SAQ 4: Anesthesia & Pain Relief

Regarding anesthesia in the A&E department:

1)      Name 4 different methods of anesthesia which can be used to reduce a Colle’s fracture.  (2 points)

2)      What is the maximum dose of lignocaine with and without adrenaline. (1 points)

3)      Name 3 general anesthetic drugs which can be used in RSI for induction and their doses. (3 points)

4)      Until what age is straight blade laryngoscope preferable and why? (2 points)

5)      Name the Mechanism of action of Suxamethonium. What are the C/I of using Suxamethonium for paralysis in adults. (2 points)

SAQ 2: Resuscitation

1. 54 years male is brought in the ED with unresponsiveness and no signs of life. There is no pulse and the monitor shows the rhythm below. He was lying in cold snow on the street for unknown duration. What is your next steps of management? (2 marks)



2. His temperature is 29 Celsius. What different steps you would take specifically in this case? (4 marks)

3. He has a pulse now and is still unconscious. What are tasks in the post resuscitation scenario? (4 marks)

SAQ 1: Resuscitation

1. Describe the EKG? (2)

2. What are the Unstable features related to the diagnosis? (2)

3. Assuming the BP is 120/90, RR is 16/min, and SpO2 is 94 % on 2 liters of Oxygen and IV Access is obtained; what is your initial management? (2)

4.Your initial treatment does not work, and the patient arrests; monitor shows the same rhythm but there is no palpable pulse. What is your initial management? (2)

5. List the reversible causes of cardiac arrest (2)

MRCEM Fast Facts Series Part A: Resuscitation

Do I need an Arterial Blood Gas (ABG)?

Is Venous Blood Gas (VBG) as good as an Arterial Blood Gas (ABG)?

In the emergency settings, we often seek a quick answer to patient’s milieu through blood gas parameters. Most ED physicians draw up the venous blood gas sample to look for the metabolic parameters and the electrolyte status of patients. However, in certain specialties and different settings, the usage of a VBG as equal to that of an ABG sample has been often disapproved.

Although an ABG sample serves as a gold standard to determine the pH, PaCO2, HCO3, lactates, and the PaO2 accurately, it, at times, gives poor indication of the electrolyte status. In addition, it comes with additional pain and risk of injury to the vessel (pseudo aneurysms, hematoma and AV fistula) and surrounding structures (nerve injury). Serial exams will need additional pricks, and also carries a risk of digital ischemia. Moreover, additional work may seem an additional delay in care too.

On the other hand, venous blood sampling is usually easier, less painful and more convenient. VBG gives you a rapid and good assessment of the pH, HCO3, and the base excess. As long as the patient is normocapnic, it gives a good estimate of the PaCO2. In cases where the pulse oximetry is reliable and the patient does not appear to be in shock state, the SpO2 is sufficient for clinical decision making. Additionally, it gives a quick estimate of the electrolytes too.

Take Home Points:

•  If you are concerned about the pH: The Venous pH has a good correlation with the arterial pH within 0.03 – 0.04 units
•  The HCO3 and the base excess has good correlation
•  Venous lactate has a good correlation with the arterial lactates unless < 2mmol/L
• If you are concerned about hypercarbia: VBG serves to be 100% sensitive in detecting hypercarbia with a cut off of PCO2 of 45 mm Hg. A venous PCO2 of more than 45 means you are hypercarbic. If you need to know the accurate CO2 levels then get an ABG
• The Venous lactate and the PCO2 may not correlate in shock states
•  Want to know the PaO2 or to calculate the A – a gradient, get an ABG

Further Readings:

Kelly, A. (2010). Review article: Can venous blood gas analysis replace arterial in emergency medical care. Emergency Medicine Australasia 22, p493–498.

 McCanny, P., Bennett, K., Staunton, P., McMahon, G. (2012).Venous vs arterial blood gases in the assessment of patients presenting with an exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med. 30(6): p896-900.

Middleton P, Kelly AM, Brown J, Robertson M. (2006). Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emerg Med J. 23(8): p622-4.

MCEM OSCE Part C: Arrythmia Management

If you are encountered with a patient with an AF or 2 degree/3 degree heart block, and asked to manage the patient, you are supposed to follow the following steps:

(The likely hint in the scenario would be that there would be a mannequin and you will be asked to demonstrate your skill to cardiovert or pace the patient. If there is a live patient, the patient would be stable and you do not have do either of these.)

• Introduce
• Transfer the patient to the Resuscitation area
• Establish Monitoring, IV access, Nasal Oxygen, and re-obtain vitals
• Ask for Labs: Venous Blood Gases for electrolytes, glucose, CBC, U & Es, Septic screen, thyroid functions for A Fib,
• CXR
• 12 Lead EKG
• Like to know if the patient has any chest pain, dizziness, SOB, syncope
• Obtain history of underlying lung disease, heart disease, thyroid disease, recent illnesses, duration of onset of symtpoms <48 ekgs="" hrs="" li="" old="">
• Medications, allergies, last meal, previous anesthesia and complications
• For AF if patient is unstable Cardiovert:

1. Consent
2. Anesthesia backup
3. Prepare airway trolley
4. Procedural sedation: Fentanyl and Midazolam
5. Attach Pads
6. Synchronize
7. Get the people and Oxygen away
8. Current 100 mA
9. Check Pulse
10. 12 Lead EKG
11. Reassess Patient
12. Consult Cardiology and Admit in ITU
13. At this moment, tell the examiner that I would like to Calculate the CHAD2 Score and get a bedside echocardiogram done.

CHAD2: CHF, Hypertension, Age > 75, DM, TIA/Stroke
CHAD gets 1 each, TIA/Stroke gets 2
0 - 1: Aspirin, 2: Grey Zone (Aspirin or Warfarin), 2+ Warfarin

• For Blocks:

1. Assess Risk of Asystole: Recent Asystole arrest, Ventricular Pause > 3 secs, 2nd degree heart block, 3rd degree heart block with Wide QRS
2. IV Atropine 0.5 mg, Can repeat in 5 minutes
3. IV Glucagon 2 mg if Beta/Calcium channel blocker toxicity
4. Arrange for TCP
5. Consent
6. Anesthesia backup
7. Prepare airway trolley
8. Procedural sedation: Fentanyl and Midazolam
9. Clean/dry/shave chest
10. Attach Pads and leads (2 cm away because of risk of arcing)
11. Mode: Pacing/Demand
12. Rate: 80/minutes
13. Current 10 mA in increment upto 50 - 100 mAmp
14. Look for Capture
15. Check Pulse
16. 12 Lead EKG
17. Reassess the patient (Tell the examiner that there is no risk of electrical hazard in touching patient during pacing)
18. Consult Cardiology for Invasive IJV Pacing
19. Reassess Patient
20. Consult Cardiology and Admit in ITU

Pediatric Resuscitation (PALS) Part B

Series of Videos by Dr. Patwari for a quick revision before going for a PALS Course or the CEM Examination.

PALS Introduction:

PALS Airway:

PALS Monitoring and Access:

 

 

PALS Drugs Part 1:

 

 

 

PALS Drugs Part 2:





 

Pediatric Resuscitation (PALS): Part A

Here are some very useful videos for educating yourself before you approach the MCEM Part B & C Examinations, or for that matter even a PALS Course.

Part 1: Overview of Pediatric Assessment

Part 2: Overview of PALS Science

 

 

(Disclaimer: Both these videos are for educational purposes only, and are taken from YouTube. It is to be used for revision purposes for exams or PALS course, and is not a substitute to the AHA and AAP Accredited PALS Course)

Succinyl Choline (Suxamethonium)

A great drug of choice for paralysis in RSI, but carries it's own list of side-effects and C/I.

Dose: 1.5 mg/kg IV

Side Efects (BAHAMAS)

Bronchospasm
Anaphylaxis
Hyperkalemia
Arrythmias (Brady and Tachy)
Malignant Hyperthermia
Apnea (especially in inadequate pseudo-cholinesterase)
Secretions (Salivation)

Contraindications (CNBC Eye)

Crush Injuries
Neurological: Spinal Cord Injury, Myotonic dystrophy
Burns
Chronic Renal Failure
Eye (Penetrating injury of the eye)

(To know more about Anesthesiology Visit www.gasexchange.com)

Approach to Traumatic Emergencies: ATLS

Here are a group of videos uploaded by Oxford Medical Videos helping us getting a proper understanding of the ideal ATLS approach to trauma cases.

Initial Assessment Normal

Initial Assessment Multi System Injury

Initial Assessment Multi System Injury Continued

Assessment in Pelvic Fracture

Another Nice and Simple Video by Univ of Miami discussing the ABC Approach in Trauma Care

The ABC's of Trauma

Pediatric Resuscitation WET FLAG

Weight               Upto1 Year       (Age in months/2) + 4
                         More than 1 Year      (Age in years + 4) x 2
If for some reason, you are not able to remember the formulae, I would recommend remembering
weight at birth 3.5 kgs, at 1 year it is 10 kgs, 5 years = 20 kgs, 10 years = 30 kgs.

Energy               4 joules/kg

Tube                  Diameter (Age/4) + 4
                         Length (Age/2) + 12

Fluids                Shock other than Trauma & DKA 20 ml/kg, Trauma & DKA 10 ml/kg

Lorazepam        0.1 mg/kg

Adrenaline        0.1 ml/kg of 1:10000

Glucose            5 ml/kg of 10% Dextrose

(Source: Mastering Emergency Medicine by C. Trivedi, 2011)

Difficult Airway

Difficult Airway

"The difficult airway is something one anticipates, the failed airway is something one experiences" - Ron Walls

Difficult airway can be due to:

1.  Difficult Bag Valve Mask (BVM); mnemonic = MOANS

2.  Difficult laryngoscopy and dificult intubation; mnemonics = LEMON

3.  Difficult cricothyrotomy; mnemonic = SHORT

4.  Difficult extraglottic devices; mnemonic = RODS

1. Difficult BVM = MOAN!

M = Mask seal not good, e.g. beard, facial deformity, etc

O = Obesity (difficult ventilate), 3rd trimester pregnancy, or obstruction e.g. neck swelling, angioedema, hematomas, cancer, etc

A = Age, elderly, loss of muscle tone to support the upper airway

N = No teeth (no teach causing caved in face)

S = Stiff lungs - upper airway obstruction - exacerbation of asthma, COPD, etc

2. Difficult laryngoscopy: use LEMON

L = Look externally, e.g. short neck, large tongue, large teeth, etc

E = Evaluate 3-3-2

        3 = adequacy of oral access

        3 = to assess capacity of mandibular space to accommodate tongue

        2 = distance of larynx to level of base of tongue

M = Mallampati scoring

O = Obstruction

        Any signs of upper airway obstruction?

        Three cardinal signs of upper airway obstruction:

        - muffled voice (hot potato voice),

        - difficult swallowing secretions,

        - stridor; when stridor happens, consider that circumference of airway reduced to
           roughly 10% of normal caliber!!!!

N = Neck mobility

3. Difficult cricothyrotomy

S = previous surgery

H = Hematoma/swelling around neck

O = Obesity

R = Radiation distortion

T = Tumor

4. Difficult Extraglottic devices

R = Restrictied mouth opening

O = obstruction upper airway

D = Disrupted or distorted upper airway

S = stiff lungs, spine of cervical

(Source: C K Sheng, 2009. Lecturer/Emergency Medicine Specialist, School of Medical Sciences, Universiti Sains Malaysia from http://emergencymedic.blogspot.ae/p/my-list-of-publications.html)

Resuscitation Guidelines ALS & APLS

The importance of knowing the guidelines cannot be further emphasized. These guidelines have been repeatedly tested in every part of the MCEM Exams. At least 2 to 3 OSCE stations in the part C are almost always reserved for these.
Not only that, knowing these guidelines will help all of us in saving or restoring several lives not only within the departmental settings, but wherever the need arises. Mastering these skills may bring up a smile and make a difference to several families.

Download here:

Resus Guidelines 2010  (Hyperlink Source: Resuscitation Council (UK))

Post Resuscitation Care (A simplified mnemonic)

A          Arterial Blood Gas
B          Blood Work Up (CBC, Electrolytes)
C          Chest X Ray/ Controlled Oxygenation - Ventilation
D          Discuss with Relatives
E          EKG
F          Full Set of Vitals (TPR, BP, Saturations)
G         Glucose
H         Hypothermia protocol
I           ICU Transfer & Care

Toxins & Antidotes

Agent	Indication
Activated charcoal with sorbital	used for many oral toxins
Adenosine	Theophylline antidote for adenosine poisoning
Atropine	organophosphate and carbamate insecticides, nerve agents, some mushrooms
Beta blocker	theophylline
Calcium chloride	calcium channel blockers, black widow spider bites
Calcium gluconate	hydrofluoric acid
Chelators such as EDTA, dimercaprol (BAL), penicillamine, and 2,3-dimercaptosuccinic acid (DMSA, succimer)	heavy metal poisoning
Cyanide antidote (amyl nitrite, sodium nitrite, or thiosulfate)	cyanide poisoning
Cyproheptadine	serotonin syndrome
Deferoxamine mesylate	Iron poisoning
Digoxin Immune Fab antibody (Digibind and Digifab)	digoxin poisoning
Diphenhydramine hydrochloride and benztropine mesylate	Extrapyramidal reactions associated with antipsychotic
Ethanol or fomepizole	ethylene glycol poisoning and methanol poisoning
Flumazenil	benzodiazepine poisoning
Glucagon	beta blocker poisoning and calcium channel blocker poisoning
100% oxygen or hyperbaric oxygen therapy (HBOT)	carbon monoxide poisoning and cyanide poisoning
Insulin- with Glucagon	beta blocker poisoning and calcium channel blocker poisoning
Leucovorin	methotrexate and trimethoprim
Methylene blue	treatment of conditions that cause methemoglobinemia
Naloxone hydrochloride	opioid poisoning
N-acetylcysteine	Paracetamol (acetaminophen) poisoning
Octreotide	oral hypoglycemic agents
Pralidoxime chloride (2-PAM)	organophosphate insecticides, followed after atropine
Protamine sulfate	Heparin poisoning
Prussian blue	Thallium poisoning
Physostigmine sulfate	anticholinergic poisoning
Pyridoxine	Isoniazid poisoning, ethylene glycol
Phytomenadione (vitamin K) and fresh frozen plasma	Warfarin poisoning and indanedione
Sodium bicarbonate	ASA, TCAs with a wide QRS

ALS Pearls for MCEM B Part 2

Use of Sodabicarbonate in Cardiac Arrest

Indications: Alkalinization to correct pH if cardio-respiratory arrest due to HYPERKALEMIA (K+ more than 5.5), TCA overdose, or prolonged arrest state

Dose: 50 ml of 8.4% solution (50 mmol)

It is not recommended to use it routinely:

1.  Exacerbates intracellular acidosis:

            a) Generates CO2 which diffuses rapidly into cells (respiratory acidosis)

b) Stimulates phosphofructokinase in glysolysis to generate more pyruvate, thereby increased lactate formation (lactic acidosis)

2. Shifts O2-Hb curve to left, thereby causing decreased release of O2

3. Negative ionotropic effect on ischemic myocardium

4. Large osmotically active Na load, causing cellular swelling

ALS Pearls for MCEM B Part 1

ALS Resuscitation Pearls:

High Quality CPR: Rate at least 100 per minute, Depth 5 – 6 cms, allowing full elastic recoil, and minimizing interruptions.

Fine VF that is difficult to distinguish from asystole should be treated as asystole with good quality CPR

Atropine is no longer recommended for PEA and Asystole (These rhythms are primarily due to myocardial pathology and not due to increased vagal tone

Reversible Causes:

4 H’s Hypoxia, hypovolemia, Hypo/Hyperkalemia (Metabolic), Hypothermia

4 T’s  Thrombosis (pulmonary/Coronary), Tamponade, Toxins, Tension Pneumothorax

When defibrillating the pre-shock pause should be kept to a minimum (less than 5 sec) by planning ahead, continuing chest compressions during charging, and using a brief safety check

Adrenaline 1 mg should be given as soon as IV/IO access (endotracheal medications have been de-emphasized) is gained in asystole/PEA and after the third shock in VF/VT

Amiodarone 300 mg IV is given after the third shock after VF/VT

Capnography should be used, if available, in an intubated patient to confirm and monitor the tube placement, quality of CPR, and to provide early recognition of ROSC

If thrombolysis is given for massive PE in cardiac arrest, CPR should be continued for 60 – 90 mins

Therapeutic hypothermia should be considered in comatose survivors of shockable and non-shockable rythms.

(Courtesy: Victoria Stacey, 2011)

Resuscitation Algorithms

Resuscitation Algorithms:

Very useful for MCEM B & C

Resuscitation Flowcharts

(Source: Resuscitation Council UK)

Resuscitation in Pregnancy

A slideshow that describes the BLS & ACLS modifications of CPR in pregnancy.

Resuscitation in pregnancy dr.krushna patel

View more PowerPoint from Abdul Sajjad Pathan

(Courtesy: Dr. K Patel, 2012, KDAH Mumbai)

Resuscitation: BLS & ACLS Update Video

There have been considerable changes in the AHA ACLS Update 2010.
Here is the link to the video on updates:

ACLS Update

Megacode Team Roles & Behavior
(The video above on Megacode is 2005 Video, and the viewer is advised to refer to the ACLS Manual 2010 update on drugs and protocols)