Sim Wars 2025 - INTERNALS

What to do when a patient goes unresponsive?

Team lead checks for pulse. If no pulse: 1. Start compressions, call for help, attach pads. 2. Airway management: BVM setup.

How to analyze rhythm during cardiac arrest?

Stop compressions (max 10 seconds), analyze rhythm: Shockable (VT/VF) or non-shockable (asystole/PEA).

What is the protocol for shockable rhythms?

1. CPR while charging. 2. Deliver shock (e.g., 150J), resume compressions. 3. Administer epinephrine or amiodarone as per cycle.

2nd round of management for shockable rhythm?

Continue compressions, administer epinephrine 1mg IV, evaluate rhythm after 2 minutes.

3rd round of management for shockable rhythm?

Continue compressions, administer amiodarone 300mg IV, evaluate rhythm after 2 minutes.

5th round of management for shockable rhythm?

Continue compressions, administer amiodarone 150mg IV, evaluate rhythm after 2 minutes.

What to do for non-shockable rhythms (asystole/PEA)?

Administer epinephrine 1mg IV immediately and every 3-5 (~4 mins/2 cycles) minutes, continue CPR in 30:2 cycles or preferably continuous BVM, assess and treat causes.

How to manage hypovolemia during cardiac arrest?

Administer IV fluid boluses (1 liter initially).

H’s and T’s of cardiac arrest?

H’s: hypovolemia, hypoxia, hydrogen ions (acidosis), hyper/hypokalemia, hypothermia. T’s: tension pneumothorax, tamponade, toxins, thrombosis (coronary & pulmonary).

Post-ROSC care: First steps?

Ensure pulse (ROSC), assess airway for spontaneous breathing, maintain SpO2 >94%, prepare for RSI if necessary.

How to manage hypotension in post-ROSC care?

1. Administer 500 mL IV fluids. 2. Use inotropes if BP is very low.

Temperature management in post-ROSC care?

Initiate Targeted Temperature Management (TTM) at 32–36°C for 24 hours.

What is the post-ROSC ventilation goal?

SpO₂: 92%-98%, PaCO₂: 35-45 mmHg.

What are reversible causes of cardiac arrest?

H’s: hypovolemia, hypoxia, acidosis, hypo/hyperkalemia, hypothermia. T’s: tension pneumothorax, tamponade, toxins, thrombosis.

When to consider emergent cardiac intervention post-ROSC?

STEMI present, unstable cardiogenic shock, mechanical circulatory support required.

What is the first step in ACLS for arrhythmias?

Identify rhythm ⇒ Determine if stable or unstable ⇒ Treat accordingly.

What are signs of instability in ACLS?

Hypotension, heart failure, chest pain, shock, reduced GCS.

General rule for treating unstable arrhythmias?

Use electricity (e.g., cardioversion/defibrillation).

General rule for treating stable arrhythmias?

Use drugs.

What is the simplified approach for ACLS?

DEAD: VF/pVT → CPR, epinephrine, advanced airway, amiodarone. ALIVE: Assess hypotension, shock, ischemia, or heart failure.

How to manage VF/pVT in ACLS?

1. Start CPR. 2. Administer epinephrine 1mg IV every 3-5 minutes. 3. Administer amiodarone 300mg, followed by 150mg.

How to manage PEA/asystole in ACLS?

1. Start CPR. 2. Administer epinephrine 1mg IV every 3-5 minutes. 3. Secure advanced airway.

What to assess for "ALIVE" rhythms in ACLS?

Hypotension, signs of shock, ischemic chest pain, acute heart failure, or altered level of consciousness (ALOC).

How to manage unstable tachycardia in ACLS?

Use electricity (e.g., synchronized cardioversion).

How to manage unstable bradycardia in ACLS?

Use pacing (transcutaneous or transvenous).

What are common presenting complaints of anaphylaxis?

SOB, rash, itch, stridor (high-pitched inspiratory), edema, angioedema.

What are potential triggers for anaphylaxis?

New medication, food, CT with contrast.

What are key investigations for anaphylaxis?

CXR (to rule out asthma), ECG.

What is the first step in managing anaphylaxis?

Remove the allergen.

What is the first-line treatment for anaphylaxis?

Epinephrine IM 1:1000, 0.5 mg every 5 minutes (up to 2 doses).

What to do if two doses of IM epinephrine are ineffective?

Administer epinephrine IV via an infusion line.

How should IV fluids be used in anaphylaxis?

Administer 1L of Hartman’s solution.

What medications are used to manage asthma-like symptoms in anaphylaxis?

Salbutamol 5 mg nebulized.

What medications are used to treat rash/itch and prevent rebound reactions?

Chlorphenamine 10 mg IV (rash/itch), hydrocortisone 200 mg IV (rebound reaction).

When should intubation be considered in anaphylaxis?

If the patient shows life-threatening symptoms (e.g., ↓RR, ↓GCS, ↓HR).

What is the procedure if intubation fails in anaphylaxis?

Perform a cricothyroidotomy: Identify cricothyroid membrane, apply betadine, make longitudinal and transverse incisions, insert a tracheostomy tube, seal in place.

What is the post-stabilization protocol for anaphylaxis?

Observe in CDU for 4–6 hours to monitor for rebound reactions.

Where should a patient be transferred if not stable enough for CDU but not critical enough for ICU?

Transfer to HDU (High Dependency Unit).

What are differential diagnoses for asthma?

Anaphylaxis, pneumothorax, congestive heart failure, pulmonary embolism.

What investigations are important in asthma?

ECG (may show sinus tachycardia), CXR (hyperinflation), ABG if SpO₂ <92% in life-threatening asthma.

What is the first step in managing asthma?

Administer oxygen via a 15L non-rebreather mask.

What is the nebulized treatment protocol for asthma?

Continuous nebulized salbutamol 5 mg and ipratropium 0.5 mg, up to 3 times.

What corticosteroid treatment is used for asthma?

Hydrocortisone 100 mg IV or prednisolone 40 mg PO.

When is ABG indicated in asthma?

If SpO₂ <92%, silent chest, cyanosis, reduced respiratory effort, or signs of tiring (life-threatening asthma).

What adjunctive treatments can be given for severe asthma?

Magnesium 2g IV, aminophylline infusion, or salbutamol infusion.

What bronchodilatory medication can be used if standard treatments fail?

Small dissociative dose of ketamine (bronchodilatory effects).

When should BiPAP be considered in asthma?

In threatening asthma with severe hypoxia or signs of respiratory failure.

What is the management for life-threatening asthma with failure to respond?

Call anesthetics for rapid intubation and ICU admission (status asthmaticus).

What to do if arrest occurs in an asthma patient?

Disconnect CPAP, pat down the chest to release trapped air, and check for pneumothorax.

What is the escalation plan if initial treatment is unsuccessful?

Refer to anesthetics for RSI or respirology for CPAP, then transfer to ICU.

What fluids are given in asthma management?

1L Hartmann’s solution over an hour.

When should ICU admission be considered in asthma?

If the patient responds to treatment but remains critical or requires close monitoring.

What are key signs of life-threatening asthma?

SpO₂ <92%, silent chest, cyanosis, decreased respiratory effort, tiring, reduced LOC, arrhythmias, or hypotension.

What are the common presenting complaints of an MI?

Central chest pain radiating to the left shoulder/arm/jaw, SOB, nausea, sweating, syncope (collapse).

What are key risk factors for an MI?

Hypertension, hypercholesterolemia, diabetes, smoking, cocaine/viagra use.

What should you ask about before administering GTN spray?

Cocaine or viagra use.

What is the differential diagnosis for MI?

Aortic dissection (may present with syncope).

What investigations are required for diagnosing MI?

ECG (for STEMI) and CXR (to evaluate for congestive heart failure or pulmonary edema).

What are key ECG findings in STEMI?

ST-segment elevation in specific leads depending on the area of infarction.

What is the initial management for congestive heart failure in MI?

1. CPAP. 2. GTN spray/infusion (avoid if BP <80 or inferior MI). 3. Furosemide 60mg IV. 4. Avoid fluids >250mL.

What medications are included in dual antiplatelet therapy for MI?

Aspirin 300 mg PO and ticagrelor 180 mg PO.

What is the protocol for GTN spray in MI?

2 sprays unless inferior MI, then use 1 spray. Avoid if BP <80.

How is pain managed in MI?

Morphine 2–3 mg IV, with caution to avoid hypotension.

What should be done if the patient crashes before MI treatment?

Manage after ROSC and follow post-arrest protocol.

How is bradycardia managed in an unstable MI patient?

Atropine is not effective. Use epinephrine infusion while awaiting transcutaneous pacing.

What should be done if the cath lab will not take an MI patient?

Administer alteplase (thrombolysis).

What precautions should be taken before sending a patient to the cath lab?

Ensure pads are in place if the patient is unstable.

What should be done for a patient in cardiac arrest due to MI?

Follow the death protocol: 1 mg epinephrine 1:10,000 IV.

What is the next step after MI stabilization?

Transfer the patient to the cath lab for definitive management.

What imaging finding indicates congestive heart failure in MI?

CXR showing diffuse infiltrates or pulmonary edema.

What respiratory signs might indicate congestive heart failure in MI?

Crackles on respiratory exam.

How should fluids be managed in congestive heart failure during MI?

Limit fluids to no more than 250mL due to risk of worsening pulmonary edema.

What is status epilepticus?

Continuous seizures or recurrent seizures without recovery of GCS between episodes.

What investigations are required for seizures?

Beta hCG (rule out eclampsia), blood glucose.

What airway considerations are critical during a seizure?

Monitor for vomiting or bleeding to prevent aspiration; consider RSI if status epilepticus or GCS does not recover.

What is the initial treatment for a seizure?

Lorazepam 4 mg IV.

What is the treatment if IV access is not available?

Midazolam 10 mg buccally (counts as one dose of lorazepam).

What is the next step if seizures persist after lorazepam?

Administer a second dose of lorazepam 4 mg IV.

What is the treatment if seizures persist after two doses of lorazepam?

Phenytoin infusion 20 mg/kg.

What is the next step if seizures persist despite phenytoin infusion?

Call anesthetics, run through the RSI checklist, and intubate if necessary.

What should be administered in pregnant patients with seizures?

1 g magnesium sulfate IV.

How is blood sugar corrected during a seizure?

200 mL of 10% dextrose IV, glucagon IM, or glucose gel buccally if IV access is unavailable.

What medication is given prophylactically if there is evidence of TBI?

Levetiracetam (Keppra).

When should an NPA/OPA and non-rebreather mask be used?

When GCS is around 8 or 9 and ventilation is insufficient; intubate if ventilation remains inadequate.

When should a BVM be used during a seizure?

Only if the patient goes into severe respiratory distress, but intubation is preferred in this scenario.

How do you manage aspiration risk during seizures?

Monitor airway closely and consider early intubation if status epilepticus or frequent vomiting occurs.

What are the common presenting complaints of sepsis?

Immunosuppression, organ dysfunction, fever, headache, altered LOC, neck stiffness, rash, seizures (e.g., meningitis).

What are the SIRS criteria for diagnosing sepsis?

HR >90, RR >20, temperature >38°C/<36°C, altered LOC, glucose >7.7 mmol/L, WBC abnormalities.

What are the three components of "The Sepsis 6"?

Give 3: Oxygen, fluids, antibiotics. Take 3: Bloods (FBC/lactate), blood cultures, monitor urine output.

What investigations are critical for diagnosing sepsis?

History, CXR, urinalysis, ECG (may show A-fib), ultrasound/CT abdomen (e.g., ascending cholangitis), nasal swab (COVID).

What is the antibiotic protocol for pneumonia from home?

Co-amoxiclav 1.2 g IV.

What is the antibiotic protocol for hospital-acquired pneumonia?

Piptazobactam 4.5 g IV.

What additional antibiotic is needed for pneumonia with COPD?

Add clarithromycin (or macrolide if allergic to penicillin).

What is the antibiotic protocol for meningitis?

Ceftriaxone 2 g IV and dexamethasone.

What is the antibiotic protocol for intra-abdominal sepsis?

Co-amoxiclav or piptazobactam + gentamycin; for septic shock, use piptazobactam + metronidazole.

How is neutropenic sepsis treated?

Piptazobactam + vancomycin.

What is the initial fluid bolus in septic shock?

30 mL/kg (~2 L); start with smaller volumes (e.g., 500 mL) for elderly patients and reassess.

What is the vasopressor of choice for septic shock?

Noradrenaline (start peripherally with phenylephrine while setting up a central line).

How should ARDS in sepsis be managed?

Intubate immediately.

How should oxygen be managed for a septic COPD patient?

Keep SpO2 between 88–92%, give 100% O2 initially, then titrate down and perform an ABG.