lt col alan guhlke, m.d. 2 edition: 1 march 2016€¦ · en route care cards, 2nd edition cleared,...

En Route Care Cards, 2nd Edition Cleared, 88PA, Case # 2016-2181. │ 1

Lt Col Alan Guhlke, M.D. 2nd Edition: 1 March 2016


Disclaimer

The information contained is provided for educational and informational purposes only; it does not constitute an endorsement or approval by the U.S. Air Force School of Aerospace Medicine, U.S. Air Force, Department of Defense, or U.S. Government of any of the products or opinions expressed by the author. This information should not be used in lieu of standard medical texts or formalized training in critical care or en route care. Questions concerning the content should be directed to the author. Author: Alan Guhlke, M.D. USAF School of Aerospace Medicine Lt Col, MC, USAF, FS AFEMSI Division Chief, AFEMSI 2510 5th Street, Bldg 840, Rm W240

[email protected] Wright-Patterson AFB, OH 937-938-3846

mailto:[email protected]


Table of Contents

Title Page

Abdominal Compartment Syndrome 5

Airway: Difficult Intubation 7

Airway: Management Algorithm 9

Airway: Peak Inspiratory Pressure High 12

Burn Care 13

Head Injury: Catastrophic 23

Head Injury: ICP - CPP 25

Hemorrhage: Acute 27

Hypotension 28

Hypoxemia 29

Pneumothorax 34

Respiratory Failure: General 35


Respiratory Failure: Vent Management 37

Respiratory Failure: Trouble Shooting 38

Respiratory Failure: Prone Positioning 39

Respiratory Failure: Lung/ECMO Team 40

Spinal Cord Injury 41

Ventilator Device Failure 43

ACLS Basics 45

References 46


Abdominal Compartment Syndrome Indicators: UOP, Peak Airway Pressure, BP, Tense Abdomen

Risk Factors: Trauma, Burns, Internal Bleeding, Massive Transfusion, Bladder Pressure > 20 mmHg

Initial Priorities Secondary

FiO2 to 100%, Adjust Vent as Necessary (avoid losing too much Tidal Volume)

Intermittently Decrease Suction Intensity on “Balad Bag”

Relax Patient: Sedation and Paralysis Do Not Remove Abdominal Dressing

Decompress: Stomach with OG/NG, Bladder Foley

Alert Accepting Hospital

Reverse Trendelenburg (not on backrest)

Initiate Vasopressors for Hypotension. Goal is Abdominal Perfusion Pressure >= 60 mmHg

Measure Bladder Pressure


Abdominal Compartment Syndrome Indicators: UOP, Peak Airway Pressure, BP, Tense Abdomen

Risk Factors: Trauma, Burns, Internal Bleeding, Massive Transfusion, Bladder Pressure > 20 mmHg

Assess for indicators above

100% FiO2

Lower TV as appropriate

Relax Patient:

Optimum Sedation

Paralysis

Decompress Stomach and Bladder

Put in

Reverse Trendelenburg

Vasopressors with Goal Abdominal

Perfusion Pressure >/= 60 mmHg

Measure Bladder Pressure if able

Intermittently decrease suction

intensity on "Balad Bag"

Call Receiving Facility


Airway -- Difficult Tracheal Intubation

Signs & Symptoms Differential Management

History of Difficulty Intubation skills deficit

If known, secure prior to flight by Anesthesia

Abnormal airway (trauma/mass) Always have a plan

Small mouth opening If Unknown:

Large tongue Alert Team/Get Help

Mallampati Grade III/IV Mask Ventilate on 100% FiO2 --Two Hand Masking --Oral/Nasal Airways --Gum Elastic Bougie

Failure to intubate after 2 attempts

Glydescope or Bronchoscope


If fails, try LMA/King LT (or go to cric)

If fails, Cricothyrotomy

Call Receiving Hospital

***Can try transtracheal jet ventilation as bridge to cric: --14 g Angiocath in cric --3 ml syringe (plunger out) --6.0 ET tube connector --Bag on 100% FiO2 (will be a lot of resistance)


Airway Management Algorithm

Mask Ventilate 100% FiO2

+/- 1/2 Hand Masking

+/- Oral/Nasal Airways

Able to

Mask Ventilate

and Maintain SpO2

Get Help and Go To

Non-Emergency Pathway

Not Able to

Mask Ventilate

or Maintain SpO2

Get Help and Go To

Emergency Pathway


Airway Emergency Pathway

Attempt Intubation

+/- Gum Elastic Bougie

+/- Glydescope

Attempt LMA, King LT, or other Supraglotic

Airway

Cricothyrotomy

Note: Patient’s SpO2 will determine how fast you move to the next step Provider may opt

to go directly to Cricothyrotomy based on experience and patient’s status

If successful, turns Emergency into Non-Emergency. Intubate through LMA or perform Cricothyrotomy.

Fails

Fails


Airway Non-Emergency Pathway

Attempt Intubation

+/- Gum Elastic Bougie

+/- Glydescope

ReAttempt Intubation

as above. Adjust to make coditions better.

Cricothyrotomy

Mask Ventilate

Mask Ventilate

Attempt LMA, King LT, or other Supraglotic Airway as bridge.

If successful, turns Emergency into Non-Emergency. Intubate through LMA or perform

Cricothyrotomy.

Mas

kin

g Fa

ils

Success


Airway - Peak Inspiratory Pressure High


PIP > 40 cmH2O or > 5 Pt Bucking Ventilator Alert Team/Get Help

High PIP Alarm if set Kinked Circuit/Tube Bag on 100% FiO2

Hard to bag ( compliance) Displaced ET Tube Assess PIP/Compliance

Tidal Volume (if PC) ET Tube Obstruction Assess BP & HR

Minute Ventilation Bronchospasm Assess ET Tube (DOPE)

Little/No Chest excursion Pneumothorax -Displacement (depth)

Ventilator “barking” Pulmonary Edema -Obstruction (suction)

Little/No ETCO2 Atelectasis -Pneumothorax-Chest

Profound Hypotension not responsive to fluids and/or vasopressors

Abdominal Compartment Syndrome

-Equipment (Vitals normal after disconnect from vent)

Desaturation Faulty Pressure Gauge

Tachycardia


Burn Care Goals: Protocol driven resuscitation, UOP 30-50 ml/hr Use this for Initial and Routine Burn Fluid Managment

Initial Priorities

Endotracheal tube: 8.0 or Larger, well secured

Resuscitation: LR initiated at 10 ml/%TBSA/hr (TBSA ≥ 15%) – Adults ≥ 40 kg --Add 100 ml/hr for every 10 kg > 80 kg

Increase/Decrease IVF by 20-25% every hour to maintain UOP 30-50 ml/hr

Circumferential Burns: Perform Escharotomies

Assess for abdominal & extremity compartment syndrome (need fasciotomies?)

5% Sulfamylon Soaked Dressing, Sulfamylon Cream (ears), Bacitracin (face)

Keep Warm and manage drainage (bring extra burn pads)

5% Albumin: Start at 24 hr post-burn (unless Difficult Resuscitation Guideline) --ml/hr = (x * %TBSA * kg)/24 30-49% (x=0.3), 50-69% (x=0.4), 70% (x=0.5)

Head Trauma: MAP adjusted accordingly. NO Lactated Ringers or Albumin.


Burn Care Goals: Protocol driven resuscitation, UOP 30-50 ml/hr Use this when UPO < 30 ml/hr OR MAP < 55 mmHg

Hypotensive Guidelines

For UPO < 30 ml/hr OR MAP < 55 mmHg

Assess for missed injury/bleeding: Optimize blood components

If above inadequate, measure CVP

CVP: Goal 8-10 cmH2O --If < 8, increase fluid rate 20-25%. --If 8-10, add Vasopressin, then Levophed

If above inadequate, consider adding pressor: --Dobutamine (if SCVO2 < 60), Epinephrine, and/or Phenylephrine

Consider/treat missed injury, acidemia, adrenal insufficiency, and hypocalcemia

If UOP < 30 but MAP, CVP, and SCVO2 at goal = accept renal insult and stop increasing IVF


Burn Care Goals: Protocol driven resuscitation, UOP 30-50 ml/hr

Use this when 24 hr predicted fluid requirements are > 6 ml/kg/%TBSA

Difficult Resuscitation Guidelines

Use this Guideline IF 24 hr predicted fluid requirements are > 6 ml/kg/%TBSA

5% Albumin: Initiate early (12-23 hr post-burn) if 24 hr predicted fluid requirements are > 6 ml/kg/%TBSA 5% Albumin Rate (ml/hr) = (x * %TBSA * Wt in kg) / 24 30-49% (x = 0.3), 50-69% (x = 0.4), 70% (x = 0.5)

IV Fluid Rate: Wean as able after initiating 5% Albumin

Abdominal/Extremity Compartment Syndrome: Monitor q 4 hr

Continue management per Hypotensive Guidelines


Burn Care: Initiation of

CPG

Calculate TBSA Burns

TBSA < 15%

NO Burn Flow Sheet

Start IVF (LR) at Standard

Maintenance Rate

Routine Burn Care

TBSA 15 - 20%

NO Burn Flow Sheet

Start IVF (LR) at

10 ml/%TBSA/hr

TBSA > 20%

Burn Flow Sheet Required

First

Medical Provider

Start IVF (LR) at

10 ml/%TBSA/hr

Calculate 24 hr Limit:

6 ml/kg/%TBSA

Go to Hourly Goal Assessment

Subsequent Medical Provider

Calculate 24 hr Limit:

6 ml/kg/%TBSA

Go to Hourly Goal Assessment

For Adults 40-80 kg -- Add 100 ml/hr for every 10 kg > 80 kg


Burn Care: Hourly Goal Assessment

Assess every hour

for Goals

12 hr Post-Burn andProjected 24 hr IVF

> 6 ml/kg/%TBSA?

or

24 hr Post-Burn?

UOP < 30 ml/hr

or

MAP < 55 mmHg

Go to Hypotensive Guidelines

UOP 30-50 ml/hr

and

MAP ≥ 55 mmHg

Continue Current IVF Rate

UOP > 50 ml/hr

and

MAP ≥ 55 mmHg

Decrease IVF Rate

by 20-25%

If Yes, start Albumin-> Go to Albumin Protocol. Otherwise, continue.

Consider Weaning Vasopressors


UOP < 30 ml/hr

or

MAP < 55 mmHg

Assess for missed injuries.

Transfuse Blood Products as Required

Assess CVP

Goal: 8-10 cm H2O

(next page)

Burn Care: Hypotensive Guidelines

(1 of 4)


Burn Care: Hypotensive Guidelines (2 of 4)

Resume Hourly Goal Assessments

Assess CVP

Goal: 8-10 cmH2O

Start Vasopression at 0.04 units/min

Add Norepinephrine 2-20 mcg/min to

MAP ≥ 55 mmHg

Add Additional Vasopressor

(next Page)

Increase IVF Rate

by 20-25%



MAP ≥ 55

CVP ≥ 8 CVP < 8

MAP < 55

MAP < 55

MAP ≥ 55


Add Additioinal Vasopressor:

Check SCVO2

Dobutamine

5-20 mcg/kg/min

to Goal MAP/SCVO2

Resses Goals

(Next Page)

Reevaluate for:

Missed Injury/Bleeding

Acidemia - pH < 7.2

Hypocalcemia - iCa < 1.2

Adrenal Insufficiency -Hydrocortisone 100 mg

every 8 hr

Epinephrine 2-20 mcg/min

or

Phenylephrine 50-200 mcg/min

to Goal MAP

Reassess Goals

(Next Page)

Reevaluate for:

Missed Injury/Bleeding

Acidemia - pH < 7.2

Hypocalcemia - iCa < 1.2

Adrenal Insufficiency -Hydrocortisone 100 mg

every 8 hr

Burn Care: Hypotensive Guidelines (3 of 4)

SCVO2 < 60 SCVO2 ≥ 60

Not At Goals

Not At Goals At Goals

At Goals


Burn Care: Hypotensive

Guidelines (4 of 4)

Reassess Goals:

UOP 30 - 50 ml/hr

MAP ≥ 55 mmHg

CVP ≥ 8 cmH2O

SCVO2 ≥ 60

UOP ≥ 30


UOP < 30 and NOT Met MAP, CVP, or

SCVO2 Goals

Achieve Goals

NOT Met


UOP < 30 and Met MAP, CVP, & SCVO2 Goals

Accept Renal Insult

Do NOT Increase IVF



Burn Care: Albumin Protocol

Use if:

12 hr Post-Burn and Projected 24 hr IVF

> 6 ml/kg/%TBSA?

or

24 hr Post-Burn?

Start 5% Albumin:

ml/hr= x * %TBSA * Wt (kg)

24

For %TBSA 30-49:

x = 0.3

For %TBSA 50-69:

x = 0.4

Attempt to wean IVF


For %TBSA ≥ 70:

x = 0.5


Head Injury: Catastrophic Non-survivable Goals: Maintain MAP > 70 mmHg, Correct Endocrine Abnormalities


Goal directed fluid resuscitation to MAP > 70mmHg

Bring plenty of extra liters of crystalloid

Vasopressors: Epinephrine and/or Dopamine to MAP > 70

Blood Products: Only if low O2 carrying capacity

Initiate T4 Protocol: If vasopressor dose > 10 mcg/kg/min

Ensure AE “DNR” paperwork complete

T4 Meds: 1 Amp D50, 2 g Solumedrol, 20 units Regular Insulin, 20 mcg Thyroid hormone (T4) + infusion 10 mcg/hr

Vigilance for DIC, Diabetes Insipidus, Pulmonary Edema, Hypothermia, and Cardiac Arrhythmias


Head Injury: Catastrophic Non-survivable Goals: MAP > 70, Endocrine Mgmt

Goal:

MAP > 70 mmHg

Goal Directed Fluid Resuscitation

If low O2 carrying capacity, consider

blood products

Goal Directed Vasopressors:

Epinephrine and/or Dopamine

If vasopressor dose

> 10 mcg/unit, Initiate T4 Protocol

Monitor for DIC, DI, Pulm Edema, Low

Temp, Arrhythmias

Call Receiving Neuorsurgeon if

changes or need recs


Head Injury: Increased Intracranial Pressure and CPP Goals: ICP < 20, CPP > 60, Euvolemia

Elevated ICP (>20 mmHg) Low CPP (<60 mmHg) ALERT: Herniation

Codman: Stopcock/Level Euvolemia: Ensure Bag Vent: 100% FiO2

Pain & Sedation: Adequate ICP: Control/Treat Goal: PaCO2 30-35

CSF: Drain & Recheck Vasopressin, then Neo/Norepi

3% Saline: Rebolus vs. Mannitol: 1 g/kg Bolus

3% Saline: 250 ml + 50 ml/hr Call Neurosurgeon Call Neurosurgeon

PaCO2 35-40

PaO2 > 80 (SaO2 > 93%)

Head: Elevated, Midline, Non-constricting C-collar and tube securing devices

Fever: Treat if > 98.6 F (mechanical and pharmacologic, as necessary)

Seizures: Assess/Treat, Prophylaxis

Paralysis: Consider (Vecuronium)

Call Receiving Neurosurgeon


Head Injury: Increased Intracranial Pressure and CPP Goals: ICP < 20, CPP > 60, Euvolemia

Check Ventric Level & Stopcocks

Sedate & Control Pain Drain CSF 3% Saline Protocol

Ensure PaCO2

35-40 mmHg

Ensure PaO2 > 80 mmHg (SaO2 > 93%)

Head elevated, midline,

nonconstricted

Temp < 99 F

Seizure Control

Ensure Euvolemia

CPP goal 60 mmHg:

Vasopressin, then Neo/Norepi

Consider Paralyzing Patient

Call Receiving Neuorsurgeon if

changes or need recs


Hemorrhage - Acute


Blood Excess sedation Alert Team/Get Help

Vitals Signs (BP, CVP, HR)

Anaphylaxis Check/Verify BP

Fluid requirement more than expected

Under-resuscitation Vasopressor Bolus-temporize

Little/Transient BP response to fluids and/or vasopressors

Vena Cava Compression (compartment syndrome)

Resuscitate (IVF, Blood) w/ pressure bag bolus

Drop in UOP Pneumothorax Stop Bleeding Source

Drop in H/H (late finding) Pulmonary Embolism 100% FiO2

Cardiac Tamponade Trend Vitals and Labs

Diuretic Therapy Call Receiving Hospital

Tachyarrhythmia


Hypotension


BP < 20% of Baseline Rate (too slow or fast)

Alert Team/Get Help

SBP < 90 mmHg Rhythm (not Normal) Bag on 100% FiO2

MAP <60 mmHg (Burn<55) Preload (low) Assess PIP/Compliance

Altered Mental Status -- volume, PTX, PE Assess BP/HR (check pulse)

Arrhythmias --Tamponade, ACS Reduce sedation

Weak/Absent Pulses Afterload (SVR low) Resuscitate--Pressure Bag

No BP or Pulse Ox --Sepsis, Anaphylaxis --Crystalloid/Colloid/Blood

Decreased ETCO2 --Epidural, Sedation --Ensure Large Bore Access

Decreased SaO2 Contractility (low) Check for/stop bleeding

Decreased UOP --Sedation, CHF, MI Temporize w/ vasopressors

--Hypoxia, Valve Leak Find/Correct cause


Hypoxemia


SaO2 < 90% or > 5% Low FiO2 Alert Team/Get Help

PaO2 < 60 mmHg Hypoventilation Bag on 100% FiO2

Cyanosis V/Q Mismatch Assess PIP/Compliance

Respiratory Distress --Pulmonary Edema Assess BP/HR (pulse)

Tachycardia (early) --Atelectasis, PE, PTX Assess ET Tube (DOPE)

Bradycardia (late or child) Anatomic Shunt -Displaced (CO2, depth)

Arrhythmias/Ischemia: ECG Metabolic Demand -Obstruction (suction)

Hypotension Low Cardiac Output -Pneumothorax-

Cardiac Arrest --Hypotension -Equipment-disconnect

Check ABG

PEEP/TV—ARDSnet?

Optimize H/H & Fluids Call ahead/divert


Hypoxemia Management

Get Help

Check Vent Settings

(PIP, Alarms)

Bag on 100% FiO2 (recheck)

Assess Compliance

Assess BP & HR

(check pulse)

High

Peak Pressures

(go to this page)

Normal

Peak Pressures

(go to this page)

Low

Peak Pressures

(go to this page)

If no pulse, initiate ACLS


Low Peak Pressures

Does NOT Resolve

with Baging

Patient Extubated

--Check Depth

--Confirm Placement by Laryngoscopy

and ETCO2

Cuff Leak

--Check Pressure

--Add Air & Recheck

--Replace ET Tube

Resolves with Baging

Vent Malfunction

--Check Settings

--Check Vent

--Replace Vent

Circuit Leak

--Check Connections

--Check Antiasphyxia Valve (754)

--Replace Circuit

Hypoxemia Management: Low

Pressures


Normal Peak Pressures

Does NOT Resolve

with Baging

Anatomic Shunt

--Mucus plugs: suction and nebs

--Follow ARDSnet

V/Q Mismatch

--Ensure appropriate ventilation and blood

pressure

--Attempt to adjust positioning

-Follow ARDSnet

Resolves with Baging

Hypoventilation

--Check/Adjust Vent Settings

Low FiO2

--Check/Adjust Vent Settings

--Check O2 supply and connections

Hypoxemia Management: Normal

Pressures


High Peak Pressures

Unequal

Chest Rise

Pnemothorax

--Needle Decompress

--Chest Tube

Equal

Chest Rise

Decreased Lung Compliance (ARDS)

--ARDSnet

External Compression

--Chest Eschar

--Abdominal Compartment

Syndrome

Obstruction

--ET Tube kink or secretions

--Circuit kink or secretions

--Bronchospasm

--PE

--Atalectasis

Pt aggitation or dyssynchrony

--Sedation

--Pain Control

--Adjust Vent

--Paralyze

ET Tube Displacement --Check Depth --Confirm Placement

Hypoxemia Management: High Pressures


Pneumothorax


Hypoxemia & Cyanosis Endobronchial ET Tube Alert Team/Get Help

Hypercarbia Obstructed ETT Bag on 100% FiO2

PIP, Compliance Bronchospasm Assess PIP/Compliance

Hypotension Pulmonary Edema Assess BP/HR (pulse)

Tachycardia Ventilator Malfunction Assess ET Tube (DOPE)

Unequal Chest Rise Circuit Malfunction -Displaced (CO2, depth)

Subcutaneous Emphysema -Obstruction (suction)

Tracheal Deviation -Pneumothorax -

Distended Neck Veins -Equipment-disconnect

Cough, tachypnea, & dyspnea

If suspect, needle chest

Chest Pain Follow with chest tube

Reassess


Respiratory Failure

Differential ARDS Criteria

Acute Respiratory Distress Syndrome (ARDS) Acute Onset (< 1 wk)

Acute Eosinophilic Pneumonia (AEP) Risk Factors Present

Acute Interstitial Pneumonia (AIP) Acute Bilat Infiltrates

Bronchiolitis Obliterans Organizing Pneumonia (BOOP)

Diffuse Alveolar Hemorrhage

Cardiogenic Pulmonary Edema

Acute Fluid Overload

ARDS Definitions Altitude Adjustment

Normal PaO2 to FiO2 ratio (P:F ratio) is > 300 (Elevations > 1,000 m)

[P:F*(Barometric Pressure/760)]

Mild ARDS = P:F ratio: 201-300

Moderate ARDS = P:F ratio: 101-200

Severe ARDS = P:F ratio: < 100


Respiratory Failure

Possible ARDS

1. Acute Onset

2. Risk Factors

3. Acute Infiltrates

No ARDSExam +/- TEE +/- CVP

Ruled Out other causes?

ARDS

Consider ARDS Imitators

-Bilobar Pneumonia

-Acute Eosinophilic Pneumonia

-Acute Interstitial Pneumonia

-BOOP

-Diffuse Alveolar HemorrhageYES

YES

NO

NO General Management

--Minimize IVF/Diuresis (CVP < 4 mmHg with effective circulation and urine output) --Convert IV meds to Enteral --Avoid unnecessary transfusion --Ensure optimal nutrition --PPI/H2 Blocker -DVT prophylaxis -Early ROM/Mobilization


Respiratory Failure: Ventilator Management

Universal Strategies Goals

Follow Lung Protective Strategies (ARDSnet) PIP </= 30-35 cmH20

Set TV 8 ml/kg PBW & titrate to 6 ml/kg within 2 hr PEEP >/= 5 cmH20

--PBW Males: 50 + 2.3 [height (inches) – 60] SaO2 = 90-95%

--PBW Females: 45.5 + 2.3 [height (inches) – 60] PaO2 >/= 60 mmHg

Set initial Rate to approximate Minute Ventilation pH 7.30-7.45

Adjust TV and Resp Rate to achieve pH and PIP Goals ***TBI pH 7.35-7.45

Utilize FiO2/PEEP ARDSnet Tables to achieve O2 Goals Rate 6-35 BPM

Methylprednisolone 2 mg/kg bolus, then 2 mg/kg/day. Only for those with ARDS in the 7-13 day window.

I:E ratio 1:2 to 1:4


Respiratory Failure: Trouble Shooting

Ventilator Dyssynchrony Severe Respiratory Acidosis

Increase air flow rate --May need > 100 ml/min

Increase Rate to 35 --Watch for Auto PEEP

Consider paralytics --Cisatracurium preferred

THAM or Bicarbonate gtt

Consider Continuous Renal Replacement Therapy (CRRT)

Consider Lung/ECMO Team Consult

Progressive Hypoxia PIP ≥ 30 cmH20

Aggressive Diuresis Lower TV to 4 ml/kg

Increase FiO2 to 0.7 and PEEP to 14 (and higher per ARDSnet as required)

Consider Prone Positioning

Consider Lung/ECMO consult Consider Lung/ECMO Consult


Respiratory Failure: Prone Positioning

Prone Considerations Prone Contraindications

Disease primarily lower lobes Facial or Pelvic Fractures

P:F ratio < 150 Anterior torso wounds or burns

Therapy: Twice Daily, 2-6 hr/session Spinal instability

Increased ICP


Respiratory Failure: Lung/EMCO Team Indications

Lung/ECMO Team Indications

PaO2:FiO2 < 100 (after elevation correction)

PaO2:FiO2 < 200 + Inhalation Injury (after elevation correction)

FiO2 > 0.7 or pH < 7.25 while on lung protective strategies

PEEP > 15 cmH2O w/ Pplat > 30 cmH20

Severe brain injury w/ PCO2 > 35-40 mmHg on a transport ventilator

Cardiogenic shock refractory to maximal medical therapy

Anatomic derangement (i.e. bronchopleural fistula, pneumonectomy)

Use of advanced ventilator modes such as APRV

Acute PE with right heart strain or hypoxemia

Multi-system organ failure (i.e. ARDS + Renal Failure)


Spinal Cord Injury Goals: Maintain Cord Perfusion Pressure, Immobilize Spine


Document neurologic exam 30o Reverse Trendelenburg

Stabilize Spine: C-collar, VSB for Unstable T-L Spine

Log Roll Every 2 hr

Perfusion: MAP 80-90 mmHg x 7 days Antibiotics if penetrating injury

Oxygenation: SaO2 > 93% DVT Prophylaxis: When cleared by Neurosurgery

Neurosurgeon: Obtain specific recommendations

Avoid steroids for spinal cord injuries sustained in Theater!


Spinal Cord Injury Goals: Maintain Cord Perfusion Pressure, Immobilize Spine

Document

Neuro & Skin Exam

Stabilize Spine:

C-collar

VSB for T/L-spine

Goal MAP:

80-90 mmHg

for 7 days

SaO2 Goal:

> 93%

Get Neurosurg specific

recommendations

Reverse Trendelenburg 30

deg

Log Roll every

2 hr

Call Receiving Neuorsurgeon if changes or need

recs


Ventilator Device Failure


Little/No Chest Movement Not Turned On Alert Team/Get Help

Little/No ETCO2 Vent Malfunction Bag on 100% FiO2 (recheck)

Hypoxemia & Cyanosis Not Plugged In Assess PIP/Compliance

TachycardiaBradycardia Battery Dead Assess BP & HR (pulse)

Hypotension Circuit Disconnect Assess ET Tube (DOPE)

Arrhythmias/Ischemia--ECG Circuit Defective -Displacement (CO2, depth)

Cardiac Arrest ET Tube Displaced -Obstruction (pass suction)

No Ventilator Cycle No/Empty O2 -Pneumothorax (Chest rise)

Abnormal Ventilator Sounds -Equipment (disconnect)

Ventilator Alarms Reassess, patient stabilizes then most likely there is an equipment issue (circuit, ventilator, or O2 source)


Troubleshoot circuit/vent, reconnect if fixed and assess patient.

Common Problems: --O2 Source Empty (change) --O2 Source Pressure “Low” (turn to 100% then 21% then back to desired) (Impact 754) --Battery not charged (plugin) --Circuit Malfunction (replace) --Bad Anti-Asphyxia Valve (tape hole)( Impact 754)


ACLS Basics


No readings/waveform on monitor

Profound Hypotension

Alert Team/Get Help

Abnormal rhythm on ECG Monitor Artifacts Treat Pt—Not Monitor

Patient Unresponsive Verify No Pulse

Not Breathing Get more Help

Drop in ETCO2 Start CPR (C-A-B)

Cyanosis Bag on 100% FiO2

No Pulse Place Defib/Monitors

Vomiting ACLS per Guidelines

H’s & T’s

Inform MCD before Shocking

Call Receiving Hospital


REFERENCES

American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2013; 118:2.

Borden Institute. Emergency War Surgery, 4th ed. 2013. Gaba, D.M., Fish, K.J., & Howard, S.K. Crisis Management in

Anesthesiology. 1994. Joint Trauma System Clinical Practice Guidelines (Zip File Download 4 Dec

2014) from http://www.usaisr.amedd.army.mil/cpgs.html. Sudrial, J., et. al. Difficult Airway Management Algorithm in Emergency

Medicine: Do Not Struggle Against the Patient, Jest Skip to Next Step. Emergency Medicine International. 2010; 2010: 826231.

lt col alan guhlke, m.d. 2 edition: 1 march 2016€¦ · en route care cards, 2nd edition cleared,...

Documents