Rosen's 10th > Resuscitation > Flashcards

Resuscitation Flashcards

(146 cards)

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1
Q

List 3 critical criteria for the decision to intubate

A

1) failure to maintain or protect the airway
2) failure of ventilation or oxygenation
3) patient’s anticipated clinical course and likelihood of deterioration

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2
Q

List 4 repositioning measures to open an airway

A

Reposition head/body
Chin lift
Jaw thrust
Insert NPA or OPA

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3
Q

List 4 techniques that should be assessed for potential success in respect to a pt’s airway and oxygenation/ventilation

A

BVM
Laryngoscopy + Intubation
Placement of SGD
Cricothyroidotomy

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4
Q

Outline Cormack Lehane glottic grading scale

A

1 = Full view of glottis

2 = Partial view of glottis or arytenoids

3 = Only epiglottis visible

4 = Neither glottis or epiglottis visible

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5
Q

Outline LEMON for Evaluation of Difficult Direct Laryngoscopy

A

Look externally (by gestalt)

Evaluate 3-3-2 rule

Mallampati scale

Obstruction or obesity

Neck mobility

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6
Q

Outline Mallampati Score

A
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7
Q

Outline ROMAN for Evaluation of Difficult Bag-Mask Ventilation

A

Radiation or Resistance to ventilation

Obstruction, Obesity & Obstructive sleep apnea

Mallampati, Male, Mask seal

Aged

No teeth

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8
Q

Outline RODS for Evaluation of Difficult Extraglottic Device Placement

A

Restricted mouth opening or Resistance to ventilation

Obstruction, Obesity, or Obstructive sleep apnea

Distorted anatomy

Short thyromental distance

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9
Q

Outline SMART for Evaluation of Difficult Cricothyrotomy

A

Surgery, Scarring

Mass (abscess, hematoma)

Access/Anatomy (obesity, edema)

Radiation

Tumour

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10
Q

List 8 ways to confirm ETT placement

A

End tidal CO2 monitor

Colourimetric CO2 detector

Ultrasound at cricoid membrane

Bougie

Bilateral air entry

Direct visualization through the cords

CXR

Fiberoptic scope

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11
Q

What defines a failed airway?

A

Failure to maintain oxygenation

Failure to BVM

> 3 attempts by experienced operator

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12
Q

In a potentially difficult airway, when are neuromuscular blocking agents ‘safe’ to use?

A

1) intubation is likely to be successful

2) oxygenation can be maintained via BMV or EGD should pt desaturate during intubation attempt

3) pt will not experience cardiovascular catastrophe or arrest from precipitous desaturation or hemodynamic collapse following administration of RSI medications

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13
Q

List 7 Ps of RSI

A
  1. Preparation
  2. Preoxygenation
  3. Preintubation optimization
  4. Paralysis with induction
  5. Positioning
  6. Placement of tube
  7. Postintubation management
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14
Q

List 4 pts that have shorter time to desaturation during apnea

A

Children
Obese adults
Late term pregnant pts
Acutely ill/injured

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15
Q

List potential awake oral intubation medication strategies

A

Topical anesthetic to posterior oropharynx

Ketamine 0.25-0.5mg/kg IV q10min
- titrate to desired level of sedation and procedural tolerance

or

Dexmedetomidine 1.0mg/kg IV over 5-10min
+/- Benzo

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16
Q

Describe action of succinylcholine

A

Depolarizing agent

Binds noncompetitively w/ ACh receptor on motor end plate, causing sustained depolarization of myocyte

45s to apnea
Lasts 6-10mins

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17
Q

Outline dosing of succinylcholine

A

1.5mg/kg IV

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18
Q

List 5 Conditions Associated With Hyperkalemia After Succinylcholine Administration

A

Burns >10% TBSA

Crush Injury

Denervation (CVA, SCI)

NeuroMuscular Dz (ALS, MS, MD)

Intraabdominal Sepsis

  • if succ given >5d after onset/time of injury
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19
Q

Describe action of rocuronium

A

Non-depolarizing agent

bind competitively to ACh receptors, preventing access by ACh and preventing muscular activity

60s to apnea
Lasts 45min

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20
Q

Outline dosing of rocuronium

A

1.2mg/kg IV

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21
Q

Outline induction dosing of etomidate

A

0.3mg/kg IV

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22
Q

List 4 potential benefits of using etomidate

A

Decrease ICP

Decrease Cerebral blood flow

Decrease cerebral metabolic rate

No adverse change to MAP or CPP

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23
Q

Outline induction dosing of ketamine

A

1.5mg/kg IV

Loss of awareness 30s
Peak 1min
Lasts 10-15min

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24
Q

Outline induction dosing of propofol

A

1.5mg/kg IV

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25
Outline induction dosing of midazolam
0.2-0.3mg/kg IV
26
List 2 situations where the reflex sympathetic response to laryngoscopy may be dangerous
1) Acute elevation of ICP 2) Hypertensive emergencies - ICH - SAH - Aortic dissection - Ischemic heart dz
27
Outline 1 med strategy for blunting the reflex sympathetic response to laryngoscopy, in cases of elevated ICP
3min before induction agents given, give Fentanyl 3mcg/kg IV over 60sec
28
List 6 possible causes of elevated ventilation pressures
- ventilator circuit obstruction - bronchospasm - mainstem intubation - tension PNA or HTX - decreased chest wall compliance - increased chest wall rigidity
29
List 5 possible causes of low ventilation pressures (& hypoxia)
- ventilator circuit leak - faulty vent connection - ETT cuff leak - accidental extubation - esophageal intubation
30
Outline Pressure-Controlled Ventilation (PC)
Set: - Pressure target - Inspiratory time - RR - PEEP Variable: - Vt - Inspiratory flow rate
31
List 3 clinical conditions to use PC ventilation
Severe Asthma Severe COPD Salicylate toxicity
32
Outline Volume-Controlled Ventilation (VC)
Set: - Vt - RR - Inspiratory flow pattern - Inspiratory time Variable: - PIP - End-inspiratory alveolar pressure
33
List 3 clinical conditions to use VC ventilation
ARDS Obesity Severe burns
34
List 2 examples of mechanical ventilation control variable
VC PC
35
List 5 examples of ventilator modes
AC (-VC or -AC) SIMV PSV CPAP BiPAP
36
List 3 benefits of PEEP in acute respiratory failure
- Increase FRC - Improves oxygenation - Decreases intrapulmonary shunting by preventing alveolar collapse
37
List 6 benefits of HFNC
1) High flow rates match pts’ inspiratory flow & volume demands - more inspired gas comes from device than ambient air increasing FiO2 2) High flow washes out anatomic dead space & replaces it with O2 3) FiO2 & flow rate can be titrated independently 4) Delivers small amt of PEEP (1-3 cm H2O) 5) Gas is humidified + heated, makes high flow rate more tolerable 6) Large nasal prongs occlude entire nares, reducing entrainment of ambient air during closed-mouth breathing
38
List 6 contraindications to HFNC
Non-patent upper airway Significant hypercarbic resp failure Depressed mental status Facial injury Inability to manage secretions Respiratory arrest
39
List 6 contraindications to NIPPV
Decreased LoC Lack of respiratory drive Increased secretions Hemodynamic instability Facial trauma Vomiting/Aspiration risk
40
List 5 benefits of NIPPV in acute cardiogenic pulmonary edema (ACPE)
Reduces WOB Improves cardiac output Decrease LV ejection pressure Decrease LV transmural pressure Reduces afterload *Possibly prevent intubation
41
Outline ROX index score for HFNC success/prediction of failure
(SpO2/FiO2) : RR <3.85 = high risk failure of HFNC, needing ETT >4.88 = lower risk of needing ETT Measure at 2, 6, 12hr after initiation
42
Define PIP
= Peak inspiratory pressure - maximum amount of pressure in the ventilator circuit during a breath cycle
43
Define Plateau Pressure
"maximal" alveolar pressure at the end of inspiration, by means of inspiratory hold
44
Outline 5 clinical features of propofol infusion syndrome
Metabolic acidosis Rhabdomyolysis Renal injury Liver injury CV collapse
45
List Potential Causes of Acute Respiratory Distress in Ventilated Pts, in presence or absence of hemodynamic compromise
W/ Hemodynamic Compromise = Immediately change to Manually Bag w/ 100% O2: - Increased intrinsic positive end-expiratory pressure (iPEEP) - Tension pneumothorax - Massive pulmonary embolus Without Hemodynamic Compromise = Search for Underlying Cause: - ETT migration into bronchus - Worsening lung compliance - ETT obstruction - Worsening airway obstruction - ETT cuff leak - Abdominal distention - Inadvertent extubation - Pulmonary embolus - Discontinuity in ventilator circuit - Pain or inadequate sedation
45
List 2 blood gas findings suggestive of shock
Base deficit > -4 Serum lactate > +4
45
Outline normal urine output, and U/O indicative of severe renal hypoperfusion
1.0mL/kg/hr <0.5mL/kg/hr
46
List 3 ideal ventilator settings in ARDS
PaO2/FiO2 <300 Vt <6cc/kg Pplat <30cm H2O
47
List 6 strategies to reduce rates of Ventilator Associated PNA
- HOB >30deg - Daily sedation vacation - Assessments of extubation readiness - PUD ppx - Oral decontamination - Gastrointestinal decompression
48
List 2 types/causes of shock that require tx w/ infusion of volume
1) Hemorrhagic shock - Traumatic - Gastrointestinal - Body cavity 2) Hypovolemia - Gastrointestinal losses - Dehydration from insensible losses - Third-space sequestration from inflammation
49
List 4 types/causes of shock that require tx w/ Volume Infusion + Vasopressor Support
Septic shock Anaphylactic shock Central neurogenic shock Drug overdose
50
List 6 types/causes of shock 2/2 impaired pump function, that require tx w/ inotropes or reversal of pump dysfnc
1) Myocardial ischemia - Coronary artery thrombosis - Arterial hypotension w/ hypoxemia 2) Cardiomyopathy - Acute myocarditis - Chronic diseases of heart muscle (ischemic, diabetic, infiltrative, endocrinologic, congenital) 3) Cardiac rhythm disturbances - AFib w/ RVR - VTach - SVT 4) Septic shock with myocardial failure (hypodynamic shock) 5) Overdose of negative inotropic drug - BB - CCB 6) Structural cardiac damage - Traumatic (e.g., flail mitral valve) - Ventriculoseptal rupture - Papillary muscle rupture
51
List 6 types/causes of shock that require Immediate Relief from Obstruction to Cardiac Output
1) Pulmonary embolism 2) Cardiac tamponade 3) Tension PTX 4) Valvular dysfunction - Acute thrombosis of prosthetic valve - Critical aortic stenosis 5) Congenital heart defects in newborn (closure of PDA, w/ critical aortic coarctation) 6) Critical idiopathic subaortic stenosis (HOCM)
52
List 4 types/causes of shock that require tx w/ Specific Antidotes Due to Cellular or Mitochondrial Poisons
Carbon monoxide Methemoglobinemia Hydrogen sulfide Cyanide
53
List biochemical findings in pts with significant traumatic hemorrhage (otherwise healthy)
Arterial lactate >4.0 PaCO2 <35 Mild hyperglycemia Mild hypoK (3.5-3.7)
54
List 3 primary effects of septic shock
1) Hypovolemia 2) CV depression 3) Induction of systemic inflammation
55
List 6 Empirical Criteria for Diagnosis of Shock
1) Ill appearance or altered mental status 2) Arterial hTN >30min duration, continuous 3) HR >100 4) RR >20 or PaCO2 <32 mmHg 5) Arterial base deficit < −4 mEq/L or Lactate >4 mM/L 6) U/O <0.5 mL/kg/h
56
Outline the Sequential Organ Failure Assessment (SOFA) Score
New 2+ or Increase of 2+ = Likely Sepsis
57
Define Septic Shock
Sepsis + req'ing Vasopressors & Lactate >2
58
List 9 Variables Indicating Tissue Hypoperfusion
Hypotension Tachycardia Low cardiac output Dusky or mottled skin Delayed capillary refill Altered mental state Low urine output Low central venous oxygen saturation Elevated lactate level
59
Outline 6 basic mgmt steps in Hemorrhagic Shock
Ensure adequate ventilation & oxygenation Immediate hemorrhage control (when possible) = traction for long bone #s, direct pressure, REBOA) + Obtain urgent consultation for uncontrollable hemorrhage Initiate isotonic crystalloid bolus (10–20 mL/kg) If evidence of poor organ perfusion & 30-min anticipated delay to hemorrhage control, begin pRBC infusion (5–10 mL/kg) In massive hemorrhage, immediate pRBCs w/ balanced transfusions of pRBCs, FFP, and PLTs Treat coincident dysrhythmias
60
Outline 4 basic mgmt steps in Cardiogenic Shock
Address inc WOB - provide O2 + PEEP for pulmonary edema Vasopressor or Inotropic support = NE +/- Dobutamine Reverse any insult (thrombolysis, PCI) Consider intraaortic balloon pump (IABP) for refractory shock
61
Outline 5 'strong recommendation' mgmt steps in Septic Shock
Obtain blood & other cx prior to ABX Begin ABX tx w/in 1hr Use broad spectrum ABX initially Crystalloid fluid resuscitation (over colloid), titrate to DYNAMIC indices, volume responsiveness, urine output Target MAP =/>65, if IVF fails to improve organ perfusion, begin vasopressors ---------------------------- Ensure adequate oxygenation - remove WOB Attempt surgical drainage or debridement Give pRBC if HGB <70
62
Define equation for Cerebral Perfusion Pressure
CPP = MAP - ICP
63
Outline guideline recommended time for neuroprognostication after cardiac arrest
at least 72hr
64
List 4 sedation medications for ICP mgmt after brain injury
Fentanyl Propofol Dexmedetomidine Phenobarbital
65
List medications for rapid reversal of ICP or cerebral herniation syndromes
Mannitol 1g/kg IV q6h - up to Serum Osm 320 23.4% NS 30mL IV q6h - up to Na 160 3% NS @ 50mL/hr or 100cc IV
66
In post-cardiac arrest seizures, outline tx
Lorazepam 4mg IV (0.1mg/kg IV) Then: Fosphenytoin 20 PE/kg IV (max 1500) or Keppra 60mg/kg IV (max 4500) or VPA 40mg/kg IV (max 3000)
67
Outline SBP and MAP goals post-ROSC
SBP >90 MAP >65
68
Outline safest PaCO2 and PaO2 after brain injury
PaCO2 btwn 35-40 PaO2 btwn 80-120 OxyHGB sat % in high 90s, with lowest FiO2 possible
69
List 3 CT brain findings of increased ICP
- compressed basal cisterns - diffuse sulcal effacement - diffuse loss of differentiation btwn gray & white matter
70
Outline CPP goal during ICP monitoring
CPP @ 60mmHg
71
Outline 7 steps of Medical Tx of Elevated ICP
1. HOB >30deg 2. Maintain neutral head & neck position to avoid jugular venous compression 3. Treat fever, target T<37degC PRN antipyretic agents, mist and surface cooling 4. Minimize triggers of ICP increases - Minimize frequent turning & suctioning. - Limit laying flat - Use analgesia and sedation 5. Initiate osmolar therapy 6. CSF drainage via ventriculostomy - monitor when clamped - drain when unclamped 7. Treat refractory ICP elevation through more aggressive interventions: - Continuous phenobarbital inf, titrated deep levels of EEG burst suppression - Mild induced hypothermia in highly refractory cases = target temp 32-36degC
72
List 2 options of Surgical Tx of Elevated ICP
- Decompressive craniectomy - Evacuation of intracranial hematoma
73
List 5 outcomes of elevated body temp in post-brain injury
Increased cerebral metabolic demand Escalates glutamate release Increase oxygen free radial production Increased cytoskeletal & BBB breakdown Increased vasogenic edema
74
List 2 early exam findings predictive of poor neurologic outcome post-ROSC
Absence of pupillary and corneal reflexes
75
List 4 clinical exam findings suggestive of poor neuro prognosis @ 72hrs post-ROSC
- absent corneal reflexes - absent reactivity or burst-suppression pattern on EEG - myoclonic status epilepticus - diffuse anoxic injury on CT or MRI
76
List 6 features of high quality CPR
Compression rate 100-120bpm Compression depth 5cm Compression fraction at least 80% Full chest recoil btwn compressions Ventilation q6secs (10 breath/min) Switch compressors q2min
77
List 12 Common Causes of Non-Traumatic Cardiac Arrest (Expansion of H&T)
CARDIAC - CAD - Cardiomyopathies - Structural abnormalities - Valve dysfunction RESPIRATORY Hypoventilation: - CNS dysfunction - Neuromuscular disease - Toxic and Metabolic encephalopathies Upper airway obstruction: - CNS dysfunction - Foreign body - Infection - Trauma - Neoplasm Pulmonary dysfunction - Asthma - COPD - Pulmonary edema - PNA - PE CIRCULATORY Mechanical obstruction: - Tension PTX - Pericardial tamponade - PE Hypovolemia: - Hemorrhage Vascular tone: - Sepsis - Neurogenic METABOLIC - HypoK - HyperK - HyperMg - HypoMg - HypoCa TOXIC - Digoxin - BBs - CCBs - TCAs - Cocaine - Opioids - Carbon monoxide - Cyanide ENVIRONMENTAL - Lightning - Electrocution - Hypothermia - Hyperthermia - Drowning or near-drowning - Asphyxiation
78
List cardiac syndromes associated w/ sudden cardiac death related to ventricular dysrhythmias
- hypertrophic cardiomyopathy - Brugada syndrome - long QT syndrome - short QT syndrome - catecholaminergic polymorphic ventricular tachycardia - arrhythmogenic right ventricular cardiomyopathy (ARVC)
79
List 7 causes of pseudo-EMD (electromechanical dissociation)
- Primary SVT - Hypovolemia - Tension PTX - Pericardial tamponade - Massive PE - Papillary muscle rupture - Myocardial wall rupture
80
List 5 Indicators of Inadequate Blood Flow During CPR
Carotid/Femoral pulse not palpable Coronary perfusion pressure <15 mmHg Arterial relaxation (diastolic) pressure <20–25 mm Hg PET CO2 <10mmHg ScvO2 <40%
81
List 6 common complications of being on extracorporeal CPR (ECMO)
- Coagulopathy - Hemorrhage - Limb ischemia - Vascular injury - Renal replacement therapy - Stroke
82
List one relative exclusion criteria for fibrinolytic therapy unique to the post–cardiac arrest patient
Evidence of significant CPR trauma such as: - pneumothorax - flail chest - pulmonary contusion w/ hemorrhage
83
List 6 post-ROSC goals
MAP 70-100 CVP 10-15 HGB >70 Lactate <2.0 Temp 32-36/37 Sat O2 94-98%
84
Define allodynia
pain from a stimulus that does not normally provoke pain
85
Define pain
unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage
86
Define Nociceptive pain
results from the activation of sensory neurons that signal pain (nociceptors) in response to noxious stimuli
87
Define Neuropathic pain
results from signal-processing changes in the central nervous system (CNS)
88
List 4 separate processes of pain
pain detection pain transmission pain modulation pain expression (perception)
89
List 3 predominant pathways/tracts for pain conduction thru spinal cord
spinothalamic spinomesencephalic spinoreticular - all in anterolateral aspect of spinal cord
90
Outline 10 Reflex Responses to Pain
1) Increased Sympathetic Tone - Vasoconstriction - Inc CO 2/2 from inc SV x HR - Inc BP - Increased metabolic rate and oxygen consumption - Decreased gastric tone and gastric emptying (may get ileus) - Decreased urinary tract tone (may get retention) 2) Endocrine Responses - Decreased insulin production - Increased cortisol levels - Increased ADH levels - Increased growth hormone levels - Increased renin, angiotensin II, aldosterone levels - Increased glucagon levels - Increased catecholamine levels 3) Respiratory Responses - Hyperventilation 4) Cortical Responses - Anxiety - Fear
91
Contrast Acute vs Chronic Pain, as they relate to inciting factor, relation to healing, psychosocial effects, and treatment
92
List 5 Common Outpatient PO Analgesics to use in Acute Pain
1. Acetaminophen 2. NSAIDs 3. Opioids used in combo w/ NSAIDs + Acetaminophen 4. Oxycodone 5. Hydrocodone
93
List 5 Common Outpatient PO Analgesics to use in Chronic Non-Cancer Pain
1. NSAIDs 2. Tramadol 3. Opioids used in combo w/ NSAIDs + Acetaminophen 4. Oxycodone, long-acting preparation, or for breakthrough pain 5. TCAs
94
List 3 Common Outpatient Analgesics to use in Neuropathic Pain
1. Gabapentin 2. TCAs 3. Carbamazepine
95
List 9 side effects of opioids
Constipation Nausea Vomiting Histaminergic reaction (mild pruritis) Sedation Respiratory depression Tolerance Physical dependence Addiction
96
List 9 Behaviours Typically Specific to Addiction
Injecting oral formulations Concurrent abuse of alcohol or illicit drugs Selling or diversion of prescription drugs Prescription forgery Obtaining drugs from nonmedicinal sources Repeated dose escalation Repeated visits to other EDs without informing prescriber Drug-related deterioration in function at work or socially Repeated resistance to changes in therapy, despite evidence of adverse drug effects
97
List 7 Disadvantages of IM Opioid Administration
Pain on injection Delayed onset of action Inability to predict therapeutic effect Inability to titrate dosage Diurnal variation in level achieved Disease state may affect level achieved Level dependent on intramuscular injection site
98
List 5 additional risk factors for GI mucosal injury in pts taking NSAIDs
Age Concomitant use of warfarin or steroids CHF DM CAD
99
List NSAIDs in order of lowest to highest relative risk of causing serious GI effects
Ibuprofen Diclofenac Naproxen Indomethacin Ketorolac
100
List 2 meds that can reduce risk of GIB when taking NSAIDs
PPI Misoprostal
101
List 5 common meds that have interactions with NSAIDs
ASA Oral AC ACEi Diuretics Steroids Lithium Nonselective COX inhibitors
102
List 6 Patients at Risk for Adverse Events during NSAID Therapy
1. Patients with dehydration, hypovolemia, impaired renal function = further renal injury 2. Patients with liver disease or CHF, & taking ACEi, ARBs, or diuretics = further cardiac or liver fnc damage 3. Older patients = enhanced risk for GI & renal events 4. Patients with asthma and known ASA hypersensitivity = increased risk of bronchospasm 5. Pregnant in 3rd trimester = NSAIDs may prolong gestation or prematurely close PDA 6. Patients who use tobacco or EtOH with hx of gastritis or PUD = increased risk for peptic ulcer or GIB
103
If pts have true allergy to all local anesthetics, what can be used?
Diphenhydramine (benadryl) w/ 1mL of 50mg/mL diluted in 5-10mL of NS = 0.5-1% solution
104
Outline safe/maximum doses of local anesthetics
W/OUT Epinephrine - Lidocaine 3-5mg/kg - Bupivicaine 1.5mg/kg W/ Epinephrine - Lidocaine 7mg/kg - Bupivicaine 3mg/kg
105
What is one risk associated with benzocaine?
Methemoglobinemia
106
List clinical features of LAST
- lightheadedness - headache - tinnitus - circumoral paresthesias - dysarthria - muscle spasm - confusion - seizures - coma
107
Outline tx of LAST
- IV benzos for seizures - follow ACLS - Intralipid infusion
108
List 6 Techniques to Reduce the Pain of Local Anesthetic Injection
Buffering of local anesthetic agents Counterirritation Slower rate of injection Use of topical anesthetics Warming of solution Distraction techniques
109
Outline example of buffering lidocaine
standard solution of sodium bicarbonate (8.4% in 50 mL) can be added to a syringe containing lidocaine in a ratio of 1:10 = 1 mL bicarbonate to 10 mL lidocaine, or 0.5 mL to 5 mL
110
List 2 topical anesthetics applied to INTACT skin
EMLA cream - apply 30-60min before Ethyl chloride and fluoromethane sprays - <1min duration
111
List 4 topical anesthetics applied to mucosal membranes
Cocaine - nasal, eye Lidocaine - nasal, oral Tetracaine - ophthalmic Benzocaine - oral
112
Name topical anesthetic applied to open skin
LET gel = lidocaine, epinephrine, and tetracaine - place for 10-20mins
113
Define Anxiolysis
state of decreased apprehension concerning a particular situation in which the patient’s level of awareness does not change
114
Define Analgesia
relief of pain without the intentional alteration of mental status, such as occurs in sedation *An altered mental state may be a secondary effect of the medications administered for this purpose.
115
Define Dissociation
trancelike cataleptic state induced by an agent such as ketamine and characterized by analgesia and amnesia. Protective reflexes, spontaneous respirations, and cardiopulmonary stability are retained. Sedation is a controlled reduction of environmental awareness.
116
Describe minimal sedation
- drug-induced state during which patients respond normally to verbal commands - ventilatory and cardiovascular functions are unaffected
117
Describe Moderate sedation and analgesia
"Conscious sedation" - drug-induced depression of consciousness during which patients respond purposefully to verbal commands, auditory only or accompanied by light tactile stimulation - resp and cardiac fnc intact
118
Describe Dissociative sedation
trancelike cataleptic state induced by the dissociative agent ketamine; it is characterized by analgesia and amnesia while protective airway reflexes, spontaneous respirations, and cardiopulmonary stability are maintained.
119
Describe Deep sedation and analgesia
- drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation - CV fnc normal - may need help with airway/ventilation
120
Describe General anesthesia
drug-induced loss of consciousness during which patients are not arousable, even with painful stimulation. The ability to maintain ventilatory function independently is impaired. Patients typically require assistance in maintaining a patent airway, and positive-pressure ventilation is required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
121
Outline ASA Physical Status Classification
122
List Equipment Needed for Procedural Sedation and Analgesia (12)
High-flow O2 source Suction Airway management equipment Monitoring equipment - Pulse oximeter - ECG monitor, defibrillator, transcutaneous pacemaker - Blood pressure monitor - Capnography Vascular access equipment Reversal agents Resuscitation drugs Adequate staff
123
List 5 sedating medications for use in procedural sedation/analgesia
Midazolam 0.05mg/kg Ketamine 1-2mg/kg Etomidate 0.1mg/kg Propofol 1-2mg/kg Dexmedetomidine 0.5–1 mcg/kg over 10 min, then 0.2–1 mcg/kg/hr
124
List 4 amnestic medications for use in procedural sedation/analgesia
Midazolam 0.05mg/kg Ketamine 1-2mg/kg Etomidate 0.1mg/kg Propofol 1-2mg/kg
125
List 3 analgesic medications for use in procedural sedation/analgesia
Fentanyl 1mcg/kg Morphine 0.1mg/kg Ketamine 0.1-0.3mg/kg
126
List benefits and risks of fentanyl
Rapid onset Short duration ↓︎Histamine release Minimal CV effects Respiratory depression Rigid chest syndrome
127
List benefits and risks of morphine
Longer lasting Hypotension Respiratory depression
128
List benefits and risks of midazolam
Rapid onset Easy to titrate Multiple routes Respiratory depression
129
List benefits and risks of ketamine
Airway reflexes maintained No resp depression Predictable Emergence phenomenon Emesis Laryngospasm Inc ICP (maybe) Inc IOP Hypertension Tachycardia
130
List benefits and risks of etomidate
Rapid onset Short duration Minimal CV effects Cerebroprotective Resp depression Myoclonus Adrenal suppression
131
List benefits and risks of propofol
Rapid onset Short duration Antiemetic Cerebroprotective Resp depression Hypotension Injection pain
132
List benefits and risks of 'ketofol'
Rapid onset Reduction in repeat dosing Reduction in emesis Recovery agitation Resp depression Increased HR
133
List benefits and risks of dexmedetomidine
Short duration Minimal ventilatory effects Bradycardia Hypotension
134
Outline safe use of naloxone
* competitive antagonist of opioids - rapid onset - clinical effects for 15-30min - should be monitored for minimum 1hr after administration - give via IN, IM, IV - start w/ 0.2mg q1-2min
135
Outline safe use of flumazenil
* competitive antagonist of benzodiazepines - reverses sedation effect of benzos, but not as effective for reversing respiratory depression - rapid onset in 1-2min - can last 30-90min - start w/ 0.2mg q1-2min - max dose 1mg adult, 0.2mg peds - NOT for pts w/ benzodiazepine dependence or a history of seizures
136
List examples of Non-Painful procedures & recommended meds
Radiologic imaging - midazolam IV - propofol IV
137
List examples of Low pain, High anxiety procedures & recommended meds
Laceration repair Central line placement Lumbar puncture - midazolam IV - propofol IV - ketamine IV
138
List examples of High pain, High anxiety procedures & recommended meds
Fracture/Joint reduction Abscess drainage Burn debridement Cardioversion Chest tube placement - Midaz + Fentanyl - Prop + Fent - Ketamine - Etomidate + Fent - Ketofol
139
List 6 complications of double-lumen endotracheal tubes (for lung isolation)
Unilateral PTX Bilateral PTX Pneumomediastinum Carinal rupture Lobar collapse Tube malposition
140
List criteria for Termination of Resuscitation by BLS or ALS providers
BLS: 1) Arrest unwitnessed by providers 2) No ROSC in field 3) No AED shocks delivered ALS: 1) Arrest unwitnessed by bystander 2) No bystander CPR 3) Arrest unwitnessed by providers 4) No ROSC in field 5) No AED shocks delivered If ANY of the above absent, transport to ED
141
List 3 elements of the qSOFA score
GCS <15 RR =/> 22 SBP
142
List 4 causes of false negative etCO2 readings after intubation
Equipment malfunction Low cardiac output states Severe bronchospasm Absence of ventilation Large alveolar dead space Displacement of ETT against lateral wall
143
List 3 causes of false positive etCO2 readings after intubation
Elevated early after Esophageal intubation Esophageal intubation w/ stomach full of previously consumed carbonated beverage Detection of high levels of other gases (NO gas in an OR) NOTE: Esophageal stomach acid may change the colourimetry CO2 detector PERMANENTLY, but would have decreasing values on monitor
144
List 3 indications to withhold CPR, excluding DNR and unsafe conditions
Obvious irreversible death (Rigor mortis, Decapitation) Traumatic arrest with no signs of life Injuries that would be unlikely to be survivable, like 100% burns ROSC achieved Newborn infant with no detectable HR for >10mins
Rosen's 10th
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