Department of surgery Icu-cpr PICTURE QUIZ march 2014 Prepared by Dr. Karam Kamal Younis Assistant professor and consultant surgeon Convener of the Department of Surgery College of Medicine University of Mosul
PT attached to this equipment shows increasing PaCO2 And decreasing PaO2 What steps can you take to improve the situation?
Check ETT Assess PT re: cyanosis, pneumothorax Check connections Check O2 supply Increase TV Increase RR Increase FiO2
How are you going to set your patient ventilation in different scenarios? Overdose in otherwise healthy patient Mode* FiO 2 (%) V T (ml/kg) CMV, A/C, IMV, SIMV Rate (breaths/min) I/E ratio 100 8 10 10 12 1:2 0 5 PEEP (cm H 2 O) Status asthmaticus CMV, A/C, IMV, SIMV 100 5 10 8 12 1:4 2.5 10 COPD exacerbation, respiratory acidosis CMV, A/C, IMV, SIMV 100 5 10 10 12 1:3 1:4 2.5 10 Cardiogenic pulmonary edema CMV, A/C, IMV, SIMV 100 8 10 10 12 1:2 2.5 15 ARDS CMV, A/C, IMV, SIMV 100 6 8 20 25 1:2 2.5 10 Hypovolemic shock CMV, A/C, IMV, SIMV 100 8 10 1:2 0 5
1. Name this device 2. Label X 3. What is the maximum size of tube through Y X Y
Intubating LMA Handle 8.0 ETT
List 2 advantages of this gadget over endotracheal tube List 2 disadvantages
Easier to insert Quicker Can be done by paramedicas or the lessertrrained No need for paralysis No need laryngoscopy / can be done blind Reusable - economical Doesn t provide definite airway Has to be re-sterilised each time; availability Damaged if reused numerous times
Procedure done to monitor PT s hemodynamic status What is the exact procedure? What is the recommended technique? List 2 complications.
Internal Jugular Central Line cannulation Seldinger s technique or US-guided Trauma to carotid A or other neck structures, hematoma, infection, pneumothorax, ruptured guidewire, dysrhythmias
a) Name the equipment b) What is the ventilation ratio
a) Name the procedure depicted) b) List 2 advantages of this equipment
1. What is this device? 2. What is it used for? 3. What factors determine its reading? 4. Describe how you would instruct your patient to use it
1. Name this device 2. Give 2 main indications 3. List 3 contra-indications
You decide to intubate this PT s trachea How would you assess the potential difficulties of intubation (in general)?
3:1:3 or 3:2:3
1. What is this device? 2. Describe your the application 3. Explain the colour change
Laceration marked X 1. What is this procedure? 2. List do s and don ts X
Digital nerve block Must do under aseptic technique, aspirate syringe before injecting LA, ensure dorsal part of finger anesthetised (dorsal branch of digital nerve), avoid intra-vascular injection, avoid using epinephrine
What is the Diagnosis?
Hyperkalemia
Hyperkalemia Wide QRS QUICKLY CONSIDER : Hyperkalemia Ventricular Tachycardia AMI TOX (TCA / Cocaine)
1. List your findings 2. What is your diagnosis?
How you avoid such complication?
Initiate CPR Rhythm Asystole ACLS algorithm After 30 mins of resuscitative efforts, no return of cardiac output, persistent asystole
Asystole Ventilate with high Continue CPR 3 mins CPR After 3 mins concentration O 2 Adrenaline 10 mcg/kg IV or IO Adrenaline 10-100 mcg/kg IV or IO Intubate IV/IO access Consider IV fluids and alkalising agents
IV fluids should be considered for the patient whose arrest has been subsequent to fluid loss or maldistribution Alkalising agents (usually sodium bicarbonate 1 mmol/kg) can be considered for patients in whom there has been prolonged asystole/tricyclic antidepressant poisoning/ hyperkalaemia. The lower dose of adrenaline (epinephrine) is now routinely recommended at the second and subsequent points but the higher dose should be considered in patients who have had a vasodilatory pathology such as septic shock or anaphylaxis and those in whom intra-arterial monitoring allows assessment of the response to the adrenaline (epinephrine) dose and shows that the response is suboptimal adrenaline (epinephrine) should be given every 3-5 minutes...