Cardiogenic shock - inadequate cardiac ouput in presence of normal blood volume

Defined as:
-cardiac index <2.2
-SBP <90 for 30 min
-PAOP >18
-SVR >2100
Treatment:
-IV fluids
-start Dobutamine alone or Dobutamine + Norephinephrine or Norepinephrine alone
-can give Epinephrine alone if Dobutamine is not available
-do not give phenylephrine alone
-Intraaortic ballon pump
-Systolic <70: Norepinephrine + Dopamine
-Systolic 70-100: Dopamine +/- Norepinephrine
-Systolic >100: Dobutamine
-Systolic >100 and Diastolic >110: Nitroglycerine or Nitroprusside, Furosemide, O2 to lower
pressure

Asthma:
Vent settings:
1. RR 6-10, PEEP 0, TV 6-8 ml/kg, Inspiratory rate 80-100 L/min, Exp time 4-5 sec
2. Use large ET tube 8 - 8.5
3. Check plateau pressure, keep below 30
4. Patients that crash on mechanical ventilation: displacement, obstruction,
pneumothorax, excretions, device malfunction, breath stacking
5. Troubleshooting of crashing ventilated patient: Suction the ET tube, change setting to
pressure controlled to limit Ppeak and Plateau pressures below 30 mmHg, decrease the
breathing rate and tidal volume, check the circuit, assess placement of the ET tube, disconnect
patient, press on chest to force exhalation, evaluate for pneumothorax
6. Rescue medications: Albuterol, IV and neb Steroids, Epinephrine, Magnesium, Heliox,
Ketamine

Tuberculosis
Sputum samples to evaluate for tuberculosis should include:
Acid-fast bacillus smear on three specimens, on three consecutive days
Mycobacterial culture on three specimens, on three consecutive days
Mycobacterial polymerase chain reaction (PCR) on at least one specimen
A patient with suspected tuberculosis requires one or more of the following specimens sent
for mycobacterial smear and culture: sputum, bronchoalveolar lavage, or gastric aspirates (in a
young child)
Obtain TST or IGRA: A TST is preferred over an IGRA in a child <5 years old.
For an adult inpatient: Mycobacterium tuberculosis infection determination by QuantiFERON-TB
Gold, In-Tube, Blood, is the preferred test
For an adult outpatient: either test can be done; TST costs less, but has concern for false-positive
results, Tuberculin skin test (TST), also called purified protein derivative (PPD), Mycobacterium
tuberculosis infection determination by QuantiFERON-TB Gold In-Tube, Blood
Indications for hospitalization: Hypotension, Dehydration, Respiratory failure, Social or
 psychiatric concerns, Altered mental status, Clinician discretion, Lives outside the local area
and is lodging at a hotel or motel, Has high infectivity (laryngeal tuberculosis/pulmonary cavity
along with a positive sputum smear), Has poor compliance with masking, Has suspected
multidrug-resistant tuberculosis, Has advanced stage of disease (e.g., in a debilitated condition
with cachexia)

Resuscitation/Cardiac Arrest
Cardiac arrest after intubation is highest in patients who are hypotensive prior to intubation.
Need to resuscitate the patient prior to intubation including IV bolus, push dose epinephrine
(1 mL of 1:10,000 dilution Epinephrine on 9 mL of NS). Administer 0.5 - 2 mL of 1:100,000
dilution epinephrine every 1-5 min. Alternatively, can use Phenylephrine 10 mL in 100 mL NS
and draw 10 mL from the dilution; administer 0.5 - 2 mL every 1-5 min as needed.
Neurologic causes can cause Bradycardia->Asystole cardiac arrest especially in patients with
subarachnoid hemorrhage. There may also be deep T-waves precordially on EKG (DeWinter's)
NSTEMI that led to cardiac arrest should be referred for emergent cardiac cath within 2 hours
Beta blockers in early STEMI can precipitate cardiogenic shock->cardiac arrest
High flow nasal cannula during apnea -> denitrogenation to prevent deoxygentation
Limited echocardiography to determine IVC variation with breathing (>15% change in IVC
diameter size with breathing) can help determine which patients need fluid vs pressors vs
inotropes to increase cardiac output and stabilize hemodynamics
ETCO2 less than 10 after 20 mins of CPR may mean futile. Successful resuscitation with CPR
will show ETCO2 35-40. Adequate CPR should have ETCO2 of at least 20.
Pulse check not needed in patients with ETCO2; continue rhythm check
Hyperoxia after cardiac arrest -> poor outcomes. Try to maintain O2 sat in the low to mid 90s
Double sequential defibrillation with anterior->anterior and anterior->posterior pads, Esmolol
500 mcg/kg bolus can reverse refractory Vfib, Amiodarone +/- Lidocaine
Improves mortality: TXA for bleeding, Albumin for SBP after paracentesis, prone positioning,
Noninvasive positive pressure ventilation, therapeutic hypotermia after cardiac arrest

Resuscitation
Intravenous fluids: Humeral head IO more rapid resuscitation
Rapid sequence intubation:
7. 0.25 - 0.5 mg/kg Ketamine in hypotensive and no cardiac disease. Avoid in elevated ICP
8. 0.6 - 1.6 mg/kg Rocuronium
9. Resuscitate first if Shock Index (SI = HR/SBP) is greater than >0.9. Decrease dose of
induction meds and give IVF, pressors
Pressors:
10. Push dose pressors: 1 cc Epinephrine vial + 9 cc saline
11. Use during hypotension after intubation
Awake intubation:
12. 4% lidocaine in an atomizer - spray to posterior pharynx to remove gag reflex
13. Use in difficult airway patients that cannot be ventilation with BVM
Preoxygenation:
14. Nasal cannula 15 lpm + Bag-mask with PEEP valve + jaw thrust
Delayed sequence intubation:
15. Give sedative -> Noninvasive ventilation (BiPAP) -> recruit alveoli
Back up Head Intubation:
16. -patient sitting up at 45 degrees rather than supine
17. -can decrease pressure on chest
Vent settings:
18. Pressure support, 6-8 cc/kg (IBW), 14 breaths/min, titrate O2 to 98-100%, PEEP 5-10,
ABG 15-30 min after intubation

Pulmonary embolism
Large PE can show:
-T wave inversion in the right precordial leads
-ST depression or elevation in AVR or V1-V2
-Sinus tachycardia with Afib
-Right axis deviation (deep S wave in lead I, tall R wave in V1)
Geneva criteria or Well's Criteria to categorize into low, intermediate, high
-if low risk, use PERC to rule out PE

Intracranial hemorrhage
-give TXA, avoid platelet transfusions
-keep glucose 140-180
-keep SBP 140-180. prevent hypotension
-prevent hypoxia during intubation
-elevate head of bed, keep pCO2 35-40 mmHg
-mannitol only with Nsurg consult
-give antiepileptic in traumatic brain bleeds

Pediatric emergencies
19. Electrical injuries - BMP, EKG, CK. Examine for arrhythmias, compartment syndrome,
thoracic injury, brain injury, pulmonary edema, ileus. Ask for type of contact AC vs DC, time of
contact (AC causes tetany). Oral commissure burn -> needs plastic surgery eval and hematoma
expansion.
20. Vomiting children - differential includes volvulus (bilious vomiting), intussusception
(intermittent abdominal pain in fetal position with cyclic resolution and recurrence),
necrotizing enterocolitis (premature infants), duodenal atresia, meconium ileus, GERD, pyloric
stenosis, DKA, meningitis, nonaccidental trauma, metabolic disorders, Gastroenteritis
(vomiting and diarrhea with normal vital signs->rx w/ Zofran).
21. Surgical abdominal emergencies: volvulus, intussusception, NEC, pyloric stenosis. Need
to resuscitate first.
22. Seizures: status epilepticus (more than 5 min). start with Benzo (Lorazepam) ->
Fosphenytoin ->Phenobarb +/- Ketamine -> Propofol
23. DKA: assess for cerebral edema (headache, irritability, fatigue, altered mental status->rx
w/ Mannitol, Hypertonic saline, elevate the head, intubation, consult Nsurg) during IVF bolus
24. Rapid sequence intubation in children: Resuscitate with fluids, Prepare push dose
Epinephrine, RSI drugs (Ketamine for sepsis, Etomidate for TBI), Succinylcholine or Rocuronium
(may defer if TBI),