ACLS, Airway Management, imaging (MIDI MOD 2)

what is the first priority in the initial patient assessment?

"the talking patient" - stimulate a verbal response, reassurance that airway is patent & ventilation is adequate

what are the signs of complete airway obstruction?

lack of audible air movement (silence), cyanosis, rapid progression to unconsciousness, "universal sign of choking"

identify some differences between adult and pediatric airways

adult cricoid cartilage is at C6 vs child at C4, so cricothyroidectomy is contraindicated in < 10 y/o

adults have higher functional residual capacity, children go through quick decompensation, children have floppy epiglottis

what is included in the GCS?

eye opening response, verbal response, motor response

GCS < 8 indicates severe brain injury & requires intubation

what must be intact for accurate pulse ox? what type of conditions is this most relevant in?

peripheral perfusion must be intact - careful in hypotensive & hypothermic patients where pulse ox could be wrong

nasal cannula - flow rate & O2 %

1-6 lpm

24-44% oxygen

high flow nasal cannula - flow rate & O2

capable of 60 lpm, 21-100% O2

provides PEEP

PEEP

maintaining positive pressure at airway opening at end of expiration allows alveoli to remain open during respiration, useful for treating patients with alveolar collapse (Gets rid of dead space)

simple O2 face mask - flow rate & O2%

6-10 lpm

40-60% O2 delivery

venturi face mask

VARIED flow rates of 2-15 lpm at 24-60% O2 delivery, frequent use in pt with chronic lung disease

partial rebreather mask

face mask + reservoir bag w/ two way valve

60-80% O2 at 10-15 lpm

non-rebreather face mask

face mask + reservoir bag with one way valve

high flow O2 at 10-15 lpm at almost 100% O2 concentration

not currently recommended

acute oxygen toxicity

presents with CNS "bert effect," increased risk with higher pressures

s/s h/a, AMS, visual changes, nausea, seizure activity

chronic oxygen toxicity

presents with pulmonary "smith effect," causes alveolar collapse

s/s pleuritic chest pain, coughing, dyspnea, hemoptysis, pulmonary edema

100% O2 is usually well-tolerated for _____ hours

24-48

what condition prevents use of head tilt chin lift?

cervical spine injury

which airway maintenance technique can be used with c-spine injury?

jaw thrust maneuver

duration of suctioning should be no more than _____ unless there is airway compromise

15 s

nasopharyngeal airway

recommended for semi-conscious or unconscious patients with INTACT gag reflex (ex postictal seizure pt, drug overdose), contraindicated in pt with facial trauma or basilar skull fracture

how do you select nasopharyngeal airway size?

measure from tip of nose to earlobe

oropharyngeal airway

used in unconscious patients WITHOUT gag reflex, inserted in mouth and lies behind tongue to displace tongue anteriorly to prevent obstruction of airway

laryngeal mask airway (LMA)

not a definitive airway, frequently used in out-patient surgeries, good "RESCUE" device for difficult airways

blindly inserted into hypopharynx, reduces gastric distention, NOT used in conscious pt or w/ gag reflex

king airway

rescue airway for prehospital providers, not considered definitive airway, must be removed prior to intubation attempts

combitube

blind insertion airway device, used as prehospital rescue device for failed intubation, double lumen device, have to determine where it is anatomically located

definitive airway options

endotracheal intubation (orotracheal, nasotracheal) or surgical airway (tracheostomy, cricothyroidotomy) (temporary)

criteria for establishing definitive airway (4)

inability to maintain patent airway, inability to maintain adequate oxygenation, AMS resulting in cerebral hypoperfusion, AMS in presence of head injury (consider GCS < 8)

describe cricoid pressure performed during intubation

sellick maneuver / BURP: back, upward, rightward pressure to reduce the risk of aspiration and help to visualize the vocal cords by moving them posteriorly

needle cricothyroidotomy

emergent airway to provide oxygen on short term basis, insertion of large bore needle through cricothyroid membrane, contraindicated in < 10 y/o

tracheostomy

can be permanent, a formalized procedure that is difficult to perform quickly, can be done percutaneous or open

describe the systematic approach to ACLS

1. BLS assessment (responsiveness, breathing & pulse, defib)

2. primary assessment (ABCs, disability, exposure)

3. secondary assessment (SAMPLE, H's & T's)

what are 4 important parameters in determining if patient is unstable or stable?

BP (hypotension), AMS, signs of shock, chest pain

general difference in treatment between stable vs unstable pt

stable gets meds then electrical activity if needed, unstable goes straight to electrical

what is the energy selection for atrial flutter & SVT?

50-100 J

what is the energy selection for afib?

120-200 J

what is the energy selection for vtach?

100 J

what is the energy selection for vfib or pulseless vtach?

120-200 J

in what general condition is pacing used?

bradycardia - either directly to it if unstable pt or atropine first if stable

what are the H's of reversible causes? 5

hypovolemia, hypoxia, hydrogen (acidosis), hypo or hyperkalemia, hypothermia

what are the T's of reversible causes? 4

tension PTX, tamponade (cardiac), toxins, thrombosis (pulm)

indications for capnography (3)

airway placement, clinical condition, ROSC

will be absent in PEA, allowing you to detect PEA before having to check pulse

end tidal spike could indicate ROSC and warrants pulse check

what does post arrest care involve?

vitals, cardiovascular support, antiarrhythmic, 12-lead EKG, transfer decision, ICU vs cath lab, target temp mgmt

what is the treatment for stable bradycardia & blocks? unstable?

stable: atropine -> pacing

unstable: straight to pacing

be sure to check rhythm AND pulses

what is the treatment for stable SVT? unstable?

stable: vagal maneuvers -> adenosine -> cardioversion

unstable: straight to cardioversion

what is the treatment for stable vtach with pulse? unstable?

stable: amiodarone or lidocaine -> cardioversion

unstable: cardioversion

what is the treatment for PEA?

CPR & epi (non-shockable rhythm !)

what is the treatment for stable TdP? unstable?

stable: magnesium sulfate -> defibrillation

unstable: straight to defibrillation

what is the treatment for vfib (pulseless)?

CPR & defibrillation, epi & amiodarone or lidocaine

what is the treatment for asystole?

CHECK LEADS

compressions & epi 1mg (non-shockable rhythm!)

what is the treatment for pulseless vtach?

CPR & defibrillation, epi & amiodarone or lidocaine

TREAT LIKE VFIB

what is the dosing for epi?

1 mg

what is the dosing for amiodarone?

start with 300mg, then 150mg

what is the dosing for lidocaine?

start with 1-1.5 mg/kg, then 0.5-0.75 mg/kg

what is the dosing for adenosine?

6 -> 12mg

what is the dosing for mag?

1-2 grams

what is the dosing for atropine?

1-3 mg max

which rhythms are most important for thinking about advanced airway?

PVTach and Vfib

which rhythms are most important for considering H & T reversible causes?

PEA and asystole

identify some dx dry CT scan helps in identifying

intracranial bleed, stroke (ischemic vs hemorrhagic), brain or spine tumors/cysts, bony abnormalities such as fractures or spinal stenosis

identify some dx CT with contrast helps in identifying

stroke (ischemic by finding site of vascular occlusion), brain / spine tumors & cysts to determine its vascularity, AVM & aneurysms, bony abnormalities such as fx, stenosis (+ finding vascular compromise)

which dx are best found with MRI?

best for evaluation of soft tissue disturbances, therefore tumors & cysts, brain infections, dementia, inflammation

PET scan - definition & uses

nuclear med imaging test, radioactive tracer bound to glucose is injected into pt to show brain function by displaying how much glucose it is using, where active areas have highest uptake ... used in eval of alzheimer's, epilepsy, parkinson's, metastatic spread of cancer

correct order for CSF analysis

tube 1 - CBC with diff

tube 2 - gram stain

tube 3 - C&S

tube 4 - cell count

what should you worry about before doing lumbar puncture? what would be the concerning s/s?

intracranial space-occupying lesions like tumors, masses, abscess that increase ICP

s/s progressively worsening headache, new h/a with focal neuro sxs, unexplained h/a in pt with cancer or HIV, new onset seizure

what can transcranial doppler US be used to identify?

blood clots, arterial stenosis, vascular vasospasm

nerve conduction study EMG

used to evaluate peripheral nerves (M&S), evaluates speed & strength of nerve impulses

used in things like peripheral nerve compression, peripheral neuropathy, diabetic neuropathy, CTS

which are the best studies for dx peripheral nerves issues?

EMG & MRI

identify some lab testing a/w peripheral nerve testing

vitamin deficiencies like B12, E, B6, diabetes like glucose, HgbA1C, immune function abnormalities, chronic renal failure (uremia), exposure to heavy metals (lead)

CT myelography

CT + contrast to evaluate spinal cord and canal, good alternative to MRI for ID of spinal stenosis, disc herniation, spondylosis, arthritis (used in CNS >> PNS)

what is the best imaging modality for suspected disc issue?

MRI

degenerative disc disease vs bulging disc

both put compression on spinal cord, but degeneration more likely to be a gradual progression & is in a/w arthritis & osteophytes, vs bulging disc more likely acute, sharp, radicular pain

spondylosis definition

broad term to include arthritic degeneration of the spine, common cause of LBP but can occur anywhere, a/w osteophyte formation, disc thinning or collapse

usually NO a/w neuro s/s

spondylolithesis

vertebral fracture that causes vertebra to slip forward, could be degenerative or traumatic, s/s variable (mild LBP -> severe w/ radiculopathy)

spinal stenosis

narrowing of spinal canal that puts pressure on the nerves, MC in cervical & lumbar spine, s/s variable from mild pain to paresthesia to muscle weakness

cauda equina syndrome

severe spinal stenosis where all nerves in lower spine are compressed, s/s of LBP, saddle paresthesia, radiculopathy, LE weakness, reduced DTRs, incontinence

hangman's fracture

fracture of bilateral pars interarticulares of C2 (or traumatic spondylolithesis), MC causes like MVA, diving, sports injuries OR geriatric pt falling face first (hyperextension neck)

jefferson's fx

burst of C1 caused by axial loading, frequently a/w additional c-spine injuries (i.e. C2 fx)

check for BCVI - internal carotid, common carotid, vertebral aaa (warrants CTA)

chance / seatbelt fracture

unstable & traumatic flexion-distraction fx in area of thoracolumbar junction, extremely high incidence of intra-abdominal injury (pancreas, duodenum, abdominal aorta, mesenteric aa) (warrants CTA)

odontoid fracture

common fx C2 dens caused by low energy falls in geriatric pt vs high energy falls in young pt, often does not cause focal neuro sxs (except type III), etiology can be related to EITHER hyperextension or hyperflexion

MC primary spinal tumors

multiple myeloma, osteosarcoma

MC secondary spinal tumors

breast, lungs, prostate

multiple myeloma

MC form plasma cell cancer that develops in bone and metastasizes throughout body, s/s bone pain, weakness, weight loss w/ low survival rate once spread

osteosarcoma

MC cancer that begins in bone, MC children/younger, xray is typically initial study but MRI is gold standard, then tissue biopsy is required to confirm

(commonly kid with vague bone pain...)

secondary spinal tumors

MC tumors of spine, see neck or back pain w/ nighttime pain that awakes pt from sleep, plain xray -> MRI (gold standard)

what can plain ABD films show?

abnormal masses, gases, bones & stones

what would an acute abdominal series typically include?

supine view of abd (AP), upright or LLD film, chest xray, prone view (most variably obtained)

describe the single AP view abd (scout film) and what its good for

pt lies supine and xray beam is vertical to floor

masses, bowel gas pattern, calcifications

describe upright view of abd and what its good for

pt stands or sits up & xray beam is horizontal to floor

pneumoperitoneum, air-fluid levels

what can the prone view of abd be good for?

identification of gas in rectum, sigmoid / ascending / descending colon

what makes up the majority of bowel gas?

swallowed air

minimal remainder is from bacterial fermentation of food

what are the exceptions to having air/gas bubble in stomach?

pt recently vomited or NG tube in place and attached to suction

describe typical appearance of small bowel

centrally placed in abdomen, diameter typically < 2.5 cm but max 5cm, valvulae conniventes markings extend across lumen (stack of coins), 2-3 air-fluid levels are normal in upright view

describe typical appearance of large bowel

peripherally placed, haustral markings do not exten completely across lumen and are widely spaced (compared to SB markings), diameter is < 6cm, should be very little air fluid level but likely stool, almost always air in rectum or sigmoid

what 3 questions can you ask yourself when trying to recognize abnormal gas patterns?

is air present in rectum or sigmoid?

are there dilated loops of SB?

are there dilated loops of LB?

loops ____ to obstruction will become dilated, peristalsis continues elsewhere, and loops ______ to obstruction are decompressed as contents are evacuated

proximal, distal

which loops will be most dilated in mechanical obstruction?

loops with largest resting diameter (cecum if LB)

loop of bowel JUST PROXIMAL to obstruction

describe functional ileus

one or more loops of bowel loses ability to propagate peristaltic waves, thus a functional type of obstruction,

can be localized ileus affecting only 1-2 loops of SB OR generalized adynamic ileus affecting all loops of LB and SB

describe localized functional ileus

focal irritation of loop of bowel can occur from adjacent inflamed organ (i.e. RUQ & cholecystitis, LUQ & pancreatitis, etc., see persistent dilation and air-fluid levels

some gas will continue to pass through (can see air in rectum & sigmoid)

what is the colon cut-off sign?

abrupt cut off of colonic gas at splenic flexure, meaning colon is likely decompressed beyond this point

where inflammatory exudate in pancreatitis causes functional spasm or mechanical narrowing at splenic flexure

describe adynamic functional ileus

entire bowel is aperistaltic or hypoperistaltic, results from abdominal or pelvic surgery or severe electrolyte imbalance (hypokalemia or DKA), see entire bowel as air-filled & dilated with longer air-fluid levels, NOT mechanical so you can still see air in rectum/sigmoid

describe small bowel mechanical obstruction

lesion obstructs the lumen leading to dilation proximal to obstruction, continuing of peristalsis heard as high pitched hyperactive bowel sounds trying to push through & emptying contents distal to obstruction

recognize more SB dilation compared to LB + step ladder appearance (LUQ -> RLQ) in distal SB obstruction