Sharp Memorial ESO Exam 2023

Asystole - Answer- 1. CPR (2 mins) 2. O2 at 15 L/min ambu bag 3. Epinephrine 1 mg IVP/IO (Use Epinephrine 0.1 mg/1ml) Repeat 3-5 mins Bradycardia - Unstable - Answer- 1. O2 at minimum 10 L/min NRBM 2. If transvenous leads or epicardial pacing wires present, connect to a pulse generator and initiate pacing per protocol. 3. Atropine 0.5 mg IVP/IO, repeat q3-5 minutes (max 3mg) 4. Transcutaneous pacing as soon as available. 5. If above algorithm is ineffective, start Dopamine 400 mg/250ml D5W infusion at 5 mcg/kg/min. Titrate to patient response up to 20 mcg/kg/min. 6. If above algorithm is ineffective, start epinephrine 2 mg/250mL NS at 2 mcg/min, titrate to patient response up to 10 mcg/min. (Note: Assess patient for adequate intravascular volume and volume status when using vasoconstrictors) Pulseless Electrical Activities (PEA) - Answer- 1. CPR (2 min) and assess for possible causes*. 2. O2 at 15 L/min ambu bag 3. Epinephrine 1 mg IVP/IO (use 0.1mg/ml), repeat q 3-5 minutes. 4. If hypovolemia known or suspected, infuse 250 mL NS (may be substitute with LR if currently infusing). Repeat in 5 minutes if no clinical improvement. 5. Stat CXR. Possible Cause of PEA - Answer- 1. Hypovolemia 2. Hypoxia 3. Hydrogen ion (Acid) 4. Hypo/Hyperkalemia 5. Hypoglycemia 6. Hypothermia 7. Tamponade 8. Toxins 9. Thrombosis 10. Trauma 11. Tension Pneumothorax Ventricular Tachycardia: Stable - Answer- 1. Call the physician for orders 2. O2 at minimum 4L/min NC and adjust per patient status 3. Obtain 12 lead EKG 4. Draw serum K and Mag ** Administer Amio 150mg SLOW PIVvover 10 mins. **Consider Adenosine (only if regular and monomorphic) Ventricular Tachycardia: Unstabel - Answer- 1. O2 at minimum 10 L/min NRBM 2. If ventricular rate greater than 150, Biphasic, synchronized cardioversion per approved energy dose listed on defibrillator. 3. If patient is awake and responsive, give midazolam (Versed) 0.5 mg IVP/IO prior to cardioversion. May report to a total of 1mg to achieve sedation. 4. Draw serum K and Mag Reverse agent for Midazolam - Answer- Romazicon. If patient has signs and symptoms of oversedation (e.g. decreased level of consciousness, respiratory rate less than 10 breaths/ min), Romazicon 0.2 mg IVP/IO, over 15 second. May repeat in 45 seconds based on patient's response, not to exceed 0.6 mg Unstable signs - Answer- 1. Hypotension 2. Tachycardia 3. Bradycardia 4. Arrhythmia 5. Tachypnea 6. Respiratory Depression 7. Apnea 8. Dyspnea 9. Decreased O2 sat 10. Change in level of consciousness 11. Increased intracranial pressure 12. Status Epilepticus Unstable symptoms - Answer- 1. Dizziness 2. Lightheadedness 3. Short of breath 4. Chest pain 5. Weakness 6. Cold 7. Diaphoretic 8. Heart palpitation 9. Anxious Ventricular Fibrillation/Pulseless Ventricular Tachycardia - Answer- ***No Stacked Shocks ***Provide continuous CPR unless defibrillating. Give medications during CPR. ***Immediate defibrillation if witnessed arrest and defibrillator is available. 1. CPR (2mins) or until defibrillator is available. 2. O2 at 15 L/min ambu bag 3. Defibrillate: Biphasic, joules per approved energy dose. 4. Epinephrine 1 mg IVP/IO (use epinephrine 0.2mg/ml) 5. Defibrillate 6. Amiodarone 300 mg IVP/IO 7. Defibrillate 8. Epinephrine 1 mg IVP/IO (use epinephrine 0.1 mg/ml) 9. Defibrillate 10. Amiodarone 150 mg IVP/IO 11. If rhythm persists, defibrillate, CPR, epinephrine 1 mg IVP/IO (use epinephrine 0.1mg/ml) q 3-5 mins Chest Pain - Answer- 1. Give aspirin 325 mg non-enteric coasted, chewed or crushed, if not contraindicated and nodose on this date. 2. O2 start at minimum 4 L/min and titrate to maintain SpO2 greater than or equal to 94%. 3. NTG 0.4 mg SL if SBP greater than or equal to 90 mmHg and/or MAP 60 mmHG and HR greater than 50. May repeat every 3-5 minutes x2. 4. Morphine sulfate 2 mg IVP/IO. If SBP greater than or equal to 90 mmHg q5minutes up to a total of 10 mg. 5. If hypotension develops and no evidence of pulmonary congestion, give 250 ml NS IV/IO (may substituted with LR if currently infusing) and resume treatment for chest pain if not relieved. 6. 12 lead EKG Hypotension: Symptomatic - Answer- 1. O2 at minimum 10 L/min NRBM 2. If hypovolemia known or suspected, infuse 250 ml NS (may be substituted with LR if currently infusing). Repeat in 5 minutes if no clinical improvement. 3. If SPB less than 90 mmHg, start dopamine 400mg/250mL D5W infuse at 5 mcg/kg/minutes. Titrate until SBP greater than or equal to 90 mmHg and /or MAP greater than 60 mmHg or up to 20 mcg/kg/min. 4. In the presence of obvious blood loss draw stat H/H and Type & Cross 2 units of pRBCs. 5. If suspecting Sepsis, follow SUSPECTED SEPSIS algorithm. For immediate Post Anesthesia Patients: (This is only administered by PACU nurse) - Answer- 1. O2 at minimum 10 L/min NRBM 2. Infuse 250 mL NS (may be substituted with LR if currently infusing). Repeat in 5 minutes if no clinical improvement. 3. If fluid bolus ineffective, Ephedrine 5mg/IVP/IO 4. If no improvement within 3 minutes, repeat Epherdine at 10 mg IVP/IO. 5. In the presence of obvious blood loss draw stat H/H and Type & Cross 2 unites of PRBCs. Increased Intracranial Pressure - Answer- In the neurologically impaired patient with dilated pupil associated with other signs of impending herniation (Note: implement only in the absence of specific ICP order) 1. Raise HOB to at least 30 degrees if patient is not hypotensive; place patient's head in midline position. 2. Hyperventilate the intubated patient with FiO2 100% to maintain pCO2 30-35 mmHg 3. Mannitol 20% (100gm/500mL) rapid IVP/IO using a filter (if filter is readily available) 4. Draw baseline serum K, Na, BUN, Cr, Glucose, and ABG. 5. Insert urinary catheter. Respiratory Depression: associated with prior narcotic or benzodiazepine administration - Answer- 1. O2 at minimum 10L/min NRBM 2. Narcotic-associated respiratory depression Administer Naloxone (Narcan) as follow (maximum dose of 0.4 mg): A: Apnea: 0.4 mg IVP/IO once B: RR less than 10: 0.1mg IVP/IO every 1 minute, may repeat x3 3. For benzodiazepine-associated respiratory depression (apnea to RR less than 10), administer flumazenil (Romazicon) 0.2 mg IVP/IO over 15 seconds. May repeat in 45 seconds based on patient's response, not to exceed 0.6 mg. Respiratory Distress: Demonstrated by change in RR and/or use of accessory muscles, altered level of consciousness or cyanotic nail beds - Answer- 1. O2 at minimum 10 L/min NRBM 2. STAT portable CXR 3. In the presence of bronchospasm: Albuterol 0.5 mL in 3 mL NS aerosol inhalation 4. The Rapid Response Team may obtain an ABG 5. The RRT may initiate non-invasive ventilation (NIV) for the following conditions in the absence of any contraindications. A: Exacerbation of COPD, asthma, acute CHF B: As a bridge to mechanical ventilation C: Contraindications for NIV i: Respiratory arrest II: Inability to maintain a patent airway or clear secretions iii: Risk for aspiration of gastric contents (nausea, vomiting or bowel obstruction) vi: Pre-existing pneumothorax without chest tube or pneumomdiastinum v: Epistaxis vi: Recent facial, oral or skull surgery or trauma vii: Encephalopathy/altered mental status viii: Hypotension due to suspected intravascular volume depletion ix: Unable to tolerate BIPAP Status Epilepticus (generalized toni