IM - We do not go IV in PEDES.
This 400 mcg IM is what is listed in the drug card, which supersedes whatever it written in the CPG
196
If any patient has obs in two purple boxes, what should you do?
This means an immediate call for backup.
197
What is the SAAS standard dilution for preparing naloxone?
Comes in: 400 mcg in 1 ml.
Add 3 ml of saline in a 5 ml syringe.
Makes 100 mg per ml.
198
What amount should be you first dose of naloxone in an unconcious patient?
You should always start with 100 micrograms IV. You can titrate following that to response.
199
How long does it take for naloxone to exert an effect?
2-5 minutes.
200
What is the maximum naloxone dose for a pede?
1600 microg.
201
In pedes do we treat them differently than adults for opiate overdoses?
Yes. We aim for full reversal.
202
What are the needed criteria for code stroke?
1. We can get to hospital, within a 4 hour timeframe from onset of symptoms.
2. Pt. who are not 'pre-morbid level of independent functioning'.
3. Travel time to nearest stroke centre is less than 60 minutes.
203
What are the hours for stroke at the stroke centres?
Lyall Mac - 8am to 8pm
Flinders- 8am to 8pm
RAH - All times
204
In a patient with stroke or STEMI...what sats would prompt oxygen?
< 94%
205
What is the most crucial thing to remember regarding prerequisites of ROSIER?
You NEED to have a BGL. Rosier score is valueless without it.
206
What is a clinical expectation regarding mental health patients?
A full set of obs, to rule out a physiological cause.
207
What is a depo?
A depo is basically a forced administration of drugs to a mental health patient. Sometimes SAPOL may call use to administer a depo.
208
What is a transfer request, as it pertains to mental health?
Another qualified health professional ,identifies a need for mental health treatment and calls us. We can still transport, sedate and restrain. However, no care and control is used as it is under anothers authority.
This type of transfer is called an 'ITO' (inpatient treatment order).
209
What does SAT score stand for?
SEDATION assessment tool~!
210
When handing over a care and control patient, what is the first step?
Note the time of care and control transfer of care. Document this.
211
What SAT score would indicate the potential need for sedation?
-1
+ 1
212
What is a crucial procedure and step associated with netting patients?
They all need to be SLS'd.
213
What are the contraindications for lorazapam?
1. COPD
2. Sleep apnea
3. 1st trimester - Pregnant
4. kids <16 of age.
5. Intoxicated
214
What can ICPs offer in regards to acute behavioural emergencies?
The have droperadol as well as midaz for sedation.
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